On the meta-analyses: that seems fair. I think my initial thought was just that the Cuijpers seemed very low relative to my priors, and the Tong seemed more in line with them. But maybe my priors are wrong! I take your point that the Tong may be too high because of how widely it casts the "unguided" net, though it still does find some meaningful difference. But on the main point I think we're in agreement: guided > unguided, and the case for unguidedness, if there is one, will depend on its relative cost-effectiveness.
On apps v. books: I think there are so many potentially countervailing effects here it's hard to trust my intuitive judgments. I see the consideration you cite, but on the other hand (I would guess) someone on a phone is more likely to defect away from self-help and to use their phones for all the other things that phones can be used for. It would be great to have more studies here. There are a few RCT's comparing print with courses delivered via the internet on a desktop/laptop, which seem to find little difference either way, but these studies are very sparse, and they're at some remove from the question of comparing self-help delivery via a printed book via self-help delivery via Whatapp.
I take the point about cost-effectiveness. Certainly the tendency in the for-profit space has been digitization. But here too there's a countervailing consideration. Digitized self-help is a natural fit for the for-profit space, since a product that can be monetized in various ways (subscriptions, advertising) and produced at 0 marginal cost offers an attractive business model. But books do not fit that model. So perhaps one role for NGO's in this space may be supporting interventions which are known to be effective but whose financials are less promising, and perhaps self-help books are a case of this.
Thanks for this reply! In general I agree on the effectiveness of guidance, as in my response to Huw above. The publication bias issue (3) is one that I hadn't thought about enough and may well distort our evidence on some of these questions.
Yes, I elided the distinction between guided and unguided. The intervention I described was maximally unguided, while most studies involve more guidance. It seems to me the 2019 meta-analysis you cite is unusually pessimistic about the unguided case (compare e.g. this 2024 meta-analysis) but agree that most of the evidence support some form of guidance. Really this is a spectrum, and the question is what is the maximally cost-effective point on the unguided to guided spectrum. Your earlier post on this makes a lot of sense to me.
I am also interested in your preference for apps over books. They are cheaper. You say "the only reason not to do this" is internet connectivity issues. But some research indicates user preference for print media over digital media, e.g. this 2022 study in a US population. Do you think switching from print to apps lowers effectiveness (but is justified by cost savings) or that it is of the same (or greater) effectiveness?
I think you're definitely right that suicide prevention is a crucial and underfunded public health issue. I think, however, that this post could use some more input from empirical work on suicidology.
You express some doubt about approaches that reduce access to means, because these merely "delay the irreversible action . . . it does not fix the issue we care about -- people not valuing their own lives."
I am skeptical about this. Consider: "Between 1963 and 1975 the annual number of suicides in England and Wales showed a sudden, unexpected decline from 5,714 to 3,693 at a time when suicide continued to increase in most other European countries. This appears to be the result of the progressive removal of carbon monoxide from the public gas supply." (Clarke and Mayhew, 1988) Note that these potential suicides were not displaced to other means, or delayed -- they simply never happened at all. The low-hanging fruit in suicide prevention are similar interventions on means, in country-specific ways: gun control in the United States, pesticides in large parts of rural China, etc.
One might respond that these interventions don't really touch the fundamental issue, which is whether people value their own lives or not. I'm inclined to argue the other way around: the fact that suicide rates shift so profoundly in response to availability of means suggest that they are not a good proxy for the value people place on their own lives. When we are concerned with the value people place on their own lives, we are most concerned with their stable and reflective judgments, and it is doubtful that suicide is revelatory of these.
One book that I found extremely helpful on summarizing and extending our best understanding of the psychology of suicide is Thomas Joiner, _Why People Die By Suicide_.
This is a compelling proposal. The use of books and peer support for the treatment of depression/anxiety is an extremely cost-effective way of increasing well-being, and even more so when focused on child mental health in LMICs.
I mainly had questions about the details of implementation, especially whether this proposal could make use of pre-existing resources. As you might know, the WHO has developed a program called Early Adolescent Skills for Emotions (EASE), for ages 10-14. Among other virtues, having a standardized framework with the imprimatur of the WHO might be attractive both from the point of view of research and of funding.
EASE is a bit different from each of the four methods you outline – for one thing, it involves some training for caregivers, which as I understand it none of your four methods does. Do you think EASE could be an appropriate intervention for your population? Would there be special obstacles to its implementation in the Philippines (according to the Mental Health Innovation Network, EASE is being trialed in Tanzania, Lebanon, Jordan, and Pakistan)?
Thanks for this really thorough and insightful proposal. I'm sympathetic with your sense of the scope of the problem. My readings suggest that the total burden of bipolar disorders is around 9 million DALYs per year, so the proposal that BSD misdiagnosed as depression is around 3 million DALYs per year seems plausible. So it's a major problem. I have some questions about implementation, especially outside of developed countries:
• My primary concern is that this is one of a family of problems arising from a lack of psychiatrists, even in developed countries. A lot of your proposal aims at improving the psychiatric expertise/education of GP's, but even your positive proposal includes a referral to a psychiatrist. My thought is that this might be workable in the UK, but it would be unworkable at the global level where the availability of psychiatrists is even lower. You address this in your proposal about "offshoring," but of course that just defers the problem (if the UK offshores to Poland, who does Poland offshore to, etc.).
I wonder whether resources might be better invested in a trans-diagnostic approach, which increases training and licensing for mid-level psychiatric experts (these are psychiatric NP's in the US system). This would potentially address the variety of psychiatric conditions that are not ideally treated in primary care, especially with an eye towards the global level.
• It bears noting that (as I understand it) this is ultimately a problem for pharmeceutical approaches. The standard medications for unipolar depression don't work for BSD, so misdiagnosis leads to mistreatment. But (to my knowledge) depression is responsive to CBT/ACT whether or not it is unipolar or bipolar. So, for non-pharmeceutical approaches to depression, the question of misdiagnosis is less significant. Given the effectiveness of those treatment (and their low-cost and scalability), shouldn't thinking about BSD lead us to allocate a greater percentage of resources to non-pharmaceutical approaches to depression?
Thanks again for this illuminating post, I hope these preliminary reactions are useful.
Thank you, Lorenzo, this is really helpful. I'm familiar w the Happier Lives Institute and the v important work that they're doing. Looking forward to learning more.
Hi everyone. I'm a therapist & academic philosopher based in Boston. I do individual therapy and also teach philosophy at Bentley University. Further info here: https://www.jmaier.net/about-me.html
I look forward to hearing more about ideas/suggestions about how to direct my own giving. I have a strong interest in promoting effective mental health interventions at scale. I've written about this a bit in a blog for Psychology Today: https://www.psychologytoday.com/us/blog/philosophy-and-therapy. Looking forward to learning from folks on this forum.
On the meta-analyses: that seems fair. I think my initial thought was just that the Cuijpers seemed very low relative to my priors, and the Tong seemed more in line with them. But maybe my priors are wrong! I take your point that the Tong may be too high because of how widely it casts the "unguided" net, though it still does find some meaningful difference. But on the main point I think we're in agreement: guided > unguided, and the case for unguidedness, if there is one, will depend on its relative cost-effectiveness.
On apps v. books: I think there are so many potentially countervailing effects here it's hard to trust my intuitive judgments. I see the consideration you cite, but on the other hand (I would guess) someone on a phone is more likely to defect away from self-help and to use their phones for all the other things that phones can be used for. It would be great to have more studies here. There are a few RCT's comparing print with courses delivered via the internet on a desktop/laptop, which seem to find little difference either way, but these studies are very sparse, and they're at some remove from the question of comparing self-help delivery via a printed book via self-help delivery via Whatapp.
I take the point about cost-effectiveness. Certainly the tendency in the for-profit space has been digitization. But here too there's a countervailing consideration. Digitized self-help is a natural fit for the for-profit space, since a product that can be monetized in various ways (subscriptions, advertising) and produced at 0 marginal cost offers an attractive business model. But books do not fit that model. So perhaps one role for NGO's in this space may be supporting interventions which are known to be effective but whose financials are less promising, and perhaps self-help books are a case of this.
Thanks for this reply! In general I agree on the effectiveness of guidance, as in my response to Huw above. The publication bias issue (3) is one that I hadn't thought about enough and may well distort our evidence on some of these questions.
Hi Huw,
This is very helpful! A couple of quick notes:
Yes, I elided the distinction between guided and unguided. The intervention I described was maximally unguided, while most studies involve more guidance. It seems to me the 2019 meta-analysis you cite is unusually pessimistic about the unguided case (compare e.g. this 2024 meta-analysis) but agree that most of the evidence support some form of guidance. Really this is a spectrum, and the question is what is the maximally cost-effective point on the unguided to guided spectrum. Your earlier post on this makes a lot of sense to me.
I am also interested in your preference for apps over books. They are cheaper. You say "the only reason not to do this" is internet connectivity issues. But some research indicates user preference for print media over digital media, e.g. this 2022 study in a US population. Do you think switching from print to apps lowers effectiveness (but is justified by cost savings) or that it is of the same (or greater) effectiveness?
I think you're definitely right that suicide prevention is a crucial and underfunded public health issue. I think, however, that this post could use some more input from empirical work on suicidology.
You express some doubt about approaches that reduce access to means, because these merely "delay the irreversible action . . . it does not fix the issue we care about -- people not valuing their own lives."
I am skeptical about this. Consider: "Between 1963 and 1975 the annual number of suicides in England and Wales showed a sudden, unexpected decline from 5,714 to 3,693 at a time when suicide continued to increase in most other European countries. This appears to be the result of the progressive removal of carbon monoxide from the public gas supply." (Clarke and Mayhew, 1988) Note that these potential suicides were not displaced to other means, or delayed -- they simply never happened at all. The low-hanging fruit in suicide prevention are similar interventions on means, in country-specific ways: gun control in the United States, pesticides in large parts of rural China, etc.
One might respond that these interventions don't really touch the fundamental issue, which is whether people value their own lives or not. I'm inclined to argue the other way around: the fact that suicide rates shift so profoundly in response to availability of means suggest that they are not a good proxy for the value people place on their own lives. When we are concerned with the value people place on their own lives, we are most concerned with their stable and reflective judgments, and it is doubtful that suicide is revelatory of these.
One book that I found extremely helpful on summarizing and extending our best understanding of the psychology of suicide is Thomas Joiner, _Why People Die By Suicide_.
This is a compelling proposal. The use of books and peer support for the treatment of depression/anxiety is an extremely cost-effective way of increasing well-being, and even more so when focused on child mental health in LMICs.
I mainly had questions about the details of implementation, especially whether this proposal could make use of pre-existing resources. As you might know, the WHO has developed a program called Early Adolescent Skills for Emotions (EASE), for ages 10-14. Among other virtues, having a standardized framework with the imprimatur of the WHO might be attractive both from the point of view of research and of funding.
EASE is a bit different from each of the four methods you outline – for one thing, it involves some training for caregivers, which as I understand it none of your four methods does. Do you think EASE could be an appropriate intervention for your population? Would there be special obstacles to its implementation in the Philippines (according to the Mental Health Innovation Network, EASE is being trialed in Tanzania, Lebanon, Jordan, and Pakistan)?
Here is an article on EASE: Improving access to evidence‐based interventions for young adolescents: Early Adolescent Skills for Emotions (EASE)
Here is a page on EASE at the Mental Health Innovation Network: Early Adolescent Skills for Emotions (EASE): a psychological intervention for young adolescents and their caregivers
Thanks for this really thorough and insightful proposal. I'm sympathetic with your sense of the scope of the problem. My readings suggest that the total burden of bipolar disorders is around 9 million DALYs per year, so the proposal that BSD misdiagnosed as depression is around 3 million DALYs per year seems plausible. So it's a major problem. I have some questions about implementation, especially outside of developed countries:
• My primary concern is that this is one of a family of problems arising from a lack of psychiatrists, even in developed countries. A lot of your proposal aims at improving the psychiatric expertise/education of GP's, but even your positive proposal includes a referral to a psychiatrist. My thought is that this might be workable in the UK, but it would be unworkable at the global level where the availability of psychiatrists is even lower. You address this in your proposal about "offshoring," but of course that just defers the problem (if the UK offshores to Poland, who does Poland offshore to, etc.).
I wonder whether resources might be better invested in a trans-diagnostic approach, which increases training and licensing for mid-level psychiatric experts (these are psychiatric NP's in the US system). This would potentially address the variety of psychiatric conditions that are not ideally treated in primary care, especially with an eye towards the global level.
• It bears noting that (as I understand it) this is ultimately a problem for pharmeceutical approaches. The standard medications for unipolar depression don't work for BSD, so misdiagnosis leads to mistreatment. But (to my knowledge) depression is responsive to CBT/ACT whether or not it is unipolar or bipolar. So, for non-pharmeceutical approaches to depression, the question of misdiagnosis is less significant. Given the effectiveness of those treatment (and their low-cost and scalability), shouldn't thinking about BSD lead us to allocate a greater percentage of resources to non-pharmaceutical approaches to depression?
Thanks again for this illuminating post, I hope these preliminary reactions are useful.
Thank you, Lorenzo, this is really helpful. I'm familiar w the Happier Lives Institute and the v important work that they're doing. Looking forward to learning more.
Hi everyone. I'm a therapist & academic philosopher based in Boston. I do individual therapy and also teach philosophy at Bentley University. Further info here: https://www.jmaier.net/about-me.html
I look forward to hearing more about ideas/suggestions about how to direct my own giving. I have a strong interest in promoting effective mental health interventions at scale. I've written about this a bit in a blog for Psychology Today: https://www.psychologytoday.com/us/blog/philosophy-and-therapy. Looking forward to learning from folks on this forum.