Comment author: egastfriend 26 April 2018 01:32:06AM 2 points [-]

Hi Elizabeth,

Thanks for writing up this review of Mental Health as an EA cause area! As you know this is an issue near and dear to my heart. You've done a great job summarizing many of the most interesting and important issues in this space.

I wanted to point out a few areas where I think this report could be improved:

DALY count: This article provides good reasons why mental health really repferents 13% rather than 7% of global DALY burden:

Trace Lithium: I think it is important to distinguish between "Lithium in the Water Supply" as a research topic (looking at naturally varying levels of lithium) versus as an intervention. If we determine that the trace lithium hypothesis is correct, i.e. that lithium is a nutritionally necessary mineral that many people are deficient in, then the best intervention would be for the FDA to issue a Recommended Daily Intake so that it gets added to fortified foods, such as vitamins. This way, people can see when Li has been added to their food, and have autonomy over consuming it. Adding lithium to the public water supply would be ethically problematic, politically difficult, and unnecessary. Unfortunately, evidence for the trace lithium hypothesis has weakened since OpenPhil wrote their report, due to this study in Demark (however, the range of Li concentrations was limited):

Suicide and Crisis Hotlines: This is a promising area for research. I haven't seen any strong RCT's on these interventions yet.

Marijuana and Opioid overdoses: New evidence has come out since you wrote this post, showing a more complex relationship. The author of the study said, "Before we embrace marijuana as a strategy to combat the opioid epidemic, we need to fully understand the mechanism through which these laws may be helping and see if that mechanism still matters in today's changing opioid crisis.” See:

MDMA for PTSD: While promising, I think the risk profile of MDMA and worldwide perception and political realities around it make it a less tractable intervention. I think Propranolol is more promising because it's already on the WHO List of Essential Medicines and very safe, as I argued in my report:

DARE: The bulk of evidence on the original DARE program showed that it had no effect -- I think it's an overstatement to say it increased drug consumption. It's also important to point out that DARE has been overhauled with help of the research community, and their new program, Keepin' it Real, has shown modest signs of success:

Methadone: I haven't read Elizabeth Pisani's book, but I don't think it's fair to say that it doesn't reduce addiction -- it's more accurate to say it doesn't reduce dependence. Addiction is defined in the DSM-V as causing problems in the patient's work/personal life, so when patients are stabilized on methadone maintenance programs (as many are), working and living normal healthy lives, they are no longer considered addicted.

Looking forward to the next iteration of this! Eric


Syllabus for Course on Effective Altruism

Our Philanthropy Advisory Fellowship at Harvard University Effective Altruism Student Group has just published an EA course syllabus that we developed: We hope this can be a helpful resource for EA groups at other schools to encourage faculty to create new courses on EA.
Comment author: egastfriend 07 February 2017 02:48:54AM *  3 points [-]

Great analysis! Very fair and balanced.

As you point out, increasing the prescriptions of opioids in the US lead to an enormous disaster -- drug overdoses now kill more Americans each year than car crashes. The regulatory environment in the US isn't great, but it's decades ahead of what most developing countries have. The fact that the US still hasn't figured out a sensible policy to managing prescription opioids makes me very skeptical that developing countries could pull it off safely.

E.g., look at these two articles. This one points out that there are already deceptive marketing practices around opioids happening in China: And this one looks at the aggressive expansion of painkillers into developing countries:

Rather than trying to expand access, the better strategy may be to advise developing countries on drug control policies to be able to better monitor opioid misuse and handle the inevitable increased availability of drugs.

Note: I'm working on a tech startup that helps people who overuse substances.

Comment author: Austen_Forrester 23 July 2016 03:18:52AM 2 points [-]

Very good report, James. I have a few comments:

  1. The DALYs calculated for mental health don't factor in the huge effect that mental health has on physical health. This may be laboursome to estimate, but should at least be considered. And you mentioned that people with MNS issues are often treated horrendously by their family/society, but that also hasn't been factored into the DALY cost estimate. An MNS disorder with a 0.4 DALY could really have a 0.9 DALY when you factor in mistreatment. I realize this is probably impossible to do, but it important to recognize that socialization side effects have huge impacts on DALYS.
  2. Sri Lanka pesticide ban cost per DALY: $1000 is pretty high. Eddleston estimated it at $2 per YLL using the actual costs of running Sri Lanka's pesticide regulation department. That figure doesn't even factor in savings in health care costs. Also, Sri Lanka and other countries have only banned a few HHPs. A total ban of HHPs could yield drastically different cost estimates. I should note that only a fraction of pesticides are classified as highly hazardous. A total HHP ban still leaves farmers with lots of choices to buy pesticides, in addition to non-chemical forms of pest control.
  3. No choice for donating to advocate for pesticide bans: Later this year, I expect that the Global Initiative for Pesticide Poisoning Prevention will begin our anti-HHP campaign. It takes a long time to do the initial steps of receiving charity status and input from all the experts in the field.
  4. Room for more funding for a program like StrongMinds doesn't make sense because it can be scaled up to LMIC around the world.
  5. I don't understand what the mental health charities have to do with children. Do StrongMinds and BasicNeeds treat children?
Comment author: egastfriend 29 July 2016 01:56:25AM *  0 points [-]

Re: DALY's for physical vs. mental health, in our full report we cite Vigo 2016 ( ) which lays out a strong argument for using a 2x adjustment for mental health DALY's. That's the approach we take in the paper.

Comment author: cdc482 22 July 2016 12:31:12PM *  0 points [-]

Have you shared this with GiveWell or Open Phil team? Especially considering that depression has such a negative impact on DALYs or QALYs (whichever you prefer), I think much of this research could be done outside of sub-Saharan Africa.

Also, where did you find the information regarding propranolol for PTSD? I remember reading about a couple studies done in Canada a couple years back that seemed promising, but concluded there was a lot more testing to be done.

Comment author: egastfriend 29 July 2016 01:53:48AM 0 points [-]

Re: Propranolol, I spoke with Dr. Alain Brunet at McGill University, who conducted some of the studies you're referring to and was very helpful in explaining the science behind it and the potential.

Comment author: Austen_Forrester 23 July 2016 03:06:02AM 1 point [-]

Excellent paper! One important factor in LMIC mental health work is sustainability. Take helplines. Far as I know, they are locally funded in poor countries, yet there are very few of them. A foreign NGO or individual could have an extremely high impact founding a helpline in a location, turning the fundraising and operation over to the local community once it gets going, and then repeating the process in subsequent cities. Dependency on foreign donors is always a last resort. The absolute cost of running a helpline is less important than the ability of the local community to support it on their own once it's set up, although startup costs are major consideration.

Also, rather than trying to extrapolate the cost of running a helpline in Africa using Australian data, I think it would be more accurate to just call one up and ask them. Or call Befrienders International, they should know. I'm sure they'd be thrilled to hear from you!

Comment author: egastfriend 29 July 2016 01:50:54AM 0 points [-]

I agree that helplines could have a very high impact. It's not mentioned in the paper, but we did look into it -- we weren't able to find an organization that we had enough confidence in to recommend. Could be an interesting challenge for an EA social entrepreneur or philanthropist to take on, though!

Comment author: cdc482 22 July 2016 12:38:44PM *  1 point [-]

This is really cool work you're doing! How much money has been donated more effectively as a result? I bet GiveWell and Open Phil would be interested in seeing the evidence generated as a result of your recommendation.

Unrelated and less interesting, I remember hearing a few years ago that the lack of benefits from providing safe drinking water (reduction in illness from water-born bacteria) was not due to a lack of technological solutions. In fact, the technology exists and is inexpensive to supply. However, there are societal and cultural difficulties in convincing people that there is any benefit to using the technology. After all, for generations they have viewed diarrhea as a part of life instead of as a symptom of unclean drinking water. I wonder what you've found related to changing social and cultural attitudes in lake or river communities.

Comment author: egastfriend 28 July 2016 03:49:55PM 0 points [-]

Thanks! We only presented this report to Draper Richards Kaplan Foundation about a month ago, but we do plan to do a long-term follow-up to see if/how they act on our recommendations. The foundation has substantial (>$100M) resources at its disposal.

As for the behavior change aspect, that's definitely a problem. I recommend GiveWell's report on Development Media International, which is one of the leading organizations working on the behavior-change aspect of this problem: So far, the evidence is mixed on DMI, but we chose to recommend them to another PAF client:

Part of our recommendations in this WaSH report are based on whether we think these new technologies will be able to achieve widespread adoption, based on the underlying technology, marketing strategy, business model, and team. One example of a social enterprise that has done this successfully is Sanergy:


Philanthropy Advisory Fellowship: Mental Health in Sub-Saharan Africa

By Ashley Demming, Eric Gastfriend, Lori Holleran, and Danielle Wang.   This is the Executive Summary of the final report from a  Philanthropy Advisory Fellowship  project advising a family foundation on grantmaking opportunities and strategy . The full report (redacted for client confidentiality) is available  here . This research was conducted on... Read More

Philanthropy Advisory Fellowship: Water, Sanitation, and Handwashing

By Jeff Glenn, Monica Kwok, and Zhihan Ma. This is the Executive Summary of the final report from a  Philanthropy Advisory Fellowship  project on identifying innovative organizations in the Water, Sanitation, and Hygiene (WaSH) space . The full report (redacted for client confidentiality) is available  here . This research was conducted... Read More
Comment author: egastfriend 10 March 2016 02:32:09PM 6 points [-]

This is definitely something I'm interested in learning more about, and haven't seen a thorough analysis from an EA perspective anywhere. I respect both Bjorn Lomborg and Martin Rees on this subject, even though they have opposing views. Bjorn Lomborg thinks that cost-benefit analysis shows reducing carbon emissions to be a bad investment compared to global health spending, and that we should instead just try to accept climate change and adapt to it. Martin Rees thinks Bjorn Lomborg is using the wrong discount rate in his calculations, and that the tail risk of catastrophic climate change alone makes its prevention a worthwhile investment. I haven't dug any further than that yet.

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