‘What role should mental health costs play in the evaluation of public health interventions such as lockdown?’ In Conversation Professor Edmund Sonuga-Barke

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In this podcast we talk to Professor Edmund Sonuga-Barke, Professor of Developmental Psychology, Psychiatry and Neuroscience at King’s College London, and Editor in Chief of the Journal of Child Psychology and Psychiatry (JCPP).

Edmund talks us through the purpose of his latest JCPP editorial ‘No pain – No gain’ – Towards the inclusion of mental health costs in balanced “lockdown” decision-making during health pandemics. He breaks this down into three sections; why we should look at the benefits and costs of lockdown to see if the intervention works, the barriers stopping people from taking this approach, and the potential path to addressing those barriers.

Edmund highlights the current need for discussion and debate around this topic and encourages listeners to share their thoughts.

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Professor Edmund Sonuga-Barke

Edmund Sonuga-Barke is currently Professor of Developmental Psychology, Psychiatry and Neuroscience working in the School of Psychiatry at the Institute of Psychology, Psychiatry and Neuroscience, King’s College London. He is an Honorary Skou Professor at Aarhus University, Denmark. He is Editor-in-Chief of the Journal of Child Psychology and Psychiatry. His work integrates Developmental Psychopathology and Neuroscience perspectives employing basic developmental science approaches to study the pathogenesis of neuro-developmental and mental health conditions; their underlying genetic and environmental risks, mediating brain mechanisms and developmental outcomes. Motivated by his own childhood experience of growing up with learning difficulties he has a particular interest in ADHD and related disorders. In 2016, Prof Sonuga-Barke was elected a Fellow of the Academy of Medical Sciences and 2018 a Fellow of the British Academy.


Interviewer: This podcast is brought to you by the Association for Child and Adolescent Mental Health, ACAMH for short. You can find more podcasts and other resources on our website, www.acamh.org and follow us on social media by searching ACAMH.

Hello, and welcome to the In-Conversation podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology Today I’m interviewing Edmund Sonuga-Barke, Professor of Developmental Psychology, Psychiatry and Neuroscience at King’s College London, and Editor and Chief of the Journal of Child Psychology and Psychiatry. The focus of today’s podcast will be Edmund’s recent editorial in the July 2021 issue of the JCPP. No pain, no gain towards the inclusion of mental health costs in balanced lockdown decision making during health pandemics.

If you’re a fan of our In-Conversation series, please subscribe on iTunes or your preferred streaming platform. Let us know how we did with a rating or review and do share with friends and colleagues. Hi Edmund. Thanks for joining me. Can you start by introducing yourself?

Professor Edmund Sonuga-Barke: Well, I think you did a very good job. I’m a professor in the Department of Child and Adolescent Psychiatry and I have been Editor and Chief of the Journal, I think now is my 11th year for my sins.

Interviewer: We’re going to focus on the latest editorial in the JCPP which is No pain, No gain, Towards inclusion of mental health costs in balanced lockdown decision making during health pandemics. Edmund, what was the purpose of this editorial?

Professor Edmund Sonuga-Barke: So I really wrote it to get a discussion going about what I think is one of the most critical questions for our field at this time. Well, just about in the wake of the covid-19 pandemic, and it’s a question that my colleagues, I think or the field in general have been very reticent to get involved with. So I thought, yeah, I think it could do a service for the field to raise it and hope that I get some reactions and responses and get people talking about this question.

And the question is, of course, what place should mental health costs take or play in the evaluation of public health interventions such as lockdown? It’s kind of surprising, people haven’t been discussing this because it seems something that’s really obvious to everybody, but nobody is talking about it, and that’s particularly because, of course, at the start of the pandemic quite serious impacts on mental health and of course, on quality of life more generally were anticipated by everybody, including, of course, the policy-makers and the governments and so forth.

So that’s one reason we should be talking about it. The second reason is that anybody who’s involved in the evaluation of interventions realises the scientific approach to doing that involves taking account of estimates of not only the benefits of the intervention, but also its costs. We’re told that it is good practice and it clearly is self-evidently good practice to employ a, sort of, a cost benefit approach to saying whether an intervention works or not. So I think that’s the key question here.

And I guess we can break that down into three bits, which I’ve kind of tried to do in the editorial. The first bit really is, is there a reason why this sort of recommended approach shouldn’t apply to lock-down and I raced my brain and I honestly can’t think of a reason why it shouldn’t apply to lock-down as an intervention. We should look at the benefits and the costs of lock-down. Part two, is why is nobody proposing that as an approach, even at this marginal point where the benefits are obviously much lower than they were at the peak of the spread of infection?

It seems such an obvious question for us to be asking. So what are the barriers? What’s stopping people asking that question? What are the principle barriers? You know, are there principle reasons we shouldn’t be asking that question, or are there more pragmatic reasons to do with political expedience and so forth? And then finally, of course, and this is what I wrote about in the editorial, is there a sort of a path to addressing those barriers so that we can have a sort of roadmap for future decisions about lock-down, because I sense that this won’t be the last time that this will be implemented, whether it’s to do with highly infectious disease like Covid, whether people are even talking about it in terms of climate change and all sorts of things now.

So we need a model whereby we can figure out if the benefits outweigh the costs of this sort of intervention.

Interviewer: We’ll explore that in today’s podcast. I just want to pick up on something you said. You mentioned that also your colleagues have been reticent to explore.

Professor Edmund Sonuga-Barke: Yeah. Whenever I discuss it, because I think it’s such a crucial question, I probably discuss it too often, there’s a, sort of, kind of embarrassed silence in the room. People look at their feet, you know. So I think there’s somehow the notion that even if you raise it somehow you’re letting the side down and risking undermining the message about the benefits of lock-down, and I’ve written about this in another editorial, actually, but I think that’s had a stifling effect on scientific debate within the field.

And of course, again, this is really about the nature of science, I suppose we’re talking now, rather than any particular recommendation about whether or not we should lock-down under what circumstances. I’m not commenting on that at all but, you know, what science requires is that we have a discussion about those things. We raise alternative positions and hypotheses and we try as best we can to test them. That is science, and we’re constantly told to follow the science, but not in a serious way for fear that you undermine public confidence in government policy.

So there’s this fascinating tension between the need to get people to follow a policy and not to undermine their confidence, but on the other hand, to allow discussion and debate, which is completely normal and natural within the scientific communities.

Interviewer: Edmund, I’m going to return specifically to the editorial and when you’re talking about costs in the editorial you’re really talking about the cost to families’ mental health.

Professor Edmund Sonuga-Barke: Yeah, I mean, obviously, that’s what I got my sub-degree of expertise in that. I’ve been working in the field for 35 years, so I’ve got some expertise in that question. Other costs, of course, of lock-down relate to kind of broader aspects of quality of life in terms of, obviously there’s self-evident ones in terms of restricting normal daily activities without hindrance, which is a definition of normal quality of life, and, of course, also civil liberties, so those are other aspects and other costs, but I don’t really have much expertise in those.

Interviewer: You talked about the barriers that stopped governments focussing on the costs as well as the benefits. So what were the barriers that stop governments from setting the benefits of lock-down against mental health costs?

Professor Edmund Sonuga-Barke: As I say in the editorial, I think there are three that I want to focus on. There are obviously others, and I’ve really not gone into the rabbit hole of motives at all. You know, that takes people down in some strange places. So none of our motives. It’s not about the sociology of science or anything. It’s about taking the decision not to consider these costs at face value. So I argue that there are three basic constraints in it all.

The first is we haven’t yet provided strong enough evidence that lock-down plays a causal role in negative impacts on mental health, and by that I mean we need to go further than the correlational studies that are being carried out. So people are showing that, for instance, in the UK, so a coast-based study by Professor Creswell in Oxford has shown there’s been a deterioration in certain aspects of mental health during the periods of lock-down, but of course that’s really correlational and we need to somehow move further towards isolating that more causal relationship between the lock-down experience and mental health effects.

And I’ve benefited from working with Professor Sir Michael Rutter, I think for 15 years on the English Romanian Adoptees Study and that’s called a natural experiment, and I think there is potential to do natural experiments. Clearly you can’t do fully randomised control trials of lock-down. It’s neither ethical nor politically expedient. So you can’t randomise to lock-down and not lock-down, but you can take advantage of chance allocations of lock-down, so you can compare the timing of lock-down in different regions.

So we did have a period where there were different levels of lock-down. So if you had the right study, you could compare the impacts of those different degrees of lock-down and the different timings of those lock-downs and start to develop a more precise mapping or matching of the effect and the exposure. So that’s what we need to do and we need definitely to… and I think people realise this. It’s just these are just difficult studies to plan and to run, obviously, particularly, you know, last March when nobody knew what on earth was going on.

Maybe we should have planned a few more relatively quickly after that. You know, maybe we needed a more co-ordinated approach from the government. I mean, they funded a lot of Covid related research. We have a study of parent training intervention designed specifically for Covid related increases in behavioural problems at home. So they funded loads of research, but maybe it’s a little bit fragmented and piecemeal. It could have been more co-ordinated identifying really what the key things are we need to focus on.

So that’s one thing I think that’s been a challenge is to persuade. It all seems a little bit speculative probably to the planners, but if we can make a stronger inference, let’s say about the causal relationship between this exposure and mental health. I think the other key thing is to recognise that the effects are going to vary enormously by setting, and we knew that probably before it started. We knew that vulnerable individuals, people with pre-existing risks, people in difficult circumstances, particularly kids in fragile families, are going to be at particular risk.

I mean, they’re the ones who are not going to sign up to studies, of course. Sometimes it’s hard to remember what it was actually like last March. We tend to forget maybe we were repressing it, but it was very restrictive, wasn’t it, and you can imagine, I think it’s great if you’ve got a lovely garden and a lovely park, and you’re allowed to go for your one walk a day or whatever it was, but if you’re living in a high-rise flat and, you know, three kids in a bedroom or something, which I don’t think our policy-makers have perhaps more bore that in mind as much as they ought perhaps. I don’t know.

Interviewer: In the editorial, I think you use the expression when you talked about the likelihood that lockdown would create a toxic cocktail.

Professor Edmund Sonuga-Barke: Yeah, I chose the words carefully because I think from what we know, you know, not about lockdown, but about other circumstances. So one of our interventions was called Families under Pressure that we designed specifically to try and give parenting tips to help, kind of, ease the pressure cooker a little bit. You know, that is a recipe for maltreatment and abuse. Particularly for kids who are going to play up a bit more, maybe they have some underlying vulnerabilities.

Maybe kids with a little bit of ADHD or autism or whatever are going to play up a bit more when they’re under pressure and frustrated and of course, worried parents are going to react a little bit more and then of course you get into this toxic cycle within families where things can escalate out of control and lead to even to maltreatment in situations where that’s never been an issue before. So this was a unique set of risk factors. You know, I’m really hoping that we’ll get a better insight into those sorts of vulnerable families.

So we have seen, for instance, a big increase in calls to the NSPCC helplines during the first and the second lock-downs from children, and there’s a big worry, I think, within child services that there’s been a significant drop in the number of referrals by social workers because, of course, they weren’t going out. They weren’t seeing what was happening. So it’s been very hard to quantify it but everything we know about family dynamics and parent, child relations and interactions would say that this is a high risk situation and all the initial data suggests that that’s the case. So I really think that should be a real focus going forward.

Interviewer: We’ll return to the various steps that you suggest in the editorial can be used to address the various limiting factors, but one of the things you mentioned in the editorial is that far from governments acting irrationally in mental health costs, you say they’re one sided, benefit focussed approach to decision making was inevitable. So why was it inevitable?

Professor Edmund Sonuga-Barke: I think under the circumstances we’ve had a little insight into the pressure under which the government were working from Mr Cumming’s testimony in the last day or two or last week or whenever it was. Nobody really knew what they were doing and I think the scientific advisers, I think they would be honest enough to say they really didn’t know how this was going to behave at that stage and the models, you know, were certainly limited in many ways that were projecting the numbers.

 So I think there was a sense of panic, and I think under those circumstances, of course, your attention or focus as a policy-maker or a researcher becomes very narrow. So you have one index and one index only, and that is infection, Covid related illness and obviously Covid related death. That’s all the focus was on and that’s completely understandable under those circumstances, but the benefits are clear, you know, of lock-down. I mean, again, I guess that has to all come out in the wash in terms of analysis of the benefits. I can’t comment on that.

That’s not my area, but in terms of the costs they’re much more diffuse. They’re much less clear-cut. We were speculating at that stage about the costs. Everybody thought there would be costs. Apart from the obvious ones, like civil liberties, that was actually part and parcel of the of the actual lock-down but, you know, in terms of mental health and other quality of life they were much more obtuse, so much more difficult to implement.

I think my concern now is that still nobody is focussing on that question. It’s not that it was not expectable under the emergency conditions. It was that it’s not been taken into account since we got a clearer handle of what was going on. You know, clearly, there’s lots of unknowns still about covid-19 that we’re still trying to get our heads around in terms of lots and lots of questions there which are which are all fascinating.

But, you know, I think what worries me is that people still aren’t asking this question about costs and benefits and that’s what I would like to see an open debate about that, and maybe we can only do it once the whole thing is finished because at that point, of course, there’s no risk of undermining the messaging because the messaging isn’t necessary, but we really do need to think of a way or develop some instruments that would allow us to develop a more nuanced modelling.

Interviewer: So you’ve talked about the need to build natural health experiments, and then a second step that you outline is developing health economic models that allow the cost of lock-down to be balanced against its benefits. You say in ways that are supported by the general public.

Professor Edmund Sonuga-Barke: I mean, I’m not a health economist. Obviously if you evaluate interventions you get involved with health economics, but is it more at a conceptual level I think at this stage, but I think, you know, this is just taken for granted in the evaluation of most interventions, even those where life and death is the issue. So it’s not to say this is just about psychiatric interventions. This is about cancer drugs. This is about drugs that extend life expectancy.

This is just the norm. That it’s been surprising that people haven’t really started to raise these questions about public health interventions like lock-down. Now that maybe because it’s a much more complicated task as I outlined in the editorial. I go through some of the challenges, I think, which kind of take the health economics beyond what it was initially developed for, not in principle, but actually in practice. How would you implement it, and I think one of the most brilliant little concepts that has come along that allows you to balance these things, that is benefits in terms of increasing life expectancy.

Say you have a drug, the benefits of that drug might be to increase life expectancy by five years. At the same time it may reduce quality of life by a certain amount, and this notion of quality adjusted life years is a really brilliant concept that allows you to combine those two elements so that one quality adjusted life year. So a value of one is a whole year lived at full quality of life and then you kind of go down from that.

Lock-down may be an extreme example of that, but in principle this should apply. This still should be manageable if we can get some of the brains in the health economic field. What’s really interesting to me, and I may be wrong on this, but I don’t think health economists have played a prominent role in the committees that are advising the government, and I think there may be an interesting point that we need to really set up. We need to really get them involved so that they can bring their expertise to bear.

I think, you know, why this is such a challenge, of course, is this is about prevention rather than cure. So that obviously has some challenges in and of itself. So in a sense you’ve got to take into account susceptibility to a disease rather than having the disease itself to reducing susceptibility, reducing risk, it’s complicated. Secondly, of course, in this case the actual costs in terms of the intervention in terms of, say, reduced quality of life are probably hitting a lot more people, given the kind of selective nature of the process of symptomatic infection, probably hitting a lot more people than the benefits of lock-down.

So that’s complicated and that’s very unusual. You wouldn’t find that in a trial, for instance. Another thing that’s really important, of course, is the cost and benefit ratio varies so much by demographics and how do you account for that? So, for instance, young people are very unlikely to die of Covid we now know or even to suffer serious health complications from Covid, very unlikely. I don’t know the figures, but it’s in the 99th centre.

On the other hand, of course, they’re experiencing a lot the costs, particularly, they were at least in the first lock-down in terms of school. So this is also very unusual. So clearly there’s a lot of work to do and I do think this is a major barrier and I think this is an area that we need to really invest in as a community and as a country, as a well, you know, global community trying to develop models that would allow us to deal with these complications and extensions of this QALY concept, because in essence, the QALY concept would say you would only lock down if the QALY gains by locking down were greater.

We’re talking about the community as a whole were greater than the QALY losses associated with lock-down. Now, that’s a really interesting bit of calculus, but we do it all the time. The other point I’m making editorial [s.l. 21:16] is because we do it all the time. In a world full of hazards and risks we have to do it or we never get out the front door. As I said, you know, what is it, 1500 fatalities on the road every year or something like that?

We could stop all those immediately. We could close all the roads now, but we don’t do that. So there is like an implicit QALY calculation going on on that basis, and of course, in a risky and hazardous situation that’s going on all the time at a government level. This would just make it all explicit which would, kind of, try and make this explicit in some way so that we can judge in the future at what point does it make sense to implement interventions that are potentially damaging to quality of life and mental health and so forth and so on?

Apart from its importance? I just thought it was a wonderfully interesting scientific challenge.

Interviewer: Is it starting to happen the idea of making these QALY calculations in relation to the impact of that?

Professor Edmund Sonuga-Barke: I don’t know, you see, I don’t know. I haven’t seen anything and I haven’t heard anybody. There are one or two papers that have tried to do some calculations, but they’re rather limited. I mean, because, of course, the costs are very-diffused and trying to estimate the cost, even in a simple trial, is quite a challenge.

So what you do is you try and translate these costs into monetary numbers. That’s how they are deciding, for instance, whether a drug should be funded on the NHS. This is the sort of analysis that’s done. You know, what’s the QALY benefit and how much does each QALY cost for this drug, and that’s when you get these heart wrenching stories where there’s a very expensive drug and it could be very valuable to a small group of people, but the NHS won’t fund it because it isn’t cost effective.

So this is obviously a very, very different application to that, but in a sense the same principles apply, or if they don’t I’d love somebody to explain to me why they don’t. This podcast and this editorial and the talks are kind of a plea to somebody to educate me as to why this shouldn’t apply to something like lock-down. I’m very open to being educated, but I think the other thing that’s really important that you said is that whatever, what they call in economics, the indifference point is, you know, where that QALY gains, QALY losses, indifference point is set, there needs to be a discussion within communities about that because that indifference point needs to chime with the cultural group within which you’re working and different cultural groups may set that very differently.

So, for instance, some cultural groups might set one additional year of, say, an 85 year old person with dementia at a much higher level than another cultural group. Do you see what I mean?

Interviewer: Yes.

Professor Edmund Sonuga-Barke: So, I mean, it sounds awful to give it that concrete nature, but that’s exactly the sorts of calculations that would have to go on, and maybe that’s not palatable to some cultures, although it’s implicit in all cultures. Those decisions are always being made in a sense. I guess what we need is an honest debate, an honest and open debate about these sorts of really challenging issues and also the nature of our mortality. It’s almost like nobody dies sometimes when you’re listening to people. You know, death is an integral part of life. So it’s not really about saving lives.

 It’s about extending lives. It’s about life expectancy, I suppose, because one thing’s for sure, and I don’t know who said it, was it Benjamin Franklin? I think he said death and taxes were the only two certain things. So it’s really about not so much life or not life. It’s about length of life and quality of life. So, yeah, really interesting questions.

Interviewer: One thing you’re partly talking about here is how you engage with communities, and you do mention as a third step in the editorial. You talk about finding a way to effectively communicate cost benefit, balance policy decisions to the public, and I’m wondering is it possible to have an effective communication strategy during a pandemic which presents these costs and benefits without overcomplicating the message?

Professor Edmund Sonuga-Barke: I honestly don’t know the answer to that question and it may not even be with the public. I think, when a scientific debate is shut down I think every scientist should feel affronted by that and when scientists are attacked because they’re proposing alternative points of view that is really shameful for science, and that has happened. I hate to say it, but I think it’s important to say and people will know, you know, the exemplars I’m talking about. I don’t need to say them specifically.

But I think that happened because of the fear that opening up debate, even within the scientific community, would undermine confidence and even having that discussion. So I don’t know what the answer is, but it does suggest to me that scientific integrity can fall victim to these emergences. I guess the same thing happened in the war, exactly the same thing. So it was like a war footing in a way. Maybe I’m being innocent and naive, a bit romantic about science, and maybe I just need to become more realistic, but certainly I felt affronted by some of the actions and some of the language and the ad hominem attacks on people’s reputations and so forth, which I thought were really, really unfair and unfortunate, and I thought we are better than that as a community of scientists. I know that’s a controversial thing to say, but I really felt that.

Interviewer: happen within the realm of child and adolescent mental health?

Professor Edmund Sonuga-Barke: I don’t know. I don’t think it should. No, I don’t think there was any shaming going on to be absolutely honest, but I think it was just simplicity, like I say, [inaudible 00:27:23]. Everybody kind of knows that you do a cost benefit analysis and there are costs and of course, psychiatrists, psychologists, child psychologists know enough to expect negative impacts of this extraordinary intervention that happened. Again, I’m not making any judgements about whether it should or it shouldn’t have happened.

I’m really talking about how we can better make those decisions as a group. It’s a funny thing, isn’t it, self-censorship. I might be getting onto hot ground here, but it’s almost like a self-censorship by a community that feels that they don’t want to break the magic of the message. I’ve always been the one to say the quiet bit out loud, unfortunately. So maybe that’s what I’m doing. I don’t know.

Interviewer: Perhaps somebody has too.

Professor Edmund Sonuga-Barke: We should be thinking about these things. We should be talking about these things because they’re so important, particularly if this is going to recur and we have to make these difficult decisions. Yes, so I honestly don’t know. So that’s within the scientific community. What about public messaging? That really comes down to trust and education. So perhaps we need alongside this discussion, this deep and serious discussion about mortality, morbidity, mental health and the values, we also need a discussion about science.

You know, what is it? People like to, kind of, fall back on a very unscientific concept of facts. A fact isn’t really a scientific concept, but there were scientists using, you know, really getting very close to talking about facts because they feel that that messaging is something people can grasp. Maybe we need to engage much more in a dialogue about what science actually is? What evidence actually is, and the limitations of evidence and the issues of really about, I suppose, probability and risk.

Now, is that possible? I honestly don’t know, but I think we should at least try and I think in a technical democracy it’s actually essential that somehow the public in general are let into the secret around what actually is science. You know, when I hear a scientist on the radio saying, I’m certain this is true. I shiver because first of all, I think are they really a scientist if they say that? You know, or I’m almost certain, that really suggests they’re not really thinking as a scientist in terms of, kind of, classical popperian and hypothetical deductive approaches and hypothesis and building and testing and so forth.

So I think we need a debate about these things within our own field because maybe we’re not educated enough about them ourselves. Whether it can work, I don’t know, but I think we should try and I think we should try and evaluate whether it can work and maybe what the best ways of doing that are, but at least I think we should be discussing it.

Interviewer: Yeah, very difficult when the public are looking to scientists for reassurance, isn’t it?

Professor Edmund Sonuga-Barke: Yeah, but we’re not nursemaids. I think they’ve taken… I think Professor Whitty and Professor Valance have taken on that role as credible sources and in a way they’ve become part of the intervention, rather than being separate from that intervention. That’s why I think, just a final thing, I think in terms of recommendations, I would say that when there is a government enquiry it should be absolutely independent of anybody who’s been involved in implementing the lock-down intervention.

They should give evidence of course. What we talk about in intervention research risk of bias and one of the biggest risks of bias is having the person who developed the intervention evaluate it. Now you can see why that might be the case. It’s not always possible for somebody else to evaluate it, but in this case, of course, it is. So I think that would be my recommendation going forward, apart from the government funding natural experiments and trying to really provide support for the development of these health economic models. I think that’s really crucial.

Interviewer: Do you have a sort of takeaway message then?

Professor Edmund Sonuga-Barke: Well, I guess the takeaway message is that we should think about lock-down as we think about any other intervention, and we should try as far as we possibly can to apply the same standards of evidence, and those standards of evidence require the estimation of the benefits and they need to be set against the costs. Clearly, there’s a way to go in terms of being able to do that, but I think we need to invest in developing instruments and tools so that we can do that for the future.

Interviewer: Brilliant. Edmund, thank you so much. For more details on Professor Edmund Sonuga-Barke please visit the ACAMH website, www.acamh.org and Twitter at ACAMH. ACAMH in spelt ACAMH and don’t forget to follow us on iTunes or your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review and do share with friends and colleagues.

This podcast was brought to you by the Association for Child and Adolescent Mental Health, ACAMH for short.


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