The WHO estimates that depression and anxiety together account for 75,000,000 DALYs annually, making up ~5% of total DALYs. In “Measuring the Impact of Mental Illness on Quality of Life”, I argue that there is good reason to think that the system used to generate these estimates severely underestimates the impact of mental illness, and thus the true damage may be much higher. To try to get an estimate on the harms of mental health and the benefits of alieviating mental health problems, I did a preliminary cost-effectiveness analysis of Mindfulness Based Stress Reduction (MBSR).
MBSR is an eight week class that uses a combination of mindfulness, body awareness, and yoga to improve quality of life and perhaps physical health for a variety of conditions.
MBSR was created by Jon Kabat-Zinn at the University of Massachusetts in the 1970s, but has spread widely since then. The exact extent of this spread is hard to measure because no official registration is required to teach mindfulness and many classes and books claim to be mindfulness inspired. For the purpose of this evaluation I looked only at things that were officially MBSR or adhered very closely to the description.
Cost of MBSR
Herman, et al. (2017) estimated the marginal cost of an MBSR class participant at $150. The first three hits on google (run in an incognito browser but suspiciously near the location from which I ran the search) for MBSR listed a cost of $395-$595, $275-$425, and $350. The difference between the top of the range and the marginal cost indicates that the high end of that range probably covers all of the costs involved with MBSR (space rental and instructor time for eight weeks of classes plus one eight hour retreat) and then some, so I will use $600 as the ceiling on costs and $150 as the floor.
MBSR has an unusually high time ongoing cost (one hour per day). To model this, I included a range of DALYs as a cost, ranging from 0 (indicating no cost) to 1/24 (as if the participant were dead for that hour). It is unclear how the one hour duration was chosen and I could not find any studies on the comparative impact of different lengths of meditation; it’s quite plausible one could get the same results in less time. For the purpose of this document I used the official program, because it was the most consistently studied.
Cost Effectiveness Analysis of MBSR
Both depression and anxiety are measured with a variety of clinical surveys. To estimate impact, I assumed that the top score on each survey caused a DALY loss equal to severe depression/anxiety, as estimated by the World Health Organization, and that a drop of N percentage points led to a drop of disability weight * N. For example, a drop of 8 points on an 80 point scale of anxiety (disability weight of severe anxiety: 0.523) causes a gain of .0523 DALYs.
For a survey of papers showing potential impact, see this spreadsheet. The estimates range from 2% to 11%, clustered around 7%.
I have created a Guesstimate model to estimate the impact of MBSR. Results were quite promising. On a randomly selected guesstimate run, the average cost was $290/DALY, with a range from $43/DALY to $930/DALY. This is close to but better than Strong Mind’s $650/DALY and overlaps with estimates of antimalarial treatment ($8.15-$150/DALY). Note that the MBSR estimate may understate the impact due to systemic biases in how DALYs are calculated. However it may also overstate the impact, as medical studies tend to overstate intervention impacts for a variety of reasons.
The model makes no attempt to account for co-morbid disorders. Individuals with depression and anxiety would likely see higher benefits, since the same hour of meditation would impact both.
This model makes the rather optimistic assumption the benefits persist for life. This assumes that the participant would have been counterfactually depressed forever without treatment. In reality the average depressive episode lasts six months, and of people who have suffered at least one episode, the average lifetime number of episodes is four. If we assume the participant gets two years of benefit out of treatment the cost becomes $1200 to $14,000/DALY, with an average of $5200/DALY.
All of the effectiveness studies cited were done on developed world citizens with only mild to moderate mental illnesses. Most were middle aged, and access to MBSR implies a minimum SES bar. It is possible that more severe depression is not amenable to MBSR, or that it is amenable and shows a larger absolute change because there is farther to improve.
I could find no studies on MBSR in the developing world, although since mindfulness meditation was originally created before there was such a thing as the developed world, there is a higher than typical chance that its usefulness will survive cultural translation.
All of the studies referenced had small sample sizes. They all show a consistent effect, but it’s possible publication bias is keeping negative studies out of view.
Official MBSR has an unusually high time cost compared to medication and therapy. The costs are high both upfront (eight weeks of classes and an all day retreat) and ongoing (one hour of meditation/day). Some patients may be able to get the benefits of MBSR with less time; others may not be able to practice at all due to the time demands.
For more on this see my shallow review of mental health .
12 thoughts on “Cost Effectiveness of Mindfulness Based Stress Reduction”
“run in an incognito browser but suspiciously near the location from which I ran the search”
If you’re using private browsing mode the server still knows your IP address, which is usually enough to get your city.
If you want to hide that as well, you’d need to use a VPN or Tor. Though even then you’ll still get results that are geocoded to somewhere (the VPN provider’s location, or the location of the Tor exit node) just probably not where you physically are.
“I included a range of DALYs as a cost, ranging from 0 (indicating no cost) to 1/24 (as if the participant were dead for that hour).”
Since people are generally only awake ~16hr/day, 1/16th seems like a better upper bound to me?
So for $290 one year of quality-adjusted life is gained?
That’s in the range of viable answers, yes.
Most of the links in your sheet “Estimates of Effect of MBSR on Anxiety and Depression” aren’t working for me.
I’m surprised that the study you cite, Herman, et al. (2017), is about costs in the USA, finds that it is cheaper to administer the treatment than it is for StrongMinds, which operates in sub-sarahan Africa.
Also, the reason you ultimately still get _better_ cost-effectiveness numbers than we did in our analysis of StrongMinds, is that you assume the benefits will continue to accrue for an average of 41 years (relative to the counterfactual). That seems quite optimistic.
For instance, Reay et. al finds that the treatment effects decay over time:
> As StrongMinds’ impact assessment only measures absolute effect, the model proxies counterfactual impact by relying on Reay et al. who compare the trajectory of IPT-G patients’ depression with an untreated control group. The model extrapolates Reay’s comparison over a ten year span to arrive at a total multiplier of original impact over time that is applied to the baseline treatment effect.
The original estimate for StrongMinds took their total budget and divided by the number of participants, which gets you the average cost, not the marginal. This is likely to look especially bad because it was a new NGO with start up costs. This has apparently gone down (http://effective-altruism.com/ea/1ha/mental_health_shallow_review/cq1?context=3)
I assume decay function with a max of 41 years, not an average of 41 years, but you raise a good point and I’ll look into the model you link to below. Thanks.
On one Guesstimate run, I get an average of 37 and a median of 42, with the following probability distribution: https://snag.gy/gIm0Py.jpg
re marginal and average: that’s true, and a good point, but it’s also true that at reasonable margins you’ll need to pay more rent, operations staff overhead, etc. But I now agree that something in the $100-500 range for a US-based MBSR participant, does not sound unreasonable.
> If we assume the participant gets two years of benefit out of treatment the cost becomes $1200 to $14,000/DALY, with an average of $5200/DALY.
It may help readers of your blog if you frontloaded this new estimate a little bit more, since it is eighteen times larger than $290/DALY.
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