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Konstantin Sietzy

Mental Health interventions may be more cost-effective than we think

Neither Giving What We Can nor GiveWell currently feature a single mental health-focused organisation in their recommendations, despite mental disorders accounting for over one-fifth of all days lived with disability worldwide.

 suggests that mental health interventions in low and middle income countries (LMIC) may be more cost-effective than previously assumed. As currently favoured interventions reach diminishing marginal returns, mental health may rapidly become an interesting field for effective donations, although some significant concerns remain about tractability.

The global mental health burden of disease

Mental, neurological and substance use disorders (MNS) account for an estimated 7.4% of the global disease burden[1]. This realisation is at the foundation of a 

 penned by Victoria de Menil on behalf of the Centre for Global Development. De Menil’s report lays out the scale of the mental health problem, estimated to affect 700 million people globally[2], and makes three specific policy recommendations:

creating incentives through results-based funding,

MNS disorders are one of the top five contributors to the global burden of disease [1], and are responsible for 37% of the total disease burden from 

[3]. Moreover, they carry a high death toll through suicides and contributing to premature mortality in various ways.

Importantly, the problem posed by mental disorders is actually getting worse: disease burden as measured in 

 increased by 38% between 1990 and 2010[1], and is expected to continue on this trajectory as populations age and demographics shift (since MNS disorders, especially neurological conditions such as Parkinson’s, disproportionately affect adults).

Finally, mental disorders are cause for some of the most serious human rights abuses committed in LMIC, both within families and communities (sexual abuse, forced restraint) and by governments (forced sterilization or incarceration).

Mental health disorders are also directly related to poverty. Stress and emotional anxiety experienced in relation with poverty may trigger mental disorders (the 

 hypothesis). Conversely, crippling healthcare costs and frequent unemployment associated with mental health problems may serve to drive individuals into poverty or keep them there (the ‘social drift’ hypothesis).

Despite a substantial literature on effective interventions, mental health is starkly neglected by LMIC governments. According to de Menil, “one third of LMIC do not have a designated budget for mental health… and among those that do, the average expenditure on mental health in low-income countries is 0.5% of the total health budget.” She contrasts the 

 in Nigeria – 90% across all diagnosable mental disorders – with an average of 32% for schizophrenia to 56-57% for depression and anxiety disorders in European countries.

Remarkably, the international donor community fares no better: only 0.7% of development spending is directed at mental health [4] (despite a disease burden of over ten times this scale relative to the global total). A significant obstacle here is the lack of reliable data on MNS disorder prevalence in many LMIC.

De Menil is adamant that the problem lies in implementation – especially at the institutional level – not in generating effective interventions: Cost-effective, proven and scalable interventions, she claims, are readily available, focusing on three examples (universal health coverage, results-based funding, cash transfers).

Importantly, de Menil’s main source of data for her cost-effectiveness estimates, the 

Disease Control Priorities in Developing Countries (DCP2) report (2006)

, is almost ten years old, calling for significant caution on any inferences made from these figures. (Disclaimer: GiveWell has further offered 

To investigate cost-effectiveness, the DCP2 authors modelled the aggregate effects of a bundle of the most effective treatment options across four disorder archetypes (schizophrenia and related non-affective psychoses, bipolar affective disorder, major depressive disorder, panic disorder).

Their analysis suggests that mental health interventions work out at $1,000-$2,000/DALY averted in Sub-Saharan Africa and $2,300-$4,500/DALY averted in Latin America and the Caribbean. (For comparison, GiveWell currently estimates 

the effectiveness of distributing anti-malarial bed nets

Since these figures represent average values across a bundle of interventions, targeting only the most effective disease incidences could prove significantly more cost-effective. De Menil mentions “a wide range [of effectiveness] across disorders and populations; brief interventions for harmful alcohol use and treatment of epilepsy with first-line anti-epileptic medicines fall towards the lower (more favorable) end, while community-based treatment of schizophrenia with first-generation medication and psychosocial care falls towards the upper end.”

), released in October 2015, reaches even more optimistic conclusions. Surveying studies on cost-effectiveness published between 2007-2012, they find broadly the same estimates while complementing the lower end of the scale with alcohol-demand reduction measures, projected at approximately $200-$1,200/DALY averted[5]. One can therefore treat $1,000-$2,000/DALY averted as a conservative estimate of the cost-effectiveness of the best mental health interventions.

 – key obstacle to effective treatment of mental health disorders. In a number of LMIC “there has been a discourse that mental health problems don’t exist.” [6] Families resort to forcible restraint out of helplessness how to deal with affected relatives. Fear of contagion of mental illness results in patients being denied physical touch or ostracised by their communities[7].

Additionally, ignorance of the neuropsychiatric causes of mental health disorders may drive communities to rely on ineffective practices such as “faith-healing rituals” or “nontherapeutic herbal supplements” (de Menil). Interventions aimed at combatting stigma are likely much harder to implement than direct-treatment interventions – pursuing change on a systemic scale may prove 

A second obstacle may affect the scalability of mental health interventions. In surveying successful examples of mental health policy reforms in four countries (India, China, Ethiopia, South Africa), de Menil repeatedly points out national and regional idiosyncrasies that may complicate transferring proven interventions from one context to another. In particular, different communities place varying degrees of emphasis on home vs. institutional care, “paraprofessionals” (traditional healers, village authorities) vs. specialist workers, recovery vs. symptom management, and openness to learning from external partners.

Which organisations currently operate in this area?

The mental health charity space is not crowded. The 

 lists only eight NGOs active in this field. Of those, only three are not limited to a specific country or region.

 appears to be the sole large charity active in reducing the global mental health disease burden. It provides “medication and psychosocial support in partnership with local governments and Ministries of Health … [, builds] the capacity of existing health professionals and services … [and] participants by encouraging them to be members of self-help groups … [and] create[s] livelihood opportunities for people with mental illness and epilepsy.”

Initial cost-effectiveness estimates of BasicNeeds’ Mental Health and Development programs support the hypothesis postulated above that targeting individual disease may prove even more effective than the DCP2 figures: 

 place the incremental cost over two years per DALY averted at $727. (For full disclosure it should be added that de Menil was employed by BasicNeeds between 2007-2010.) BasicNeeds claims to have helped “over 646,000 people in 12 countries.”

Is mental health a promising area for Effective Altruism?

Mental health interventions are important considering their neglectedness and the scale of the disease burden. The political nature of stigma-related obstacles to change provide some problems for tractability, but local interventions circumventing these problems are conceivable; de Menil’s policy recommendations may provide promising starting points for developing more effective interventions.

It seems that mental health interventions may not be among the most effective right now, but given their comparative cost-effectiveness, may rank high in succession when the best current programs approach 

give to one of the charities currently working on improving mental health in LMIC

. The most plausible candidate appears to be BasicNeeds, although limited available data means there is significant uncertainty about the effectiveness of their programs. Before doing this, you might want to read about Giving What We Can’s 

pursue or fund further research into what are the most effective interventions in the mental health sphere

. A lack of data (e.g. on treatment gaps or the effectiveness of existing interventions) and of highly effective policy recommendations reflect major room for further study of this area. Mental health disease burden alleviation currently seems neglected, and as some other effective charities approach funding saturation, there will be demand for new opportunities to direct funding.

consider setting up an effective mental health charity yourself

. The scale of the problem is significant in LMIC, and the same considerations about neglectedness listed above apply here. The upcoming DCP3 report is likely a good starting point for which disorders allow for the most effective interventions. Advice on setting up your own effective charity can be found 

Whiteford, Degenhardt et al. (2013), as cited in Victoria de Menil. 2015. 

"Missed Opportunities in Global Health: Identifying New Strategies to Improve Mental Health in LMICs."

 CGD Policy Paper 068. Washington DC: Center for Global Development.

Patel and Saxena (2014), as cited in de Menil

Bloom, Cafiero et al. (2011), as cited in de Menil

Gilbert, Patel et al. (2015), as cited in de Menil.

“Addressing the Burden of Mental, Neurological, and Substance Use Disorders: Key Messages from Disease Control Priorities, 3rd Edition.”

Summerfield (2013), as cited in de Menil.

Human Rights Watch (2012), as cited in de Menil.

Michelle Hutchinson

Giving What We Can is a community of effective givers – an international society that helps people commit to giving more, and giving more effectively. Our members donate at least 10% of their career incomes to the charities they believe will help others the most. Now we need your help to keep our momentum into 2016.

Giving What We Can needs your support this Christmas

Giving What We Can is a community of effective givers – an international society that helps people commit to giving more, and giving more effectively. Our members donate at least 10% of their career incomes to the charities they believe will help others the most.

Over the last year, our community has doubled in size. Our members have now collectively 

donated more than $10 million, and pledged over half a billion dollars

! We have been testing out a range of ways to attract and retain new members, and seem to have found some to be really successful. Amongst these are 

We would like to capitalise on a successful 2015 by scaling up some of the most promising avenues for attracting and retaining new members. To do so, we need to increase our team size. We've been lucky enough to have had really excellent applicants in our recent recruitment round. In order to carry out our plans — detailed in 

 — we need to reach our fundraising goal.

We think that the most relevant considerations for choosing whether to donate to us are our strong track record, and our plans for growth. But we also regularly calculate our effectiveness, to ensure that we are providing a substantial leverage ratio for our top charities. Our 

 for this indicates that for every $1 spent by Giving We Can, around $103 (counterfactually adjusted and time-discounted) will be moved to top charities.

, of which we already have £193,000 pledged. We therefore need to raise a further £282,000. You can find a full breakdown of our budget, along with details on our plans and our cost-effectiveness estimates on our 

 — you’ll also find a link with instructions for how you can donate.

If you decide to support us, I’d like to extend a huge thanks on behalf of the 

 — your generosity means that we can continue to help make the world a better place as effectively as possible.

Allan Saldanha

Quadruple your donation to SCI!

I have always been keen on matched fundraising. Not only does it increase the amount of money raised, but it also involves collaborating with other people and makes people feel better about the money they donate. This is why I set up a fundraising page for SCI, quadrupling donations this Christmas.

I always used to look for donation matching appeals to increase the impact of my donation. However, after reading about effective altruism, I learnt how some charities are many times more effective than others - to a degree that can dwarf the impact of donation matching to less effective charities. I 

 Giving What We Can in 2014 and have since tried to use donation matching to fundraise for the most effective charities.

It’s obviously important to try to publicise effective altruism and the most effective charities to as wide an audience as possible. Matched fundraising has allowed me to reach out to my friends, family and colleagues – hopefully leading them to donate more to effective charities and eventually to more people joining Giving What We Can.

My own personal experience was that I only became a Giving What We Can member after a matching appeal.

I first heard of Giving What We Can from an article about Toby Ord in 2010. I was very impressed with the idea of donating 10% of your income to effective charities, but it seemed like too big a commitment at the time and I forgot all about it.

In 2013, while looking for matched fundraising on the internet, I came across 

- a matched fundraising campaign for the 

 (AMF). This led me to read about AMF, and I was astonished to learn that 

a life was saved for every £2,000 donated to AMF

. I was delighted to make a matched donation to such an effective charity, and was then contacted by Rob Gledhill from Giving What We Can. After discussions with Rob and some deliberation, I decided I would make the pledge once I got back to work. I started a new job in May 2014 and took the pledge then.

Last Christmas I took advantage of generous donation matching offered by 

 to offer quadruple matching for donations to AMF. I offered to match all donations up to £5,000. After Charity Science's matching, this would be multiplied to £20,000. In the event, we had generous donations of £6,700 before I decided to close my chequebook (!), and Charity Science's matching as well as gift aid multiplied our fundraising to a total of £32,632- see 

 Based on Givewell’s estimates, our fundraiser saved 15 lives!

This year, I’m again taking advantage of Charity Science’s generous matching with a quadruple matching fundraiser for the 

 (SCI)- another of Giving What We Can’s 

. SCI works in sub-Saharan Africa to supply drugs and health education to protect against schistosomiasis (bilharzia) and other Neglected Tropical Diseases (NTDs) caused by intestinal worms. NTDs are so-called because treatment is cheap and effective, but interventions in the area are chronically underfunded due to lack of publicity. Schistosomiasis is the most deadly NTD, killing an 

SCI has a strong track record, and its cost-effectiveness is so high that it has been designated a “best buy” in public health by the World Health Organisation. The cost per treatment is only 50p. Givewell's evaluators 

 that similarly to AMF, a life is saved for every £2,000 or so donated to SCI (estimates are subject to substantial uncertainty). So I’ve set up a 

 offering to quadruple donations- I’ll match all donations up to a total of £8,000 (capped at £1,000 per individual) made before 25th December, and with charity science's matching, all donations will be quadrupled (or more including gift aid). This page can only accept GBP donations and only offers UK Tax deductibility.

, and maybe consider setting up your own quadruple fundraiser page for SCI (with a carefully chosen maximum total of course) and publicise effective altruism to your friends, family and colleagues! If you’d like to discuss setting up your own quadruple fundraiser, please get in touch with me (

Many Thanks for your generosity! Allan Saldanha

Larissa Hesketh-Rowe

Got the Black Friday Blues? Looking for an alternative to relentless sales, offers, adverts and spending? Today is the day for you. Happy #GivingTuesday!

Happy #GivingTuesday!

This weekend I battled against a tide of shoppers as I followed my brother to look at MP3 players. The shops were heaving with people. Why were so many people crowded in John Lewis on a Friday morning?

Black Friday is the day after Thanksgiving which is said to signal the beginning of the shopping season in the run up to Christmas. It has spread from the US to other countries. Last year, Black Friday became 

the biggest UK shopping day of the year for the first time

Yet, despite all the hype around the Black Friday weekend and despite the noticeable crowds, sales have actually 

Well, retailers have been running sales for a lot longer to mitigate some of the chaos seen in stores in 2014. There has also been a big 

. During yesterday’s Cyber Monday shoppers were 

, almost a third more than last year, according to analysts at Experian-IMRG.

And perhaps people are looking for an alternative to relentless offers, adverts and spending.

If you are one of those people today is a day for you.

#GivingTuesday is a global day of giving.

, covering countries like The United States, United Kingdom, Australia, Singapore, Canada, much of Latin America and Israel. It is an opportunity to come together to show the world why it’s good to give. Whether it’s making a donation, volunteering your time or just spreading the word, #GivingTuesday is here to encourage and remind us to give something back this festive season.

The simple idea behind #GivingTuesday is to encourage people, charities and businesses to donate time, money or their voice to help a good cause.

 the average spend per person on Black Friday in the US was $380.95. Even donating half of that instead could provide 25 anti malarial bed nets or 95 deworming tablets.

This shows that giving needn’t be a sacrifice, it is simply a different way to spend your money. It is a chance to do something really meaningful with your hard earned cash.

Here at Giving What We Can we are always encouraging others to join us in giving to 

), because that means helping more people. In some cases 

 by the Charities Aid Foundation, 35% of people in Britain say they will donate today as part of #GivingTuesday.

By donating to the best charities you can do even more. Our 

 are recommended because they do the most good with your donations. If you give to them this #GivingTuesday you know you’ll be helping as many people as possible.

For less than $7.50 you provide someone with a bednet to protect them against malaria if you give to the Against Malaria Foundation. That’s the best deal you’ll see all weekend.

Instead of sending your loved ones out into the sales to try and guess at what you might like, why not donate your Christmas this year? Ask friends and family to donate to a high impact charity for you as a gift rather than risking another novelty jumper. It is a lovely way to share the holiday season and give back.

Charity Science have done all the hard work for you with their popular 

Why not help us show others how much we can achieve by donating to the charities that do the most good?

Share this post or change your profile picture or cover photo to the ones below to show your support for giving well this #GivingTuesday.

#GivingTuesday is a fantastic way to get people thinking about giving - but it doesn’t have to stop there. Our members 

 of their income (1% for students, the unemployed and pensioners) to charities that will have the biggest impact.

If a typical US citizen gave 10% of his or her income to the right NGO, then every year 

they could distribute 700 mosquito nets, preventing 190 cases of malaria and 2 deaths, or treat 7,100 people for neglected tropical diseases

Even if you are not ready for the full pledge you can 

 to tackle extreme poverty, which is just incredible.

Together we can make a big difference. So give generously, give effectively and do good this #GivingTuesday.

Coralie Oddy

According to research conducted across the UK, France, Germany and the USA, 80% of people agree with this statement: "Despite investment in aid, not much has changed for those in poverty over the last twenty years." But this statement is false.

Switching the story: how to change the narrative on development

According to research conducted by Bond across the UK, France, Germany and the USA, 80% of people agree with this statement:

‘Despite investment in aid, not much has changed for those in poverty over the last twenty years.’ [1]

Extreme poverty has actually halved over the last twenty years

Clearly, 80% of people have formed a belief about development based on unreliable evidence. Surely if we show them the real facts – with hard evidence to back up our claims - we can create a different attitude to international development and maximise giving?

In fact, the evidence would suggest it isn’t as simple as that. Statistics on poverty and the impact we can make convinced me to take the Giving What We Can pledge, but it is probably precisely because I’m drawn to statistics and evidence-based research that effective altruism appealed to me in the first place. It makes sense that facts and figures would help to convince the stereotypical Effective Altruist – the analyst, the programmer, the maths or philosophy graduate– but what of the population at large?

The 2014 Narrative Project sought to understand the public perception of international development, and how changing our ‘stories’ about aid can promote positive engagement

The research found that there was a generally negative perception of international development, with a focus on waste and what doesn’t work – rather than what does. Foreign aid is viewed as ‘a good idea done badly’.

the project identified an ‘undecided audience’ who - if reached in the right way - could significantly increase support for development and become effective donors.

The Narrative Project found that around a third of the public are ‘engaged’ with international development – they have some knowledge of the issues and regard ending poverty as at least ‘somewhat important’ – 

this represents a reachable audience for the Effective Altruism movement.

Yet the data on progress which so appeals to ‘natural’ EAs may fail to influence this group. Personal beliefs heavily impact the weight we give to facts. Perhaps instead of providing new research and clear infographics, 

we should be focusing on changing prevailing narratives about the impact of international development by telling stories which truly resonate with the public.

This formed the second part of The Narrative Project’s research. They explored the themes that were the most influential in creating positive perceptions of development and increasing the likelihood of donating. 

We need to emphasise these themes when we discuss Effective Altruism with potential new supporters

Blog

Mental Health interventions may be more cost-effective than we think

Giving What We Can needs your support this Christmas

Quadruple your donation to SCI!

Happy #GivingTuesday!

Switching the story: how to change the narrative on development

Highlights from 2014 - 2015

Where should we donate to do the most good? - Essay Competition 3rd Prize

Where should we donate to do the most good? - Essay Competition Runner up

Reach for systemic change

Where should we donate to do the most good? - Essay Competition Winner