Commentary
The Global Dissemination of Psychological Treatments: A Road Map for Research and Practice 'espite the need to disseminate effective psychological treatments, they are inherently difticult to scale up. In this overview, we describe strategies for increasing the availability of psychological treatments, which include increasing the number of therapists through task shifting, providing training via the Internet, and promofing the use of therapist-free forms of treatment delivery. Mental disorders are common, yet even in resource-rich cotintries most people who have them are not receiving treatment (1). In resource-poor countries, the proportion not in treatment is even higher (1, 2). This discrepancy needs to be rectified, as reasonably eftecfive pharmacological and psychological treatments are available for many disorders. This commentary considers strategies for increasing the availability of psychological treatments and proposes a road map for research and practice. Increasing the Number of Therapists
The evidence supporting most psychological treatments has come ftom studies in which the intervention has been delivered by highly trained health care professionals (generally clinical psychologists or psychiatrists). Therapists of this type are in short supply in resotirce-rich countries (3); in resource-poor settings they barely exist at all. In India, for example, with its population of L2 '
buiion, there are approximately 5,000 mental health professionals, the majority of whom have not been trained
If psychological treatments are to Have the greatest penetration, priority must ¿,g „¿^g„ ^^ ^/^^ optimization of
to deliver psychological treatments.
The worldwide shortage of thera-
i j •
•
program-led mterventtons.
pists is being addressed in various ways. The obvious solution is to train more of them. This is the main strategy of the Improving Access to Psychological Treatments (IAPT) program being implemented across England (4). A strategy that is likely to have a far greater impact is a more contentious one: "task shifting" or "task sharing." This strategy involves training less-qualified people, including peers, to take on tasks that have previously been undertaken by more highly qualified individuals (5). As applied to mental health interventions, task shifting is being used mainly in resourcepoor settings, although it is of relevance to health care delivery everywhere. One concern about task shifting is that it risks compromising quality of care. However, studies of task-shifting in medicine and surgery indicate that this need not be the case, and the same appears to be true of psychological treatments (6). Scaling Up Therapist Training
Both training more therapists and task shifting have the potential to increase the availability of psychological treatments. One major barrier that remains is training the therapists, be they mental health professionals of the type employed by IAPT or This article is featured in this month's AJP Audio AmJ Psychiatry 171:5, May 2014
ajp. psych iatryon line, org
495
COMMENTARY
community health workers in rural Pakistan. The method currently used to train therapists is not scalable. Training therapists how to implement psychological treatments typically involves three components, all of which are thought to be necessary (7-9). The first is attending an introductory workshop given by an expert in the treatment. This introduction provides an overview of the intervention and its strategies and procedures. The second component is reading wriften material describing the treatment. The third component is thought to be particularly important: implementing the treatment under the supervision of someone proficient in it. Thefirstand third components are simply not scalable, least of all in the global context. Few experts are available to give workshops, and not many people are sufficiently experienced to provide supervision. Two solutions have been proposed. The first is the "train the trainer" model, in which certain therapists are trained to be future trainers (10). This solution is nowhere near capable of training the number of therapists required worldwide, let alone in a reasonable period of time. The other solution is "web-centered training" (11), which is designed to be capable of training large numbers of therapists simultaneously. In this form of training, a specially designed training web site describes and illustrates the treatment in great detail and incorporates features to help trainees grasp key concepts and master the main procedures. Web-centered training may be used alone or accompanied by support from a nonspecialist (guided training). Thus, even with guidance, web-centered training is highly scalable. Webcentered training is currently being tested in a pilot study involving all eligible therapists across a country in Europe. Promoting Program-Led Treatments
Even if therapist training can be successfully scaled up, therapist-led interventions will always be limited in their impact (Figure 1). It is unlikely tliere will ever be sufficient therapists, who are appropriately trained and distributed, to meet the needs of individuals with detected mental disorders. Moreover, therapist-led interventions wiU never reach those who do not seek help. How can psychological treatments benefit them? The answer may lie in the development and promotion of "program-led" forms of treatment, in which the intervention is delivered by the program itself rather than by a therapist. These therapist-free interventions involve self-help (i.e., individuals treating themselves) and thus there is no need for them to present for treatment. Self-help versions of many of the evidence-based psychological treatments are available, and some have good evidence to support them (12, 13). Untü recently, these treatments have been delivered in the form of self-help books, but increasingly they are being provided via the Internet. These two forms of delivery have their pros and cons. Printed material is potentially accessible everywhere, whereas online treatments have more limited penetration, even in resource-rich countries, although this is changing fast. What is particularly attractive about the online mode of delivery (web-centered treatment) is the fact that the treatment can be personalized to match the characteristics of the individual and his or her specific problems, something that cannot be achieved with a one-size-fits-aU self-help book. Online treatments can also be designed to exchange real-time information with compatible smartphone applications (apps), a feature that might enhance their effectiveness. The Way Forward
If psychological treatments are to have the greatest penetration, priority must be given to the optimization of program-led interventions. Until recently, this has been a relatively neglected research area, but interest in online self-help 496
ajp.psychiatryonline.org
•
Am J Psychiatry 171:5, May 2014
COMMENTARY
FIGURE 1 . Forms of Treatment Delivery and Their Influence on the Availability of a Psychological Treatment
Train more therapists Task shifting or sharing Web-centered training of therapists
Self-help interventions delivered via books or the Internet
Guided self-help (with nonspecialist support)
Pure self-help
is burgeoning, and empirically supported online treatments for depression and most of the anxiety disorders are now available (14, 15). However, the take-up and completion rates are modest, as is adherence (16). If there is a consistent finding, it is that these problems are reduced if the program is accompanied by some form of external support (15), but herein lies a danger. If the support has to be provided by someone with specialist experience, scalability will be seriously compromised. Instead, and in common with web-centered training, the support should be from a nonspecialist so that the intervention remains program led. Ideally, support should be provided remotely over the telephone or Internet (i.e., via a voice over IP service), as this would open up the possibility of a call center model of providing guidance, in which support is centrally provided. The optimization of program-led treatments will not be enough on its ovm. It needs to be accompanied by research on how to maximize treatment penetration. Mental health literacy needs to be enhanced, especially in developing countries, and greater appreciation of the value of self-help is needed by both the general public and mental health professionals. This will require responsible marketing of the approach. It will also be important for health care systems to integrate programled (i.e., therapist free) and therapist-led forms of treatment so that individuals who do not or cannot benefit from the former can move smoothly on to the latter. To achieve these ambitious goals, collaboration needs to be forged between individuals who develop psychological treatments and those in the fields of public mental health and global mental health in particular. With such collaboration, and given recent advances in treatment, training, and technology, much might be achieved. References 1. Demyttenaere K, Bruffaerts R, Posada-Villa J, Gasquet I, Kovess V, Lepine JP, Angermeyer MC, Bernert S, de Girolamo G, Morosini P, Polidori G, Kikkawa T, Kawakami N, Ono Y, Takeshima T, Uda H, Karam EG, Fayyad JA, Karam AN, Mneimneh ZN, Medina-Mora ME, Borges G, Lara C, de Graaf R, Ormel J, Gureje O, Shen Y, Huang Y, Zhang M, Alonso J, Haro JM, Vilagut G, Bromet EJ, Gluzman S, Webb C, Kessler RC, Merikangas KR, Anthony JC, Von Korff MR, Wang PS, Brugha TS, Aguilar-Gaxiola S, Lee S, Heeringa S, Pennell BE, Zasiavsky AM,
AmJ Psyciiiatry 171:5, May 2014
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COMMENTARY
2. 3. 4. 5. 6.
7.
8. 9. 10.
11. 12.
13. 14. 15.
16.
Ustun TB, Chatterji S; WHO World Mental Health Survey Consortium; Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World iVIental Health Surveys. JAMA 2004; 291 ;2581-2590 Kohn R, Saxena S, Levav I, Saraceno B; The treatment gap in mental health care. Buil World Heaith Organ 2004; 82;858-866 Kazdin AE, Biase S; Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspect Psychol Sei 2011; 6;21-37 Clark DM; Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders; the lAPT experience. Int Rev Psychiatry 2011; 23;318-327 Kakuma R, Minas H, van Ginneken N, Dal Poz MR, Desiraju K, Morris JE, Saxena S, Scheffler RM; Human resources for mental health care; current situation and strategies for action. Lancet 2011; 378:1654-1663 van Ginneken N, Tharyan P, Lewin S, Rao GR, Romeo R, Patel V; Non-specialist health worker interventions for mental health care in low- and middle- income countries. Cochrane Collaboration (Epub ahead of print, Nov 19, 2013) Weissman MM, Verdeli H, Gameroff MJ, Bledsoe SE, Betts K, Mufson L, Fitterling H, Wickramaratne P; National survey of psychotherapy training in psychiatry, psychology, and social work. Arch Gen Psychiatry 2006; 63;925-934 Beidas RS, Kendall PC; Training therapists in evidence-based practice; a critical review of studies from a systems-contextual perspective. Clin Psychol (New York) 2010; 17;1-30 Herschell AD, Koiko DJ, Baumann BL, Davis AC; The role of therapist training in the implementation of psychosocial treatments; a review and critique with recommendations. Clin Psychol Rev 2010; 30;448-466 Ray ML, Wilson MM, Wandersman A, Meyers DC, KatzJ: Using a training-of-trainers approach and proactive technical assistance to bring evidence-based programs to scale; an operationalization of the interactive systems framework's support system. Am J Community Psychol 2012; 50;415-427 Fairburn CG, Cooper Z; Therapist competence, therapy quality, and therapist training. Behav Res Ther 2011 ; 49;373-378 Cuijpers P, Donker T, van Straten A, Li J, Andersson G; Is guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? a systematic review and meta-analysis of comparative outcome studies. Psychol Med 2010; 40:1943-1957 Haug T, Nordgreen T, Ost LG, Havik OE: Self-help treatment of anxiety disorders: a meta-analysis and metaregression of effects and potential moderators. Clin Psychol Rev 2012; 32;425-445 Andrews G, Cuijpers P, Craske MG, McEvoy P, Titov N; Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care; a meta-analysis. PLoS ONE 2010; 5:e13196 Newman MG, Szkodny LE, Llera SJ, Przeworski A; A review of technology-assisted self-help and minimal contact therapies for anxiety and depression; is human contact necessary for therapeutic efficacy? Clin Psychol Rev 2011; 31;89-103 Christensen H, Griffiths KM, Farrer L; Adherence in Internet interventions for anxiety and depression. J Med Internet Res 2009; 11;e13 CHRISTOPHER G. FAIRBURN, F.MED.SCI. VIKRAM PATEL, F.MED.SCI.
From the Department of Psychiatry, Oxford University, Oxford, United Kingdom; the Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London; and the Sangath Centre, Alto Porvorim, Goa, India. Address correspondence to Professor Fairburn ([email protected]). Commentary accepted for publication Dec. 20, 2013 (doi: 10.1176/appi.ajp.2O13.13111546). Presented in part at the seventh World Congress of Behaviorai and Cognitive Therapies, Lima, Peru, July 22-25, 2013. The authors report no financial relationships with commercial interests. Prof. Fairburn is supported by a Wellcome Principal Research Fellowship (046386), and his work on dissemination is supported by a Wellcome Strategic Award (094585). Prof Patel is supported by a Wellcome Senior Research Fellowship in Clinical Science and grants from the Wellcome Trust, NIMH, the Department for International Development, and Autism Speaks.
498
ajp.psychiatryonline.org
Am J Psychiatry 171:5, May 2014
Copyright of American Journal of Psychiatry is the property of American Psychiatric Publishing, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
The Global Dissemination of Psychological Treatments: A Road Map for Research and Practice 'espite the need to disseminate effective psychological treatments, they are inherently difticult to scale up. In this overview, we describe strategies for increasing the availability of psychological treatments, which include increasing the number of therapists through task shifting, providing training via the Internet, and promofing the use of therapist-free forms of treatment delivery. Mental disorders are common, yet even in resource-rich cotintries most people who have them are not receiving treatment (1). In resource-poor countries, the proportion not in treatment is even higher (1, 2). This discrepancy needs to be rectified, as reasonably eftecfive pharmacological and psychological treatments are available for many disorders. This commentary considers strategies for increasing the availability of psychological treatments and proposes a road map for research and practice. Increasing the Number of Therapists
The evidence supporting most psychological treatments has come ftom studies in which the intervention has been delivered by highly trained health care professionals (generally clinical psychologists or psychiatrists). Therapists of this type are in short supply in resotirce-rich countries (3); in resource-poor settings they barely exist at all. In India, for example, with its population of L2 '
buiion, there are approximately 5,000 mental health professionals, the majority of whom have not been trained
If psychological treatments are to Have the greatest penetration, priority must ¿,g „¿^g„ ^^ ^/^^ optimization of
to deliver psychological treatments.
The worldwide shortage of thera-
i j •
•
program-led mterventtons.
pists is being addressed in various ways. The obvious solution is to train more of them. This is the main strategy of the Improving Access to Psychological Treatments (IAPT) program being implemented across England (4). A strategy that is likely to have a far greater impact is a more contentious one: "task shifting" or "task sharing." This strategy involves training less-qualified people, including peers, to take on tasks that have previously been undertaken by more highly qualified individuals (5). As applied to mental health interventions, task shifting is being used mainly in resourcepoor settings, although it is of relevance to health care delivery everywhere. One concern about task shifting is that it risks compromising quality of care. However, studies of task-shifting in medicine and surgery indicate that this need not be the case, and the same appears to be true of psychological treatments (6). Scaling Up Therapist Training
Both training more therapists and task shifting have the potential to increase the availability of psychological treatments. One major barrier that remains is training the therapists, be they mental health professionals of the type employed by IAPT or This article is featured in this month's AJP Audio AmJ Psychiatry 171:5, May 2014
ajp. psych iatryon line, org
495
COMMENTARY
community health workers in rural Pakistan. The method currently used to train therapists is not scalable. Training therapists how to implement psychological treatments typically involves three components, all of which are thought to be necessary (7-9). The first is attending an introductory workshop given by an expert in the treatment. This introduction provides an overview of the intervention and its strategies and procedures. The second component is reading wriften material describing the treatment. The third component is thought to be particularly important: implementing the treatment under the supervision of someone proficient in it. Thefirstand third components are simply not scalable, least of all in the global context. Few experts are available to give workshops, and not many people are sufficiently experienced to provide supervision. Two solutions have been proposed. The first is the "train the trainer" model, in which certain therapists are trained to be future trainers (10). This solution is nowhere near capable of training the number of therapists required worldwide, let alone in a reasonable period of time. The other solution is "web-centered training" (11), which is designed to be capable of training large numbers of therapists simultaneously. In this form of training, a specially designed training web site describes and illustrates the treatment in great detail and incorporates features to help trainees grasp key concepts and master the main procedures. Web-centered training may be used alone or accompanied by support from a nonspecialist (guided training). Thus, even with guidance, web-centered training is highly scalable. Webcentered training is currently being tested in a pilot study involving all eligible therapists across a country in Europe. Promoting Program-Led Treatments
Even if therapist training can be successfully scaled up, therapist-led interventions will always be limited in their impact (Figure 1). It is unlikely tliere will ever be sufficient therapists, who are appropriately trained and distributed, to meet the needs of individuals with detected mental disorders. Moreover, therapist-led interventions wiU never reach those who do not seek help. How can psychological treatments benefit them? The answer may lie in the development and promotion of "program-led" forms of treatment, in which the intervention is delivered by the program itself rather than by a therapist. These therapist-free interventions involve self-help (i.e., individuals treating themselves) and thus there is no need for them to present for treatment. Self-help versions of many of the evidence-based psychological treatments are available, and some have good evidence to support them (12, 13). Untü recently, these treatments have been delivered in the form of self-help books, but increasingly they are being provided via the Internet. These two forms of delivery have their pros and cons. Printed material is potentially accessible everywhere, whereas online treatments have more limited penetration, even in resource-rich countries, although this is changing fast. What is particularly attractive about the online mode of delivery (web-centered treatment) is the fact that the treatment can be personalized to match the characteristics of the individual and his or her specific problems, something that cannot be achieved with a one-size-fits-aU self-help book. Online treatments can also be designed to exchange real-time information with compatible smartphone applications (apps), a feature that might enhance their effectiveness. The Way Forward
If psychological treatments are to have the greatest penetration, priority must be given to the optimization of program-led interventions. Until recently, this has been a relatively neglected research area, but interest in online self-help 496
ajp.psychiatryonline.org
•
Am J Psychiatry 171:5, May 2014
COMMENTARY
FIGURE 1 . Forms of Treatment Delivery and Their Influence on the Availability of a Psychological Treatment
Train more therapists Task shifting or sharing Web-centered training of therapists
Self-help interventions delivered via books or the Internet
Guided self-help (with nonspecialist support)
Pure self-help
is burgeoning, and empirically supported online treatments for depression and most of the anxiety disorders are now available (14, 15). However, the take-up and completion rates are modest, as is adherence (16). If there is a consistent finding, it is that these problems are reduced if the program is accompanied by some form of external support (15), but herein lies a danger. If the support has to be provided by someone with specialist experience, scalability will be seriously compromised. Instead, and in common with web-centered training, the support should be from a nonspecialist so that the intervention remains program led. Ideally, support should be provided remotely over the telephone or Internet (i.e., via a voice over IP service), as this would open up the possibility of a call center model of providing guidance, in which support is centrally provided. The optimization of program-led treatments will not be enough on its ovm. It needs to be accompanied by research on how to maximize treatment penetration. Mental health literacy needs to be enhanced, especially in developing countries, and greater appreciation of the value of self-help is needed by both the general public and mental health professionals. This will require responsible marketing of the approach. It will also be important for health care systems to integrate programled (i.e., therapist free) and therapist-led forms of treatment so that individuals who do not or cannot benefit from the former can move smoothly on to the latter. To achieve these ambitious goals, collaboration needs to be forged between individuals who develop psychological treatments and those in the fields of public mental health and global mental health in particular. With such collaboration, and given recent advances in treatment, training, and technology, much might be achieved. References 1. Demyttenaere K, Bruffaerts R, Posada-Villa J, Gasquet I, Kovess V, Lepine JP, Angermeyer MC, Bernert S, de Girolamo G, Morosini P, Polidori G, Kikkawa T, Kawakami N, Ono Y, Takeshima T, Uda H, Karam EG, Fayyad JA, Karam AN, Mneimneh ZN, Medina-Mora ME, Borges G, Lara C, de Graaf R, Ormel J, Gureje O, Shen Y, Huang Y, Zhang M, Alonso J, Haro JM, Vilagut G, Bromet EJ, Gluzman S, Webb C, Kessler RC, Merikangas KR, Anthony JC, Von Korff MR, Wang PS, Brugha TS, Aguilar-Gaxiola S, Lee S, Heeringa S, Pennell BE, Zasiavsky AM,
AmJ Psyciiiatry 171:5, May 2014
ajp. psycii i a try on iine.org
497
COMMENTARY
2. 3. 4. 5. 6.
7.
8. 9. 10.
11. 12.
13. 14. 15.
16.
Ustun TB, Chatterji S; WHO World Mental Health Survey Consortium; Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World iVIental Health Surveys. JAMA 2004; 291 ;2581-2590 Kohn R, Saxena S, Levav I, Saraceno B; The treatment gap in mental health care. Buil World Heaith Organ 2004; 82;858-866 Kazdin AE, Biase S; Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspect Psychol Sei 2011; 6;21-37 Clark DM; Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders; the lAPT experience. Int Rev Psychiatry 2011; 23;318-327 Kakuma R, Minas H, van Ginneken N, Dal Poz MR, Desiraju K, Morris JE, Saxena S, Scheffler RM; Human resources for mental health care; current situation and strategies for action. Lancet 2011; 378:1654-1663 van Ginneken N, Tharyan P, Lewin S, Rao GR, Romeo R, Patel V; Non-specialist health worker interventions for mental health care in low- and middle- income countries. Cochrane Collaboration (Epub ahead of print, Nov 19, 2013) Weissman MM, Verdeli H, Gameroff MJ, Bledsoe SE, Betts K, Mufson L, Fitterling H, Wickramaratne P; National survey of psychotherapy training in psychiatry, psychology, and social work. Arch Gen Psychiatry 2006; 63;925-934 Beidas RS, Kendall PC; Training therapists in evidence-based practice; a critical review of studies from a systems-contextual perspective. Clin Psychol (New York) 2010; 17;1-30 Herschell AD, Koiko DJ, Baumann BL, Davis AC; The role of therapist training in the implementation of psychosocial treatments; a review and critique with recommendations. Clin Psychol Rev 2010; 30;448-466 Ray ML, Wilson MM, Wandersman A, Meyers DC, KatzJ: Using a training-of-trainers approach and proactive technical assistance to bring evidence-based programs to scale; an operationalization of the interactive systems framework's support system. Am J Community Psychol 2012; 50;415-427 Fairburn CG, Cooper Z; Therapist competence, therapy quality, and therapist training. Behav Res Ther 2011 ; 49;373-378 Cuijpers P, Donker T, van Straten A, Li J, Andersson G; Is guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? a systematic review and meta-analysis of comparative outcome studies. Psychol Med 2010; 40:1943-1957 Haug T, Nordgreen T, Ost LG, Havik OE: Self-help treatment of anxiety disorders: a meta-analysis and metaregression of effects and potential moderators. Clin Psychol Rev 2012; 32;425-445 Andrews G, Cuijpers P, Craske MG, McEvoy P, Titov N; Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care; a meta-analysis. PLoS ONE 2010; 5:e13196 Newman MG, Szkodny LE, Llera SJ, Przeworski A; A review of technology-assisted self-help and minimal contact therapies for anxiety and depression; is human contact necessary for therapeutic efficacy? Clin Psychol Rev 2011; 31;89-103 Christensen H, Griffiths KM, Farrer L; Adherence in Internet interventions for anxiety and depression. J Med Internet Res 2009; 11;e13 CHRISTOPHER G. FAIRBURN, F.MED.SCI. VIKRAM PATEL, F.MED.SCI.
From the Department of Psychiatry, Oxford University, Oxford, United Kingdom; the Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London; and the Sangath Centre, Alto Porvorim, Goa, India. Address correspondence to Professor Fairburn ([email protected]). Commentary accepted for publication Dec. 20, 2013 (doi: 10.1176/appi.ajp.2O13.13111546). Presented in part at the seventh World Congress of Behaviorai and Cognitive Therapies, Lima, Peru, July 22-25, 2013. The authors report no financial relationships with commercial interests. Prof. Fairburn is supported by a Wellcome Principal Research Fellowship (046386), and his work on dissemination is supported by a Wellcome Strategic Award (094585). Prof Patel is supported by a Wellcome Senior Research Fellowship in Clinical Science and grants from the Wellcome Trust, NIMH, the Department for International Development, and Autism Speaks.
498
ajp.psychiatryonline.org
Am J Psychiatry 171:5, May 2014
Copyright of American Journal of Psychiatry is the property of American Psychiatric Publishing, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
