Here is the spreadsheet. I would like to add error margins and more detailed epistemic status analysis at some point. The main variables affecting the cost effectivenes and somewhat uncertain are:
Effectiveness of treatment - I chose to assume that getting a correct diagnosis and treatment with lamotrigine leads to recovery of 10% of patients, compared to being treated with SSRIs. This is just a guesstimate based on the best evidence available, which is still insufficient. Perhaps the first step to the success of this intervention would be gathering more evidence in support of lamotrigine, but the cost involved may render it no longer cost-effective.
Percentage of patients with BSD among those seeking primary care treatment for depression (or, in a variant of the intervention, among patients who failed to recover on their first SSRI). The data exists for patients hospitalised for a major depressive episode (27%), and for patients referred to a psychiatrist for mood disorders (36%), but these numbers may be larger than what we need. On the other hand, it is roughly consistent with the 5% 12-month prevalence of depression and 2% prevalence of BSD.
Thank you! I have some more detailed notes on the calculations I made, and the resulting numbers are in the post, but creating a proper spreadsheet with it is a good idea! I'll do it on Monday (edit: Tuesday-Wednesday, life's too busy!) and update the post.
David Nash and I are organising a lightning talk session where we hope to feature presentations of several new cause ideas from the contest. If you submitted an entry and happen to be in London on 25th October, we'd love you to come along to the event with a short presentation. If you're interested, please get in touch. Here are more details about the event.
Thank you for your comment and sorry for the late response!
The questionnaire that I suggest does factor in sleep patterns; agreed that it is a very meaningful symptom that needs to be factored into the diagnosis.
I would strongly advise against your final suggestion though -- triggering a hypomanic episode on purpose seems like a really dangerous idea! Even if you succeeded in triggering hypomania as opposed to mania, you're unlikely to manage to get seen by a GP while in that state. If you're that desperate, it's probably safer to lie to your doctor and say you have had a hypomanic episode than actually trigger it on purpose in order to be truthful...
Thank you for your comment and sorry for the late response!
As far as I understand, there is no pre-existing pathway for laypeople to suggest topics for new panels, there is only the opportunity to contribute to ongoing ones. Taken from their website:
Decisions on which new topics to develop guidelines on, and in what order, are based on factors such as:
the priority given to the topic by commissioners and professional organisations, and organisations for people using services, their families and carers
the health and care burden, and the potential to improve outcomes and quality of life.
A topic selection oversight group at NICE considers topics for guideline development, taking these factors into account. NICE then discusses topics identified in this way with NHS England, the Department of Health and Social Care, and Public Health England, and a prioritised list is agreed by these 3 bodies.
I am currently trying to figure out the best way of tapping into this process.
When it comes to factoring in treatment cost -- the point of my intervention is identifying which patients would benefit from being treated with lamotrigine (which is a generic drug) rather than SSRIs (which is what they are currently prescribed). My guess is that it should be cost-neutral (it's replacing one generic drug with another), but I haven't checked how much the respective medicine costs the NHS. I agree it would be worth doing.
A suggestion: consider using DeepL as a first step. I discovered it a couple of months ago and found it to be astonishingly good, much better than Google Translate. In my experience it almost eliminates the need for "translators" as opposed to "proofreaders", which might save a lot of time and money. As an experiment, I've just pasted the initial few paragraphs of Astronomical Waste into it and translated them into Polish. The result was understandable and grammatically correct; there were a few clunky phrases that a person fluent in Polish could quite easily rewrite in a more elegant way in a few minutes.
I've just been writing a post about this very idea when I stumbled on this post, so I'd love to continue the discussion!
My tentative intention would be translating the information found in The Knowledge, or some subset of it, into a video game. In order for it to be cost-effective, the video game would need to be:
Actually a good game. I suspect many games designed as edutainment (or having social impact, a political message etc.) fail to achieve their goals, while fun games which just “happen” to teach something can be quite effective. Programming basics (Human Resource Machine, a good few other games), physics (Kerbal Space Programme), history (Crusader Kings and a multitude of other games), the exact steps of performing an appendectomy (Life & Death - I admit it's quite niche, but I actually still remember how to do it ;) ), etc.
Easy to implement with a small team and on a small budget. Modding probably is the way to go, though it might interfere with making the game available for free, which is my next point. As much as I love Don’t Starve, modding This War of Mine, Rimworld or NEO Scavenger might be a better idea, since those games have more realistic aesthetics, which might enable us to reuse more assets. One Hour One Life might also be a good one to look at since it’s already open source.
Free and cross-platform (or at least playable on mobile). We would want to reach as many people as possible, and checking off these 2 boxes would probably boost it by one or two orders of magnitude compared to a paid PC game.
Some reasons why creating this video game (or an EA-aligned video game) might be a good idea:
I conjecture that many more people would engage with a video game presenting a particular topic in a fun way than with a non-fiction book on the same subject. A relevant comparison (cursory research suggests that for both books and video games reviews correspond to roughly 2% of sales):
NEO Scavenger by Blue Bottle Games has 3,700 Steam reviews (9,000 if you combine PC and mobile sales), and I think NEO Scavenger is as niche as it gets. This War of Mine is a more successful (but still relatively low-budget) indie game in the same genre, tackling a similar topic, and has sold 4.5 million copies and has 63K reviews. Note: both of these are paid-for games; intuitively, they would probably have had at least 10x more downloads if they were free.
There’s probably quite a significant overlap between EAs and people who dabble in coding video games as a hobby. We could capitalise on that; if the game is a spare time passion project for a bunch of us, that could theoretically lead to infinite cost effectiveness - assuming we don’t accidentally create the most addictive video game ever and end up causing more harm than good ;) (For a more serious analysis of cost-effectiveness see below).
The broader EA community would hopefully help promote the game, and give us feedback in the design process.
Things to consider:
Cost effectiveness. Realistically, I think the game would need some development budget; this would lower the risk of the team getting burnt out or distracted from the game by other priorities. We’d need to estimate how many people we hope to reach, how much they would learn, and put a dollar value on teaching a random gamer the Haber–Bosch process.
This interesting article on profitability of indie games isn’t exactly heartening – even if we assume that making the game free would broaden our reach, we’d need to sanity-check that we have a greater chance of success than an average game developer.
I have some more thoughts and ideas I’d love to discuss with anyone interested in getting involved in the project.
P.S. As a tangent, I was also thinking about another idea for an EA-aligned video game; something like Reigns or Democracy 3 where you’re a multi-billionaire starting a charitable foundation aiming to solve all the world’s problems. The player would have to assign donations to various causes (possibly including longermism and animal welfare), while balancing PR, fundraising, talent pool etc. In order to not put people off, I think it would need to be very low-key about its EA message, perhaps not even mentioning the term – it’s just that donating to malaria net distribution would “happen” to bring you closer to victory than sponsoring a new museum.
Thank you for your comment, you make some really good points!
When it comes to the lack of psychiatrists: I agree it's a very difficult issue and I'm not trying to solve it here, but rather sidestep it. I do include a psychiatrist referral in my proposal, but I completely understand that the best one could hope for there is helping the patient see an overworked NHS psychiatrist e.g. in a year rather than two years. The main element of my proposal is having the GP be able to directly prescribe bipolar-appropriate medication, without necessitating the involvment of a psychiatrist. This is what already happens with unipolar depression and antidepressants, and the fact that it's possible in primary care averts a massive amount of suffering and lessens the load on the secondary care psychiatric system.
I haven't thought about including NPs in my analaysis, thanks for pointing out this possibility. As far as I understand, in the UK they mostly work in mental health institutions, so a BSD patient would be unlikely to encounter them unless they make a suicide attempt. I need to look into how it works in other countries.
It's really difficult to determine how effective therapy is compared to medications; I'd love to see a large clinical trial comparing BSD patients' outcomes on placebo, lamotrigine, SSRIs, a few other medications, therapies like CBT or IPSRT, following the cohort for a good few years, studying whether people who didn't improve on one type of treatment improve on another etc. I don't think we'll ever get such comprehensive data; we're stumbling in the dark and it's quite frustrating.
I definitely agree that many depressions, unipolar or bipolar, improve on CBT, but I'm quite sure there is a percentage of patients with BSD (or depression, for that matter), where the problem is almost purely physiological (some kind of chemical imbalance in the brain) rather than psychological -- so relying solely on therapy would be like trying to therapise away cancer or diabetes. How big is this percentage, and how does it compare to BSD cases amenable to therapy? We don't have enough data to say.
I also think that pursuing non-pharmaceutical approaches to depression is somewhat less neglected than advocating for improving access to medication, including in EA circles, hence my focus on the latter.
Completely agreed re uncertainty when it comes to intervention outcomes, trying to get any concrete numbers in order to calculate cost-effectiveness almost made me give up, and what I ended up going with is still very nebulous.
When it comes to intervention 2: I absolutely don't expect any realistic degree of GP education to suddenly make them competent in giving BSD patients fully adequate support. Perhaps I should have better phrased it as "efficiently informing GPs that the guidelines have changed and that they should follow them" rather than "educating GPs". In this context, I see educating GPs as a neccessary evil: they are the ones gatekeeping access to medication and who will choose whether to follow NICE guidelines or not. I suspect many of them don't keep up to date with changes in guidelines, so in order for intervention 1 to have any effect it would need to be followed up with somehow translating it into clinical practice. It would be even better if it could be done on autopilot, where the GP can be a Chinese room completely unaware of what BSD even is, just following a flowchart along the lines of "Depressed? Antidepressants didn't work? Fill out this questionnaire... Scored high? Here's lamotrigine, please read the leaflet, next!". This is why implementing, getting approval for and distributing diagnostic and treatment decision making software to be used by GPs for patients with depression could be very effective - I listed it among the concrete steps to take, but perhaps I should have given it more prominence in the interventions list.
Intervention 3 on its own could definitely contribute to GPs taking the correct action - a plucky patient saying "I have BSD, give me lamotrigine!" would hopefully trigger a flow like "BSD? Let me look that up... Okay, I'm supposed to ask you to fill out a questionnaire. Scored high? Here's lamotrigine, please read the leaflet, next!".
I have to confess I'm somewhat biased towards a pharmaceutical approach when it comes to BSD. This makes me see the intervention you suggested (connecting patients with people who have a similar problem) specifically in case of BSD more as a means towards an end (the patient getting enough information to convince a GP to prescribe correct medications) rather than a goal in itself (I imagine in many patients, and in my personal experience, no amount of talking with other sufferers, emotional support, group therapy, self-help info etc. would do much to help, while the correct medication would make the problem dissapear completely - though I admit other sufferers might have the opposite experience, which loops back into the whole outcome uncertainty issue).
Specifically in case of BSD, there would also be the issue that by default the patient would seach for "depression support groups" rather than "BSD support groups". Actually, it would be brilliant if your solution could help people correctly self-diagnose by making them go through a questionnaire-based decision tree, to later direct them to the appropriate group. Perhaps it wouldn't even need to be categorical or DSM-based, but use some ML solution grouping people according to the weights they've given to various symptoms or other markers.
That being said, I think your idea is very interesting! I'd love to talk more about it and potentially get involved - let's connect :)
Congrats on the social relationships as a metric proposal, it was a fascinating read!
Disclaimer: I was personally affected by this problem in the past, and this is how I became aware of it as a potential cause. However, I consider myself cause-impartial: I chose to present this particular cause because I think it is overlooked and potentially promising, and because I happened to have some insight into it. I did my best to find impartial sources, and in cases of conflicting studies I tended to go with those which gave less support to my overall claims. (I wasn’t 100% comfortable disclosing this under my full name on a public forum in the main post, but I’m somehow more at ease with it being a comment ;) ).
Here is the spreadsheet. I would like to add error margins and more detailed epistemic status analysis at some point. The main variables affecting the cost effectivenes and somewhat uncertain are:
Thank you! I have some more detailed notes on the calculations I made, and the resulting numbers are in the post, but creating a proper spreadsheet with it is a good idea! I'll do it on Monday (edit: Tuesday-Wednesday, life's too busy!) and update the post.
David Nash and I are organising a lightning talk session where we hope to feature presentations of several new cause ideas from the contest. If you submitted an entry and happen to be in London on 25th October, we'd love you to come along to the event with a short presentation. If you're interested, please get in touch. Here are more details about the event.
Thank you for your comment and sorry for the late response!
The questionnaire that I suggest does factor in sleep patterns; agreed that it is a very meaningful symptom that needs to be factored into the diagnosis.
I would strongly advise against your final suggestion though -- triggering a hypomanic episode on purpose seems like a really dangerous idea! Even if you succeeded in triggering hypomania as opposed to mania, you're unlikely to manage to get seen by a GP while in that state. If you're that desperate, it's probably safer to lie to your doctor and say you have had a hypomanic episode than actually trigger it on purpose in order to be truthful...
Thank you for your comment and sorry for the late response!
As far as I understand, there is no pre-existing pathway for laypeople to suggest topics for new panels, there is only the opportunity to contribute to ongoing ones. Taken from their website:
I am currently trying to figure out the best way of tapping into this process.
When it comes to factoring in treatment cost -- the point of my intervention is identifying which patients would benefit from being treated with lamotrigine (which is a generic drug) rather than SSRIs (which is what they are currently prescribed). My guess is that it should be cost-neutral (it's replacing one generic drug with another), but I haven't checked how much the respective medicine costs the NHS. I agree it would be worth doing.
A suggestion: consider using DeepL as a first step. I discovered it a couple of months ago and found it to be astonishingly good, much better than Google Translate. In my experience it almost eliminates the need for "translators" as opposed to "proofreaders", which might save a lot of time and money. As an experiment, I've just pasted the initial few paragraphs of Astronomical Waste into it and translated them into Polish. The result was understandable and grammatically correct; there were a few clunky phrases that a person fluent in Polish could quite easily rewrite in a more elegant way in a few minutes.
I've just been writing a post about this very idea when I stumbled on this post, so I'd love to continue the discussion!
My tentative intention would be translating the information found in The Knowledge, or some subset of it, into a video game. In order for it to be cost-effective, the video game would need to be:
Some reasons why creating this video game (or an EA-aligned video game) might be a good idea:
Things to consider:
I have some more thoughts and ideas I’d love to discuss with anyone interested in getting involved in the project.
P.S. As a tangent, I was also thinking about another idea for an EA-aligned video game; something like Reigns or Democracy 3 where you’re a multi-billionaire starting a charitable foundation aiming to solve all the world’s problems. The player would have to assign donations to various causes (possibly including longermism and animal welfare), while balancing PR, fundraising, talent pool etc. In order to not put people off, I think it would need to be very low-key about its EA message, perhaps not even mentioning the term – it’s just that donating to malaria net distribution would “happen” to bring you closer to victory than sponsoring a new museum.
Thank you for your comment, you make some really good points!
When it comes to the lack of psychiatrists: I agree it's a very difficult issue and I'm not trying to solve it here, but rather sidestep it. I do include a psychiatrist referral in my proposal, but I completely understand that the best one could hope for there is helping the patient see an overworked NHS psychiatrist e.g. in a year rather than two years. The main element of my proposal is having the GP be able to directly prescribe bipolar-appropriate medication, without necessitating the involvment of a psychiatrist. This is what already happens with unipolar depression and antidepressants, and the fact that it's possible in primary care averts a massive amount of suffering and lessens the load on the secondary care psychiatric system.
I haven't thought about including NPs in my analaysis, thanks for pointing out this possibility. As far as I understand, in the UK they mostly work in mental health institutions, so a BSD patient would be unlikely to encounter them unless they make a suicide attempt. I need to look into how it works in other countries.
It's really difficult to determine how effective therapy is compared to medications; I'd love to see a large clinical trial comparing BSD patients' outcomes on placebo, lamotrigine, SSRIs, a few other medications, therapies like CBT or IPSRT, following the cohort for a good few years, studying whether people who didn't improve on one type of treatment improve on another etc. I don't think we'll ever get such comprehensive data; we're stumbling in the dark and it's quite frustrating.
I definitely agree that many depressions, unipolar or bipolar, improve on CBT, but I'm quite sure there is a percentage of patients with BSD (or depression, for that matter), where the problem is almost purely physiological (some kind of chemical imbalance in the brain) rather than psychological -- so relying solely on therapy would be like trying to therapise away cancer or diabetes. How big is this percentage, and how does it compare to BSD cases amenable to therapy? We don't have enough data to say.
I also think that pursuing non-pharmaceutical approaches to depression is somewhat less neglected than advocating for improving access to medication, including in EA circles, hence my focus on the latter.
Thanks for the insightful comment!
Completely agreed re uncertainty when it comes to intervention outcomes, trying to get any concrete numbers in order to calculate cost-effectiveness almost made me give up, and what I ended up going with is still very nebulous.
When it comes to intervention 2: I absolutely don't expect any realistic degree of GP education to suddenly make them competent in giving BSD patients fully adequate support. Perhaps I should have better phrased it as "efficiently informing GPs that the guidelines have changed and that they should follow them" rather than "educating GPs". In this context, I see educating GPs as a neccessary evil: they are the ones gatekeeping access to medication and who will choose whether to follow NICE guidelines or not. I suspect many of them don't keep up to date with changes in guidelines, so in order for intervention 1 to have any effect it would need to be followed up with somehow translating it into clinical practice. It would be even better if it could be done on autopilot, where the GP can be a Chinese room completely unaware of what BSD even is, just following a flowchart along the lines of "Depressed? Antidepressants didn't work? Fill out this questionnaire... Scored high? Here's lamotrigine, please read the leaflet, next!". This is why implementing, getting approval for and distributing diagnostic and treatment decision making software to be used by GPs for patients with depression could be very effective - I listed it among the concrete steps to take, but perhaps I should have given it more prominence in the interventions list.
Intervention 3 on its own could definitely contribute to GPs taking the correct action - a plucky patient saying "I have BSD, give me lamotrigine!" would hopefully trigger a flow like "BSD? Let me look that up... Okay, I'm supposed to ask you to fill out a questionnaire. Scored high? Here's lamotrigine, please read the leaflet, next!".
I have to confess I'm somewhat biased towards a pharmaceutical approach when it comes to BSD. This makes me see the intervention you suggested (connecting patients with people who have a similar problem) specifically in case of BSD more as a means towards an end (the patient getting enough information to convince a GP to prescribe correct medications) rather than a goal in itself (I imagine in many patients, and in my personal experience, no amount of talking with other sufferers, emotional support, group therapy, self-help info etc. would do much to help, while the correct medication would make the problem dissapear completely - though I admit other sufferers might have the opposite experience, which loops back into the whole outcome uncertainty issue).
Specifically in case of BSD, there would also be the issue that by default the patient would seach for "depression support groups" rather than "BSD support groups". Actually, it would be brilliant if your solution could help people correctly self-diagnose by making them go through a questionnaire-based decision tree, to later direct them to the appropriate group. Perhaps it wouldn't even need to be categorical or DSM-based, but use some ML solution grouping people according to the weights they've given to various symptoms or other markers.
That being said, I think your idea is very interesting! I'd love to talk more about it and potentially get involved - let's connect :)
Congrats on the social relationships as a metric proposal, it was a fascinating read!
Disclaimer: I was personally affected by this problem in the past, and this is how I became aware of it as a potential cause. However, I consider myself cause-impartial: I chose to present this particular cause because I think it is overlooked and potentially promising, and because I happened to have some insight into it. I did my best to find impartial sources, and in cases of conflicting studies I tended to go with those which gave less support to my overall claims. (I wasn’t 100% comfortable disclosing this under my full name on a public forum in the main post, but I’m somehow more at ease with it being a comment ;) ).