Crossposted from Charity Entrepreneurship's Blog here
Introduction
There has been recent discussion within effective altruism around global mental health as a new cause area. In the 2018 EA survey, it was included as a potential top cause area, and around 4% of EAs identified it as their top priority [1]. This has led us to think about whether Charity Entrepreneurship (CE) should do prioritisation research on mental health as a potentially high-impact cause area. Many of us at CE have been convinced that this is a promising enough area to investigate as one of the four areas for our 2020 incubation program. In this post, I will explain which factors convinced us to expand our portfolio of cause areas for the next incubation round to include mental health.
Top Reasons to Focus on Mental Health
The huge disease burden of mental illness
On broad considerations of scale and neglectedness, it is shocking to see how little government funding is spent in this area relative to the size of the problem. Self-harm, mental, neurological, and substance use disorders account for 12% of the global burden of disease when measured in DALYs [2]. However, in 2016, the median government spending on mental healthcare was 2.4% of all healthcare spending. This level of spending “represented an imbalance in the ratio between disease burden and efficiently allocated spending, ranging from 3:1 in Canada and the USA to 435:1 in Haiti” [2]. The lack of sufficient government funds dedicated to this issue means that 78% of those with mental illness in high-income countries—and up to 96% in low-income and lower-middle-income countries—do not receive treatment [3]. This massive treatment gap indicates the need for more organisations and funding to solve the problem.
Despite a strong evidence base, mental health is not well prioritised
As with global poverty, there is already a well-established evidence base that we can use in our prioritisation work as there have been numerous pilot studies and randomised controlled trials conducted in global mental health. Organisations such as the Mental Health Innovation Network [4] compiled a library of previous pilot programs dating back at least six years. Many of these pilots performed well, and now only lack prioritisation to channel the talent and funding necessary to bring them to scale. Thus the problem is not a lack of well-evidenced, effective treatments; it is that they are not being implemented or prioritised adequately in the nonprofit sector.
Mental health interventions could be cost-effective in both low- and high-income countries
Generally, the most cost-effective charities work in lower- and middle-income countries, but mental health may be a cost-effective area even in high-income countries. When considering which charities to support, many foundations and funders are focused on a particular country in which they’d like to see interventions take place. For this reason, mental health charities operating in high-income countries may be able to access a pool of resources not available to other effective charities. The existing opportunities available to these funders are much less cost-effective than the average global health program. However, it might be very difficult to switch their donation from one cause to another. Providing them with more cost-effective giving opportunities within their preferred field and geography would drive money away from less effective mental health programs. This means that even if mental health interventions turn out not to be as cost-effective as the best global health program, there is still a substantial opportunity for impact, particularly as a charity entrepreneur.
The importance of mental health may be underrated by other metrics
Another factor to consider is the continuing development of measurements of subjective wellbeing (SWB)—measures of self-reported happiness and life satisfaction—over the past 40 years. In the past, we thought the best proxy measures for someone's quality of life were increased income, disability-adjusted life years (DALYs), and lives saved. However, we tend to think that increasing income or reducing disability are just instrumental goals that we value for their effects on individuals’ overall wellbeing. Instead, it seems plausible that we should be trying to measure SWB directly, as this better captures what we care about.
Here, I will briefly summarise the main argument for using SWB scores as a direct measure of wellbeing [5]. Subjective wellbeing is something that can be measured through self-reports and captures something different from conventional measures. When considering interventions through a SWB lens, working on mental health stands out as an even more significant and neglected way of improving SWB, because it has relatively little funding, and the effect that mental illness can have on our quality of life extends far beyond what is captured by DALYs. When comparing cash transfers to interpersonal psychotherapy group (IPT-G) on SWB metrics [6], some estimates of IPT-G suggest that it could be four times as cost-effective as just giving out cash, which is a standard poverty alleviation intervention carried out by e.g. GiveDirectly.
Work on mental health is robust to changes in moral views
If you are uncertain about which ethical system is correct and you subscribe to a moral parliament model [7], mental health may be a good cause area. Improving happiness directly is viewed positively by virtually all ethical systems. Regardless of your views on population ethics or how much weight you give to non-human animals, who may be negatively impacted by other interventions (e.g. the meat-eater problem [8] for global health interventions), improving the quality of human lives is good. This means that the benefits of working on mental health as opposed to other cause areas are more robust to changes in your views on ethics. Therefore, even if it does not appear to be the most effective given your current moral views, it may still be valuable to work on mental health, as it is more likely to maintain its value regardless of future moral updates.
The Effective Altruism movement is increasingly interested in mental health
The decision to evaluate mental health and subjective wellbeing charity ideas was also affected by the recent influx of interest from the EA community. Analysis of the 2019 application round [9] indicates that applicants with an EA background are more likely to be accepted to our incubation program. Thus, this increased interest has expanded the number of good charity entrepreneurship candidates that want to work in this area. Beyond alleviating a limiting factor for Charity Entrepreneurship, this increased interest within our epistemic peers can be seen as evidence for the promisingness of the cause area.
Conclusion
All these factors lead us to believe that mental health is a promising new cause area. This is particularly the case for charity entrepreneurs who can utilise existing research and funding to bring effective, evidence-based treatments to scale. This will help reduce the massive treatment gap in the mental health space, and will greatly improve the lives of the affected population.
References
1. EA Survey 2018 Series: Cause Selection - EA Forum [Internet]. [cited 2019 Nov 25]. Available from: https://forum.effectivealtruism.org/posts/hP6oEXurLrDXyEzcT/ea-survey-2018-series-cause-selection
2. Daniel V Vigo Devora Kestel PKPPGTPRA. Disease burden and government spending on mental, neurological, and substance use disorders, and self-harm: cross-sectional, ecological study of health system response in the Americas. The Lancet Public Health. 2018;4:89–96.
3. Thornicroft G E al. Undertreatment of people with major depressive disorder in 21 countries. PubMed [Internet]. [cited 2019 Nov 25]; Available from: https://www.ncbi.nlm.nih.gov/pubmed/27908899
4. | Mental Health Innovation Network [Internet]. Mental Health Innovation Network. [cited 2020 Jan 21]. Available from: https://www.mhinnovation.net/innovations?mode=List
5. Plant M. Doing Good Badly? Philosophical Issues Related to Effective Altruism [Internet] [Doctor of Philosophy]. University of Oxford; 2019 [cited 2019 Nov 25]. Available from: http://www.plantinghappiness.co.uk/wp-content/uploads/2019/11/M-Plant-Doing-Good-Badly.pdf
6. Cause profile: mental health - EA Forum [Internet]. [cited 2019 Nov 25]. Available from: https://forum.effectivealtruism.org/posts/XWSTBBH8gSjiaNiy7/cause-profile-mental-health
7. Moral uncertainty - Effective Altruism Concepts [Internet]. Effective Altruism Concepts. [cited 2020 Jan 18]. Available from: https://concepts.effectivealtruism.com/concepts/moral-uncertainty/
8. The meat-eater problem - Effective Altruism Concepts [Internet]. Effective Altruism Concepts. [cited 2020 Jan 18]. Available from: https://concepts.effectivealtruism.com/concepts/the-meat-eater-problem/
9. Application Process for the 2019 Charity Entrepreneurship Incubation Program - EA Forum [Internet]. [cited 2020 Jan 21]. Available from: https://forum.effectivealtruism.org/posts/fNRSGinhWqPZtuo3T/application-process-for-the-2019-charity-entrepreneurship