The Moral Urgency of Mental Health | Hacker News Reader

The Moral Urgency of Mental Health

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55 pointsarikr41 comments

> Overall, the researchers claim, eliminating depression and anxiety would reduce misery by 20%, whereas eliminating poverty would reduce it by just 5%.

Why are these framed as independent factors? For many people the lack of financial stability is a primary source of depression and anxiety. When you truly don't know how your are going to afford next week's food/medication/rent, survival instinct kick in causing anxiety and huge mental burden that can make it difficult to focus on anything else.

One of the easier ways to fix a large amount of depression and anxiety is financial stability.

> If your neighbor becomes richer, you feel poorer.

While, I completely support increased funding to mental health services for everyone, as someone trying to figure out how to pay for a new $100/month insulin prescription with a laughably tiny disability check and a medicare "donut hole", this is pretty offensive. Feeling bad because you can't keep up with the consumerism rat race isn't "misery".

> Why are these framed as independent factors?

Because people have lived in poverty for thousands of years without debilitating depression and anxiety.

One can live in poverty without living in misery.

> as someone trying to figure out how to pay for a new $100/month insulin prescription

Last weekend, another internet stranger recommended prescriptionhope.com, which charges $50/mo/script. [0]

> Why are these framed as independent factors? For many people the lack of financial stability is a primary source of depression and anxiety.

Not only that:

- poverty "can change your genes and increase your chances of depression" [1]

- relieving poverty (by $73/mo) "significantly improves mental health" [2]

- "anxiety disorders in poor moms likely to result from poverty, not mental illness" [3]

Of course, not everyone agrees. Some researchers found that improving mental health led to improved financial situations (and not the other way around.) [4] Regardless of which has a larger causal effect on the other, studies continue to show the two are certainly linked, and not independent factors.

[0] https://imgur.com/gallery/ROYXD

[1] https://www.independent.co.uk/news/science/depression-anxiet...

[2] blog/news writeup: https://www.madinamerica.com/2015/11/relieving-poverty-signi...

abstract: https://link.springer.com/article/10.1007/s10597-015-9950-9

[3] https://www.sciencedaily.com/releases/2012/07/120720083312.h...

[4] https://www.theatlantic.com/health/archive/2011/10/poverty-a...

Yes and no. Purpose, structure, exercise/activity, nutrition, sleep, support and not constantly living in uncertainty, stress, misery and/or isolation help. (In my case, treatment-resistant depression is the default setting irrespective of circumstances, Maslow's hierarchy items or socioeconomic status.)

LA's skidrow and Cook County jail's mental healthcare system are quintessential consequences of deinstitutionalization (d20n). Institutionalization, as it existed prior to 1973, was certianly slavery illegal under the 13th amendment (Souder v. Brennan) and not about the panacea of meds or uncaring Reagan. If institutions had simply been funded properly instead of being capriciously abolished, the costs vs. externalities to patients and society would've been far less (ie self-medication, police costs, hospital costs, etc.) Simply, d20n diffused the responsibilities and costs for necessary social services everywhere else, but they didn't and won't magically disappear because people are still people. The moral thing to do is rebuild sufficient and various levels of mental care facilities with proper funding such that patients get services they may not know they need, instead of dying slowly and miserably at a bus station.

Another big failure of d20n was the canyons which patients fell into when they were sent to underfunded, poor execution of Kennedy's legacy for Community Mental Health Centers, which left many homeless and in limbo. Instead of a spotty patchwork of services, US counties must be required to coordinate services and provide any missing that comprehensively address: drug treatment, social rehabilitation, housing, work, training/education, health/dental/vision/mental health and social work without the patchwork of duct-tape, missing services and callous neglect that exists today. Homeless people are people.

> In the United Kingdom, it costs about £650 per patient to provide psychotherapy, which is effective for about 50% of patients. That figure indicates how much governments would need to spend, but does not take into account what they might get back.

they don't appear to provide a source for this. The English NHS collects, and publishes, a lot of data for the IAPT (Improved access to psychological therapies programme). IAPT provides access to short forms of therapy such as cognitive behaviour therapy (which would normally be about 7 weeks).

http://www.digital.nhs.uk/catalogue/PUB30153

> In August 2017 there were:

> 113,541 new referrals

> 83,330 referrals entered treatment

> 47,100 referrals finished a course of treatment, of which:

> 88.5 per cent waited less than 6 weeks and 98.9 per cent waited less than 18 weeks to enter treatment

> 43,922 started treatment at caseness, with 50.8 per cent moving to recovery

there's a large unweidly spreedsheet with results for each provider.

the latest figures are here: http://content.digital.nhs.uk/iaptmonthly

psychotherapy is less than 10% effective. In fact, its almost no science.

And when it goes wrong the practitioner will lie in your medical records to cover it up. When it goes even more wrong and the person is dead they'll just say "s(he) had serious issues". Having said that, I've seen it do wonders for some people.

It worked really well for me, but I probably wasn't as mentally ill as a lot of people who would seek psychotherapy. Either that or my therapist was just really good or we had a good working relationship.

Trying to act on how I feel continues to be the hardest thing I have ever had to do.

Not sure if you're religious it not, but let me phase it like that. God put you on Earth to be you and do it your way. In an evolutionary context, it's a random process where the value of an individual can only be determined in hindsight after you're gone. Hence you need to be you and leave judgement to the ages. If you're at all concerned about that, you're a long way from being cluster B or dark triad, so don't sweat it.

Citation please, preferably a meta-analysis.

It does provide a source, if you click on the anchor for the cost, which seems to be the basis for the whole article given that the summary sounds so similar: https://www.penguin.co.uk/books/184573/thrive/

I'm sure that number conveniently omits continuing costs, and provides no standard for what effective means.

This doesn't touch on a potentially even bigger barrier to adoption of better mental health care: that those who benefit from better mental health care often aren't the people paying for it, and that it is really really hard to measure the specific financial benefits of improving mental health in a way that will convince payers / employers / government to actually put real money on the line

Mental Health for those in crisis is fucked. If you feel suicidal, you get locked up. It’s as simple as that.

While simultaneously, you can have a person clearly unable to provide self care who is denied access to any kind of inpatient care because they are not "a danger to themselves or someone else."

My own personal theory on this matter is that a lot of emotional state is feedback loops.

Have a positive environment where things tend to go well and everyone else likes you? Then you share in to that same environment (drink the Koolaid).

Have a mostly neutral or slightly negative environment? Then you end up circling the drain hoping to have an energy exchange that allows you escape velocity in to the above rather than...

Having a mostly negative environment; even if it's just a little. The slow crushing weight of reality and those around you chips away at every part of your being and self until there is nothing left but a broken and hateful individual. May become either a neutron star (hermit) or go supernova (usually leading to jail or death).

Well, not necessarily. About 6 years ago I checked myself into the ER in crisis and was released 4 hours later because I had checked myself into the ER.

Mental health needs to be a huge priority.

I have several teenager relatives all depressed. The constant social media and comparisons to the top 10% of people in beauty, intelligence, money, and etc are destroying them. Ive caught my teenage nephew and niece watching tons of plastic surgery qa on youtube.

We really need to get our primate impulses in check. Im hoping the research on brain implants will help overcome our ugly genetic history.

I am hopeful that we will soon see AI-based psychotherapy available at scale at a price such that anyone who wants it will be able to get it. I can imagine that it would be more or less like having a telephone conversation with a real therapist, except in this case the therapist is an AI application running in a datacenter.

I think we will see something like this in the next five to ten years.

Thoughts?

Are you familiar with: https://woebot.io/

It acts as a cognitive behavioral therapy tool.

I was not. Thank you for that link.

Thank you for sharing this!

It would be great if that were possible, but a lot of the value of therapy comes from the therapeutic relationship rather than a specific type of therapy. Most types of psychotherapy tend to have the same level of effect in studies, suggesting there is no "recipe" for the type of therapy that works. This phenomenon also suggests (but does not prove) that the human relationship, rather than therapeutic program, accounts for the measured improvement in outcomes

Not to say an AI tool wouldn't be helpful for some people, but it isn't clear it would be that useful. And i don't know of any evidence or plausible hypotheses that an AI tool could work for anything other than mild anxiety or depression

AI + human therapy could potentially be better than human therapy alone however

I thought Cognitive Behavioral Therapy was actually the only kind of talk therapy that showed greater effect than placebo.

Cognitive behavioral therapy is a more standardized and measurable type of therapy than things like interpersonal therapy or problem solving therapy or psychodynamic therapy, and thus it is easier to study in a controlled setting. So there are more studies of CBT than other types of therapy just because it is easier to study

I don't have references offhand but there are controlled studies that show benefit of other types of therapy

Overall all though, all psychotherapy studies are messy

That makes sense. If you want to go beyond self reporting, you have to use very long term measures like employment, incidence of suicide, etc. And of course it's very hard to guarantee that an individual pursued and sustained a specific type of therapy for a substantial amount of a long term study period.

The idea you're raising, the differential efficacy of CBT, is a myth originating in the politics of psychiatry and psychology, especially in the 70s and 80s. There is abundant evidence for psychotherapy, but no evidence that any type is better than any other, especially when you control for publication bias. It's the "common factors" phenomenon, where therapies that have some baseline characteristics all do about equal. It's well documented and known, but people in the field often pretend it doesn't exist.

There may be some tendency for some therapies to work better for some people more than others, but identifying how to match people to therapies hasn't been demonstrated well or replicably.

Interesting. Is this based on your personal observations of the published literature or are there systematic reviews that concur?

I think it would be helpful in a different way. To put it simple, it would give people in suffering, more time to talk.

I don’t think it can replace the human relationship, but it could act as helper, a listener, or something between the patient and the therapist. It could listen for hours very cheap, provide feedback, replay things previously said by the patient helping in auto reflection, create a report for the therapist, etc.

Yes, we do need the therapeutic relationship, but for most that is too expensive. Take for example someone that can only afford 2 therapies a month. That’s simply not enough in times of crisis, when the thoughts in your head can be compared with a bull stampede.

That's a really good point and I agree that those tools could really help people. Anonymous expression of suffering can be therapeutic; people say things to Siri that they've never told anyone

I just have an adverse intellectual and emotional reaction when I hear people suggest AI / some app is the solution to mental illness. It devalues the hard and thankless work that therapists do, reduces people's deep suffering to a trivial engineering problem, naively presumes superiority to the centuries of research humankind has done on the mind and suffering, and is just logically and factually incorrect

There are plenty of ways to improve access to care that would have more cost-effective benefit than AI. If people started investing in those then maybe we could actually see some improvement

/endrant

Yeah, a trivial engineering problem, what could possibly go wrong?.

I wonder which are those other cost-effective ways to improve access to care you refer to...

Was probably aggressive to characterize it as "trivial"

Some examples of cost effective interventions include better mental health and substance abuse treatment in primary care (methadone tx for example), integration of medical and behavioral health reimbursement and relaxing some onerous rules like not being able to bull for medical and behavioral services on the same day (though I think this is improving), better training and supervision for mental health professionals, more rigorous research into group therapy, Better education on psychiatric meds for PCPs, more follow up etc

This seems like a case where you have downgraded the meaning of "AI" to match its current commercial connotations. A relationship with an AGI >= a relationship with a human, at least in intellectual terms.

The big hope, that AFAIK we have not abandoned, is that AGIs will be able to walk into a messy human situation, diagnose exactly what the dynamics are, and recommend the optimal thing to do to fix things. This could happen via an ELIZA-like interface or through a broader perceptual engagement. The point, though, as the GP suggested, is that AGI could quickly learn to far exceed the perceptiveness and skill of a human therapist, and do so on an inconceivable scale.

It's the idea of developing an "ecology of mind", as Gregory Bateson put it. To be able to diagnose quickly and accurately disorders (individual and collective) that currently require lucky individual insights and experience to identify.

My broader point was that much of the benefits of psychotherapy can be attributed to social or emotional factors, not intellectual factors. While there is considerable debate about this, a lot of people are of the mind that therapy is not about precisely diagnosing some issue and then saying something to a patient to optimally fix things. If AI becomes emotionally and socially intelligent, maybe they can do good therapy. But if you think that mental illness can be solved through deterministic problem solving, logic and recommending the optimal thing to do to fix things, i would view that perspective as not consistent with our current understanding of neuroscience and mental illness

I'd question whether you are trying to reduce the problem of mental illness to fit the capabilities of the tool you are working with, rather than trying to earnestly understand the problem

I'm a mental health service user who has experienced psychosis and multi-week hospitalisation. I know what I'm talking about when I express hope for a more objective and -- ideally -- by today's standards seemingly omniscient AGI for treatment/therapy. Human therapists are unfortunately variable in quality, and they often participate in a system of casual oppression of the mentally ill, even if you discount whatever they charge for their services.

So, I don't lack earnestness. On the contrary, I strongly believe in a reductionist model of the brain. Who would deny that a sufficiently advanced AGI should be able to diagnose and treat mental illness, enlisting whatever social and emotional (or biopsychosocial) interventions are necessary or economical.

You seem to be waving your hands and saying that physical reality is not susceptible to deterministic modelling and interventions; or maybe you just mean that the brain is too complex for AGI to grasp. Either way, I think you overestimate the diversity and functional complexity of mental disorders, and underestimate the capability of a focused diagnostic intelligence. The promise of AGI is that it will get to the bottom of the dynamics of the patient's disorder. Once you have that picture, you can deploy appropriate social/emotional resources (and much more economically, which means it could actually happen in dysfunctional health systems.)

Even if it's just "good enough" and in the right direction. That would be a huge improvement on the existing situation.

As for AI being "the tool I am working with", I'm not involved in AI/ML in any way. AGI to me means human-equivalent intelligence, however implemented. The hope that it could be massively augmented relative to a human expert is uncontroversial (for example, it is anticipated in the way that self-driving car systems will learn from parallel acquisition of data by many vehicles.)

So, as a patient, it seems to me that better insight into the dynamics of the illness (via AI) is a huge potential benefit. Human generosity and empathy is often helpless in the face of severe mental illness -- relatives suffer for years without any hope of improvement. So I'm not sympathetic to the idea that what is needed is just more uninformed but kind and generous front-line human cannon fodder. Mental health is a very difficult profession.

Thank you for the detailed response, and I apologize for the assumptions I made about your background. I just get a bit upset and irrational sometimes about this subject, because it is one I care a lot about

I understand that human therapists can do just as much harm as good and that a lot of patients are treated terribly by the system. I think the best way to have near term positive impact on patients with mental illness is to expand access to current evidence based care and high quality practitioners. I am not talking about generous and kind front line human cannon fodder, but service models that expand access to high quality evidence based care and support and empower the mental health professionals that deal with severe, complex patients so these patients don't have to deal with terrible destructive therapists

For serious mental illness and psychosis, I understand that expanding access to services is not always enough, although we do have existing pharmaceutical interventions that can help certain patients, and that improving access to some of these medications could be helpful.

I appreciate your comment that I am "hand waving", but I believe that proponents of an AI solving mental health are likewise hand-waving and assuming that mental illness can 1) be reduced to a problem that is tractable with current or near term AI tools or 2) that the singularity and godlike AI is inevitable. As far as I know, both of those are beliefs, not foregone conclusions. I am open to being convinced, but i have not seen any solid evidence or specific hypotheses for how AI would help mental illness beyond chatbots, and while chatbots can certainly help some people they will not be a cure all

I would love to see evidence that I am overestimating the diversity and complexity of mental illness. From what I understand we don't know enough about these conditions to know how complex and diverse they are, but our current tools have failed to bound or characterize the complexity or diversity of mental illness in a way that make them tractable problems. Decades of study of the genetics and mechanisms of depression have failed to yield any breakthroughs, and we couldn't even predict which genes are associated with the disease (no serotonin / dopamine genes are that strongly correlated with disease). Fmri and eeg have horrible resolution and do very little to elucidate biochemical pathways. No new drugs with novel mechanisms have been developed for psychiatric disorders in decades. I'm not an AI expert by any means, but without tools to collect useful data, I can't see how AI could deliver much that is useful in terms of characterizing the biology of disease and intervening

Rather than invest in AI, I would like to see more investment in higher resolution, dynamic tools to analyze molecular pathways in the brain in Vivo. That would probably generate enough low hanging fruit that you could develop better treatments without AI tools

I went to a talk by Tom Insel, the former head of NIMH who was at Verily and now at a MH startup, and he told a story about how he gave a talk on the research of genetics in mental illness to a group of patients and their families. A parent of a child with sever mental illness stood up and said "you don't get it. The house is on fire and you're talking about the chemistry of the paint". Maybe I'm missing something, but I sort of feel like this when people talk about AI or apps for mental illness

Anyway I appreciate you sharing your thoughts so objectively, fairly and openly and hope that mental health care will improve through AI or other means

Overall, the researchers claim, eliminating depression and anxiety would reduce misery by 20%, whereas eliminating poverty would reduce it by just 5%. If we want to reduce misery in the developed world, then mental health is the biggest challenge we need to overcome.

Everything I have ever seen suggests that the chronically poor have intractable personal issues, such as medical problems, mental health problems, learning disabilities or other personal issues. So this seems like a false dichotomy to me.

I would see it as less a false dichotomy than just recognizing that these issues are not always orthogonal.

I don't really understand that use of the word orthogonal.

But for clarity's sake: I have read about issues like poverty for decades. In any given year, about 10 to 15 percent of Americans are below the federal poverty level. But only about 2 percent of Americans are chronically poor. This is typically defined as below the federal poverty level for at least 5 years out of 10.

In fact, I have even seen stats that suggest that being in the bottom 20 percent in one year is actually a reasonable predictor for being in the top 20 percent the following year. Some people below the federal poverty level in a given year are temporarily unemployed and job hunting. In some cases, they are actually starting a new business. So, most folks don't stay below the poverty level.

The people who are chronically poor are the ones that have significant personal challenges. These personal challenges both make them miserable and are also a root cause of their poverty. If they can't resolve their personal issues in some manner, they remain poor.

I have not only studied such things, I have lived it. Misery is not just having X problem, but knowing that you may never be able to resolve it and that the world does a really sucky job of providing some means for people like you to have some kind of baseline level of comfort. It is a kind of personal hell.

> I don't really understand that use of the word orthogonal.

You can imagine a two-dimensional graph with the quantity "intractable personal issues" on one axis and "chronically poor" on the other. But when the level of chronic poorness varies, sometimes the level of intractable personal issues varies as well, leading to the motion of the quantity along both axes at the same time.

That is moving the measurement in one dimension sometimes results in its motion in the other dimension, so there is no way to move completely orthogonally(perpendicularly) to one axis. This is what is meant by "not completely orthogonal."

Thanks. One of the great mysteries of HN may have just been solved for me.

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