CBPRA-00573; No of Pages 5: 4C

Available online at www.sciencedirect.com

ScienceDirect
Cognitive and Behavioral Practice xx (2015) xxx-xxx

www.elsevier.com/locate/cabp

SPECIAL SERIES
Technology and Mental Health
Guest Editor: Jonathan S. Comer

Introduction to the Special Series: Applying New Technologies to Extend the

Scope and Accessibility of Mental Health Care
Jonathan S. Comer, Florida International University

Rapidly developing and affordable information and communication technologies, broadening Internet availability, and increasingly
sophisticated capacities for live home-based and mobile broadcasting have transformed how we communicate, work, and learn. The
growing potential for technological innovations to transform the scope of psychological interventions and extend the accessibility of
evidence-based mental health care for traditionally underserved individuals holds enormous promise. New technologies also offer
exciting opportunities to broaden the reach of treatment dissemination efforts to previously unimaginable capacities. As the
incorporation of new technologies into clinical practice and training efforts becomes increasingly routine, a new set of ethical, legal, and
risk management issues must be carefully considered and as a field we must be cautious against technological innovations and
opportunities advancing at a pace more rapid than the development of appropriate consensus guidelines and relevant regulatory
standards. This special series (a) addresses key matters of consideration regarding the appropriate, safe, and secure application of
technology into mental health care from leading experts in the emerging field of behavioral telehealth, and (b) presents recent efforts that
illustrate the promise, potential, and challenges associated with the incorporation of new technologies into mental health care.

T HE public health burden associated with mental

illness is staggering. Almost one quarter of the U.S.
population has suffered from a mental disorder in the
past 12 months (Kessler, Chiu, Demler, & Walters, 2005),
and roughly half of the population will meet criteria for a
mental disorder at some point during their lifetime
(Kessler, Berglund, et al., 2005). These disorders are
associated with enormous personal, family, and societal
costs (Breslau, Lane, Sampson, & Kessler, 2008; Comer,
Blanco, et al., 2011; Kessler et al., 2006; Merikangas et al.,
2007; Swendsen et al., 2010), and the very heavy toll of
mental health problems is broadened when considering
mental health concerns beyond simply diagnosable mental
disorders (see Angold et al., 1999). Roughly 30% of youth
with severe mood dysregulation do not meet formal criteria
for a mental disorder but nonetheless exhibit considerable
clinical impairments (Brotman et al., 2006). Relationship
problems are linked to tremendous clinical impairments,
and childhood adversities (e.g., parental mental illness and
criminality, family violence, maltreatment) are associated
Keywords: behavioral telehealth; telemedicine; telemental health;
technology
1077-7229/13/© 2015 Association for Behavioral and Cognitive
Therapies. Published by Elsevier Ltd. All rights reserved.
with roughly one in four adult-onset disorders (Green
et al., 2010). Given the enormous scope and impact of
mental health problems, it is encouraging that tremendous
advances have been made over the past few decades in the
development and evaluation of psychological treatments
that can meaningfully reduce symptoms and associated
impairments (Barlow, 2008).
Despite the great advances in intervention science,
however, gaps persist between treatments in experimental
settings and services available in routine practice settings.
Regrettably, the vast majority of individuals in need of
mental health care are simply not receiving the best of
what our science has to offer. In a given year, only 40% of
Americans with mental disorders have received treatment
in the prior year, and less than one-third of those who do
receive treatment are receiving their care from a mental
health care professional (Wang, Lane, et al., 2005). Among
the minority of affected individuals who do receive care,
the median delay in treatment initiation after initial dis-
order onset ranges from 6 to 23 years across disorders
(Wang, Berglund, et al., 2005), and only a small proportion
of these individuals receive research-supported services
(Weisz, Sandler, Durlak, & Anton, 2005).
These daunting problems in the utilization and quality
of mental health services can be attributed in large part to
a number of systematic barriers that interfere with the

Please cite this article as: Comer, Introduction to the Special Series: Applying New Technologies to Extend the Scope and Accessibility of
Mental Health Care, Cognitive and Behavioral Practice (2015), http://dx.doi.org/10.1016/j.cbpra.2015.04.002
2 Comer
availability, accessibility, and acceptability of evidence-based
care. Inadequate numbers of mental health professionals
restrict care availability. Professional workforce shortages in
mental health care, particularly in rural and other remote
regions, leave roughly 50% of the population affected by
mental illness without a mental health provider in their
geographic proximity. Kazdin and Blase (2011) argue that
the discrepancy between the number of affected individuals
and the number of available providers is so dire that even
doubling the mental health workforce would yield only a
minor improvement in care availability when considered
from a broad public health perspective. Transportation
barriers further restrict care, as considerable numbers of
individuals in need have no way to travel to receive services.
For those with mental health services available locally, long
wait lists at underfunded clinics slow the speed with which
services are delivered. Not surprisingly, psychological treat-
ments have assumed a less prominent role in outpatient
mental health care in recent years (Olfson & Marcus, 2010),
and those who do receive psychological treatments are not
necessarily receiving evidence-based care (Sandler et al.,
2005) due to serious problems in the effective dissemination
of supported treatments (McHugh & Barlow, 2010).
Problems in the availability of quality psychological treat-
ments place increased burdens on the pharmacologic
dimensions of care. Not surprisingly, in recent years we
have witnessed striking increases in the concerning use of
off-label pharmacologic regimens with limited efficacy and
safety data being used to manage mental health problems for
which well-tolerated psychological treatments have been
supported in research settings (Comer, Mojtabai, & Olfson,
2011; Comer, Olfson, & Mojtabai, 2010).
Although evidence-based psychological treatments
grounded in strong theory and supported by rigorous
controlled trials have undoubtedly helped many individ-
uals, at a population level the great advances in
intervention science have had very little of a meaningful
public health impact. Despite our efforts, we are in danger
of becoming the proverbial tree falling in the woods with
no one there to hear it. We must ask ourselves: Are we
making any noise with our work?
Technological Innovations May Help Overcome
Traditional Barriers to Care
Rapidly developing and affordable information and
communication technologies, broadening Internet avail-
ability, and increasingly sophisticated capacities for live
home-based and mobile broadcasting have transformed
how we communicate, work, and learn. It is estimated that
over three-quarters of U.S. citizens have regular Internet
access, with almost all of these individuals having
household Internet access (United States Census
Bureau, 2011). This is particularly promising given that
in 2003 only half of U.S. households had Internet access.
Please cite this article as: Comer, Introduction to the Special Series: Applying New Technologies to Extend the Scope and Accessibility of
Mental Health Care, Cognitive and Behavioral Practice (2015), http://dx.doi.org/10.1016/j.cbpra.2015.04.002
In addition, recent federal commitments have invested
several billions of dollars to expanding Internet access to
underserved areas, and it has been projected that in the
coming years Internet access will show the same house-
hold ubiquity traditionally demonstrated for telephones.
Mobile technologies have become increasingly affordable
each year, and technological literacy has been steadily
improving across all demographic groups.
Importantly, technological advances hold tremendous
promise for remedying the very serious problems noted
above in the broad quality and accessibility of mental
health care, and a number of leading telemental health
programs are already incorporating new technologies in
highly innovative ways to broaden the reach of supported
care (see Comer, Furr, et al., 2014; Crum & Comer, in
press; Myers, Valentine, & Melzer, 2007; Myers et al.
2010). With technological literacy and Internet availabil-
ity both rapidly rising (see Chou et al., in press), and rural
and low-income Americans among the fastest-growing
populations acquiring Internet access, delivery methods
drawing on new technologies can transcend geographic
barriers to quality care and remotely deliver evidence--
based care to affected individuals, regardless of their
proximity to an expert mental health facility or the
manpower of their local mental health workforce.
Moreover, remote technologies have the transformative
potential to expand the ecological validity of treatment by
reaching clients in the very settings that are most
problematic. Rather than having to generalize what has
been learned in the clinic to real-world settings, remote
technologies allow clients to learn and practice new skills
in the very environments in which those skills are needed
(see Comer, Elkins, et al., 2014).
Telemedicine refers to the use of electronic media to
facilitate real-time interactions for the provision of care
usually delivered in person, and remote technologies are
already being incorporated across a range of health care
disciplines. Given that mental health care relies primarily
on verbal communication and visual observation, innova-
tors in clinical psychology are increasingly considering
how telemedicine methods may offer transformative
opportunities to overcome geographical barriers to care.
The use of telemedicine methods for the delivery of
mental health care is still an emerging field, and as such
has been referred to by many different names in its
infancy—e.g., behavioral telehealth (Comer & Barlow,
2014), telemental health (Myers & Turvey, 2013), telepsychol-
ogy, and telepsychiatry (Myers et al., 2007). Since the first of
these terms, telepsychiatry, was initially used in 1973 to
characterize live consultation services using “interactive
television” to connect experts at Massachusetts General
Hospital to a remove medical site (Dwyer, 1973), there
has been a steady increase in the number of scholarly and
empirical papers devoted to the use of remote
 Introduction: Technology
technologies to extend mental health services. According
to Web of Science, there were 596 scientific publications
between 1995 and 2013 that addressed behavioral
telehealth (or telemental health, telepsychology, or
telepsychiatry), with the number of publications increas-
ing rather steadily across time (see Figure 1). Roughly
40% of these publications were printed since 2010,
suggesting a very strong uptick in interest in the topic.
As the incorporation of new technologies into clinical
practice and training efforts increasingly works its way into
mainstream clinical practice, a new set of ethical, legal,
and risk management issues must be carefully considered
and as a field we must be cautious against technological
innovations and opportunities advancing at a pace more
rapid than the development of appropriate consensus
guidelines and relevant regulatory standards. This special
issue: (a) addresses key matters of consideration regard-
ing the appropriate, safe, and secure application of
technology into mental health care from leading experts
in the emerging field of behavioral telehealth, and (b)
presents recent efforts that illustrate the promise,
potential, and challenges associated with the incorpora-
tion of new technologies into mental health care.
Contributing Articles in This Series
There are three sections in this special series on
technology and mental health care. The first section provides
guiding overviews and thorough considerations of key areas
in the emerging field of behavioral telehealth. First, Kramer,
Kinn, and Mishkind (this issue) address the legal, regulatory,
and risk management issues that are central to the use of
technology to remotely deliver mental health care. Second,
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
Figure 1. Number of scholarly publications between 1995 and 2013 on behavioral telehealth, telemental health, telepsychology, or
telepsychiatry.
Please cite this article as: Comer, Introduction to the Special Series: Applying New Technologies to Extend the Scope and Accessibility of
Mental Health Care, Cognitive and Behavioral Practice (2015), http://dx.doi.org/10.1016/j.cbpra.2015.04.002
3
Nelson and Duncan (this issue) address the use of real-time
videoteleconferencing for the delivery of cognitive-beha-
vioral therapy, and address ethical and procedural issues
inherent in such work and challenges for optimizing
therapeutic alliance. Third, Jones and colleagues (this
issue) address the use of mobile technologies to extend
and enhance clinical practice, which is one of the
fastest-growing practice trends in behavioral telehealth.
Fourth, Khanna and Kendall (this issue) provide an overview
of how new technologies offer exciting opportunities to
broaden the reach of treatment dissemination efforts to
previously unimaginable capacities. Specifically, their paper
focuses on the use of web-based training to promote the
development of compenent cognitive-behavioral therapists.
In the second section of this special series, the papers go in
greater depth to provide detailed descriptions of leading
individual behavioral telehealth efforts that nicely illustrate
the promise, potential, and challenges associated with the
incorporation of new technologies into mental health care.
Comer and colleagues (this issue) present their work using
videoconferencing, webcameras, and Bluetooth earpieces to
provide Internet-delivered Parent-Child Interaction Therapy
(I-PCIT) directly to families in their own homes. Parents of
children with early behavior problems broadcast live family
interactions via a webcam from their home to a remote
therapist who provides real-time bug-in-the-ear coaching to
optimize positive attention and communication and to
promote effective discipline strategies. Chu, Rizvi,
Zendegui, and Bonavitacola (this issue) then present their
novel program that tailors dialectical behavior therapy to
address the specific needs of school refusing youth that
incorporates a web-based coaching component to provide
4 Comer
active, real-time skills coaching to families at the times of
greatest need and in the contexts that are most problematic
(e.g., at home during morning hours). Next, Shealy and
colleagues (this issue) present their program for treating
adolescent traumatic stress that draws on videoconferencing
technology to remotely deliver care to underserved popula-
tions. Finally, Possemato and colleagues (this issue) present
their web-based self-management program for recent
combat veterans with posttraumatic stress disorder and
substance use problems.
The third and final section of this special series
discusses future directions for clinical and research efforts
drawing on technology to expand the scope and reach of
children’s mental health services. There is perhaps no
one in the field who has done more than Dr. Alan Kazdin
to bring attention to the reality that at a population level
our great advances in intervention science have to date
had very little of a meaningful public health impact. Dr.
Kazdin’s most recent work urging the field to consider-
ably broaden its portfolio of mental health treatment
options and move beyond an exclusive focus on tradi-
tional brick and mortar services that treat just one patient
at a time (e.g., Kazdin & Blase, 2011) has already had an
enormous impact in the field, and has directly or
indirectly influenced much of the work throughout this
special series. And so it is rather fitting that we conclude
our special series with a sage and cautious commentary
from Dr. Kazdin (this issue) on the increasing use of new
technologies to expand the reach and scope of mental
health care.
References
Angold, A., Costello, E., Farmer, E. Z., Burns, B. J., & Erkanli, A. (1999).
Impaired but undiagnosed. Journal of the American Academy of Child
and Adolescent Psychiatry, 38(2), 129–137.
Barlow, D. H. (Ed.). (2008). Clinical handbook of psychological disorders,
4th ed. New York: Guilford Press.
Breslau, J., Lane, M., Sampson, N., & Kessler, R. C. (2008). Mental
disorders and subsequent educational attainment in a US national
sample. Journal of Psychiatric Research, 42, 708–716.
Brotman, M. A., Schmajuk, M., Rich, B. A., Dickstein, D. P., Guyer, A.
E., Costello, E., … Leibenluft, E. (2006). Prevalence, clinical
correlates, and longitudinal course of severe mood dysregulation
in children. Biological Psychiatry, 60, 991–997.
Chou, T., Comer, J.S., Turvey, C.L., Karr, A., & Spargo, G. (in press).
Technical considerations for the delivery of real-time child
telemental health care. Journal of Child and Adolescent
Psychopharmacology.
Chu, B. C., Rizvi, S. L., Zendegui, E. A., & Bonavitacola, L. (this issue).
Dialectical behavior therapy for school refusal: Treatment
development and incorporation of web-based coaching. Cognitive
and Behavioral Practice, this issue.
Comer, J. S., & Barlow, D. H. (2014). The occasional case against broad
dissemination and implementation: Retaining a role for specialty
care in the delivery of psychological treatments. American
Psychologist, 69, 1–18.
Comer, J. S., Blanco, C., Hasin, D. S., Liu, S. M., Grant, B. F., Turner, J.
B., & Olfson, M. (2011). Health-related quality of life across the
anxiety disorders: Results from the National Epidemiologic Survey
on Alcohol and Related Conditions (NESARC). Journal of Clinical
Psychiatry, 72, 43–50.
Please cite this article as: Comer, Introduction to the Special Series: Applying New Technologies to Extend the Scope and Accessibility of
Mental Health Care, Cognitive and Behavioral Practice (2015), http://dx.doi.org/10.1016/j.cbpra.2015.04.002
Comer, J. S., Elkins, R. M., Chan, P. T., & Jones, D. J. (2014). New
methods of service delivery for children’s mental health care. In
C. A. Alfano, & D. Beidel (Eds.), Comprehensive evidence-based
interventions for school-aged children and adolescents New York: Wiley.
Comer, J. S., Furr, J. M., Cooper-Vince, C., Kerns, C., Chan, P. T.,
Edson, A. L., … Freeman, J. B. (2014). Internet-delivered,
family-based treatment for early-onset OCD: A preliminary case
series. Journal of Clinical Child and Adolescent Psychology, 43, 74–87.
Comer, J. S., Furr, J. M., Cooper-Vince, C., Madigan, R. J., Chow, C.,
Chan, P., … Eyberg, S. M. (this issue). Rationale and consider-
ations for the internet-based delivery of parent-child interaction
therapy. Cognitive and Behavioral Practice, this issue.
Comer, J. S., Mojtabai, R., & Olfson, M. (2011). National trends in the
antipsychotic treatment of psychiatric outpatients with anxiety
disorders. American Journal of Psychiatry, 168, 1057–1065.
Comer, J. S., Olfson, M., & Mojtabai, R. (2010). National trends in child
and adolescent psychotropic polypharmacy in office-based prac-
tice, 1996-2007. Journal of the American Academy of Child and
Adolescent Psychiatry, 49, 1001–1010.
Crum, K.I., & Comer, J.S. (in press). Using synchronous videoconfer-
encing to deliver family-based mental health care. Journal of
Child and Adolescent Psychopharmacology.
Dwyer, T. (1973). Telepsychiatry: Psychiatric consultation by interactive
television. American Journal of Psychiatry, 130, 865–869.
Green, J. G., McLaughlin, K. A., Berglund, P. A., Gruber, M. J., Sampson,
N. A., Zaslavsky, A. M., & Kessler, R. C. (2010). Childhood adversities
and adult psychiatric disorders in the National Comorbidity Survey
Replication I: Associations with first onset of DSM-IV disorders.
Archives of General Psychiatry, 67, 113–123.
Jones, D. J., Anton, M., Gonzalez, M., Honeycutt, A., Khavjou, O.,
Forehand, R., & Parent, J. (this issue). Incorporating mobile
phone technologies to expand evidence-based care. Cognitive and
Behavioral Practice, this issue.
Khanna, M. S., & Kendall, P. C. (this issue). Bringing technology to training:
Web-based therapist training to promote the development of
competent cognitive-behavioral therapists. Cognitive and Behavioral
Practice, this issue.
Kazdin, A.E. (this issue). Technology-based interventions and reducing
the burdens of mental illness: Perspectives and comments on the
special series. Cognitive and Behavioral Practice, this issue.
Kazdin, A. E., & Blase, S. L. (2011). Rebooting psychotherapy research
and practice to reduce the burden of mental illness. Perspectives on
Psychological Science, 6, 21–37.
Kessler, R. C., Akiskal, H. S., Ames, M., Birnbaum, H., Greenberg, P.,
Hirschfeld, R. A., … Wang, P. S. (2006). Prevalence and effects of mood
disorders on work performance in a nationally representative sample
of U.S. workers. American Journal of Psychiatry, 163, 1561–1568.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., &
Walters, E. E. (2005). Lifetime prevalence and age-of-onset
distributions of DSM-IV disorders in the National Comorbidity
Survey replication. Archives of General Psychiatry, 62, 593–602.
Kessler, R. C., Chiu, W., Demler, O., & Walters, E. E. (2005).
Prevalence, severity, and comorbidity of 12-month DSM-IV
disorders in the National Comorbidity Survey replication. Archives
of General Psychiatry, 62, 617–627.
Kramer, G. M., Kinn, J. T., & Mishkind, M. C. (this issue). Legal,
regulatory, and risk management issues in the use of technology
to deliver mental health care. Cognitive and Behavioral Practice, this
issue.
McHugh, R. K., & Barlow, D. H. (2010). The dissemination and
implementation of evidence-based psychological treatments: A
review of current efforts. American Psychologist, 65, 73–84.
Merikangas, K. R., Ames, M., Cui, L., Stang, P. E., Ustun, T., Von Korff,
M., & Kessler, R. C. (2007). The impact of comorbidity of mental
and physical conditions on role disability in the US adult
household population. Archives of General Psychiatry, 64,
1180–1188.
Myers, K. M., Valentine, J. M., & Melzer, S. M. (2007). Feasibility,
acceptability, and sustainability of telepsychiatry for children and
adolescents. Psychiatric Services, 58, 1493–1496.
Myers, K. M., Stoep, A. V., McCarty, C. A., Klein, J. B., Palmer, N. B.,
Geyer, J. R., & Melzer, S. M. (2010). Child and adolescent
 Introduction: Technology
telepsychiatry: Variations in utilization, referral patterns, and
practice trends. Journal of Telemedicine and Telecare, 16, 128–133.
Myers, K., & Turvey, C. L. (2013). Telemental health: Clinical, technical, and
administrative foundations for evidence-based practice. New York: Elsevier.
Nelson, E., & Duncan, A. B. (this issue). Cognitive behavioral therapy
using televideo. Cognitive and Behavioral Practice, this issue.
Olfson, M., & Marcus, S. C. (2010). National trends in outpatient
psychotherapy. American Journal of Psychiatry, 167, 1456–1463
http://dx.doi.org/10.1176/appi.ajp.2010.10040570.
Possemato, K., Acosta, M. C., Fuentes, J., Lantinga, L. J., Marsch, L. A.,
Maisto, S. A., Grabinski, M., & Rosenblum, A. (this issue). A
web-based self-management program for recent combat veterans
with PTSD and substance misuse: Program development and
veteran feedback. Cognitive and Behavioral Practice, this issue.
Sandler, I., Ostrom, A., Bitner, M. J., Ayers, T. S., Wolchik, S., & Daniels, D. S.
(2005). Developing effective prevention services for the real world: A
prevention service development model. American Journal of Community
Psychology, 35, 127–142 http://dx.doi.org/10.1007/s10464-005-3389-z.
Shealy, K. M., Davidson, T. M., Jones, A. M., Lopez, C. M., & de
Arellano, M. A. (this issue). Delivering an evidence-based mental
health treatment to underserved populations using telemedicine:
The case of a trauma-affected adolescent in a rural setting.
Cognitive and Behavioral Practice, this issue.
Swendsen, J., Conway, K. P., Degenhardt, L., Glantz, M., Jin, R.,
Merikangas, K. R., … Kessler, R. C. (2010). Mental disorders as risk
factors for substance use, abuse and dependence: Results from the
10-year follow-up of the National Comorbidity Survey. Addiction,
105, 1117–1128.
Please cite this article as: Comer, Introduction to the Special Series: Applying New Technologies to Extend the Scope and Accessibility of
Mental Health Care, Cognitive and Behavioral Practice (2015), http://dx.doi.org/10.1016/j.cbpra.2015.04.002
5
United States Census Bureau (2011). Statistical abstract of the United
States: 2011. Retrieved April 4, 2013, from. http://www.census.
gov/compendia/statab/2011/tables/11s1154.pdf.
Wang, P. S., Berglund, P., Olfson, M., Pincus, H. A., Wells, K. B., &
Kessler, R. C. (2005). Failure and delay in initial treatment contact
after first onset of mental disorders in the National Comorbidity
Survey replication. Archives of General Psychiatry, 62, 603–613.
Wang, P. S., Lane, M., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler,
R. C. (2005). Twelve-month use of mental health services in the
United States: Results from the National Comorbidity Survey
replication. Archives of General Psychiatry, 62, 629–640.
Weisz, J. R., Sandler, I. N., Durlak, J. A., & Anton, B. S. (2005).
Promoting and protecting youth mental health through evidence-
based prevention and treatment. American Psychologist, 60,
628–648.
Funding for this work was provided by NIH (K23 MH090247) and by
the Charles H. Hood Foundation.
Address correspondence to Jonathan S. Comer, Ph.D., Mental Health
Interventions and Technology (MINT) Program, Center for Children
and Families, Department of Psychology, Florida International University,
11200 S.W. 8th Street, Miami, FL 33199; e-mail: jocomer@fiu.edu.
Received: March 7, 2015
Accepted: April 2, 2015
Available online xxxx