ODD Clinical Trial

This post is a sort of advertisement, except that no one's getting paid anything. A colleague of mine and his group just got a 2 year grant to conduct a trial of Regulation Focused Psychotherapy (RFP) for the treatment of Oppositional Defiant Disorder in children ages 5-12. This is the flyer:

That's the advertisement part. I think it's a great idea. But just to be clear, not only am I not being paid, I'm not involved in the study in any way except feeling pleased about it, and writing this post.

Why do I think it's a great idea? The American Academy of Child and Adolescent Psychiatry has a brochure about ODD. It describes treatment for ODD, which includes a combination of Parent-Management Training Programs and Family Therapy, Cognitive Problem-Solving Skills Training, Social-Skills Programs and School-Based Programs, plus or minus medication.

These are all useful tools, but none of them addresses the underlying affects, and difficulty in regulating these affects, that children with ODD experience. That's where RFP comes in.

The group conducting the study recently published the Manual of Regulation-Focused Psychotherapy for Children (RFP-C) with Externalizing Behaviors: A Psychodynamic Approach.

In it, they describe the way, "RFP-C enables clinicians to help by addressing and detailing how the child’s externalizing behaviors have meaning which they can convey to the child," and more specifically, that RFP-C can:

• Achieve symptomatic improvement and developmental maturation as a result of gains in the ability to tolerate and metabolize painful emotions, by addressing the crucial underlying emotional component.
• Diminish the child’s use of aggression as the main coping device by allowing painful emotions to be mastered more effectively.
• Help to systematically address avoidance mechanisms, talking to the child about how their disruptive behavior helps them avoid painful emotions.
• Facilitate development of an awareness that painful emotions do not have to be so vigorously warded off, allowing the child to reach this implicit awareness within the relationship with the clinician, which can then be expanded to life situations at home and at school.

That's my pitch. So if you know anyone in the New York City area who could benefit from this trial, whether child, parent, educator or clinician, please get this information to them.

Thanks.

Outside In

In the context of my working on building my own practice website, I found a NY Times article, Inner Peace? The Dalai Lama Made a Website for That, compelling to read.

The website is, Atlas of Emotions, and it's not really about inner peace. It's more about the Dalai Lama's notion of emotions as reactive internal events that prevent inner peace, combined with information about the five emotions considered universal by the 149 experts surveyed for this purpose.

The emotions are:

Anger
Fear
Disgust
Sadness
Enjoyment

The site was conceived by the Dalai Lama as a "map of the mind", and developed by Dr. Paul Ekman (for $750,000), who conducted the survey, and has done pioneering work in nonverbal behaviors, especially facial expressions. He now has a company called the Paul Ekman Group, or PEG, which will teach you, for a fee, to read people's expressions and determine if, for example, they are lying. He was a major consultant for Inside Out, the Pixar movie that illustrates the emotional life of a girl named, Riley (I assume based on the expression, "Living the life of Riley," meaning the good life). He was also consultant and inspiration for the main character on the TV series, "Lie to Me", which I know nothing about.

The site is primarily visual, with the imagery designed by a company called, Stamen, that creates data visualizations. It's interesting that the colors used to depict the five emotions on the site:

match the colors of the corresponding characters in Inside Out:

I probably shouldn't be including either of these images without permission, but the Disney-fication was just so striking. Then again, we do associate colors with feelings, like red with anger, blue with sadness, and green with disgust, and red and green, at least, are related to changes in skin color that occur with their associated emotions. I don't know about purple with fear or yellow/orange with enjoyment.


The way the site works is you land on the home page, with those five circles of emotion, which are called, "continents". Remember, this is supposed to be a map. If you click on a continent, you get a brief description. For example, Sadness brings up, "We're saddened by loss."

You also get a menu to the right which lists, Continents, States, Actions, Triggers, Moods, and Calm. If you go to States, after you've clicked on Sadness, you get a graph of various states related to sadness, with overlaps, from least intense to most. The least intense for Sadness is Disappointment, "A feeling that expectations are not being met." The most intense is Anguish, "Intense agitated sadness."

There are left and right arrows to switch to other basic emotions, but also a down arrow, corresponding to the menu on the right, with more about the emotion you're looking at. The next one down is Actions, with another visual including a range of possible actions for each given state. For anguish, you can seek comfort, which is considered a constructive action. You can mourn, which is ambiguous. And you can withdraw, which is destructive.

This is a good illustration of one of the main limitations of the site-that it oversimplifies, but that probably makes it more widely accessible.

The next down is Triggers, which are either universal, like losing a loved one, or learned, like perceiving a loss of status.

And next down is Moods, the "longer lasting cousins" of emotions. For Sadness, the corresponding mood is Dysphoria.

That's as deep as the graphics go. The only thing left is calm, which you access from the right hand menu. It has nothing but a short description:

Experiencing Calm

A calm, balanced frame of mind is necessary to evaluate and understand our changing emotions. Calmness ideally is a baseline state, unlike emotions, which arise when triggered and then recede.

The only other feature of the site is a link to the "Annex", where you can find the scientific basis for the work, some more complicated definitions, the signals of emotional display, and a page of "Psychopathology", which lists various DSM diagnoses related to each emotion.

I wasn't thrilled with this page. For one thing, I disagreed with some of the categorization. For example, as an anxiety disorder, OCD was listed under Fear. But etiologically, at least from an analytic standpoint, OCD is more about a way of dealing with aggression, so I would have listed it under Anger. It also lists Mania under enjoyment, with a qualification about it being pathological enjoyment. But I don't think this is what's actually meant by the term, Enjoyment.

And this page doesn't mention the DSM, even though it includes diagnoses like Disruptive Mood Dysregulation Disorder (DMDD).


Overall, I have mixed feelings about the Atlas of Emotions. On the one hand, it recognizes that we usually don't know why we feel what we feel, or do what we do, and that's useful to know. To quote the NY Times quoting the Dalai Lama:

“We have, by nature or biologically, this destructive emotion, also constructive emotion,” the Dalai Lama said. “This innerness, people should pay more attention to, from kindergarten level up to university level. This is not just for knowledge, but in order to create a happy human being. Happy family, happy community and, finally, happy humanity.”

On the other hand, the goal is a calm state:

“When we wanted to get to the New World, we needed a map. So make a map of emotions so we can get to a calm state.”

I think this calm state is supposed to be an absence of emotion, either good-feeling or bad-feeling, a Buddhist ideal, so emotion is viewed as the enemy:

“Ultimately, our emotion is the real troublemaker,” he said. “We have to know the nature of that enemy.”

When I read this, I was reminded of the talk I attended, that I wrote about in Laughing Rats, where Jaak Panksepp noted that, "Most learning takes place through affective shifts." So if we contain our emotions, do we prevent ourselves from learning new things?

And in that same talk, Jean Roiphe noted that, "Ego functioning often involves "taming" certain affects, especially through thought and language, but it also involves intensifying some affects, so that people can feel truly alive. A full human life can't be reduced to an all or nothing switch of feeling in response to external events."

Also, I'm not sure "calm" isn't an emotion.

Maybe I just have trouble with this because I'm so steeped in a culture of neurotically exaggerated emotions, so the ideal of inner peace isn't just unattainable, it's laughably unapproachable, which, for me, quickly turns into undesirable.

NAC

I've been hearing a lot about N-Acetylcysteine (NAC) in the treatment of psychiatric disorders, so I thought it would be worth looking into.

A 2015 systematic review in Neuroscience and Biobehavioral Reviews has the following abstract:

N-acetylcysteine (NAC) is recognized for its role in acetaminophen overdose and as a mucolytic. Over the past decade, there has been growing evidence for the use of NAC in treating psychiatric and neurological disorders, considering its role in attenuating pathophysiological processes associated with these disorders, including oxidative stress, apoptosis, mitochondrial dysfunction, neuroinflammation and glutamate and dopamine dysregulation. In this systematic review we find favorable evidence for the use of NAC in several psychiatric and neurological disorders, particularly autism, Alzheimer's disease, cocaine and cannabis addiction, bipolar disorder, depression, trichotillomania, nail biting, skin picking, obsessive-compulsive disorder, schizophrenia, drug-induced neuropathy and progressive myoclonic epilepsy. Disorders such as anxiety, attention deficit hyperactivity disorder and mild traumatic brain injury have preliminary evidence and require larger confirmatory studies while current evidence does not support the use of NAC in gambling, methamphetamine and nicotine addictions and amyotrophic lateral sclerosis. Overall, NAC treatment appears to be safe and tolerable. Further well designed, larger controlled trials are needed for specific psychiatric and neurological disorders where the evidence is favorable.


I'm not sure how they drew their conclusions. They have a rating system called, Grade of Recommendation (GOR), from A-best, to D-worst, and N-no studies identified. They also state, at least for some disorders, whether they recommend NAC for treatment, from Yes to No, with Mixed in between.

They found only 1 GOR of A, for Bipolar disorder, and even that they recommended as Mixed.

The B/Mixed were:

Addiction-Cannabis
Addiction-Cocaine
Autism
Depressive Disorder
Impulse Control-Trichotillomania
Schizophrenia.

Specifically:

-In one study of NAC in treating and preventing symptoms during the maintenance phase of Bipolar Disorder, when compared to placebo, the NAC group demonstrated a significant improvement on the Montgomery–Asberg Depression Scale (MADRS), Bipolar Depression Rating Scale (BDRS).

-Cannabis-dependent adolescents and young adults given NAC and counseling had significantly fewer positive urine cannabinoid tests than those given placebo and counseling.

-There may or may not have been a reduction in cravings for Cocaine.

-Children with Autism had less irritability.

-A large randomized controlled trial in individuals with major depressive disorder (MDD) and MADRS score ≥ 18 showed improvement in multiple outcome measures – in the NAC group when compared to placebo add on treatment to usual treatment for 12 weeks.

-In a medium sized trial, significant improvements were found on the Massachusetts General Hospital Hair Pulling Scale, the Psychiatric Institute Trichotillomania Scale and the CGI in participants who received NAC as compared to the placebo group.

- I can't figure out from the paper what NAC did for patients with Schizophrenia.


Everything else was worse.

However, NAC was pretty well-tolerated, with no serious side effects, so it's probably worth a try in conditions not responding well to other treatments. At least, I think that's their conclusion. Also, other than the IV form used in acetaminophen overdose, and the Sub-Q form used in ALS studies, NAC is sold over the counter as an oral medication, with doses ranging from 2-2.4g/day.

Posited mechanisms of action for NAC include effects on:

Oxidative Stress
Mitochondrial Dysfunction
Inflammatory Mediators
Glutamate Neurotransmission
Long Term Neuroadaptation
Dopamine Neurotransmission
Serotonergic Neurotransmission

Check out this visual:

http://www.cell.com/trends/pharmacological-sciences/fulltext/S0165-6147(13)00002-3

To get into a little more clinical nitty-gritty, there are a number of trials posted on clinicaltrials.gov, most without results.

One that did have results looked at NAC in alcohol dependence, with the primary outcome  measure Alcohol consumption in percentage of heavy drinking days:

No statistical analysis was provided.

Another was NAC in pediatric trichotillomania:

Again, no statistical analysis.

However, when I plug the raw data into 1 Boring Old Man's table,  (see also DIY Study Evaluation) I get:

The trichotillomania study had a p value of 0.185, a Cohen's D effect size of 0.433, and a 95% CI of -0.202 to 1.068 (In case it's too hard to read). So there's no statistically significant difference.

The Alcohol study's data was weird, with no calculable p value, and negative Cohen's D's, so then I tried change in means, which was negative, and that got p=0.533; Cohen's D=0.190; CI (-0.403-0.782). I'm not sure if that's a legitimate calculation on my part.

Basically, the numbers are bad, and I only decided to include the spreadsheet as practice at evaluating a study.

So now I ask myself, "Would I prescribe or recommend NAC?" Based on this post, I'd have to say maybe. I'd probably stick to the conditions I listed above. Maybe I'd use it as an add-on for depressive symptoms in between bipolar episodes, or in unipolar depressed patients stable on medication but with some residual symptoms. I might suggest it to patients trying to stop using cannabis or cocaine. I don't treat children, but I think if I did, I'd feel more comfortable prescribing NAC for irritability than risperdal. If I ever had a patient with trichotillomania, I'd be willing to try it. And maybe as an adjunct for anxiety or something in schizophrenia.

The bottom line is probably that it won't hurt, and it might help.

Building a Website-The Pricing

First, I want to thank people who read my first website post and made suggestions about using Blogger, Wordpress, and Google for my website.  I'll incorporate those into my research.

I'm continuing to figure out which company I'm going to use to build my practice website. As part of my research, I found a wonderfully helpful site called, The Site Wizard, that contains all kinds of information like the definition of a domain name, and html tutorials. The author does not allow his material to be reproduced all or in part, so I'll just have to paraphrase, and you have the link.

The question of pricing is more complicated than I expected, because different website builders or platforms have different features, with different charges. So I've tried to narrow things down to basic costs-the site itself, and the domain name.

But let's discuss basics.

What is a Web Host?
A Web Host is a home for your website. The companies I've been looking at, Weebly, Duda, Squarespace, and Web.com, are all web hosts. They have lots of computers, or access to cloud space, where your website will live. Duda, for example, claims to offer hosting on Amazon Cloud.

What is a Domain Name?
If I want my own site, that I name myself, that doesn't belong to some larger thing like this blog does to blogger, I need a domain name, which is like a business name. As long as I register it and pay the annual fee, it's mine whether or not I choose to have a website associated with it. That makes me the owner of the domain name, and allows me to take it with me if I switch web hosts.

You register your domain name, for an annual fee, with an organization called, ICANN, which has a list of domain name registrar companies that you need to register through. GoDaddy, the website builder I rejected in my last post, is also a domain name registrar, so I may need to reconsider using it. Google is also a registrar.

Some web hosts provide a domain name free for the first year, and then charge the annual fee. Many let you import a domain name you already own for less money than they would charge for getting you the domain name. And reputedly, some dubious web hosts will register your domain under their name, making them the owner. But apparently, those companies are largely gone.

Domains also come in different suffixes, like .com, .org, .company, .biz, .education, and respective costs depend on something called, "TLD", or Top Level Demand.

So let's look at the cost of a website at the various companies, including a domain name, and let's assume I want to call my website, "MyPsychiatry.com," provided that name is available.

Let's also assume I'm not going to use the free sites available via the web hosts I'm considering. They exist, but they have ads, and I can't use my own domain name.

And finally, I'm just considering price in this post. I'm ignoring various features, for now, because it just gets too complicated to look at all at once.

Google would charge me $12/year for that name. Google would also need me to use blogger or squarespace or something as my web host, so that would be additional.

Squarespace charges $20/year for the domain name, including the first year, but that $20 fee doesn't increase in subsequent years, something I haven't seen clearly indicated on other sites. It also includes something called, "WHOIS Privacy" which I don't really understand but seems to protect some information about you, as the domain name owner.

Then there's the website fee. The personal site costs $16/month or $12/month billed annually, and if you get the annual plan, they waive the first year's domain fee. The Business site's corresponding prices are $26 and $18 per month.

Wordpress:

This is Wordpress' price chart for website plans. It doesn't say anything about an annual fee for a domain name.

Duda does not sell custom domain names. The'll set up a subdomain on their free plan, which would be mypsychiatry.dudaone.com. But if I want a custom domain name, I have to go elsewhere. They have lists of compatible registrars, including Hover and GoDaddy, but they have a partnership with Hover which allows you to purchase a domain name from Hover while you're setting up your Duda site. Hover's .com pricing is $12.99 the first year, then $14.99 for annual renewals.

This is Duda's pricing:

Duda does have that excellent one-time payment of $299 site for life deal. I checked, and you can switch from a monthly or annual plan to a site for life plan, but they do say they may not have that deal forever.

Blogger is probably the best deal, financially. The web hosting is free, and you can get a custom domain name through them for $10/year. Blogger allows up to 20 standalone pages, so I could include things like the Surprise Act form and my office policies. The main problem with blogger is that sites tend to look like blogs, not websites. Some people have done amazing things with customization, check out this article  and this one to see some impressive sites. But these were customized with html code, so if I knew html, this would be great, but since I don't I'd probably consult someone professional to help me at least get started, adding to the cost.

Weebly has a pretty good deal:

The domain is free for the first year, and $19.95 each additional year, with discounts for extended terms.

I really find GoDaddy unnerving. They have a domain name auction site, where you can purchase a domain name that someone else swept up. For example, mypsychiatry.com isn't available. But mypsychiatrist.com is available for $14.99/year, plus an initial $5700.00 purchase fee. I used the 2 decimal places so you wouldn't think it was $57. On the other hand, mypsychiatry.net and .org are each $11.99/year. As I mentioned in my last post, they also have web hosting, but I find interacting with their site very unpleasant.

Finally, I couldn't find domain name prices on Web.com. Mypsychiatry.xyz was available, as well as .net, but all the "pricing" said was, "Add to cart." So I added .xyz to the cart so I could see the price, and pressed "continue". It was $1.95/month (not year), with a "*" I couldn't find the text to, and an option to keep my information private or not. Then it asked for my information before giving me a real price, and that's where I stopped.

And now for the spreadsheet:

From a strictly monetary perspective, Blogger is the best deal. I'm now quite sure I'm not interested in GoDaddy and Web.com, so I'm ruling those out. Everything else is somewhere in between, and will depend on specific features.

I'm also wondering if the most useful thing I learned in researching this topic is that I should buy up a bunch of domain names and charge exorbitantly for people to purchase them from me.

Building A Website-The Template

I've been blogging for a little over three years now, which is hard to believe. I feel like I'm about average on the tech-y scale, and I certainly feel like a web presence is an important thing for any business to have. But I'm just starting to consider setting up a website for my private practice.

The main reason I've delayed this long is that since I don't use email to communicate with patients due to privacy/confidentiality and delay-in-treatment concerns, there didn't seem to be a point to a website where the contact information consists of a phone number.

Also, I knew I'd want an attractive, professional-looking site, but I didn't want to pay a lot of money to a designer for a site, the function of which is to get people to call me. There are some nice mixes of low and high tech, like a wooden iPhone case, or 3D printing a yarn winder, but a website with a phone number didn't seem to qualify as such a mix.

I finally decided to cave when I was researching my Analytic Evidence post, and I checked out the website of John Thor Cornelius, whose YouTube presentation I referenced in the post. I'm not sure how he'd feel about my linking to his site, which is why I haven't done so.

It's a thoughtful site, not glitzy, not overwhelming, but with all the information prospective and current patients might need about his practice, in addition to the ability to pay bills via PayPal, and I thought, yeah, this can be done well.

There are companies out there that design websites just for doctors, but they're expensive, and I don't need or want all the EMR integration stuff. So I've pretty much decided that, at least initially, I'll design my own site, for free, or for as little money as possible, and then see how it goes.

A few things I need to figure out before creating my site:

I need to decide what information to include on it. I'll need a decent headshot, contact info with a map feature, and a brief paragraph describing myself and my practice philosophy, which means I need to figure out what my practice philosophy is. I'm pretty sure I have one, I've just never articulated it. And I need to articulate it in a way that feels confident and inviting, but not exhibitionistic.

I need to decide how much information to provide about myself. Is a CV a good idea? Will that much information interfere with therapy?

I need some kind of description of what patients can expect from treatment.

I need to include my practice policies, which I already have written up. And I want to include the Surprise Act forms indicating that I don't accept insurance, and what my fees are, because that way I don't need to hand the stupid forms to my patients.

And I'd like patients to be able to pay through the site, but I need to understand how that impacts privacy.

I also need to pick a free or cheap website builder. I did several online searches including "build your own website free", "website builder for physicians,", and "best website builder for doctors". After googling around, I found a few I want to look into:

Weebly
Wix
Sitebuilder
Duda
Squarespace
GoDaddy
Web.com

Web.com seems to have the highest rating when I looked up reviews, but my first concern was the template. Specifically, I wanted to find a template that looks like it's professional for a doctor, not professional for a lawyer, or a restaurant, or a dog-walker. My theory is that if such a template exists, then the company has probably had a number of doctors design sites through it, which feels like a "safer" bet to me. I don't want my site to look amateurish, but I also don't want it to look like I'm a graphic designer or the APA.

Note that contrary to my inclination, I'm not including images because I assume these sites are pretty proprietary with their stuff. Or maybe I'm wrong and they want the advertising.

Sitebuilder has a template category specifically for professional services, and it includes a physician page which is a little slick for my taste, but usable. What I didn't like about it was that it was the only site for which I had to register before I was allowed to see the available templates.

Weebly's closest business theme was for a law firm, and the next closest theme was a personal one that was basically a large business card.

Similarly, Wix's closest templates were Dentist and Doula.

Squarespace had nothing specifically medical, but I thought it had the most aesthetically pleasing themes.

GoDaddy has what I think of as a "jittery" site, where there's too much information thrown at you at once, and you just want to close the page. I don't think that bodes well for my own site. I did briefly look at their templates though, and I didn't much care for them.

The same was true for web.com-too busy, with only a small sampling of templates, all fairly ugly.

My favorite was Duda, which allowed access to templates, and had a specific medical template that looks about right to me. Also, their templates are responsive, which means they adjust themselves to whatever device the user is on, and can be customized for specific devices, i.e. you can make your smartphone page a bit different from your laptop page.

Well, okay, just this one image, since I'm saying it's my favorite:

Here's a spreadsheet summary of the templates:

Based on this information, I'm going to rule out GoDaddy, Sitebuilder, and Wix. I'm not crazy about Web.com but I'm going to keep it in the running because it gets consistently high ratings, so maybe there's more to it than I've seen thus far.

OOOOOOKLAHOMA!

Good news for doctors in Oklahoma, also known as the "Sooner State", "...in reference to the non-Native settlers who staked their claims on the choicest pieces of land prior to the official opening date."

I learned from an email from the National Board of Physicians and Surgeons (NBPAS, See, "Another Board", and "Summing Up 2015"), that in response to pressure from physician groups like NBPAS, the Oklahoma state legislature has passed a bill stating that Maintenance of Certification (MOC) cannot be required as a condition of licensure, reimbursement, employment or admitting privileges. The bill was approved by the governor on April 11, 2016.

The link to the bill is here. You need to click on "SB1148" in the upper left-hand corner to view the actual bill. The relevant language is the following, with an otherwise identical clause included further on for osteopathic doctors:

G.  Nothing in the Oklahoma Allopathic Medical and Surgical Licensure and Supervision Act shall be construed as to require a physician to secure a Maintenance of Certification (MOC) as a condition of licensure, reimbursement, employment or admitting privileges at a hospital in this state.  For the purposes of this subsection, "Maintenance of Certification (MOC)" shall mean a continuing education program measuring core competencies in the practice of medicine and surgery and approved by a nationally-recognized accrediting organization.

Go, Oklahoma! And because I'm a little giddy about this small but important victory, I'm including this Sesame Street clip:

Investing in Mental Health

According to the NY Times, which does not lie, while mental health care is scarce in parts of the US, it's virtually non-existent in most of the world, with one mental health professional per 1 million people in developing countries.

This is the push behind the World Health Organization's (WHO's) goal to, "...move mental health to the forefront of the international development agenda," and the focus of a conference in Washington this week.

In support of this goal is a paper published yesterday in the Lancet Psychiatry, Scaling-up treatment of depression and anxiety: a global return on investment analysis, by Chisholm, et al. The study was funded by Grand Challenges Canada, which supports, "Bold Ideas with Big Impact in global health," and is, itself, funded by the Canadian government.

I was curious about the study, in particular, how they went about assessing something huge like economic impact of mental illness, and what interventions they think would be helpful. They used the OneHealth tool, which you can download here, to estimate the number of people with depression and anxiety disorders living in 36 large countries, constituting 80% of the world's population, and 80% of the global burden of depression and anxiety disorders. The countries were a mix of low-, middle-, and high-income. Incidentally, I didn't download the OneHealth tool even though it looks really interesting because it's designed for Windows, feh, and I would have to do funny things to my precious Mac to use it. But there's an introductory tutorial on YouTube, and boy does OneHealth have a lot of fascinating data for countries, and powerful functionality.


Quite reasonably, in my opinion, they excluded prevention as a type of treatment, because the evidence for it is weak, and not easily generalizable. Interventions included, "...basic psychosocial treatment for mild cases, and either basic or more intensive psychosocial treatment plus antidepressant drug for moderate to severe cases." The choice of intervention is based on WHO's Mental Health Gap Action Programme (mhGAP), where the recommended treatment for moderate to severe depression is:

Anxiety and mild depression are considered, "Other Significant Emotional or Medically Unexplained Complaints." In those cases, the recommended treatment is:

INT are advanced psychosocial interventions which take, "...more than a few hours of a health-care provider’s time to learn and typically more than a few hours to implement." They include Behavioral Activation, CBT, Contingency Management Therapy, Family Counseling or Therapy, Interpersonal Psychotherapy, Motivational Enhancement Therapy, Parent Skills Training, Problem-Solving Counseling or Therapy, Relaxation Training, and Social Skills Therapy.

I have to say I'm a little skeptical about how effective these interventions will be. However, their computations were based on the assumption that there would be only a 5% improvement in the ability to work, and productivity at work, as a result of treatment. So their expectations were modest-if someone would normally miss 20 days of work per year, how much money would it cost or save if that person only missed 19 days per year. At least, that's how I understand it.

They were looking for the total cost of scaling-up treatment, as well as effects on three categories:

Health Return = increased healthy life years gained as a result of treatment
Value of Health Returns = I don't really understand this
Economic Return = enhanced levels of productivity


One table I initially skimmed over but now realize is quite important is:

Current and target levels of scaled-up treatment coverage for depression and anxiety disorders (all interventions combined), by country income level 

It reflects the idea I pointed out above that their expectations are modest. Currently, 7% of people who need it get treatment in low-income countries. With the scaled-up program, that number will rise to 34%, which means that 2/3 of people who need treatment won't get it.

The article notes that, "...very few studies have assessed the extent to which effective depression treatments get people back into work." So that's an important question to try to answer. They looked at absenteeism, meaning days lost to work, and "presenteeism", meaning partial days of impaired activity while at work. I guess that includes things like staring off into space.

Let's review. They used this powerful, OneHealth tool to see how many people in the world suffer from depression and anxiety. And they also used the tool to determine the economic impact of these illnesses when they're treated, and when they're not treated. Then they figured out how many more people would need treatment in order to get a 5% increase in productivity. They estimated the cost of the additional treatment, and they estimated how much money would be saved (or made, depending on your perspective) by having that many more people back at work.

And this is what they found:

Costs and benefits of scaled up treatment of depression and anxiety disorders, 2016–30

The total investment is $91.5 billion for depression, plus $55.7 billion for anxiety, equals approximately $147 billion.

They claim that, "...scaled-up treatment leads to 43 million extra years of healthy life over the scale-up period [2016-30]." I don't understand how they determined this, but they placed an economic value on these healthy life-years, the "Value of Health Returns".  For depression, it's $258 billion, and for anxiety, $52 billion, for a total of $310 billion.

In terms of economics, they got $230 billion for depression, and $170 billion for anxiety. That's a total of $400 billion.

To summarize, just looking at pure dollar amounts, over a 15 year period, you put in $147 billion, you get out $400 billion, yielding a total benefit to cost ratio of 2.3-3 : 1.

The discussion describes some limitations. For example, it notes that is a modest return on investment. By comparison, in another OneHealth model, the benefit to cost ratio for malaria was 28-40 : 1. But they also mention that they didn't include things like reduction in unemployment- and welfare-benefits in their analysis, so that could change the ratio.

Another limitation is that unlike the prevalence of of depression and anxiety, the prevalence of treated depression and anxiety is unknown. Meaning that even if you invest in and set up programs, they may not be implemented well. Also, treating more people, for example in remote locations, may drive up the cost of treatment.

Plus, the study didn't consider the negative effect of maternal depression on early child development, the health, social, and economic benefits of effective treatment of maternal depression on the cognitive and physical development of newborns, the monetary and non-monetary impact of effective treatment on family and other caregivers, and the effect of depression and its treatment on physical health outcomes.

To these considerations I would add my own concerns about the particular interventions the WHO recommends. However, I will concede that while the whole endeavor is about the bottom line, and may not make that much emotional difference to that many people, some people will be helped, and that's more than are helped now. And, more importantly, if things work out like they want them to, they will have demonstrated that helping more people actually saves money. I hope they're right.