MentalHealthinSubSaharanAfrica

HarvardUniversityEffectiveAltruismStudentGroup

PhilanthropyAdvisoryFellowshipReport

ByAshleyDemming,EricGastfriend,LoriHolleran,andDanielleWang

ForChildReliefInternational

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TableofContents

TableofContentsExecutiveSummary

SupplementalResourcesTheProblem

SizeofProblemProblemFocus:Depression

TractabilityPromisingInterventions

PsychoeducationCognitiveBehavioralTherapyModuleBasedTreatmentCrisisAssistance

CosteffectivenessEstimatesCostEffectivenessComparison:MentalHealthvs.Sanitation

OrganizationsRecommendedOrganizations

AldermanFoundationAEGISTrustNEPI(NetworkforEmpowermentandProgressiveInitiative)

OtherOrganizationsConsideredLifelineInternationalImerse

ResearchOpportunitiesPropranololTraceLithiumComputerbasedCBTOtherareasconsidered

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ExecutiveSummaryMentalhealth,asdefinedbytheWorldHealthOrganization,isastateofwellbeinginwhicheveryindividualrealizeshisorherownpotential,cancopewiththenormalstressesoflife,canworkproductivelyandfruitfully,andisabletomakeacontributiontoherorhiscommunity.

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AlthoughtraditionallymentalhealthhasnotbeenconsideredanimmediatecauseforconcerninSubSaharanAfrica,itisincreasinglyreceivingmoreattentionastheextentinwhichpeoplesufferfromvariousdisordershasbecomeapparent.Assuch,withinthisreport,ourteamseekstoquantifyandanalyzetheburdenofmentalhealthdisordersintheregion,focusingontotaldisabilityadjustedlifeyears(DALYs)fromthe2013GlobalBurdenofDiseaseStudy.IdentifyingdepressivedisordersasbeingthetopcontributortototalDALYsrelatedtomentalhealthinSubSaharanAfrica,wediveintopromisinginterventionssuchasPsychoeducation,CognitiveBehavioralTherapy,ModuleBasedTreatment,andCrisisAssistanceandattempttoestimatetheircosteffectiveness.Tounderstandtheirpotentialimpact,acosteffectivenesscomparisonofmentalhealthtosanitationisdetailed.Basedonresearchandinterviews,weprovideinformationonvariousorganizationsoperatinginSubSaharanAfricawithinthementalhealthfield.BasedonouranalysisonnotonlytheorganizationsbutalsoonthementalhealthlandscapeinSubSaharanAfricaasawhole,weprovidethreespecificrecommendationsforinvestmentconsideration,theAldermanFoundation,AEGISFoundation,andNetworkforEmpowermentandProgressiveInitiative,astheseorganizationsshowpotentialinleadership,scalability,costeffectivenessofprograms,andprovensuccess.Finally,wethenseektohoneinoncurrentresearchopportunitiesrelatedtodepressivedisordersandothersimilarmentalhealthareasofconcern.Theresearchareaswerecommendare:propranololforPTSD,tracelithiumforsuicide,andcomputerbasedCBTforanxiety/depression.

SupplementalResourcesResearchspreadsheet:Problems,Interventions,Experts,andOrganizationshttps://docs.google.com/spreadsheets/d/1iX5wDxeH_NFRmuuGlhQghaFD3i7Vbuw5tK_0Ipgs/edit?usp=sharingTracelithiumliteraturereview:https://docs.google.com/spreadsheets/d/1uQUufnBVw3QsA_PQI8DzSp6qlySRgy85j3mb92_AWI/edit?usp=sharing

1 http://www.who.int/features/factfiles/mental_health/en/

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https://docs.google.com/spreadsheets/d/1iX5wDxeH_NFRmu-uGlhQ-ghaF-D3i7Vbuw5tK_0Ipgs/edit?usp=sharinghttps://docs.google.com/spreadsheets/d/1iX5wDxeH_NFRmu-uGlhQ-ghaF-D3i7Vbuw5tK_0Ipgs/edit?usp=sharinghttps://docs.google.com/spreadsheets/d/1uQUu-fnBVw3QsA_PQI8DzSp6qlySRgy85j3mb92_AWI/edit?usp=sharinghttps://docs.google.com/spreadsheets/d/1uQUu-fnBVw3QsA_PQI8DzSp6qlySRgy85j3mb92_AWI/edit?usp=sharinghttp://www.who.int/features/factfiles/mental_health/en/

TheProblem

SizeofProblemToquantifythemagnitudeofmentalhealthacrosstheworld,researchershavereliedontheGlobalBurdenofDiseaseStudy,specificallythecalculationofdisabilityadjustedlifeyears(DALYs).DALYsareessentiallythesumoftheYearsofLifeLost(YLL)duetoprematuremortalityinthepopulationandtheYearsLostduetoDisability(YLD)forpeoplelivingwiththehealthconditionoritsconsequences. Therefore,tounderstandtheimpactofmentalhealthas2

comparedtootherdiseases,onecanlookatrelatedDALYs.OfthetotalDALYsforSubSaharanAfricafor2013(allages,allsexes)at554,262,341,mentalandsubstanceusedisordersaccountfor21,490,540(approximately4percent).ThebreakdownoftheburdenforSubSaharanAfricaisasfollows:

MentalandSubstanceUseDisorder DALYSSchizophrenia 1,237,783Alcoholusedisorders 1,644,871Drugusedisorders 2,148,901Opioidusedisorders 711,682Cocaineusedisorders 67,017Amphetamineusedisorders 192,260Cannabisusedisorders 28,458Otherdrugusedisorders 1,149,483

Depressivedisorders 8,524,467Majordepressivedisorder 7,660,183Dysthymia 864,284

Bipolardisorder 1,024,784Anxietydisorders 2,363,886Eatingdisorders 231,065Anorexianervosa 38,052Bulimianervosa 193,013

Autisticspectrumdisorders 1,080,142Autism 682,691Aspergersyndrome 397,452

Attentiondeficit/hyperactivitydisorder 79,838Conductdisorder 1,153,976

2 http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/

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Idiopathicintellectualdisability 1,157,431Othermentalandsubstanceusedisorders 843,396Total 21,490,540Tofurthercomprehendthescaleofrelateddisorderstoothersintheregion,belowisagraphicalcomparisonascompiledbytheGlobalBurdenofDiseaseStudy(seementalhealthsectionboxedintheupperleftcorner).

Itisimportanttonotethatselfharmisreportedoutsideofthescopeofthementalandsubstanceusedisorders.Forthe2013study,selfharmwasreportedat2,414,509DALYsand50,325DeathsforSubSaharanAfrica.Deathsfrommentalandsubstanceusedisorderswasreportedat40,115.WhiletheGlobalBurdenofDiseaseStudyhasbeenwidelyacceptedasanappropriatemeasuringtoolfordeterminingtheimpactofmentalandsubstanceusedisorders,theStudyisnotwithoutflawincalculatingthetrueburden.Accordingtoarecentstudy,theburdenofmentalillnessisactuallyunderestimatedbymorethanathirdusingcurrentapproaches. Theybelieve3thisunderestimationisfrom:overlapbetweenpsychiatricandneurologicaldisordersthegroupingofsuicideandselfharmasaseparatecategoryconflationofallchronicpainsyndromeswithmusculoskeletaldisordersexclusionofpersonalitydisordersfromdiseaseburdencalculationsandinadequateconsiderationofthecontributionofseverementalillnessto

3 Estimatingthetrueglobalburdenofmentalillness.Vigo,Danieletal.TheLancetPsychiatry,Volume3,Issue2,171178.

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mortalityfromassociatedcauses.Usingtheiradjustment,amoreaccuratepictureoftheburdenofmentalhealthandsubstanceabuseinSubSaharanAfricawouldbe68%oftotalDALYsinsteadof4%.Therefore,mentalhealthisapressingandgrowingissueinSubSaharanAfricaasmoreresearchandinsightintoitstrueburdenisrevealed.

ProblemFocus:DepressionAsindicatedinthebreakdownofmentalandsubstanceusedisorders,depressivedisordershasthelargestburdenofdiseaseinregardstototalDALYsinSubSaharanAfrica.Depressivedisorderscanbefurtherdividedintomajordepressivedisorderanddysthymia(Achronicdepressionofmood,lastingatleastseveralyears,whichisnotsufficientlysevere,orinwhichindividualepisodesarenotsufficientlyprolonged,tojustifyadiagnosisofsevere,moderate,ormildrecurrentdepressivedisorder ),withmajordepressivedisorderhavingasubstantially4higherburden.Nevertheless,ascountrieswithinSubSaharanAfricaarenotuniform,itiskeytounderstandtheburdenonanindividualbasis.BelowisthedetailontheDALYsper100,000peopleforeachcountryofinterest(aspreselected).DALYsper100,000peoplewereusedforcomparisontotakeintoaccountdifferencesinpopulationsize.

DALYSper100,000people

CountryDepressivedisorders Dysthymia

Majordepressivedisorder

Rwanda 1,165 95 1,070Uganda 1,148 84 1,063Kenya 1,147 98 1,049Botswana 1,012 110 902Tanzania 1,089 93 996Namibia 999 109 891Togo 928 97 831Mali 763 86 677Liberia 750 95 655Asshowninthetable,Rwandaappearstohavethelargestburdenofdiseasefromdepressivedisordersascomparedtotheothercountries.Tofurtherdiveintodepressivedisordersasitrelatestopostpartumdepressioninwomen(aspreselected),additionalanalysisisneededtodeterminethenumberofwomenaffectedbythedisease.

4 http://apps.who.int/classifications/icd10/browse/2015/en#/F34.1

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Assumptions:FemalePopulation:UnitedNationsDepartmentofEconomicandSocialAffairs,PopulationDivisionWorldPopulationProspects(2015)forwomenaged15to49years.PercentageNeverGivingBirth(4549):StatComplier(DHSProgram,USAID)TotalFemales(1549)EverGivingBirth:EstimationfromFemalePopulationandPercentageNeverGivingBirth(4549)PrevalenceofPostpartumDepression:AfteranalyzingvariousstudiesonpostpartumdepressioninSubSaharanAfrica,prevalenceappearstoexpandacrossawiderange,withoutanagreeduponpercentage.Therefore,weconductedasensitivityanalysistoestimatethenumberofwomenineachcountry.AspostpartumdepressionintheUnitedStatesisreportedatapproximately10percent,weassumethisisafairestimateforfurthercalculationswithinthisreport.Asshowninthetable,postpartumdepressionappearstoaffectmorewomeninTanzaniaandKenyaonanabsolutebasisatapproximately1,100,000.Therefore,aninterventiontotargetpostpartumdepressioninoneofthesecountrieswouldseemtohavethegreatestpotentialimpact.Nevertheless,aninterventioninanyofthelistedcountriesisclearlyneededbasedonthecalculatedaffectedpopulation.

TractabilityExaminationofpotentialinterventionstrategiesrevealednumeroustechniquesdemonstratingeffectivenesswithinSubSaharanAfrica(SSA).Themajorityofinterventionsconsideredfocusonimprovingawarenessandknowledgerelatedtomentalhealthissues,andtargetsymptomsassociatedwithdepression.Additionalmentalhealthissuesaddressedincludeanxietyandanxietybasedconcerns,relationaldistress,suicidality,andconductrelatedbehaviors.

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PromisingInterventions

PsychoeducationWhileallcognitivebehavioralstrategieswillpresumablyincludepsychoeducationwithintheirinterventionintroduction,oneinterventionconsideredreliedsolelyonpsychoeducationbasedconcepts.Thisinterventionreliedonatwosessionpsychoeducationstrategy,targetingparentsofchildren(meanage12.3years,60.8%female)inBurundiwhohadbeenscreenedforelevatedpsychosocialdistress(Jordans,Tol,Ndayisaba,&Komproe,2013).Thefirstsessionaimedatincreasingdialogueandunderstandingofproblemsaffectingchildren(i.e.,alcoholismofparents,maltreatment,gangformation),aswellasofwaysofcommunicatingwithchildren.Thesecondsessionfocusedonadvisingparentshowtomanagetheirchildrensproblems(i.e.,settinglimits,promoteschoolattendance),specificallyaimingtocorrectmaladaptivediscipliningstrategies(e.g.,instructionstoavoidharshcorporalpunishment).Thesegroupswereledbytwolaycommunitycounselors,providingpsychoeducationto58parents(97associatedchildren).Astatisticallysignificantdifferencewasdemonstratedbetweeninterventiongroupandcontrolgroupformeanchangescoresonaggression,whichcomprisedasignificantreductionofaggressionintheinterventiongroupandasignificantincreaseinthecontrolgroup(p

ModuleBasedTreatmentWithinSSA,twoseparatemodulebasedtreatmentstrategieswereidentified,includingaClassroomBasedPsychosocialIntervention(CBI)andaSteppedCareIntervention(SCI).Modulartreatmentsrelyonprotocolizedinterventions,whichmayguideinteractionsonapersessionortaskspecificbasis.CBIisaschoolbasedpsychosocialinterventionwithaimstoreducedistressandincreaseresilienceandempowermentthroughenhancingcopingandprosocialbehavior.TheCBIinterventionwasdevelopedbyCentreforTraumaPsychologyinBoston.NumerousstudiesconductedwithinLMICshaveutilizedCBIandfoundtheinterventiontobeeffective.CurrentCBIinterventionswithinSSAhavespecificallyfocusedonchildren,ages616,affectedbyconflictinLMICs(Barry,Clarke,Jenkins,&Patel,2013).Theprotocolincluded15sessions,deliveredovercourseof5weeks,providedbyparaprofessionals.Outcomesincludedimprovementwhenexaminingattributionalstyle(howanindividualcharacterizesthefactorsassociatedwithnegativeoutcomes),perceivedcredibility,interpersonaltrust,communicationskills,levelsofselfblame,hyperactivity,emotionalsymptoms,conductproblems,andpeerproblems.Whilethetechniquehasbeenfoundtobewidelyeffective,ithasdemonstratedreducedbeneficialnessforboys1216yearsofage.SCIisamanualizedmulticomponentsteppedcareinterventionpackagefordepression,whichincludesspecificpreoutlinedgoalsforeachsessionwiththeoverallprograminvolvingpsychoeducation,activityscheduling,andproblemsolving.WhileSCItargetsdepression,italsoincludescomponentsthatmaypositivelyinfluencenumeroussourcesofdistress.InarecentstudyutilizingSCIinNigeria,18primaryhealthcareproviders(6nurses,3communityhealthofficers,and9communityhealthextensionworkers),whoreceiveda3daySCItraining,providedeitherSCI(intervention)ortreatmentasusual(control)to234individuals(Oladeji,Kola,Abiona,Montgomery,Araya,&Gureje,2015).At6monthsfollowup,depressionsymptomshadimprovedin73.0%fromtheinterventionarmcomparedto51.6%control.Comparedtothemeanscoresatbaseline(PHQ9,WHOQOLB,&WHODAS),therewasimprovementinthemeanscoresonalloutcomemeasuresinbotharmsatsixmonths.AkeystrengthofSCIisthatexistinglowerlevelhealthcareworkerscanprovidetheintervention,whichimprovessustainabilityofcommunitymentalhealthprogramsutilizingSCI.Currently,anotherSCIbasedresearchprojectisunderwaytargetingdepressionspecificallyamongperi&postnatalwomen.

CrisisAssistanceCrisisassistancetechniquestraditionallyrelyonmannedphonecenters,allowingforindividualsexperiencingcrises,typicallyrelatedtoaddictionorsuicidality,tocallandaccessresourceswhilereducingbarrierstoaccessingcare(e.g.stigmaorlackofavailability/accessibility).Crisishotlinesaremannedbylayvolunteerswhohaveusuallyreceivedsomeformoftraining,alongwithprofessionalmentalhealthserviceworkers.Aftertheimmediatecrisishasbeendeescalated,thosewhodemonstratehighriskcanbereferredtotherapistsoragenciesthat

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provideservicestoprovidemorecomprehensivecare.InastudyintheU.S.examiningtheefficacyofbriefphonebasedtherapyprovidedtoindividualsutilizingcrisishotlines,itwasfoundthatcomparedtothewaitlistcontrol,providingbriefpsychotherapyledtoastatisticallysignificantreductionofsymptomsasmeasuredbytheBriefSymptomInventory(Fvalue=8.02,p

increasedfunctioningoftheindividualreceivingservices.Additionally,whenconsideringtheeffectivenessoftheinterventioninmonetaryterms,onaverage,weestimatethatacrisishotlineinSubSaharanAfricawouldcostonly~$40tosignificantlyhelpanindividualtypicallythroughthereductionofmentalhealthsymptoms.51TrainingCosts:

2psychiatristsrequiredfor7dayseachtotrainthetrainees(6daysoftrainingand1dayofpreparationeach):$27(projecteddailyphysiciansalary)x2peoplex7days=$378.

9primaryhealthcareworkers,representingthosewhowereworkingwithintheinterventionclinics,underwent6daysoftraining(aninitial3daytrainingandafollowup3daytrainingapproximatelyonemonthintothestudy):54hoursoftrainingover6daysperworkerx9healthcareworkersx$3.75hourlytrainingwage=486hoursoftrainingx$3.75perhour=$1,822.50

9primaryhealthcareworkers,representingthosewhowereworkingwithinthecontrolclinics,underwent2daysoftraining:18hoursoftrainingover2daysperworkerx9healthcareworkersx$3.75hourlytrainingwage=162hoursoftrainingx$3.75perhour=$607.50

ProgramSalaries:

Salaryfor9healthworkersandonesupervisorovertreatmentperiod(Potentialof16weeksoftreatmentamong3interveningsites(9healthworkers)=$2,880,onesupervisorsalaryfor16weeks=$3,200)=$6,080.00

*Anadditional30%tototalprogramcostsareincorporatedinordertoaccountfortheProjectedoverheadcosts(administrativecosts,monitoringandevaluation,etc.).ProgramTotal:

$11,554(TrainingandSalaries=$8,888+Overheadcosts=$2,666)CostPerParticipant:

$11,554(totalcosts)/234(samplesize)=$49perparticipant2CostprojectionsassociatedwiththeSCIprogramwereestimatedbasedoncostsreportedwithintheMillenniumVillagesProject,whichoutlinedtrainingcosts($300),monthlysalaryforCHWs/paraprofessionals($80),andmonthlysalaryforsupervisors($800)whoweremainlydoctorsandcouldsuperviseupto30CHWs.Theseestimatesrepresentaveragecostsassociatedwiththeproject,whichwasconductedacross10developingcountries.3165patientsparticipatedintheintervention,withimproveddepressionscoresbeingobservedin73.0%oftheinterventionparticipantscomparedto51.6%inthetreatmentasusualgroupat6monthsfollowup(OR2.7).Weestimatethat21%oftheinterventionpatientsbenefitedover

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whattheywouldhavereceivedinTAU,intermsofsignificantlyreducingtheirdepression($1,463.28x.21=$307reductionineconomicburdenassociatedwithdepressionwhencomparedtothosereceivingTAU).4Assuming21%ofparticipantsbenefitinSCIrelativetoTAU:$49/participant/0.21=$233.5Lifelinehas$21MAUDinfundingandreceives822,000callsperyear.$21MAUD/822,000calls=$25/call.WedonotconvertAUDtoUSDbecausebefore2015,thetwocurrencieswereroughly11.Rhee2005estimatedaCohensd=0.75effectsizeforacrisishelpline,whichtranslatesinto1outof3.7peoplesignificantlyhelped.$25/call*3.7=$92.5percasehelped.LifelineisaglobalorganizationprimarilybasedinAustralia,socostpercasehelpedinSubSaharanAfricawouldlikelybe24xcheaper,so$2550percasehelped.

CostEffectivenessComparison:MentalHealthvs.SanitationSinceCRIalsoinvestsinsanitationefforts,itisimportanttoconsidertheimplicittradeoffinfundingmorementalhealthworkvs.moresanitationwork,fromtheperspectiveofwhichinterventionsyieldmorebangforthebuckintermsofcostperpositiveoutcomereached.DALYsprovideausefulmetricforcomparingoutcomesacrossdifferentdiseases,butasourreportmentionspreviously,thismetrictendstosystematicallyundervaluementalhealth,byasmuchasafactorof3.Furthermore,reasonablepeoplemaydifferfundamentallyontherelativeweightsassignedtodifferenthealthoutcomessuchasphysicalillness,death,ormentalillness,whichwouldleadtodifferentfundingdecisions.Therefore,wevetriedtoexaminethisquestionfrombothanadjusted(witha2xboostformentalhealth)costperDALYapproachandandcostper(counterfactuallyadjusted)outcomeapproach.ForcomparinginterventionsonacostperDALYmetric,theDiseaseControlPrioritiesProject(DCP3http://dcp3.org/)providesthebroadestandmostrigorousanalysis.Forthemostcosteffectiveinterventionsagainstdiarrhealdisease,suchasdisinfectingwater,promotinghandwashing,andoralrehydration,estimatesrangebetween$100200perDALYaverted.

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http://dcp-3.org/

Source:http://dcp3.org/sites/default/files/chapters/DCP3%20RMNCH%20Ch9.pdf

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http://dcp-3.org/sites/default/files/chapters/DCP3%20RMNCH%20Ch9.pdf

Source:http://dcp3.org/sites/default/files/chapters/DCP3%20RMNCH%20Ch17.pdfTheDCP3recommendsepisodictreatmentinprimarycarewithantidepressantsasoneofthemostcosteffectiveinterventionsagainstdepression.TheyestimatethatforSubSaharanAfrica,costeffectivenessintheseinterventionswouldberoughly$1,400perDALYaverted.

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http://dcp-3.org/sites/default/files/chapters/DCP3%20RMNCH%20Ch17.pdf

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Source:http://dcp3.org/sites/default/files/chapters/DCP3%20Mental%20Health%20Ch_12.pdfHowever,theseassumptionsarehighlysensitivetothespecificsoftheindividualprogramonestudyinThailandfoundthatmaintenancetherapydeliveredviaprimarycareachievedcosteffectivenessof$437/DALY.

Source:http://dcp3.org/sites/default/files/chapters/DCP3%20Mental%20Health%20Ch_12.pdfGivena2xadjustmentfactortoaccountforDALYsundercountingtheseverityofmentalhealth,a~$400/DALYantidepressionprogramwouldbenearlyonparwiththe$100200/DALYsanitationinterventions,butifweexpectthataverageantidepressioninterventionsinSubSaharanAfricawillcostroughly$1,400/DALY,thenthatwouldbe46timeslesscosteffectivethansanitationworkaftertheadjustment.Anotherapproachistolookatcostperoutcomeachieved.OuranalysisabovesuggeststhattheSCIinterventioncost$233percaseofdepressionhelped,andthatintheory,acrisishotlineinAfricacouldcostaslittleas$40percaseofdepressionhelped.Notethattheseareourownbackoftheenvelopecalculations.InourreviewofNEPILiberia,weciteastudywhichconcludedthatNEPIcanpreventacrime(suchastheft,burglary,ordrugdealing)forjust$21.Tocomparethesenumberstosanitationinterventions,welookedataWorldBankstudyinChinathatestimatedthecosteffectivenessofmovingfromsharedtoilets/latrinestoimproved

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http://dcp-3.org/sites/default/files/chapters/DCP3%20Mental%20Health%20Ch_12.pdfhttp://dcp-3.org/sites/default/files/chapters/DCP3%20Mental%20Health%20Ch_12.pdf

sanitationoptions.Itfoundthatsanitationimprovementscostroughly$3percaseofdisease(generallydiarrhea)averted,and~$6,000perdeathaverted.

Source:https://www.wsp.org/sites/wsp.org/files/publications/WSPEAPESI2YunnanProvinceChinaTechnicalPaper_0.pdfGiventheuncertaintyaroundtheseestimates,andthedifficultyofweighingthesubjectiveseverityoftheoutcomes(diseasevs.crime,depressionvs.death),wedonothaveanyspecificrecommendationonhowtoprioritizethesetwoareas,otherthantocarefullyconsiderthetradeoffsandimplicitvaluejudgments.

References

Barry,M.M.,Clarke,A.M.,Jenkins,R.,&Patel,V.(2013).Asystematicreviewoftheeffectivenessofmentalhealthpromotioninterventionsforyoungpeopleinlowandmiddleincomecountries.BMCPublicHealth,13(1),119.Jordans,M.D.,Tol,W.A.,Ndayisaba,A.,&Komproe,I.H.(2013).AcontrolledevaluationofabriefparentingpsychoeducationinterventioninBurundi.SocialPsychiatryAndPsychiatricEpidemiology,48(11),18511859.Oladeji,B.D.,Kola,L.,Abiona,T.,Montgomery,A.A.,Araya,R.,&Gureje,O.(2015).ApilotrandomizedcontrolledtrialofasteppedcareinterventionpackagefordepressioninprimarycareinNigeria.BMCPsychiatry,15RheeWK,MerbaumM,StrubeMJ,SelfSM.Efficacyofbrieftelephonepsychotherapywithcallerstoasuicidehotline.SuicideLifeThreatBehav.2005Jun35(3):31728.

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https://www.wsp.org/sites/wsp.org/files/publications/WSP-EAP-ESI2-Yunnan-Province-China-Technical-Paper_0.pdfhttps://www.wsp.org/sites/wsp.org/files/publications/WSP-EAP-ESI2-Yunnan-Province-China-Technical-Paper_0.pdf

Vally,Z.,&Maggott,C.(2015).Evaluatingtheoutcomeofculturaladaptationsofcognitivebehaviouraltherapyforadultdepression:Ametaanalysisoftreatmentstudiesindevelopingcountries.InternationalJournalForTheAdvancementOfCounselling,37(4),293304.

Organizations

RecommendedOrganizations

AldermanFoundationDescription:TheAldermanFoundationisoneofthelargestorganizationsoperatingspecificallyinthementalhealthspaceinsubsaharanAfrica.ItoperatesasanNGO,withthegoaloftransformingmentalandpsychologicalcareforthoseaffectedbywarandorganizedviolence.Thefoundationtouches30Kpatientsperyear(education&treatment),targetingawiderangeofdisordersfromdepressiontopsychologicalstress.Theyarethefrontlineformentalhealthcare.Thereareseveraldifferentcomponentstotheirwork

Clinicalcareistheprimarycomponent.Currently,thereare15treatmentcentersinUganda,mostlylocatedinlevel3traumacenters.Thefoundationtrainslaymenascommunityhealthworkerstodelivercare.Theybelievethatthereisashortageoftrainedclinicians,andthisgapwillbedifficulttofill.Thecommunityhealthworkersarealsoresponsibleforrecruitingandeducatingthecommunity.

Maternalmentalhealthistargetedtoreducementalhealthissuesbeforeandafterbirth.

Currentlyscalingtheprogramtotreat4,000momsacross4clinicsperyear.

NewprojectsincludetheRhinoRefugeeCamp(mentalhealthservicesforthosefleeingfromSudanandintotheRhinoRefugeeCamp)andChildSoldierProject(healemotionalwoundsofformerchildsoldiers)

Location:Itcurrentlyoperatesclinicsin3countries(Uganda,Kenya,Cambodia),withitsprimarypresenceinUganda.Team:Thefoundationcurrentlyhas6staffmembers,basedinNewYork,buttravelingfrequentlytoUganda.ItalsohasabroadBoardofAdvisors,InternationalBoard,andClinicalAdvisors.Theoperatingteamisdedicatedandhasabroadrangeofrelevantexperiences(internationalhumanitarianrelief,PhDinglobalmentalhealth).Funding/Budget:[Redacted]

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Costperoutcome:Intermsofefficacy,AldermanFoundationisfocusedonoutcomesacrossthewholespectrumofmobilization,assessment,andtreatment.Theyestimatetheirtreatmentcostsat$37/patient(conversationwithAllanFreedman),but$50/patientmaybemoreaccurate($1.5Mbudget/30,000patients).However,thereissignificantopportunitytoimproveunderstandingtoreturnoninvestment.Theybelievethatthisiscriticalwork,however,donothavethefundingearmarkedtosupportthiswork.OurrecommendationistheAldermanfoundationisaveryinterestingpotentialtarget.TheapproachispracticalandcanbescaledtomoreareasofUgandaandmorecountries.Thereisanexistingstrongrelationshipwiththegovernment.Also,AldermanFoundationhasafantasticleadershipteam,withawiderangeofeducationalandpracticalexperienceforoperatingamentalhealthorganization.Thefirstwaveoffundingcouldbeusedtoanalyzethereturnofinvestmentontheirapproachandalsotoresearchtheoptimalapproach.SourcesfortheAldermanFoundationincludetheirwebsiteandinterviewwithAllanFreedman,ExecutiveDirectoratAldermanFoundation.

AEGISTrustDescription:Worksincountrieswhohavesufferedmasstraumas,suchasgenocides.Aegisfocusesonpeacebuildingeducation,whichoftenhavepsychologicalcomponents,whichincludecriticalthinking,personalresponsibilityandvalues,andempathy.TheAegisTrusthasdevelopedasuccessfulmodelforpeaceeducationinRwanda,givingtensofthousandsofyoungpeopleacrossthecountrytheknowledgeandtoolstoovercomethelegacyoffearandsuspicionleftbythegenocide,tobreakthelongtermcycleofviolenceandtobuildreconciliation,trustandcooperationforabrighterfuture.12,000childrenhavereceivedservicesinRwanda.Thepeaceeducationprogramhelpstoincreaseawarenessandempathyamongyouthtoinoculatefuturegenerationsagainsttheoutbreakofatrocities.Givenitssuccess,theprogramisbeingscaledupinRwanda,andAegisislookingtoreplicatetheprogramssuccessinotherEastandCentralAfricancountries,suchasKenya,SouthSudanandaspartofapublicUSAIDprivatepartnershipintheCentralAfricanRepublic.Thishaspotentialtobeusedasamodeltobreakcyclesofhatredthroughadoptingthisapproachwithinamentalhealthlens.Location:MostsignificantpresenceinRwandaTeam:WhiletheTrustisheadquarteredintheUK,eachcountrywhereitoperateshastheirownteam,soallmembersdirectlyinchargeofprogramsinRwandaarelocatedinRwanda(mainlyRwandese).Fundingsources:[Redacted]

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Recommendation:WerecommendAEGISTrustbecauseLorihasworkedwiththeminthepast,andweareconfidentthattheirstaffisinvestedintheprojectstheyareimplementing,andthattheorganizationiscapableofeffectivelyintroducingprogramsinto,andaddressingtheneedsof,thesurroundingcommunity.

NEPI(NetworkforEmpowermentandProgressiveInitiative)Intervention:CulturallyadaptedCBT+UnconditionalCashTransfersLocation(s):Liberia,buttheteamisalsointerestedintrainingsimilarorganizationsinGhana,Uganda,andS.Sudanontheirmethodology.Description:NEPIsupportsmenformerlyengagedinLiberiastwocivilwarsbyrehabilitatingthemthroughculturallyadaptedcognitivebehavioraltherapy.Theirflagshipprogram,SustainableTransformationofYouthinLiberia(STYL),teachesmenlivinglivesofcrimetobecomemainstreammembersofsocietybyacting,dressing,andthinkingdifferentlythroughan8weekgrouptherapyprogram.NEPIpartneredwithColumbiaUniversitydevelopmenteconomistChrisBlattmanandInnovationsforPovertyAction(IPA)torunanRCTontheSTYLprogram,whichalsoincludedatestofa$200unconditionalcashtransfer.TheRCTfoundimpressivelystrongimpactsfortheSTYLprogramcombinedwiththecashtransfer.Team:NEPIwasfoundedin2000byKlubosumoJohnsonBorh.Mr.BorhwasforcedtofightinCharlesTaylorsarmyattheageof19,butmanagedtoescape.HewasrehabilitatedthankstotheworkofotherNGOs,anddecidedtodedicatehiscareertogivingbacktosociety.HeearnedaBachelorsdegreeinEconomicsinLiberia,andearnedaMastersinNonprofitManagementfromColumbiaUniversitySchoolofSocialWorkin2015.AlltheteammembersareLiberian.Budget:[Redacted]Fundingsources:[Redacted]Impact/Measurement:NEPIisunusualamongAfricannonprofitsinthatithasparticipatedinconductingahighlyrigorous(n=1,000)RCTanddemonstratedstrong,costeffectimpacts.TheRCTbyChrisBlattman/IPAfoundthatwhenCBTwascombinedwithcashtransfers,therewerelargesustainedfallsincriminalandantisocialbehaviorby50%foratleast1year.Thestudyalsomeasuredlowerimpulsivityandfoundthatthetreatmentincreasedincome(by$4/wk)temporarilyforafewmonths.Theoutcomesmeasurementreliedonselfreporteddata,butBlattmansteamrandomlyselected8%ofparticipantsforavalidationgroup,whomtheyfollowedaroundalldaytoobserveandmeasurecriminalandantisocialbehavior,andfoundtheselfreporteddatatobeaccurate.

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CostperOutcomeEstimate:Blattmanestimates$21percrimeaverted,includingthecostofCBT+cashtransfer.Commoncrimesincludetheft,robbery,drugdealing,andpickpocketing.Thismeasure,alreadyimpressive,doesnotcapturetheadditionalbenefitsofsustainedselfesteem.SourcesConversationwithJohnsonBorhandGuguZawoo,4/6/2016.InternalNEPIdocumentsIPA:SustainableTransformationforYouthinLiberiapolicynote(http://www.povertyaction.org/sites/default/files/publications/sustainabletransformationforyouthpolicymemo.pdf)FreakonomicsPodcast:Idontknowwhatyouvedonewithmyhusbandbuthesachangedman(http://freakonomics.com/podcast/idontknowwhatyouvedonewithmyhusbandbuthesachangedmananewfreakonomicsradioepisode/)Blattman,ChristopherandJamison,JulianC.andSheridan,Margaret,ReducingCrimeandViolence:ExperimentalEvidenceonAdultNoncognitiveInvestmentsinLiberia(December16,2015).AvailableatSSRN:http://ssrn.com/abstract=2594868

OtherOrganizationsConsidered[Redacted]Therearealso3otherorganizationsthatcametoourattentionattheendoftheproject,whichwedidnothavetimetofullyreview,butaredeservingoffurtherconsideration:

AfricanMentalHealthFoundation http://www.africamentalhealthfoundation.org/ NGOinKenya ResearchandadvocacyonmentalhealthinAfrica

AFFIRM:AfricaFocusonInterventionResearchinMentalHealth http://www.affirm.uct.ac.za/ AcademicprojectbasedatUniversityofCapeTown,butactiveinEthiopia,

Ghana,Malawi,SouthAfrica,Uganda,andZimbabwe. Costeffectivenessresearchandcapacitybuilding FundedbyNationalInstituteofMentalHealth(USA)

PRIME:ProgrammeforImprovingMentalHealthCare http://www.prime.uct.ac.za/ ResearchconsortiumacrossfiveMinistriesofHealth(Ethiopia,India,Nepal,

SouthAfrica&Uganda),withpartnersintheUKandtheWorldHealthOrganization(WHO).

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http://www.poverty-action.org/sites/default/files/publications/sustainable-transformation-for-youth-policy-memo.pdfhttp://www.poverty-action.org/sites/default/files/publications/sustainable-transformation-for-youth-policy-memo.pdfhttp://freakonomics.com/podcast/i-dont-know-what-youve-done-with-my-husband-but-hes-a-changed-man-a-new-freakonomics-radio-episode/http://freakonomics.com/podcast/i-dont-know-what-youve-done-with-my-husband-but-hes-a-changed-man-a-new-freakonomics-radio-episode/http://ssrn.com/abstract=2594868http://www.africamentalhealthfoundation.org/http://www.affirm.uct.ac.za/http://www.prime.uct.ac.za/

Focusedonresearch&advocacytointegratementalhealthintoprimaryandmaternalhealthcaresystemsinordertoaddressthetreatmentgap

FundedbyDepartmentforInternationalDevelopment(UKDFID)

ResearchOpportunitiesThereisanastoundinglackofaccesstomentalhealthcareinSubSaharanAfricaanddevelopingcountriesingeneraltheWHOestimatesthat7685%ofthosewithseverementalhealthissuesinthedevelopingworldreceivenocareatall. Onewaytoaddressthisgapwould5

betotriplespendingonmentalhealthintheregion,fromroughly$160Mperyear(estimated) 6

to$480Mperyear,butthatwouldrequiredramaticshiftsinhealthbudgetinginthosecountriesandbyaidagencies.Analternativeapproachwouldbetoresearchandpromotenewinterventionsthatcouldpotentiallytriplethecosteffectivenessofmentalhealthspending.Therearesomenewinterventionsonthehorizonwhichlookpromisinginthisregard,whichmaybeworthfundingfromanexpectedvalueperspective(probabilitymultipliedbypotentialimpact)evenwithalowprobabilityofsuccess(astrategyofpursuingmoonshots).

PropranololProblemArea:PTSDDescription:Psychologistsusedtobelievethatmemoriesareresistanttochange,onceformed.However,newevidencehasbroughttolightaprocessofreconsolidation,inwhichmemoriesaremodifiedandreencodedeachtimetheyarerecalled.Thisfindingledtoasearchforwaystomodifytraumaticmemoriesthroughreconsolidation.Propranolol,abetablockeroriginallyintendedtotreathighbloodpressure,hasbeenknowntorelieveanxiety,andhasnowbeentestedasawaytoremovethestressfromtraumaticmemoriesduringreconsolidation,findingsuccessinbothratsandhumans.ThetherapeuticprocedureinvolvesaclinicianprovokingtherecallofatraumaticmemoryinapatientsufferingfromPTSD,immediatelyfollowedbyanoraldoseofpropranolol,inupto6sessions.PropranololrequiresaprescriptionintheUS,butisgenerallysafeformostpeopleandhasmildsideeffects.ItisalreadyontheWHOlistofessentialmedicines,soitisgeneric,cheap,andwidelyavailable.ThistreatmentstandsoutoverexistingapproachestoPTSDinitssimplicityandeffectiveness.Evidence:Dr.MerelKindtattheUniversityofAmsterdamhaspublishedanecdotalaccountsofsuccesswiththistreatment,whichshehelpedpioneer(Lavine2012).Dr.AlainBrunetatMcGill

5WHOSecretariatReport,December2011:http://apps.who.int/gb/ebwha/pdf_files/EB130/B130_9en.pdf6Ibidreportsanaverageof$0.20spentperyearpercapitaonmentalhealthindevelopingcountries.PopulationofSubSaharanAfricais800M.800,000,000*$0.20=$160,000,000.

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http://apps.who.int/gb/ebwha/pdf_files/EB130/B130_9-en.pdf

hasconductedasmallscale(n=19),doubleblind,randomizedcontrolledtrialinwhichonlyonesessionofpropranololtreatmentwasadministeredtopatients,whichfoundlarge,statisticallysignificanteffectsinphysiologicalresponsestotraumaticstimuli.Hefolloweditupwithaseriesofpilotsofmultisessionpropranololtherapy,whichfoundthat7080%losttheirPTSDdiagnosisfollowingthetreatment,comparedto8%ina(nonrandomized)controlgroup(Brunetetal,2011).Bycomparison,standardtreatmentsforPTSDareestimatedtoworkabouthalfthetime(Kar2011).Dr.Brunetalsoperformedarandomizedexperiment(n=45)inNepalthatcomparedpropranololwithparoxetine(SSRI)forPTSDtreatment(Descamps2015).Paroxetineneedstobetakenfor1year,costsmorethanpropranolol,hasbadsideeffects(weightgain,sexualdysfunction,increasedimpulsivity),andhasahighdropoutrate.EffectivenessinrelievingPTSDsymptomswasthesameinbothconditions,meaningthatpropranololmaybeacosteffective,acceptabletreatmentforPTSDinnonWestern,lowincomecontexts.Hewasalsofunded$1.9MbytheUSDepartmentofDefenseforaplacebocontrolledrandomizedcontrolledtrial(n=48),whichfoundasignificanteffect,buthasnotbeenpublishedyet(ConversationwithDr.Brunet).Hehasalsoreceived$1MinfundingfromanetworkofParisianhospitalstotrain100clinicianstoadministerpropranololtreatmentforPTSDto400victimsoftheNovember13,2015terrorattacks,andhisstudytherewillfocusoncomparingcosteffectivenessagainsttreatmentasusual.Costeffectiveness:Propranololtreatmenthassignificanteffectsafter1session(

SymptomsandDisorder:3OpenLabelTrials.JournalofClinicalPsychopharmacology,31(4),547550.http://doi.org/10.1097/JCP.0b013e318222f360Crair,B.(2016,May1).TheCureForFear.RetrievedMay27,2016,fromhttps://newrepublic.com/article/133008/curefearDescampsM,KienzlerH,SharmaB,SapkotaRP,PedersenD,BrunetA.(2015).IsReconsolidationBlockadeaViableTreatmentOptionforTraumaRelatedMemoriesinLMICs?InternationalSocietyforTraumaticStressStudies.Poster#THU358.FoaEB,McLeanCP,CapaldiS,&RosenfieldD.(2013).Prolongedexposurevssupportivecounselingforsexualabuserelatedptsdinadolescentgirls:Arandomizedclinicaltrial.JAMA,310(24),26502657.http://doi.org/10.1001/jama.2013.282829Giles,J.(2016,May27).BetaBlockersTackleMemoriesofHorror.RetrievedMay27,2016,fromhttp://www.nature.com/drugdisc/news/articles/436448a.htmlKar,N.(2011).Cognitivebehavioraltherapyforthetreatmentofposttraumaticstressdisorder:areview.NeuropsychiatricDiseaseandTreatment,7,167181.http://doi.org/10.2147/NDT.S10389Lavine,R.(2012,February1).EndingtheNightmares:HowDrugTreatmentCouldFinallyStopPTSD.TheAtlantic.Retrievedfromhttp://www.theatlantic.com/health/archive/2012/02/endingthenightmareshowdrugtreatmentcouldfinallystopptsd/252079/ConversationwithDr.AlainBrunet,McGillUniversity,6/18/2016ConversationwithDr.MargaretAltemus,WeillCornellSchoolofMedicine,6/3/2016

TraceLithiumProblemArea:SuicideDescription:Whatiftherewasanundetectedvitamin/mineraldeficiencycausingmentalhealthproblemsforhundredsofthousandsofpeopleeachyear?Thatisthetracelithiumhypothesisthatlithium,anelementsimilartosodium,isanessentialmineralrequiredforhealthybrainfunction,whosedeficiencyleadstomentalhealthproblemsandincreasedriskofsuicide.Thebulkoftheevidenceforthishypothesiscomesfromcorrelationalstudies,startedin1970(Dawson1970),whichhavefoundthatcommunitieswithhigheramountsofnaturallyoccurringtracelithiumintheirwatersupplytendtohavelowersuiciderates.Thisissuehasalsobeen

24

brieflyexaminedbytheOpenPhilanthropyProject,whichconcludedthatifthecausaleffectoftracelithiumholdstrue,itcoulddecreasethenumberofannualsuicidesby10%(OpenPhilanthropyProject2015).Somestudieshavealsolookedatratesofhomicide,crime,andotherindicatorsofmentalhealthproblems,andfoundtracelithiumtobeinverselycorrelatedwiththoseoutcomesaswell,suggestingthatifitworks,tracelithiumwouldimprovementalhealthinageneralwayonapopulationlevel.Asiswellknown,lithiumiswidelyusedasamoodstabilizerforbipolardisorder,andissurprisinglyeffective.However,thehighdosageused(1800mg/day) comeswithanumberofunpleasantsideeffectsforbothphysicalandmental7

health.Thetraceamountconsideredinthesestudiesamountstolessthan1mg/day(Schrauzer2002),suggestinganentirelydifferentmechanismofactionwhichhopefullyavoidstheharmfulsideeffects.Furthermore,manypeoplehaveassumedthatpublichealthofficialswouldactonthisbyaddinglithiumtopublicdrinkingwatersuppliesaswasdonewithfluoridehowever,thatislikelytofacesignificantpoliticaloppositionandraisesethicalconcernsregardingconsent.Amorepracticalapproach,iftheevidencebearsoutthenecessityoflithiumasanessentialmineral,wouldbefortheFDAtoissueaReferenceDailyIntake(RDI)asitdoesforothervitaminsandmineralssuchaspotassiumorsodium,andthenfortifyspecificfoodssuchassaltormultivitaminswiththeproperamount.BeingabletoreadtheamountoflithiumontheNutritionFactslabelwouldpreservethepublicsabilitytoavoidaddedlithium.Developingcountrieswouldlikelyfollowsuitwiththeirownfortificationprograms(astheyhavedonewithiodine,vitaminsAandD,etc.)astheseprogramsarestraightforwardtoimplementandenormouslycosteffective.Evidence:Ericcompiledalistofalltheoriginalresearchonthistopic(spreadsheethere)duetogapsintheexistingliteraturereviews.Outof13studies,9foundstrong,significantcorrelationswithtracelithiumandloweredsuiciderates.However,manyofthestudieswerepoorlydesignedduetosmallsamplesizes,lackofvariabilityinlithiumlevels,orfailingtocontrolforconfoundingfactors.Only4ofthestudiesdidwellonthesecriteria(Kapusta2011Bluml2013Pompili2015Ishii2015),and3ofthose4foundsignificanteffectsforthecorrelation.Eachofthose4studieswasconductedinadifferentcountry,butsofar,allofthesecorrelationalstudieshavelookedatdevelopedcountries(US,Europe,andJapan)nobodyhaslookedatthisissueindevelopingcountriesyet,butbiologicalmechanismstendtotranslatewellacrossgeographies.Thebiologicalmechanismforlithiumonthebrainisnotwellunderstoodyet(ateitherhighorlowdoses),butneuroscienceresearchhasfoundthatlowlevelsoflithiumhaveneuroprotectiveeffectsandreduceoxidativestressincellculturesofhumanneurons(Allagui2009Nciri2013).Therehasonlybeenoneverysmallscale(n=24)randomizedcontrolledtrialoftracelithiuminhumans(Schrauzer1994),whichwassuccessfulinfindingapositiveeffectonmood,butonecannotplacemuchweightonit.Thebulkoftheevidenceliesonamoderatecorrelationwhichcannotalwaysbereproduced,soahealthydoseofskepticismisrequired.Iestimatea10%chancethatthetracelithiumhypothesisturnsouttobecorrect.

7Drugs.com:http://www.drugs.com/dosage/lithium.html

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https://docs.google.com/spreadsheets/d/1uQUu-fnBVw3QsA_PQI8DzSp6qlySRgy85j3mb92_AWI/edit?usp=sharinghttp://www.drugs.com/dosage/lithium.html

CostEffectiveness:Despitealowprobabilityofsuccess,researchontracelithiumstilllooksveryattractivefromanexpectedvalue(probabilitymultipliedbyimpact)perspective.Lithiumitself,asanaturallyoccurringelement,wouldbeveryinexpensiveinthequantitiesneededforafortificationprogram(1mg/person/year).ProjectHealthyChildren,anonprofitthatrunsfortificationprogramsindevelopingcountries,estimatesthattheirprogramscostonly$100,000percountryperyear. Ifweconservativelyestimatethatitwouldtake$50Mofresearchfunding8

(anarbitraryestimate)toconclusivelydeterminewhetherlithiumisanessentialmineral,andthatifso,fortificationprogramscouldbeimplementedworldwidethatwouldreducethe800,000annualsuicidesby10%,andconsideronlythefirst5years,thenthecostperlifesavedwouldberoughly$1,400. 9

LeadingResearchers:

NestorKapucha,MedicalUniversityofVienna https://www.researchgate.net/profile/Nestor_Kapusta

MarcoHelbich,UniversityofUtrecht http://www.uu.nl/staff/MHelbich

DanielSmith,UniversityofGlasgow http://www.gla.ac.uk/researchinstitutes/healthwellbeing/staff/danielsmith/

FundingStrategy:Tracelithiumresearchisprobablyunderfundedfortwomainreasons:asanelement,itcannotbepatented,sopharmaceuticalcompanieshavenointerestinit,anditsnegativeperceptionbythepublichasmadegovernmentfunderswaryofsupportingit(Fels2014).Anadditionalfactormaybethatgovernmentfunderstendtoberiskaverseintheirfundingdecisions,potentiallymissinghighriskhighrewardopportunities.Dr.MarcoHelbichofUniversityofUtrechtthinksmorecorrelationalstudiesareneeded,butwithsmallerareasastheunitofanalysis(andthereforehighersamplesizes)thanthosepreviouslyconducted(personalcommunication).Dr.DanielSmithofGlasgowUniversitythinksthatrandomizedcontrolledtrialswouldbethebestwaytomovethefieldforwardnow(personalcommunication).Dr.NestorKapustaoftheMedicalUniversityofViennathinksthatitisstilltooearlyforrandomizedcontrolledtrials,andthatmoreresearchisneededontheneurobiologicaleffectsatthecellularlevel(OpenPhilanthropyProject2015).Thereseemstobeaneedforanonprofitorganizationthatwouldprioritize,coordinate,andfundresearchinthisarea,andalsoengagegovernmentfundersandpolicymakersinthisissue.SourcesAllagui,M.S.,Nciri,R.,Rouhaud,M.F.,Murat,J.C.,ElFeki,A.,Croute,F.,&Vincent,C.(2009).Longtermexposuretolowlithiumconcentrationsstimulatesproliferation,modifies

8ProjectHealthyChildren:http://projecthealthychildren.org/whatwedo/cost/9(($50Mresearchfunding/10%chanceofsuccess)+(100countries*$100,000percountryperyear*5years))/(800,000suicides*10%prevented*5years)=$1,375expectedcostperlifesaved

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https://www.researchgate.net/profile/Nestor_Kapustahttp://www.uu.nl/staff/MHelbichhttp://www.gla.ac.uk/researchinstitutes/healthwellbeing/staff/danielsmith/http://projecthealthychildren.org/what-we-do/cost/

stressproteinexpressionpatternandenhancesresistancetooxidativestressinSHSY5Ycells.NeurochemicalResearch,34(3),453462.http://doi.org/10.1007/s1106400898048Blml,V.,Regier,M.D.,Hlavin,G.,Rockett,I.R.H.,Knig,F.,Vyssoki,B.,Kapusta,N.D.(2013).LithiuminthepublicwatersupplyandsuicidemortalityinTexas.JournalofPsychiatricResearch,47(3),407411.http://doi.org/10.1016/j.jpsychires.2012.12.002Dawson,E.B.,Moore,T.D.,&McGanity,W.J.(1970).Themathematicalrelationshipofdrinkingwaterlithiumandrainfalltomentalhospitaladmission.DiseasesoftheNervousSystem,31(12),811820.Fels,A.(2014,September13).ShouldWeAllTakeaBitofLithium?TheNewYorkTimes.Retrievedfromhttp://www.nytimes.com/2014/09/14/opinion/sunday/shouldwealltakeabitoflithium.htmlIshii,N.,Terao,T.,Araki,Y.,Kohno,K.,Mizokami,Y.,Shiotsuki,I.,Iwata,N.(2015).Lowriskofmalesuicideandlithiumindrinkingwater.TheJournalofClinicalPsychiatry,76(3),319326.http://doi.org/10.4088/JCP.14m09218Kapusta,N.D.,Mossaheb,N.,Etzersdorfer,E.,Hlavin,G.,Thau,K.,Willeit,M.,LeithnerDziubas,K.(2011).Lithiumindrinkingwaterandsuicidemortality.TheBritishJournalofPsychiatry,198(5),346350.http://doi.org/10.1192/bjp.bp.110.091041Nciri,R.,Desmoulin,F.,Allagui,M.S.,Murat,J.C.,Feki,A.E.,Vincent,C.,&Croute,F.(2013).NeuroprotectiveeffectsofchronicexposureofSHSY5Ytolowlithiumconcentrationinvolveglycolysisstimulation,extracellularpyruvateaccumulationandresistancetooxidativestress.TheInternationalJournalofNeuropsychopharmacology/OfficialScientificJournaloftheCollegiumInternationaleNeuropsychopharmacologicum(CINP),16(2),365376.http://doi.org/10.1017/S1461145712000132OpenPhilanthropyProject.StatementofInterestinResearchontheHealthEffectsofTraceLithiuminDrinkingWater(2015,December).RetrievedMay28,2016,fromhttp://www.openphilanthropy.org/healtheffectsoftracelithiumindrinkingwaterPompili,M.,Vichi,M.,Dinelli,E.,Pycha,R.,Valera,P.,Albanese,S.,Baldessarini,R.J.(2015).RelationshipsoflocallithiumconcentrationsindrinkingwatertoregionalsuicideratesinItaly.TheWorldJournalofBiologicalPsychiatry:TheOfficialJournaloftheWorldFederationofSocietiesofBiologicalPsychiatry,16(8),567574.http://doi.org/10.3109/15622975.2015.1062551Schrauzer,G.N.(2002).Lithium:occurrence,dietaryintakes,nutritionalessentiality.JournaloftheAmericanCollegeofNutrition,21(1),1421.

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Schrauzer,G.N.,&deVroey,E.(1994).Effectsofnutritionallithiumsupplementationonmood.Aplacebocontrolledstudywithformerdrugusers.BiologicalTraceElementResearch,40(1),89101.

ComputerbasedCBTProblemArea:Anxiety/DepressionDescription:AnumberofcompaniesandresearchgroupshavedevelopedselfserviceappsorwebsitesthatdeliverCognitiveBehavioralTherapy(CBT)treatmentforanxietyanddepression.Thesetoolsenableuserstointeractivelyreadcontent/watchvideosandcompletehomeworkassignments,designedtogivethemcognitiveskillstopreventbadpatternsofthought.Wheneffective,appbasedCBTishighlyscalableandcosteffectiveduetothefactthatpatientscanuseitthemselveswithoutatrainedmentalhealthprofessional(Solomonetal,2015).Evidence:AlthoughonelargeRCTfoundnoeffect(Gilbodyetal2015),RCTsofotherprogramsinothercontextshavefoundsignificanteffects(Guilleetal,2015Solomonetal,2015Vernmark2010Warmerdam2008).TworecentmetastudiesofselfservicecomputerizedCBTfoundittobehelpful,witheffectsizesofd=0.25(Andersson2009)andd=0.36(Richards2012).Toillustrate,aneffectsizeofCohensd=0.30translatestoasignificantbenefitforoneoutofevery11peopletreated. 10

FundingStrategy:[Redacted]CostEffectiveness:InSubSaharanAfrica,SouthAfricawouldbethemostattractivemarket,with23Msmartphoneusers,halfthecountryspopulation(MyBroadband2015).AlthoughtheWHOestimatesthat>75%ofpeopleinLMICswithseverementalillnesshavenoaccesstotreatment,thisshouldbeloweredtoperhaps50%forthesmartphoneusingpopulationgiventhattheyhavehighersocioeconomicstatusthantherestofthepopulation.IncidenceofdepressioninSouthAfricaisroughly5%(Dewey2013),leavingatargetpopulationof575,000.Ifthepromotionalcampaignmanagedtoreach20%ofthetargetpopulation,thatwouldcreate115,000usersfortheapp.Assumingthat1in11peoplearesignificantlyhelped,basedontheresultsofthemetastudies,wouldleadtoroughly10,000casesofdepressionsignificantlyimproved.Atacostof$300,000,thistranslatesto$30percasehelped,assumingtheprojectissuccessful,whichwouldbehighlycosteffective.Sources:

10Formoreinformation,see:http://rpsychologist.com/d3/cohend/

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http://rpsychologist.com/d3/cohend/

Andersson,G.,&Cuijpers,P.(2009).Internetbasedandothercomputerizedpsychologicaltreatmentsforadultdepression:ametaanalysis.CognitiveBehaviourTherapy,38(4),196205.http://doi.org/10.1080/16506070903318960Dewey,C.(2013,November7).Astunningmapofdepressionratesaroundtheworld.RetrievedJune7,2016,fromhttps://www.washingtonpost.com/news/worldviews/wp/2013/11/07/astunningmapofdepressionratesaroundtheworld/Gilbody,S.,Littlewood,E.,Hewitt,C.,Brierley,G.,Tharmanathan,P.,Araya,R.,REEACTTeam.(2015).Computerisedcognitivebehaviourtherapy(cCBT)astreatmentfordepressioninprimarycare(REEACTtrial):largescalepragmaticrandomisedcontrolledtrial.BMJ(ClinicalResearchEd.),351,h5627.Guille,C.,Zhao,Z.,Krystal,J.,Nichols,B.,Brady,K.,&Sen,S.(2015).WebBasedCognitiveBehavioralTherapyInterventionforthePreventionofSuicidalIdeationinMedicalInterns:ARandomizedClinicalTrial.JAMAPsychiatry,72(12),11921198.http://doi.org/10.1001/jamapsychiatry.2015.1880MyBroadband.SouthAfricasbigsmartphoneInternetuptake.(2015,May28).RetrievedJune7,2016,fromhttp://mybroadband.co.za/news/smartphones/127556southafricasbigsmartphoneinternetuptake.htmlRichards,D.,&Richardson,T.(2012).Computerbasedpsychologicaltreatmentsfordepression:asystematicreviewandmetaanalysis.ClinicalPsychologyReview,32(4),329342.http://doi.org/10.1016/j.cpr.2012.02.004Solomon,D.,Proudfoot,J.,Clarke,J.,&Christensen,H.(2015).eCBT(myCompass),AntidepressantMedication,andFacetoFacePsychologicalTreatmentforDepressioninAustralia:ACostEffectivenessComparison.JournalofMedicalInternetResearch,17(11),e255.http://doi.org/10.2196/jmir.4207Vernmark,K.,Lenndin,J.,Bjrehed,J.,Carlsson,M.,Karlsson,J.,Oberg,J.,Andersson,G.(2010).Internetadministeredguidedselfhelpversusindividualizedemailtherapy:ArandomizedtrialoftwoversionsofCBTformajordepression.BehaviourResearchandTherapy,48(5),368376.http://doi.org/10.1016/j.brat.2010.01.005Warmerdam,L.,vanStraten,A.,Twisk,J.,Riper,H.,&Cuijpers,P.(2008).Internetbasedtreatmentforadultswithdepressivesymptoms:randomizedcontrolledtrial.JournalofMedicalInternetResearch,10(4),e44.http://doi.org/10.2196/jmir.1094

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http://mybroadband.co.za/news/smartphones/127556-south-africas-big-smartphone-internet-uptake.htmlhttp://mybroadband.co.za/news/smartphones/127556-south-africas-big-smartphone-internet-uptake.html

Otherareasconsidered

Psilocybin Psilocybinistheactivehallucinogenicsubstanceinmagicmushrooms.Although

itmayseemstrange,ithasbeendemonstratedtohavestrongtherapeuticeffectsintreatingdepressionandaddictionwithjustonesession(CarhartHarrisetal,2016Sessa&Johnson,2015).However,weconcludedthatwidespreadadoptionisunlikelytobepracticalgivensafetyconsiderations,asitcancausepanicattacksandpsychosisinpsychologicallyvulnerablepeople(Cowen2016vanAmsterdam,etal,2011ConversationwithDr.Gastfriend).

PsychologicalFirstAid PsychologicalFirstAidoperatesonatrainthetrainermodelthatteachespeople

howtoappropriatelyrespondtotheneedsofothersduringorafteracrisis.Althoughcommonlyusedworldwideandwellregardedbyexpertconsensus,threerecentreviewsfoundadearthofevidenceontheintervention(Dieltjens2014Fox2012Shultz2014).Althoughmoreresearchinthisareawouldbehelpful,ourcursoryassessmentisthatitwouldbemorevaluabletoinvestintrainthetrainermodelsthatalreadyhaveastrongevidencebase(SCI,CBT,etc.)orresearchareaswithpotentialforgreaterimpact(suchaspropranolol).

Sources:Psilocybin:CarhartHarris,R.L.,Bolstridge,M.,Rucker,J.,Day,C.M.J.,Erritzoe,D.,Kaelen,M.,Nutt,D.J.(2016).Psilocybinwithpsychologicalsupportfortreatmentresistantdepression:anopenlabelfeasibilitystudy.TheLancetPsychiatry.http://doi.org/10.1016/S22150366(16)300657Cowen,P.(2016).Alteredstates:psilocybinfortreatmentresistantdepression.TheLancetPsychiatry.http://doi.org/10.1016/S22150366(16)300876Sessa,B.,&Johnson,M.W.(2015).Canpsychedeliccompoundsplayapartindrugdependencetherapy?TheBritishJournalofPsychiatry,206(1),13.http://doi.org/10.1192/bjp.bp.114.148031vanAmsterdam,J.,Opperhuizen,A.,&vandenBrink,W.(2011).Harmpotentialofmagicmushroomuse:areview.RegulatoryToxicologyandPharmacology:RTP,59(3),423429.http://doi.org/10.1016/j.yrtph.2011.01.006

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ConversationwithDr.DavidGastfriend,MD,formerDirectorofAddictionResearchatMassachusettsGeneralHospital(andalsoEricsdad),5/25/2016PsychologicalFirstAid:ConversationwithDr.GeorgeEverly,JohnsHopkinsBloombergSchoolofPublicHealth,5/28/2016Dieltjens,T.,Moonens,I.,VanPraet,K.,DeBuck,E.,&Vandekerckhove,P.(2014).ASystematicLiteratureSearchonPsychologicalFirstAid:LackofEvidencetoDevelopGuidelines.PLoSONE,9(12).http://doi.org/10.1371/journal.pone.0114714Everly,G.S.,LeeMcCabe,O.,Semon,N.L.,Thompson,C.B.,&Links,J.M.(2014).Thedevelopmentofamodelofpsychologicalfirstaidfornonmentalhealthtrainedpublichealthpersonnel:theJohnsHopkinsRAPIDPFA.JournalofPublicHealthManagementandPractice:JPHMP,20Suppl5,S2429.http://doi.org/10.1097/PHH.0000000000000065Fox,J.H.,Burkle,F.M.,Bass,J.,Pia,F.A.,Epstein,J.L.,&Markenson,D.(2012).Theeffectivenessofpsychologicalfirstaidasadisasterinterventiontool:researchanalysisofpeerreviewedliteraturefrom19902010.DisasterMedicineandPublicHealthPreparedness,6(3),247252.http://doi.org/10.1001/dmp.2012.39Shultz,J.M.,&Forbes,D.(2014).PsychologicalFirstAid.DisasterHealth,2(1),312.http://doi.org/10.4161/dish.26006

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