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MichaelPlant comments on Cost Effectiveness of Mindfulness Based Stress Reduction - Effective Altruism Forum

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Comment author: MichaelPlant 04 December 2017 12:37:17AM *  2 points [-]

Hello Elizabeth, thanks for writing this up. I think this is important work so please take all my points belows as friendly suggestions for improving the methodology so we can get a better answer or just clarificatory questions because I don't know what something is (I always find it quite hard to understand other people's CEA models).

Saying MBSR will have an effect for 38 years after treatment seems extremely generous. Do you have any data either way on how long the benefits of mindfulness last for? I've seen stuff saying CBT works for 5 years on depression(/anxiety) without much of a drop, but 38 years is very long.

What is 'time cost of initial work'?

What does 'negative years of life after treatment' refer to?

The effects of MBSR on deprssion/anxiety (or is it just anxiety? I haven't check the studies yet) you report are much weaker than I expected. The 7% number suggests that just 7% of the 'DALY-badness' of anxiety has been removed, suggesting it makes a dent in, rather than 'cures', the condition. Do you know what's going on here? Is MBSR partially effective (and how does this compare to CBT)? Are these perhaps studies on low anxiety people that got completed cured? Something else? I would think the effect, while it lasts, would have a much higher impact.

Time cost for continued practice seems odd to me. First, it's pretty implausible every person who went on an MBSR course would do 1 hour's practice each day (and very implausible if you assume they will do this for a next 39 years!). Second, you seem to be assuming the DALY weight of each hour meditating is 0.5, which is roughly as bad as it is to be anxious anyway, no? Surely time meditating can't be that painful. Unless you think meditation is actually unpleasant, something people suffer through to get less stressed when not meditating, I'd remove that part of the CEA. Meditation seems neutral/good IME. The appropriate counterfactual is how pleasant is meditation vs whatever they would have been doing instead with that time (e.g. watching tv?).

Your model also seems to assume that, if not for the treatment, the person wouldn't have had MBSR at all. Given the spread of mindfulness practice worldwide, I think this is better thought of as "if we fund this intervention, how much earlier will it cause 1 average person to start practising mindfulness than they otherwise would have?" If they person would have been an avid mindfulness-er 5 years later anyway, the effect is just 5 years. There's also the possible counterfactual that teaching this one person caused them to speed up the spread of mindfulness because they pass it on to their friends. And there's the possibility they would have used something else, such as CBT, to treat their depression/anxiety, anyway rather than left it untreated. Or that their depression/anxiety would have ended naturally. I'm unsure how to work through these counterfactuals, but it ought to be flagged even if you ultimately say "I'm just going to leave aside these counterfactual effects as too complicated".

Another worry comes when I ask myself "would this be a good thing for EAs to fund?" It seems anyone with access to the internet could self-teach mindfulness if they really wanted to. Hence the relevant obstacles are that people don't want to do it or aren't aware of it. I doubt there are hordes of people who know about MBSR and would do it but are lacking the funds to pay for the course themself. In the developed world, people could probably cough up $300 themselves. It seems a bit weird for EAs to be paying for the medical treatments of other people in the developed world. Suppose, instead, this is a medical treatment to be offered the depressed/anxious in the developing world. Then my concern is one of cultural barriers and that take up of mindfulness would be quite low (intuitively, this seems like a bigger problem for mindfulness than CBT).

If the true obstacles aren't money but awareness or motivation, that suggests the better things for EAs to do might be paying for public campaigns that advertise mindfulness, e.g. via Developed Media International. My concern is then neglectedness: there are(/will be) companies trying to market mindfulness to people for a profit. If this is true, EAs might want to leave this to the market to provide and do something else. I'm not quite sure how to think about this either.

Comment author: Elizabeth 04 December 2017 07:09:05AM 2 points [-]

These are all great comments, thank you.

Saying MBSR will have an effect for 38 years after treatment seems extremely generous. Do you have any data either way on how long the benefits of mindfulness last for? I've seen stuff saying CBT works for 5 years on depression(/anxiety) without much of a drop, but 38 years is very long.

The only studies I remember (and it's been a while since I did this) checked in at 18 months and still showed significant improvement. I'd be very interested if you have a source for the CBT numbers, since that seems directly applicable.

What is 'time cost of initial work'?

Time to attend the class.

What does 'negative years of life after treatment' refer to?

guesstimate doesn't have a sigmoid function, so I used a constant minus a lognormal range.

The effects of MBSR on deprssion/anxiety (or is it just anxiety? I haven't check the studies yet) you report are much weaker than I expected.

All of the studies I read were on mild-to-moderate depression or anxiety, and ended with people having no-to-mild depression/anxiety on average. It wouldn't surprise me if in reality some people got very large benefits and others got none, which would make this a somewhat better intervention because people who didn't benefit could stop.

you seem to be assuming the DALY weight of each hour meditating is 0.5, which is roughly as bad as it is to be anxious anyway, no? Surely time meditating can't be that painful.

I think treating it as bad as death is a ceiling we won't reach, but I do think many people find meditation actively unpleasant, especially if they have a mood disorder, relative to doing something distracting. If meditation were more fun than watching TV we wouldn't have to justify it with long term health.

Another worry comes when I ask myself "would this be a good thing for EAs to fund?" It seems anyone with access to the internet could self-teach mindfulness if they really wanted to.

The costs of learning are so low relative to the costs of practicing they end up not making a big difference in the model.

It seems a bit weird for EAs to be paying for the medical treatments of other people in the developed world.

I am surprised to hear you say that, given your emphasis on mental health, which is suffering independent of material circumstances. Given that only 40% of Americans have the savings for an unexpected $1000 bill (https://www.prnewswire.com/news-releases/63-of-americans-cant-afford-500-car-repair-or-1000-emergency-room-visit-300200097.html) , I find it quite realistic that people would benefit from others paying for care, although I expect the time to take the class and practice to be even bigger barriers.

Then my concern is one of cultural barriers and that take up of mindfulness would be quite low (intuitively, this seems like a bigger problem for mindfulness than CBT).

My intuition is the opposite: CBT was developed in a very specific cultural context and seems to take as an assumption that nothing is actually wrong. Mindfulness meditation has been practiced for... long enough that getting an actual date is infeasible.

If the true obstacles aren't money but awareness or motivation, that suggests the better things for EAs to do might be paying for public campaigns that advertise mindfulness, e.g. via Developed Media International. My concern is then neglectedness: there are(/will be) companies trying to market mindfulness to people for a profit. If this is true, EAs might want to leave this to the market to provide and do something else. I'm not quite sure how to think about this either.

My research on media interventions was very pessimistic, even for DMI (http://effective-altruism.com/ea/1ha/mental_health_shallow_review/). This time could be different, but I think it's a very hard problem.

I think you raise a valid point that there's a vibrant market in mindfulness apps, and I'd be very curious to know how they stacked up to the formal program.