Behaviour Research and Therapy 88 (2017) 7e18

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Behaviour Research and Therapy

journal homepage: www.elsevier.com/locate/brat

Addressing the treatment gap: A key challenge for extending

evidence-based psychosocial interventions
Alan E. Kazdin
Department of Psychology, Yale University, 2 Hillhouse Avenue, New Haven, CT 06520-8205, USA

a r t i c l e i n f o a b s t r a c t

Article history: Remarkable progress has been made in developing psychosocial interventions for a broad range of
Received 16 May 2016 psychiatric disorders for children, adolescents, and adults. In addition many efforts are well underway to
Received in revised form address the research-practice gap, which refers to the dissemination evidence-based treatments from
9 June 2016
controlled settings to clinical care. The present article focuses on the treatment gap, which refers to the
Accepted 21 June 2016
discrepancy in the proportion of the population in need of services and the proportion that actually
receives them. Currently, in the United States (and worldwide), the vast majority of individuals in need of
mental health services receive no treatment. Although there are many reasons, the dominant model of
Keywords:
Treatment gap
delivering psychosocial interventions in both research and clinical practice makes it difficult to scale
Models of intervention delivery treatment to reach the large swaths of individuals in need. That model includes one-to-one, in person
treatment, with a trained mental health professional, and provided in clinical setting (e.g., clinic, private
practice office, health-care facility). The article discusses the development of delivery models that would
permit reaching more individuals in need, highlights criteria for developing such models, and illustrates
novel models already available. The article proposes that our next challenge is to reach individuals in
need with the many excellent interventions we have developed but through a diversified set of delivery
models.
© 2016 Elsevier Ltd. All rights reserved.

The development of evidence-based psychosocial interventions
(EBPIs) is truly a remarkable advance. As is well known, EBPIs refer
to interventions that have been evaluated in randomized controlled
clinical trials, where treatments, client samples, and outcomes have
been well specified, and where the effects have been replicated by
an independent research team. 1 A current priority is to disseminate
E-mail address: alan.kazdin@yale.edu.
1
The criteria for delineating treatments considered to have empirical support
have evolved over time and among different countries, states and provinces within
a country, professional organizations, and public and private agencies (e.g.,
Chambless & Ollendick, 2001; Charman & Barkham, 2005; Tolin, McKay, Forman,
Klonsky, & Thombs, 2015). The terminology has varied too as illustrated by
empirically supported treatments, empirically validated treatments, evidence-
based psychotherapies, evidence-based practice, and others (e.g., American
Psychological Association, 2006; Goodheart, Kazdin, & Sternberg, 2006). The dif-
ferences among criteria and meanings among the terms are not pivotal to the focus
of this article. In addition, this term has adopted the broad term that emphasizes
evidence-based psychosocial interventions. Interventions is used rather than
treatments because many of the models that can improve mental health and
decrease mental disorders are well outside what would normally be called
treatment.
treatment from research to clinical practice or addressing research-
practice gap. Extending interventions from research to practice is a
critical step in the process of improving mental health care.
Another step is extending treatments in ways that go well beyond
clinical practice and to reach the large number of people in need of
clinical care but who are not receiving services. Disseminating
EBPIs to clinical practice alone will not necessarily address this
latter need.
The article discusses the development of delivery models that
would permit reaching more individuals in need, highlights criteria
for developing such models, and illustrates novel models already
available. The overall thesis is that a key challenge in the coming
years is to develop interventions that can have broad impact on
reducing the burdens of mental illness by ensuring that treatment
reaches unserved individuals. Examples of how this can be ach-
ieved are drawn from multiple disciplines that can help extend
interventions with an evidence base.

http://dx.doi.org/10.1016/j.brat.2016.06.004
0005-7967/© 2016 Elsevier Ltd. All rights reserved.
8 A.E. Kazdin / Behaviour Research and Therapy 88 (2017) 7e18
1. Treatment gap
1.1. Overview of the problem
The treatment gap refers to the difference in the proportion of
people who have disorders or a particular disorder (prevalence)
and the proportion of those individuals who actually receive care
(Kohn, Saxena, Levav, & Saraceno, 2004; Patel, Maj et al., 2010). In
the context of mental health, considerable evidence has addressed
each component of the gap to outline the nature of the problem
(Andrade et al., 2014; Becker & Kleinman, 2013; Merikangas et al.,
2011; Steel et al., 2014; Whiteford et al., 2013). In the United States,
millions of children, adolescents, and adults experience significant
mental health problems and receive no help whatsoever. For
example, from reports of the National Comorbidity Study, we have
learned that 26% of the US population meet criteria for a psychiatric
disorder within the past 12 months (Kessler et al., 1994; Kessler,
Chiu, et al., 2005). This increases to 46% of the population over
the course of life (Kessler, Berglund et al., 2005). For ease of
computation consider that approximately 25% of the US population
experience a psychiatric disorder during a given year and 50% in
their lifetime. From a US population of approximately 320 million,
this translates to 80 million and 160 million people, respectively.
Important to add is that the estimates may be conservative; some
disorders (e.g., schizophrenia) as well as subsyndromal (subclini-
cal) disorders often are omitted from surveys of prevalence.
Separate lines of research have addressed the extent to which
individuals in need of services actually receive them. In the US,
approximately 70% in need of services do not receive any services
(Kessler, Demler et al., 2005). Ethnic minority groups (e.g., African,
Hispanic, and Native Americans) have much less access to care than
do European Americans (e.g., McGuire & Miranda, 2008). For
example, African Americans are less likely to have access to services
than are European Americans (12.5 vs. 25.4%), and Hispanic
Americans are less likely to have adequate care than are European
Americans (10.7 versus 22.7%; Wells, Klap, Koike, & Sherbourne,
2001). The lack of available services for most people and system-
atic disparities among those services underlie the importance of
delivering services in ways that can reach many more people as
well as target special groups.
The problem of high prevalence rates and a gap in the propor-
tion who receives treatment has been studied internationally. The
World Health Organization ([WHO] Mental Health Survey
Consortium, 2004) provided extensive data on the treatment gap
from surveys of over 60,000 adults in 14 countries in the Americas,
Europe, Middle East, Africa, and Asia. The proportion of re-
spondents who received treatment for emotional or substance-use
disorders during the previous 12 months ranged from a low of 0.8%
(Nigeria) to a high of 15.3% (United States). These percentages refer
to those who received treatment among those in need. These
numbers convey that the vast majority 99.2% and 84.7%, respec-
tively (by subtracting the above percentages from 100%) of in-
dividuals in need did not receive treatment. The general finding is
that most people with a diagnosable psychiatric condition do not
receive treatment.
Among the small minority of individuals who receive services
what exactly do they receive? In the WHO study, “receiving ser-
vices” was based on asking respondents if they ever saw any con-
tact from a long list of caregivers either as an outpatient or inpatient
for problems with emotions, nerves, mental health, or use of
alcohol or drugs. Included were mental health professionals (e.g.,
psychiatrist, psychologist), general medical or other professionals
(e.g., general practitioner, occupational therapist), religious coun-
selors (e.g., minister, sheikh), and traditional healers (e.g., herbalist,
spiritualist). The list varied among countries depending on local
circumstances where types of healers may vary. The precise service
provided by these individuals was not identified. Also, the duration
of the intervention was not known, but receiving services required
at least one contact. Thus when we say that 15% of individuals
received treatment, information is ambiguous and could be one
contact with someone who has had no training in mental health.
In the US, the National Comorbidity Survey-Replication study
also has provided data on who receives treatment as well as some
further information about the nature of that treatment (Wang, Lane
et al., 2005). Over 9000 individuals with psychiatric disorders
answered questions about their treatment that included who the
service provider was (e.g., psychiatric, family physical, social
worker, spiritual advisor and others) and the type of treatment they
received (e.g., self-help group, medication, hospital admission).
Minimally adequate treatment was defined as receiving an inter-
vention (e.g., medication, psychotherapy) that followed evidence-
based guidelines for the specific disorder and included multiple
contacts (rather than only one visit). For individuals with a psy-
chiatric disorder, 21.5% received treatment from a mental health
specialist; 41.7% received treatment if this is expanded to include
contact with any health-care person, in addition to those trained in
mental health. For individuals who did not meet criteria for dis-
order (subsyndromal disorder), 4.4% received treatment from a
mental health specialist and 10.1% received treatment if this is
expanded to include any contact. Overall, across the entire sample,
only 32.7% were classified as receiving at least minimally adequate
treatment. The investigators concluded that only one third of
treatments provided met minimal standards of adequacy based on
evidence-based treatment guidelines.
Other conclusions were noted from this survey. First, treatments
were used that have unclear benefits. For example, the comple-
mentary and alternative treatments accounted for 31.3% of all
mental health visits despite the absence of evidence attesting to
their effectiveness. Second, most services and mental health visits
were consumed by individuals without meeting the criteria for
disorders. Because the cut point for a diagnosis (clinical, subclinical)
is difficult to defend and because more disorders are conceived as
on a spectrum, “subclinical” may well be in need of or profit from
treatment. It does mean that those with greater severity of
dysfunction may not be consuming most of the available services.
1.2. General comments
Key points summarize the state of the treatment gap. First, most
individuals with mental disorders do not receive treatment and
that applies to the US and other countries. There is no single
summary percentage one can provide because of variation among
studies in: the disorders that are included (e.g., subsyndromal
disorders, substance use and abuse, personality disorders), in what
“counts” as treatment, and the list of who is included as potential
service providers (e.g., mental health professional, religious leader),
and ethnicity, culture, and country of the sample. And yet, through
it all it is clear that we are not providing treatment to the large
majority of people in need of services.
Second, when treatment is provided, it includes a variety of
interventions administered by mental health professionals, health-
care professionals in other areas (e.g., general practitioners), and by
others (e.g., religious leaders, healers). This care usually refers to
some contact. Yet that contact is not necessarily formalized psy-
chological treatment or medication.
Third and related, EBPIs are used infrequently for mental dis-
orders for the proportionately few individuals who receive care.
Epidemiological surveys have not been designed to probe in depth
precisely what the interventions are, how long they are adminis-
tered, and whether the persons administering the treatment are
 A.E. Kazdin / Behaviour Research and Therapy 88 (2017) 7e18
trained in use of the treatment. Yet, we know from other sources as
well that evidence-based treatments are not being used for mental
and substance use disorders as a general rule (Institute of Medicine
[IOM], 2001, 2006). The goals for individual patients and service
providers are not just to receive and provide any treatment but
rather to receive and provide the best treatments and specifically
those that have an evidence base. In addition to ensuring that the
most well supported interventions are provided to those who seek
and receive treatment, we need to extend these treatments to the
much larger group of people in need who receive no services at all.
2. Dominant model of treatment delivery
2.1. Overview
There are many impediments or barriers that stand in the way of
people receiving mental health interventions (e.g., Andrade et al.,
2014; Corrigan, Druss, & Perlick, 2014; Hinshaw & Stier, 2008).
These include primarily system issues (e.g., out of pocket costs,
proximity to mental health services and health professionals) and
attitudinal issues (e.g., stigma, mental health literacy). I return to
the topic later because extending treatment on a large scale re-
quires addressing multiple barriers. Yet, for the present discussion,
consider one related to the treatments we develop and over which
we have some control. That impediment I refer to here as the
dominant model of treatment delivery, i.e., the most frequent way
psychological interventions are provided to individuals who seek
treatment.
For purposes of this discussion, it is critical to distinguish a
treatment technique from how that treatment is delivered. The
distinction is easily conveyed in multiple contexts. For example, in
our daily lives, our “to do” list to keep us on track (the intervention)
can come to us in many ways including smartphone alerts, calendar
reminders, a physically printed copy (how quaint), and verbal ap-
peals from loving partner (the models of delivery). In the context of
physical health care, some vaccines (the intervention) can be pro-
vided by injection, nasal spray, orally, or needle-free patch (the
models of delivery). In the context of mental health care, so too can
we distinguish the intervention (cognitive behavior therapy) from
the models of delivery (e.g., by a live therapist, smartphone “app,”
or the Web).
In relation to various forms of traditional, cognitive-behavioral,
and other therapies, the dominant model of delivery has three
interrelated characteristics.
1. Treatment sessions are provided in person and one-to-one with
a client (individual, couple, family);
2. Treatment is administered by a highly trained (e.g., Master’s or
doctoral level) mental health professional; and
3. Sessions are held at a clinic, private office, or health-care facility.
To be sure, there are changes, as in the use of technology as I
mention later. Even so, in research and clinical practice, the model
continues to rule. We are familiar with the term “treatment as
usual,” to refer to the practices that are routinely used in a clinical
service. Not yet coined, is “treatment delivery model as usual,”
which I am referring to as the dominant model as a less cumber-
some term.
This model of delivery has strong historical connections to
medicine and in that context is referred to as the physician’s practice
model (C. Christensen, Grossman, & Hwang, 2009). Indeed, histor-
ically many psychological techniques (e.g., Mesmerism, hypnosis,
psychoanalysis) that have played pivotal roles in the development
of contemporary psychosocial therapies were provided by physi-
cians (e.g., Anton Mesmer, James Braid, and Sigmund Freud,
9
respectively) and followed the usual medical practice model of
seeing the doctor for individual sessions, but the setting occa-
sionally included “house” calls rather than a clinical setting or a
private office (e.g., Breuer & Freud, 1957). Currently in the US, the
vast majority of psychosocial treatments are administered in the
one-to-one, in-person therapy model, with a mental health pro-
fessional, and at a setting to which the client must go. This model
applies to EBPIs as well as the much larger number of interventions
yet to be evaluated empirically including treatments as usual. This
dominant model has been enduring, is in demand, and can deliver
many EBPIs.
2.2. Limitations of the model in reaching people
The dominant model may limit the degree to which treatment
can be extended to reach many individuals in need. Meeting with a
mental health professional individually in treatment conveys that
constraints of the model. To begin, there are many mental health
professionals but not enough to meet the demands using the
dominant model. The estimated number of mental health pro-
fessionals in the US who provide services is approximately 700,000
(Hoge et al., 2007). This is likely to be an underestimate given the
range of providers not usually counted, including other pro-
fessionals (e.g., pastoral counselors) and individuals with various
titles (e.g., personal coaches, healers). Even so, it is difficult to
envision that the number could help sufficiently if 25% of the US
population in any given year meets criteria for a psychiatric disor-
der leaving aside those with subclinical disorders.
An initial reaction might be to claim that it is not the model of
delivery that is the problem but the fact that we just need more
trained mental health professionals who can provide treatment.
Having more mental health professionals might be valuable, but
cannot be expected by itself to have significant impact on reaching
palpably more people. The main reasons relate to the geographical
distribution, interests, and composition of the professional work-
force. Consider these in turn. First, in the US, mental health pro-
fessionals are concentrated in highly populated, affluent urban
areas and in cities with major universities (Health Resources and
Services Administration, 2010). All of the states in the US include
rural areas where the concentration of people to square miles of
land is low (www.hrsa.gov/ruralhealth/aboutus/definition.html).
For these areas and small towns more generally, very few and more
commonly no mental health professionals may be available.
Second, the majority of mental health professionals do not
provide care to populations and clinical problems for which there is
an especially great demand (children and the elderly, individuals of
minority groups, special populations in need such as victims of
violence, single-mothers, individuals of lower income). For
example, most psychiatric disorders have their onset in childhood
and adolescence but most individuals in the mental health pro-
fessions are trained in the treatment of adults. At the other end of
the age spectrum, the proportion of elderly individuals is expand-
ing rapidly in the US (and worldwide) and are increasingly un-
derserved in mental (and physical) health services (IOM, 2011a;
2012). Too few mental health professionals are trained to provide
services to the elderly.
Finally, disproportionately few mental health professionals
reflect the cultural and ethnic characteristics of those in need of
care. Individuals do not necessarily have to be treated by persons of
the same ethnic and cultural group with which they identify. Yet
entering into treatment, forming an alliance, being able to
communicate in one’s primary language, and having a shared view
of psychological problems can all depend on having a match ther-
apist and patient in relation to ethnicity and culture. A mismatch of
ethnicity and culture between prospective client and therapist at
10 A.E. Kazdin / Behaviour Research and Therapy 88 (2017) 7e18
minimum adds another obstacle for receiving services.
For the above reasons, expanding the workforce to deliver
treatment with the usual, in-person, one-to-one model of care,
with a trained mental health professional is not likely to have major
impact on reaching the vast number of people in need of services.
The increased person power is not likely to provide treatments
where they are needed, for the problems that are needed, and
attract the cultural and ethnic mix of clientele that are essential.
Professional organizations and funding agencies that provide sup-
port for trainees can incentivize professional development in areas
of need (e.g., training in rural psychology, mental health services for
special groups). Also, we would never want to turn down more
resources to provide services. It is just that as a solution to the
problem of increasing the scale of interventions, increasing more of
what we are doing now in relation to the model of delivery will not
suffice in closing the treatment gap.
Another feature of the dominant model raises similar concerns
in reaching individuals in need. Requiring clients to go to a special
setting (e.g., clinic, private office) is a constraint too. Settings where
services are provided are not readily available for most individuals.
And “going” to a setting raises a host of other barriers that are both
system issues (e.g., transportation) and attitudinal issues (e.g.,
stigma). I will return to other facets of the dominant model
including many promising ways in which they are being addressed.
2.3. General comments
One-to-one, in-person therapy is referred to here as the domi-
nant model because clinical practice, graduate school training,
clinical program accreditation, pre- and post-doctoral internships,
and research on psychosocial interventions draw heavily on this
model. The dominant model has benefits that are already well
known. In relation to the present article, that model has served as
the basis for identifying and developing EBPIs and for adminis-
tering the treatments in clinical work. Nothing of my comments
detracts from these remarkable gains. And for individuals who have
access to that model, there may be little need to provide new ways
of delivering treatment. My focus pertains to what would be
needed to reach the largely unserved majority of individuals in
need of mental health services.
The need to move to additional models has spanned decades
~ oz, 1978; Collins, Insel,
(e.g., A. Christensen, Miller, & Mun
Chockalingam, Daar, & Maddox, 2013; Ryder, 1988). And, within
the mental health professions, the models of delivering psychoso-
cial interventions have expanded. Many of these involve the use of
technology and online versions of treatment that draw on the Web
and other media, including video, phone, and application software
(apps) for smartphones and tablets. I will mention technology
further later.
3. Addressing the treatment gap
3.1. Characteristics of treatment that would help reach individuals
in need
Typically, as we develop treatments, we begin with a focus on a
clinical disorder, a model of how that disorder may come about,
how treatment can address key components of the disorder, and
what we might draw from the human and nonhuman animal
research in the way of principles or techniques. We then begin tests
of treatment. If one considers cognitive therapy for depression and
prolonged or graduated exposure for anxiety, for examples, many of
these steps have been critical for developing these interventions.
The viability of this model needs no more proof than the successes
of these many other EBPIs.
I am suggesting we begin in the next stage of EBPIs to expand
the focus in how we develop the interventions or at least consid-
erations to which we attend from the outset. Consider the goal or
target as reaching a large number of individuals who are unserved
by current treatments. We begin with the question: What are key
characteristics we would want of treatments and models of de-
livery to achieve that goal? Table 1 lists several characteristics that
might guide our development of treatment and focus our attention
on delivery. The characteristics I mention might be considered as a
preliminary guide rather than a comprehensive list. Also, there is
no need for a single model to meet all or even most of these
characteristics. Rather multiple models are likely to be needed to
reach people in different contexts.
3.2. Illustrations of novel models delivery
Multiple models have emerged from global health care, busi-
ness, economics, and the mediadall well outside of traditional
psychological and psychiatric care (see Kazdin & Blase, 2011;
Kazdin & Rabbitt, 2013). Table 2 provides several models of de-
livery and their key characteristics. I highlight three examples to
convey different ways in which treatments can reach large
numbers of individuals and in which key characteristics noted in
Table 1 can be addressed.
3.2.1. Task shifting
Task shifting is a method to strengthen and expand the health-
care work force by redistributing the tasks of delivering services to
a broad range of individuals with less training and fewer qualifi-
cations than traditional workers (e.g., doctors, nurses) (see WHO,
2008). 2 This redistribution allows an increase in the total num-
ber of health workers (e.g., nonprofessionals, lay individuals) to
scale up the scope of providing services. The concept and practice of
task shifting are not new and currently are in place in many
developed countries (e.g., Australia, England, United States) where
nurses, nurse assistants, and pharmacologists provide services once
reserved for doctors. Also, community health workers, a term
defined long before task shifting was developed, have provided
specific health services (e.g., birthing, neonatal care, immunization)
in developing and developed countries and with demonstrated
efficacy (e.g., Bang, Reddy, Deshmukh, Baitule, & Bang, 2005;
Greenwood et al., 1989).
Task shifting emerged from global health initiatives, particularly
in developing countries. These initiatives focused on treating and
preventing infectious (e.g., malaria, HIV/AIDS, tuberculosis) and
noncommunicable disease (e.g., cardiovascular disease, diabetes,
cancer, respiratory disease) and improving living conditions and
education (e.g., IOM, 2010; 2011b; United Nations, 2000; WHO,
2011a). These initiatives provide an important context because
they contended with key challenges of meeting health-care needs
in many cultures, under a variety of conditions (e.g., enormous
resource constraints, geographical obstacles), and where people in
need of services were not receiving them. Key strategies to address
the problems included reorganizing and decentralizing health
services to accommodate the limited traditional resources and
infrastructure (e.g., medical personnel, hospitals). The majority of
task-shifting applications have focused on physical health in
developing countries (e.g., Ethiopia, Haiti, Malawi, and Namibia)
where shortages of human resources and the burden of illness (e.g.,
2
Task sharing is also a term that is used. Task shifting and sharing both involve
distributing the tasks normally provided by health professionals to lay individuals
or at least sharing those. For present purposes, I will refer to task shifting to
encompass both of these to make the points.
 A.E. Kazdin / Behaviour Research and Therapy 88 (2017) 7e18 11

Table 1
Key characteristics of modes of treatment delivery to reach people in need of services.

Characteristic Defined

Reach
Scalability
Affordability
Expansion of the nonprofessional work force
Expansion of settings where interventions are provided
Feasibility and flexibility of intervention delivery
Flexibility and choice of alternatives for clients within a
particular type or class of effective interventions
Capacity to reach individuals not usually served or well served by the traditional dominant service
delivery model
Capacity to be applied on a large scale or larger scale than traditional service delivery
Relatively low cost compared to the usual model that relies on individual treatment by highly trained
(Master’s, doctoral degree) professionals
Increase the number of providers who can deliver interventions
Bring interventions to locales and everyday settings where people in need are likely to participate or
attend already
Ensure the interventions can be implemented and adapted to varied local conditions to reach diverse
groups in need
Allow choice or alternative ways to meet the criteria for what would be an effective intervention.
Exercise and meditation, for examples, two very broad classes of intervention that affect mental health
and clinical dysfunction. Yet, there are multiple options of precisely what is done to achieve similar
outcomes.

Table 2
Illustrations of novel models of delivering health services to expand the reach to the community level.

Model Key characteristic Examples Sample

references with
illustrations

Task Shifting Expanding the workforce by using lay individuals to administer Used worldwide for treatment and prevention of HIV/AIDS. WHO (2008)
interventions that otherwise might be delivered by health Recently extended to mental health service delivery. Patel et al.
professionals. (2010)
Disruptive A process in which services or products that are expensive, The delivery of health screening and treatment in shopping Christensen
Innovations complicated, and difficult to deliver move in novel ways to alter malls, drug stores, and grocery stores. Use of smartphones, apps, et al. (2009)
these characteristics. In health care, services are brought to tablets to assess and deliver mental health interventions. Rotheram-Borus
people more than bringing people to the services. et al. (2012)
Interventions in Expansion of health care beyond clinics and traditional settings Delivery of health screening and education messages in hair Linnan et al.
Everyday to places that people normally attend for other reasons. Overlaps salons. (2001)
(unconventional with disruptive innovation but comes from different tradition Madigan, Smith-
settings) and draws on different settings (e.g., schools, work place, Wheelock, and
churches, hair salons, barber shops). Krein (2007)
Best-buy Interventions selected based on their cost-effectiveness, To reduce use of tobacco use, raising taxes, protecting people Chisholm et al.
Interventions affordability, feasibility for the setting (e.g., country, city), and from cigarette smoke, warning about the dangers of smoking, (2007)
other criteria. Conceived as an economic tool to help countries and enforcing bans. WHO (2011a)
select among evidence-based strategies to have impact, where
impact is quantified (estimated) for different strategies.
Life-style changes A range of behaviors individuals can engage in that are known to Exercise has broad impact on health and physical health. Deslandes et al.
have impact on physical and/or mental health including (2009)
controlling diet, exercising, meditation, and interacting with Walsh (2011)
nature.
Use of Social Media Use of widely available material that includes social networking Writing regularly as part of blogging to draw on many evidence- Baker and Moore
(e.g., Facebook, Twitter,, texting, YouTube, Skype) that bring based expressive writing interventions; meeting with a therapist (2008)
people together in novel ways and to present information, to or support group in a virtual social world. Gorini, Gaggioli,
obtain assessment, and to provide feedback or delivery of Vigba, & Riva
interventions. Interventions can be brought to people where ever (2008)
they are through these media connections.
Entertainment Use of television or radio to deliver health-care messages and to Early application focused on reducing the birthrate and use of
Singhal and
Education model health-promoting behaviors. A culturally sensitive long- birth control in Mexico. Rogers (1999)
running series (e.g., TV series) in which different characters take Singhal, Cody,
on different roles, deal with the challenges related to the focus of Rogers, and
the intervention, and model adaptive strategies. Sabido (2003)
Use of Technologies Use of Web-based interventions delivered remotely. Several self- Use of Internet-based treatment for cigarette smoking. Web- Harwood and
help procedures rely on web-based treatment, mobile apps, are based self-help treatment for clinical depression. L’Abate (2010)
included here as well. This category overlaps with social media Mun ~ oz et al.
but has a separate literature. (2016); Titov
et al. (2015)
Community Developing partnerships between academics and community Development of an implementation strategy to engage agencies Bluthenthal et al.
Partnership members for close collaboration on developing and then to provide services for individuals who are underserved. (2006)
Model implementing action plans for providing community services. Wells et al.
The model is a comprehensive process of planning through (2013)
tracking and evaluating the services.

Note. These models occasionally have overlapping characteristics (e.g., bringing interventions to the people in need rather than asking individuals in need to come to special
settings) but are worth distinguishing because they come from different traditions, disciplines, and collaborations. Each of the models in the table is elaborated and illustrated
in greater depth elsewhere, beyond the specific references listed next to each model (Kazdin & Blase, 2011; Kazdin & Rabbitt, 2013).

HIV/AIDS) are acute. Empirical evaluations have shown task shift- levels of patient and counselor satisfaction (WHO, 2008).
ing to rapidly increase access to services, reach large numbers of Task shifting was extended to mental health problems because
individuals in need, yield good health outcomes, and have high of its ability to be scaled up to provide services to individuals who
12 A.E. Kazdin / Behaviour Research and Therapy 88 (2017) 7e18
otherwise did not have access to care and its adaptability to diverse
countries, cultures, and local conditions. An exemplary application
of task shifting in mental health was a randomized controlled trial
of treatment of anxiety and depression in India (Patel, Weiss et al.,
2010, 2011). Twenty-four public and private facilities (including
more than 2700 individuals with depression or anxiety) received a
stepped-care intervention beginning with psychoeducation and
then interpersonal psychotherapy, as needed and as administered
by lay counselors. The lay counselors had no health background and
underwent a structured two-month training course. Medication
was available as was specialist attention (health professional) for
suicidal patients. At 6 and 12 months after treatment, the inter-
vention group had higher rates of recovery than did a treatment-as-
usual control group administered by a primary health-care worker,
as well as lower severity symptom scores, lower disability, fewer
planned or attempted suicides, and fewer days of lost work. Overall,
the study showed that lay counselors could be trained to admin-
ister interventions with fidelity and that their interventions
reduced the rates of disorder in a large sample. This is an excellent
example of extending EBPIs developed in controlled research set-
tings to community applications but with a change in the model of
delivery of those treatments. An EBPI, interpersonal psychotherapy,
constituted one of the treatments, but the novelty was in the model
of delivery that allowed the intervention to reach many more
people than typically is the case in the dominant model where a
mental health professional delivers the intervention.
Other studies have demonstrated the impact of task shifting as a
model of delivery for the treatment of depression and schizo-
phrenia (e.g., Balaji et al., 2012; Rahman, Malik, Sikander, Roberts, &
Creed, 2008). These demonstrations not only establish the clinical
utility of task shifting but add to the evidence that lay counselors
can deliver effective treatment and that outcome effects are not
sacrificed in the process. Moreover, studies evaluated outcomes on
a larger-than-usual scale for psychological intervention studies,
evaluated and monitored treatment fidelity, and included follow-
up, among other features.
As any single model of delivering treatment, task shifting has its
own unique challenges. Among them is the two-fold task of
obtaining personnel. The first of these tasks is to recruit the in-
dividuals who will deliver treatment. This is easier in most cir-
cumstances that obtaining trained mental health professionals, but
still can be an issue depending on the scope and scale of the
treatment that is to be delivered and other potential constraints
(e.g., applications in multiple rural settings). The second personnel
challenge is obtaining sufficient trainers to develop the skills in
those who provide direct treatment. In some of the physical health
task-shifting work, administration of treatment (e.g., medication)
was more straightforward than administration of psychotherapy
would be. These challenges do not at all detract from the contri-
butions of task shifting. Moreover, many of the concerns I highlight
here in passing have been addressed empirically in early applica-
tions of task shifting (WHO, 2008). The broader point is worth
making. Multiple models of delivery or a portfolio of models will be
needed to overcome the limitations any single model (Kazdin &
Blase, 2011).
3.2.2. Best-buy interventions
Economics of physical health care have added to the impetus to
identify novel models of providing services and these have been
extended to mental health care. A survey of world business leaders
by the World Economic Forum indicated that chronic disease (e.g.,
cardiovascular disease, cancer) is a major threat to economic
growth globally (Bloom et al., 2011; WHO, 2011b). Disability and
mortality not only exert economic impact on individuals, families,
and households, but also on industries and societies through
consumption of health-care services, loss of income, productivity,
and capital expenditures that could otherwise support public and
private investment. Best-buy interventions have emerged from this
context to designate interventions for physical illnesses, particu-
larly the control of chronic diseases globally (IOM, 2010).
Best buy refers to an intervention for which, “there is compel-
ling evidence that is not only highly cost effective, but is also
feasible, low-cost (affordable), and appropriate to implement
within the constraints of a local health system” (WHO, 2011a, p. 2).
Best buy also considers features such as appropriateness for the
setting (e.g., culture, resources), capacity of the health system to
deliver a given intervention to the targeted population, technical
complexity of the intervention (e.g., level of training that might be
required), and acceptability based on cultural, religious, and social
norms.
Identifying best-buys was conceived as an economic tool to help
countries evaluate how to achieve a given amount of change, given
the number of eligible individuals in need of the intervention, the
potential savings of those changes, and the cost differences of
alternative strategies (e.g., Chisholm, Lund, & Saxena, 2007;
Chisholm & Saxena, 2012; WHO, 2011b). For example, in one
analysis four criteria (health impact, cost-effectiveness, cost of
implementation, and feasibility of scaling up) were used to identify
best-buy interventions that would have significant public health
impact on noncommunicable diseases including cardiovascular
disease, cancers, diabetes, and chronic lung disease (WHO, 2011a).
Best buys for cardiovascular disease and diabetes were counseling,
multi-drug therapy, and aspirin. These were selected in light of the
reduction of disease burden and very low cost. The example is not
necessarily one that applies to all locales. The best-buy in-
terventions can differ for a given disorder and country in light of
variation in the health-care resources, infrastructure, and distri-
bution of the population (e.g., very sparsely populated areas).
Best-buy interventions for physical diseases often focus on do-
mains of functioning that overlap with and are part of behavior,
lifestyle, and mental health, as reflected in substance use and abuse
(e.g., alcohol and tobacco). For example, for alcohol use, best-buy
interventions include enhanced taxation of alcoholic beverages
and comprehensive bans on advertising and marketing, based on
their favorable cost-effectiveness, affordability overall, and feasi-
bility. Excessive alcohol use was identified as a best buy for
reducing the incidence of cardiovascular diseases and cancers, and
the impact would be likely to extend to other burdensome condi-
tions (e.g., cirrhosis of the liver, depression, traffic injuries and
deaths; WHO, 2011a). More explicit designations of best buys have
been identified for select mental disorders. For example, for clinical
depression, generically produced antidepressant medication, brief
psychotherapy, and treating depression in primary care qualified as
best buys (Chisholm et al., 2007). For psychoses, treating people
with antipsychotic drugs and with psychosocial support are
regarded as best buys.
Best-buy interventions are based on estimates of utilization and
impact, relying on mathematical models (e.g., Chisholm et al.,
2007). Empirical tests of the model are then conducted to ensure
that well-intended, feasible, and scalable interventions yield the
intended outcomes and in fact are best buys. Also, as in any large-
scale intervention, sustaining the integrity of the intervention can
be a challenge. Yet, some best-buy interventions (e.g., selective
taxes, bans on advertising to reduce substance use and abuse) differ
from the usual psychological interventions and do not require
compliance by clients in the same way as psychosocial treatments
usually do and do not require adherence to a specific treatment
protocols by therapists. Also, we have evidence from research as
well as large-scale reports that taxes can be effective (see
Desmond-Hellmann, 2016). Of course, taxes and advertising have
 A.E. Kazdin / Behaviour Research and Therapy 88 (2017) 7e18
their own problems (e.g., black market sales that are not taxed,
advertising not reaching the target population), but these different
problems are precisely the reasons why we need multiple models
of delivering interventions. No single model or small set of models
is likely to reach the vast majority in need of services and we would
want models with different benefits as well as liabilities.
3.2.3. Disruptive innovations
Disruptive technology or disruptive innovations emerged from
business rather than health care (Bower & Christensen, 1995; C.;
Christensen, 2003; C.; Christensen et al., 2009). The concept per-
tains to a change in a product or service that is not a linear,
evolutionary, or incremental step. Rather the product or service
often provides a disruptive, disjunctive, or qualitative leap and
develops or extends a market that is not otherwise being served.
Disruptive innovation theory refers to the process by which
products or services that are complicated, expensive, and less
affordable move to novel delivery models and products that change
these characteristics. The concept of disruptive innovation is much
less familiar but the many innovative products and services that
illustrate its application are part of our daily lives. Examples include
innovations in manufacturing (e.g., interchangeable parts, assem-
bly line in car production), business (e.g., cell phone, smartphone,
tablet), consumer purchasing (e.g., via credit cards, smartphones,
and PayPal), social networking (e.g., Facebook, Twitter, LinkedIn),
and health care (e.g., home pregnancy tests, medical robotics, and
urgicare, walk-in, and minute clinics) (see C. Christensen et al.,
2009). These innovations often provide simpler, less expensive, or
more convenient solutions to problems and often can be scaled to
reach people who would not otherwise have access.
Telemedicine, which refers to the use of communication and
information technology to extend the reach of medical practice, is
one example of a disruptive innovation that has changed how and
where some patients receive medical care (e.g., Roine, Ohinmaa, &
Hailey, 2001). Telemedicine has been in use for over 40 years
(www.americantelemed.org/). At the same time, leaps in both
hardware and software have extended the range of remote appli-
cations, as illustrated by the development of diverse specialty areas
(e.g., telepsychiatry, telesurgery, teleopthamology. teleaudiology,
teleneurology) (e.g., Buck, Manges, & Kaboli, 2016; Martini et al.,
2013; Wooton, 2003). (Teleproctology looks like it still remains
behind.) Other disruptive innovations in health care have utilized
nonmedical settings, such as drug stores and shopping malls, to
provide a range of services to measure blood pressure or choles-
terol, treat various illnesses (e.g., allergies, pinkeye, strep throat)
and skin conditions (e.g., cold sores, minor burns, wart removal),
and provide vaccines (e.g., flu shots). Patient referrals can be made
if the tests reveal the need for further diagnostic work or
intervention.
Disruptive innovations could provide more accessible ways of
delivering mental health interventions (see Rotheram-Borus,
Swendeman, & Chorpita, 2012). Many interventions already have
extended to mental health care through the use of smartphones,
tablets, apps, the Web, and video conferencing (e.g., Backhaus et al.,
2012; Barak, Hen, Boniel-Nissim, & Shapira, 2008; Bennett-Levy
et al., 2010; Parikh & Huniewicz, 2015; Price et al., 2014). For
example, smartphones and tablets provide opportunities for
assessing psychological states and bringing interventions to in-
dividuals in their everyday lives. The assessment can provide
feedback in real time that can activate treatment from one’s
communication device. To illustrate, biofeedback (as one inter-
vention for stress) in years past required traveling to a facility (e.g.,
a lab) with the suitable equipment. Currently, many portable and
affordable devices (for measuring heart rate, blood pressure, blood
glucose levels) are available to the public and can provide the
13
necessary feedback or periodic monitoring in everyday life (i.e.,
wherever the individual is at a given point in time) (e.g., Pallavicini,
Algeri, Repetto, Gorini, & Giuseppe Riva, 2009; Zhang, Wu, Wang, &
Wang, 2010). Sensors that monitor heart or breathing rate and
provide information immediately (e.g., in color or graphical
display) can prompt the use of relaxation and other self-
management techniques (e.g., RelaxLine, 2010; StressEraser,
2012). Apps for smartphones and tablets are constantly emerging
and now allow assessment, feedback, and applications of in-
terventions that can change mental health care. Smartclothing that
tracks a variety of biological measures, used more commonly in
relation to exercise and athletics, will no doubt find its way into
assessment and treatment feedback loops.
Online delivery of treatment is a disruptive intervention that
extends of the dominant model of therapy. Multiple options are
available online for the treatment of anxiety and depression (e.g.,
Spek et al., 2007). These programs often include the same core
cognitive behavioral treatment sessions as used with in-person
treatment (e.g., scheduling of positive activities, identifying and
challenging cognitive distortions) and are divided into sessions
(with video clips describing key information and assigned home-
work) that patients can complete from home. There are now scores
of other evidence-based self-help psychosocial interventions for a
range of psychological problems (Bennett-Levy et al., 2010;
Harwood & L’Abate, 2010). These interventions can leap over
many of the usual barriers of receiving treatment and expand on
the dominant model of in-person, individual psychotherapy at a
clinic.
The use of technology to deliver psychosocial interventions vary
in the extent to which they utilize facets of the dominant model. For
example, some Web-based treatments are administered one-to-
one by a mental health professional but do not require the client
to go to a clinic. Others are based on self-help and may involve no
therapist at all. All variations can contribute to extending treatment
to those who otherwise would not receive services. Yet, we still
need demonstrations that technology in fact can and does reach
large numbers of individuals and in the process has impact.
Such extensions are emerging. For example, in one demon-
stration cognitive behavioral treatment was provided on line as a
course (Titov et al., 2015). Support was provided by a trained
therapist by phone or email on a weekly basis. Even so, with the use
of trained therapists (characteristics of the dominant model), the
treatment was 1471 individuals completed treatment (out of 2049
who enrolled). Use of a trained therapist (one feature of the
dominant treatment model) still allowed larger than usual scale
application of treatment (mean therapist time per case was
112 min).
An example of a very large-scale application consisted of a Web-
based intervention for smoking cessation (Mun ~ oz et al., 2016). The
program was available in two languages (Spanish and English) and
was visited by over 290,000 individuals from 168 countries. Data
reported for over 7000 participants revealed smoking quit rates
ranging from 39 to 50% at different points of assessment up to an
18-month follow-up. This program advanced the notion of Massive
Open Online Interventions (MOOI) to resemble the model (Massive
Open Online Courses-MOOC) in education. MOOI would make
available interventions that could reach individuals on a scale as the
demonstration in the context of cigarette smoking.
As I noted, technology has many forms and formats. It is useful
to consider technology at an early stage, even though facets (e.g.,
telepsychiatry) are not new. And yet, other technologies with some
use in both mental and physical health care (e.g., social robotics) are
rather unfamiliar (see Rabbitt, Kazdin, & Scassellati, 2015).
There are a number of issues related to the strengths, limits, and
potential of technology (Bennett & Glasgow, 2009). First, and most
14 A.E. Kazdin / Behaviour Research and Therapy 88 (2017) 7e18
relevant to the present article, there are few applications of tech-
nology demonstrating that interventions can be scaled to reach
large numbers and produce significant (statistically, clinically)
clinical outcomes. Evidence for these might well be on the horizon,
but there has been cogent concern voiced that the contribution of
the use of technology may be oversold at this time or at least until
better scaling with outcome evidence are forthcoming (Bauer &
Moessner, 2013; Tomlinson, Rotheram-Borus, Swartz, & Tsai, 2013).
Second, technologies, bring their own set of limitations related
to adoption including acceptability of the public in the context of
“treatment,” maintaining participation in a program that may not
be or seem individualized, and access to the internet where these
are available. Interestingly, the utility and adoption of technology
(by clinical services, therapists, and clients) may well improve in
the next decade as a function of cohort effects. Younger age in-
dividuals are increasingly at home with technology and social
media and young children in familiar routinely chat with relatives
via cell phones and Skype. Indeed, it is not so surprising to learn
that a 9-month old infant accidentally rented a car online (Kim,
2015). The overall point is clear. Technology even if at some early
stage is central to our everyday lives and awaits newborns as they
enter the world. (Actually, there are many apps parents can use to
monitor and bond with the fetus so the fetus can begin exposure to
technology earlier.) How technology is viewed and accessed may
well change as most people are “connected” to the Web most of the
time.
Finally and related, thinking about the use of technology would
profit from a revolution. To stretch our thinking of what technology
can do, let us go beyond improved ways of reaching people to
entirely new interventions (Kazdin, 2015). A useful distinction has
been noted in a discussion of the physical Internet, which is an
active area of work in industry, engineering, and manufacturing.3
As one researcher noted in that context, “It’s [the physical
internet] not about a better way of doing what you now do. It’s
about doing things you’ve never thought of doing before” (Gue, as
quoted in Wible, Mervis, & Wigginton, 2014, p. 1106). The comment
is instructive by keeping both facets in mind. We want to do things
better (e.g., deliver EBPIs better, more broadly, with greater reach,
and so on). In addition, also want to rethink all facets of treatment
and what technology offers that is not just novel ways of delivering
what we have available now.
The distinction is not dichotomous but sensitizes us to options
to consider and foster truly novel ways of helping people that do
not follow from standard treatments (i.e., what we do now). For
example, for both treatment and prevention large-scale and fully
automated and individualized interventions can be designed to
promote exercise (e.g., Hurling et al., 2007). Also, for individuals
with stress, psychosocial symptoms, and impairment, support
programs could be made routinely available and alleviate both
mental and physical health problems (e.g., Bouma et al., 2015). Or
let us be much more ambitious. A huge problem in physical and
mental health care is treatment adherence. For example, for major
(and minor) diseases getting individuals to follow through on
3
The physical internet refers to a way of transforming how physical objects (e.g.,
manufactured goods) are transported, stored, supplied, and used to achieve greater
efficiency as well as sustainability. Achieving this transformation requires collab-
oration and standardization of manufacturing, shipping, retailing, regulating, and
the movement of goods across many boundaries (e.g., geographical, industry,
proprietary). This is referred to metaphorically as an Internet to emphasize the
standardization and communication that characterizes the more familiar digital
Internet. In manufacturing, there are enormous differences among industries,
companies, countries, and so on that limit efficiencies and these not only influence
costs, but also sustainability of resources and utilization of the work force (see
Montreuil, 2011; www.physicalinternetinitiative.org/.
treatment (e.g., activities, taking medication, monitoring biological
states, getting follow-up checkups, filling and refilling medication
prescriptions) is an issue with direct impact on disability and
mortality (e.g., cardiovascular disease, cancer, diabetes, HIV/AIDs).
As another example, “matching markets” is used extensively to
match consumers with products and messages that are especially
relevant to them (e.g., traveling, lodging, purchasing special prod-
ucts, and taxi services) (see Azevedo & Weyl, 2016). Perhaps this
could be extended to mental health in some way so that people
could be better targeted for the information, options, and services
that might be of use to them. Mental health literacy is a huge
problem (Jorm, 2012) and perhaps messages could be better tar-
geted (matched) to consumers most likely to profit from them.
Technology is moving forward but these comments and those of
others (e.g., Bennett & Glasgow, 2009) indicate that the potential
has yet to be exploited.
If technology as a means of providing mental health services
takes the route of other disruptive innovations, the landscape of
treatment may change considerably. When disruptive innovations
first emerge (e.g., personal computer, cell phone), they do not
compete head-to-head with the traditional product (e.g., main-
frame computer, centralized computers in industry and on cam-
puses, landline phones, pay phones). Over time the innovation may
begin to compete and take over as the product develops and the use
expands. The expansions include greater convenience, ease of use,
and portability in relation to original products. Perhaps innovative
treatment delivery models that are disruptive including those
involving technology will have a similar course.
3.3. General comments
My illustrations of convey that novels model of delivery have
been applied and raise the prospect of providing evidence-based
interventions on a large scale. Some of the models make clear the
distinction between treatment technique (the procedures or means
of altering a clinical problem) from the model of delivery (how that
technique is dispensed or provided). Task shifting is one example
where EBPIs (e.g., cognitive behavior therapy, interpersonal psy-
chotherapy), well established in the dominant model are delivered
by lay individuals. In other models the distinction between tech-
nique and delivery is blurred. For example, best-buy interventions
can be well outside the usual psychosocial techniques (e.g., taxes,
advertising) and are delivered in ways well outside of traditional
treatment (e.g., laws, social policy).
Many of the models have emerged and been applied to physical
health (e.g., chronic and infectious disease) but prompted exten-
sions to mental health for a few key reasons. First, global health
initiatives to address physical health-care services revealed gaps in
mental health services (IOM, 2010; WHO, 2011b). Many barriers for
delivering care for physical health care to large swaths of in-
dividuals in need, particularly in developing countries, were
recognized to be similar to the barriers of providing mental health
care (Lancet Global Mental Health Group, 2007; Sharan et al.,
2009). Consequently, models for delivering treatment proved to
be applicable to both mental and physical health services. As
highlighted with best-buy interventions, an intervention with a
primary target of reducing one type of dysfunction (e.g., substance
use and abuse) may have direct consequences on other types of
dysfunction (e.g., physical disease and mortality).
Second, it has become increasingly clear that mental and
physical health are inextricably intertwined, with bidirectional,
reciprocal, and comorbid relations. For example, a variety of com-
mon influences promote both physical and mental illness. Some of
the more familiar culprits include inflammation and stress, but
there are now many others including as air pollutants and
 A.E. Kazdin / Behaviour Research and Therapy 88 (2017) 7e18
particulates (e.g., Bakian et al., 2015; Lim et al., 2012), breastfeeding
practices (e.g., Krol, Rajhans, Missana, & Grossmann, 2014; Oddy
et al., 2010), microbiota in our guts (e.g., Kleiman et al., 2015;
Nowakowski et al., 2016), and mitochondrial abnormalities
(Rezin, Amboni, Zugno, Quevedo, & Streck, 2009; Rossignol & Frye,
2015). In addition, psychological factors (e.g., depression) can
directly influence the course of physical diseases (e.g., heart dis-
ease, HIV by decreasing medication adherence). More generally,
reducing the burdens of physical health cannot neglect mental
health, as reflected in the oft-cited statement there is “no health
without mental health” (Prince et al., 2007, p. 859; WHO, 2005, p.
11). In any case, models of delivering treatments can apply to both
physical and mental health and several treatments may be ex-
pected to have impact on both as well.
Finally, the move to integrated health care that provides physical
and health-care services in the same facility further conveys
recognition of the benefits of treating mental and physical health in
juxtaposition (e.g., Collins et al., 2013; Crowley & Kirschner, 2015;
Richardson et al., 2005). Integration provides greater opportunity
to reach a segment of the population that seeks physical health care
and in that process will have access to mental health care as well. Of
course, there are many who do not seek or obtain physical health
care. However, the key point is to have multiple models of delivery
of mental health services to capture an increasing portion of the
individuals otherwise receive no services. Integrated care does not
have to be the solution but could be a significant part of multiple
strategies.
The models I have illustrated and otherwise listed add to the
dominant model and increase the likelihood of reaching more
people who are not being served but in need of mental health care.
Those who are unserved within a country or among different
countries are heterogeneous in culture, ethnicity, geography, re-
sources, infrastructure for providing and receiving care, and many
other characteristics that can influence treatment delivery. The
cultural sensitivity issue warrants further comment. Many of the
EBPIs have been developed, evaluated, and implemented largely in
Western cultures and could readily vary in applicability and effec-
tiveness among diverse cultures. It is true that many EBPIs do not
vary in effectiveness across the few ethnic cultural groups (out of
thousands internationally) to which they have been extended (e.g.,
Miranda et al., 2005). Add to that a small number of EBPIs that
began with the cultural and ethnic groups of interest as a basis for
developing treatment.
The novel models I have mentioned begin with a different and
complementary point of departure for developing ethnically and
culturally sensitive conditions. They begin with a multicultural and
indeed global perspective and as part of that are designed to
accommodate local conditions including what is feasible, not just
economically, but what is acceptable to those who would be the
recipients of intervention. For example, in task shifting lay mem-
bers of the communities in which treatment is provided are directly
involved in delivery of the care. Thus, one is delivering and
receiving interventions among one’s peers of the same culture,
ethnicity, and traditions. In best-buy interventions, precisely what
interventions are likely to be appropriate is determined by local
conditions and resources (e.g., government, political, likely impact)
and in that sense also are compatible with the culture and society. A
seemingly great best-buy intervention (e.g., taxes, advertising,
medication) might not fit at all for a given country and culture not
just for feasibility or relevance but because one or more of these is
not an acceptable way of exerting influence effectively in that
culture. The unique contribution of the multiple models approach
is that it begins with the goal, namely, reaching people in need to
reduce the burdens of mental illness. As I noted in discussing
technology or integrated care, as two examples, any one model will
15
miss key segments of the population in need of services. But mul-
tiple models, particularly those that begin with what characteristics
are needed to provide treatment on a large scale, are likely to have
the needed impact.
4. Barriers to mental health care: context and considerations
The impediments to providing and receiving care do not hinge
or completely fall to the model of delivering treatment. There are of
course many reasons the vast majority of individuals in need of
psychological services receive no treatment. To begin, receiving
services for psychological dysfunction encompasses multiple steps
that include experiencing symptoms or some form of dysfunction,
identifying those as symptoms or something in need of help,
deciding whether action is needed to do something about the
symptoms, identifying the options for intervention (e.g., a psy-
chosocial “treatment” or something else), seeking and actually
obtaining treatment if that is the option selected, beginning the
treatment, and remaining in treatment as needed, and with
recurrent disorders traversing the process or abbreviated variants
again. These seem like a natural flow of steps and once one started
the rest of the steps would unfold. Actually, there are multiple
obstacles at each of steps that can impede or prevent the individual
from moving forward and receiving care (Jorm, 2012). For example,
many people (approximately one third of individuals in a survey of
six countries) believe professional mental health care is worse than
or equal to no help at all for mental disorders. Even when the
process does unfold, there are remarkable delays. From identifying
the problem through help seeking, usually many years (~8 years)
have elapsed (Thompson, Issakidis, & Hunt, 2008; Wang, Berglund
et al., 2005).
Several specific barriers impede seeking and obtaining mental
health services (Andrade et al., 2014; Corrigan et al., 2014; Hinshaw
& Stier, 2008). Although their elaboration is beyond the goals of the
present article, they are important to mention in the context of
novel models of treatment (please see Table 3 for a summary list of
barriers). Varied models differ on the impediments they overcome
(and present).
Some interventions that were listed in the novel models of de-
livery can surmount or side-step some of the barriers. For example,
self-help technology based treatments (via the Web or “apps) can
be done privately and are much less likely to circumvent the stigma
about going to a “formal” treatment at a clinic setting. (There is of
course the variant referred to as self-stigma and here conceding
that one needs treatment and beginning that treatment may
remain an impediment.) Similarly, best-buy interventions, when
they pertain to social policy, also are largely out of the mental-
health-care system and seeking or going for services and mental
health illiteracy are not salient issues.
Addressing the treatment gap is likely to require novel models of
delivery as I have suggested. Yet, there is more to the challenge to
which we must attend, as reflected in barriers. The initial task is to
take more of a population-based conceptual view in developing
treatment. What characteristics need to be included in our in-
terventions to give them a broad reach? It is useful to consider that
multiple models are likely to be needed to optimize coverage and
options among individuals in need. Different models surmount and
present a different profile of barriers and together reach a larger
proportion of individuals in need than the current dominant model
or any single model. The importance of collaborations to develop
and use such models is underscored by the challenge of reducing
the treatment gap. As illustrated from my examples of novel models
emanate from diverse disciplines and collaborations among them
(e.g., public health, business, economists, and policy makers). Many
disciplines can play critical roles and build on our strengths in
16 A.E. Kazdin / Behaviour Research and Therapy 88 (2017) 7e18

Table 3
Barriers to mental health care.

Barrier type Brief description

System factors
A. Cost of Mental Health Treatment is not affordable because services are not covered by insurance of the client, not completely covered, and the out-of-pocket costs
Services are too expensive.
B. Policy and Legal Government policies (e.g., state, province) as well as third-party payers may restrict what conditions can be treated and reimbursed. These
Constraints constraints also include limited financial resources as a matter of budgets, policy, or law that provides too few services and therefore less
accessible services. Services are not available in the locales where they are needed.
Attitudinal Factors
A. Stigma Concerns among potential clients or consumer of treatment with being labeled (diagnosed) with a mental disorder or by being associated with
treatment for a mental disorder.
B. Mental Health Literacy Lack of information or education about psychiatric conditions, whether one has a form of disorder that could be treated, and what the options
are for treatment,
C. Cultural and Ethnic Individuals of cultural and ethnic minorities have less access to services for health care in general, including mental health care.
Influences Views about whether psychological problems warrant treatment, entry into any health care service, or seeking treatment can vary widely.
Some problems (e.g., anxiety, depression) may not be seen as warrant of “treatment” or involvement in a health care system. This is not mental
health literacy which is more about knowing but rather more firmly rooted in cultural practices and beliefs.
Other Factors
A. Case Identification Not identifying up individuals at risk early in their course toward dysfunction. The absence of systematic assessments early in life that would
identify individuals at risk.
B. Model of Treatment Psychosocial interventions for mental disorders usually are delivered in person, one-to-one, a mental health professional, at a special facility
Delivery or setting.

developing, testing, and establishing treatments with rigorous noted (Table 2) is intended to be the new “dominant” model. Also,
empirical support. there is no need to replace or eliminate the dominant model of one-
to-one, in-person therapy administered by a mental health pro-
fessional. That model is quite fine but just one that reaches rela-
5. Conclusions
tively few people among those in need of services.
There is a huge need worldwide for interventions that reduce
EBPIs represent an enormous research advance. The comments
the personal and social burdens of mental illness. Our research
of the present article are designed to build on these gains. We are
began and continues with the study of EBPIs in highly controlled
now at the first point in history where behavioral and social sci-
settings. With that success, increased attention has been accorded
ences have established a large set of treatments with rigorous sci-
extending these to clinical practice through diverse dissemination
entific evidence on their behalf. This accomplishment has to be
efforts. The focus of this article was on delivering treatments in
savored as an evolutionary leap that allows us to consider what is
ways that reach the vast majority of individuals in need of services
needed for the next set of breakthroughs. The vast majority of EBPIs
who are not otherwise served by clinical practice. The advances in
rely on a model of providing services that is one-to-one, in person
EBPIs have made this gap in our knowledge more salient and
treatment delivered by a mental health professional and usually in
perhaps that will make it more likely to be addressed in the coming
a special setting. This model has proven itself as a platform for
years.
effective treatments. What is clear now is that multiple models of
treatment delivery are needed to ensure that diverse swaths of
Author note
individuals can be reached.
In this article, I discussed novel models of delivering treatment
Many facets of this article have been directly influenced by Terry
that are not merely “potential” options that could be used. They are
Wilson. Our collaboration on evidence-based treatments began in
used now in different contexts but not very often to deliver mental
1976 as we spent a year together (Center for Advanced Studies in
health services. Perhaps the exception is the use of technology to
the Behavioral Sciences, Stanford, California) along with luminaries
deliver treatments. That use itself has different modes of delivery.
in research whose contributions were well established (W. Stewart
For example, at one extreme, technology based treatments are one-
Agras, Nathan Azrin, Walter Michel, Jack Rachman). The group was
to-one with a trained professional and face-to-face (e.g., Skype or
charged with the task of evaluating research on behavioral thera-
encrypted equivalent) (two components of the dominant model of
pies. Terry and I collaborated on a couple of books and articles and
delivery). The advantage is that a client does not need to go to a
daily volleyball games part of the routine of the Center. Working
setting where treatment is delivered. At the other extreme,
together was such a privilege (given Terry’s enormous scholarship
technology-based treatment can include no-trained mental health
and thinking) and a joy (given our friendship and his wit). To our
professional (e.g., self-help, online) and here none of the compo-
collaborations, we brought complementary skills and talents. Ter-
nents of the dominant model is invoked. Yet, beyond technology,
ry’s well known scholarship, incisive thinking, and enviable talent
multiple models are available that are less familiar. They draw on
as a writer and communicator were his contributions. To comple-
advances from multiple disciplines beginning with those in deliv-
ment those, I brought proofreeding skills (whoops, sorry) and, at
ering physical health care but also drawing on health care, business,
the risk of being immodest, fairly solid keyboarding and collating
economics, and the mediadall well outside of traditional psycho-
abilities. Terry and his work have had enduring impact on me and
logical and psychiatric care. I listed several models and illustrated
so many colleagues and students, as well as professionals world-
three (task shifting, best buy, and disruptive innovations) that have
wide who have had the pleasure of reading his work but lamen-
emerged in the context of providing physical health care but have
tably have yet to interact with him personally.
also entered into mental health care.
The diverse models begin with the requirements of scaling up
References
and sensitivity to local conditions (e.g., resources, geography,
ethnicity and culture) that may influence delivering care. No one American Psychological Association Presidential Task Force on Evidence-Based
model of delivery is needed. Thus, no single model of those I have Practice. (2006). Evidence-based practice in psychology. American
 A.E. Kazdin / Behaviour Research and Therapy 88 (2017) 7e18
Psychologist, 61, 271e285.
Andrade, L. H., Alonso, J., Mneimneh, Z., Wells, J. E., Al-Hamzawi, A.,
Borges, G., … Kessler, R. C. (2014). Barriers to mental health treatment: Results
from the WHO World Mental Health surveys. Psychological Medicine, 44(06),
1303e1317.
Azevedo, E. M., & Weyl, E. G. (2016). Matching markets in the digital age. Science,
352(6289), 1056e1057.
Backhaus, A., Agha, Z., Maglione, M. L., Repp, A., Ross, B., Zuest, D., … Thorp, S. R.
(2012). Videoconferencing psychotherapy: A systematic review. Psychological
Services, 9, 111e131.
Baker, J. R., & Moore, S. M. (2008). Blogging as a social tool: A psychosocial exam-
ination of the effects of blogging. Cyberpsychology & Behavior, 11, 747e749.
Bakian, A. V., Huber, R. S., Coon, H., Gray, D., Wilson, P., McMahon, W. M., et al.
(2015). Acute air pollution exposure and risk of suicide completion. American
Journal of Epidemiology, 181, 295e303.
Balaji, M., Chatterjee, S., Koschorke, M., Rangaswamy, T., Chavan, A.,
Dabholkar, H., … Patel, V. (2012). The development of a lay health worker
delivered collaborative community based intervention for people with schizo-
phrenia in India. BioMed Central Health Services Research, 12. On line at www.
biomedcentral.com/1472-6963/12/42/.
Bang, A. T., Reddy, H. M., Deshmukh, M. D., Baitule, S. B., & Bang, R. A. (2005).
Neonatal and infant mortality in the 10 years (1993-2003) of the Gadchiroli
field trial: Effect of home-based neonatal care. Journal of Perinatology, 25,
92e107.
Barak, A., Hen, L., Boniel-Nissim, M., & Shapira, N. (2008). A comprehensive review
and a meta-analysis of the effectiveness of Internet-based psychotherapeutic
interventions. Journal of Technology in Human Services, 26, 109e160.
Bauer, S., & Moessner, M. (2013). Harnessing the power of technology for the
treatment and prevention of eating disorders. International Journal of Eating
Disorders, 46, 508e515.
Becker, A. E., & Kleinman, A. (2013). Mental health and the global agenda. New
England Journal of Medicine, 369(1), 66e73.
Bennett-Levy, J., Richards, D. A., Farrand, P., Christensen, H., Griffiths, K. M.,
Kavanagh, D. J., et al. (Eds.). (2010). Oxford guide to low intensity CBT in-
terventions. Oxford, UK: Oxford University Press.
Bennett, C. G., & Glasgow, R. E. (2009). The delivery of public health interventions
via the internet: Actualizing their potential. Annual Review of Public Health, 30,
273e292.
Bloom, D. E., Cafiero, E. T., Jane -Llopis, E., Abrahams-Gessel, S., Bloom, L. R.,
Fathima, S., … Weinstein, C. (2011). The global economic burden of non-
communicable diseases. Geneva: World Economic Forum. available at: www.
weforum.org/EconomicsOfNCD.
Bluthenthal, R. N., Jones, L., Fackler-Lowrie, N., Ellison, M., Booker, T.,
Jones, F., … Wells, K. B. (2006). Witness for wellness: Preliminary findings from
a community-academic participatory research mental health initiative.
Ethnicity and Disease, 16(1). S1eS18-34.
Bouma, G., Admiraal, J. M., de Vries, E. G., Schro €der, C. P., Walenkamp, A. M., &
Reyners, A. K. (2015). Internet-based support programs to alleviate psychosocial
and physical symptoms in cancer patients: A literature analysis. Critical Reviews
in Oncology/Hematology, 95, 26e37.
Bower, J. L., & Christensen, C. M. (1995). Disruptive technologies: Catching the wave.
Harvard Business Review, January-February (pp. 43e53).
Breuer, J., & Freud, S. (1957). Studies in hysteria. New York: Basic Books.
Buck, J., Manges, K., & Kaboli, P. (2016). Asynchronous teleneurology: A systematic
review of electronic provider-to-provider communications (P3. 400). Neurology,
86(16 Supplement), P3eP400.
Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological
interventions: Controversies and evidence. Annual Review of Psychology, 52,
685e716.
Charman, D., & Barkham, M. (2005). Psychological treatments: Evidence-based
practice and practice-based evidence. InPsych. Available on line at www.
psychology.org.au/publications/inpsych/highlights2005/.
Chisholm, D., Lund, C., & Saxena, S. (2007). Cost of scaling up mental healthcare in
low- and middle-income countries. British Journal of Psychiatry, 191, 528e535.
Chisholm, D., & Saxena, S. (2012). Cost effectiveness of strategies to combat
neuropsychiatric conditions in sub-Saharan Africa and South East Asia: Math-
ematical modelling study. British Medical Journal, 344, e609.
Christensen, C. M. (2003). The innovator’s solution: Creating and sustaining successful
growth. Boston, MA: Harvard Business School.
Christensen, C. M., Grossman, J. H., & Hwang, J. (2009). The innovator’s prescription: A
disruptive solution for health care. New York: McGraw Hill.
Christensen, A., Miller, W. R., & Mun ~ oz, R. F. (1978). Paraprofessionals, partners,
peers, paraphernalia, and print: Expanding mental health service delivery.
Professional Psychology, 9, 249e270.
Collins, P. Y., Insel, T. R., Chockalingam, A., Daar, A., & Maddox, Y. T. (2013). Grand
challenges in global mental health: Integration in research, policy, and practice.
PLoS Medicine, 10(4), e1001434.
Corrigan, P. W., Druss, B. G., & Perlick, D. A. (2014). The impact of mental illness
stigma on seeking and participating in mental health care. Psychological Science
in the Public Interest, 15(2), 37e70.
Crowley, R. A., & Kirschner, N. (2015). The integration of care for mental health,
substance abuse, and other behavioral health conditions into primary care:
Executive summary of an American College of Physicians Position paper. Annals
of Internal Medicine, 163(4), 298e299.
Deslandes, A., Moraes, H., Ferreira, C., Veiga, H., Silveira, H., Mouta, R., et al. (2009).
17
Exercise and mental health: Many reasons to move. Neuropsychobiology, 59,
191e198.
Desmond-Hellmann, S. (2016). What if? A letter from the CEO of the bill and linda
gates foundation. Available on line from the Foundation at http://www.
gatesfoundation.org/2016/ceo-letter?wt.mc_id¼05_25_2016_02_ceoletter16_
gf-pgoogle_&wt.tsrc¼gfpgoogle.
Goodheart, C. D., Kazdin, A. E., & Sternberg, R. J. (2006). Evidence-based psycho-
therapy: Where practice and research meet. Washington, DC: American Psycho-
logical Association.
Gorini, A., Gaggioli, A., Vigba, C., & Riva, G. (2008). A second life for eHealth:
Prospects for use of 3-D virtual worlds in clinical psychology. Journal of Medical
Internet Research, 10(3). no pagination.
Greenwood, B. M., Greenwood, A. M., Snow, R. W., Byass, P., Bennett, S., & Hatib-
N’Jie, A. B. (1989). The effects of malaria chemoprophylaxis given by traditional
birth attendants on the course and outcome of pregnancy. Transactions of the
Royal Society of Tropical Medicine and Hygiene Journal, 83, 589e594.
Harwood, T. M., & L’Abate, L. (2010). Self-help in mental health: A critical review. New
York: Springer.
Health Resources and Services Administration. (2010). Health professional shortage
areas: Mental health designated populations. Rural Assistance Center. Retrieved
from www.raconline.org/maps/mapfiles/hpsa_mental.png.
Hinshaw, S. P., & Stier, A. (2008). Stigma as related to mental disorders. Annual
Review of Clinical Psychology, 4(1), 367e393.
Hoge, M. A., Morris, J. A., Daniels, A. S., Stuart, G. W., Huey, L. Y., & Adams, N. (2007).
An action plan for behavioral health workforce development. Washington, DC:
Department of Health and Human Services.
Hurling, R., Catt, M., De Boni, M., Fairley, B. W., Hurst, T., Murray, P., … Sodhi, J. S.
(2007). Using internet and mobile phone technology to deliver an automated
physical activity program: Randomized controlled trial. Journal of Medical
Internet Research, 9(2), e7.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the
21st century. Washington, DC: National Academies Press.
Institute of Medicine. (2006). Improving the quality of care for mental and substance
use conditions. Washington, DC: National Academies Press.
Institute of Medicine. (2010). Promoting cardiovascular health in the developing
world: A critical challenge to achieve global health. Washington, DC: National
Academies Press.
Institute of Medicine. (2011a). Child and adolescent health and health care quality:
Measuring what matters. Washington, DC: National Academies Press.
Institute of Medicine. (2011b). Country-level decision making for control of chronic
diseases. Washington, DC: National Academy Press.
Institute of Medicine. (2012). The mental health and substance use workforce for older
adults: In whose hands? Washington, DC: National Academies Press.
Jorm, A. F. (2012). Mental health literacy: Empowering the community to take ac-
tion for better mental health. American Psychologist, 67, 231e243.
Kazdin, A. E. (2015). Technology-based interventions and reducing the burdens of
mental illness. Cognitive and Behavioral Practice, 22, 359e366.
Kazdin, A. E., & Blase, S. L. (2011). Rebooting psychotherapy research and practice to
reduce the burden of mental illness. Perspectives on Psychological Science, 6,
21e37.
Kazdin, A. E., & Rabbitt, S. (2013). Novel models for delivering mental health ser-
vices and reducing the burdens of mental illness. Clinical Psychological Science, 1,
170e191.
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(6), 593e602.
Kessler, R. C., Chiu, W. T., 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(6), 617e627.
Kessler, R. C., Demler, O., Frank, R. G., Olfson, M., Pincus, H. A., Walters, E. E., et al.
(2005). Prevalence and treatment of mental disorders, 1990 to 2003. New En-
gland Journal of Medicine, 352, 2515e2523.
Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., et al.
(1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in
the United States: Results from the National Comorbidity Survey. Archives of
General Psychiatry, 51, 8e9.
Kim, S. (2015, April). Priceline acknowledges baby as ’unusual’ purchaser of $516 car
rental. ABC News, Good Morning America. Available online at: https://gma.
yahoo.com/priceline-acknowledges-baby-unusual-purchaser-516-car-rental-
201043173-abc-news-personal-finance.html.
Kleiman, S. C., Watson, H. J., Bulik-Sullivan, E. C., Huh, E. Y., Tarantino, L. M.,
Bulik, C. M., et al. (2015). The intestinal microbiota in acute anorexia nervosa
and during renourishment: Relationship to depression, anxiety, and eating
disorder psychopathology. Psychosomatic Medicine, 77, 969e981.
Kohn, R., Saxena, S., Levav, I., & Saraceno, B. (2004). The treatment gap in mental
health care. Bulletin of the World Health Organization, 82(11), 858e866.
Krol, K. M., Rajhans, P., Missana, M., & Grossmann, T. (2014). Duration of exclusive
breastfeeding is associated with differences in infants’ brain responses to
emotional body expressions. Frontiers in Behavioral Neuroscience, 8, 459.
Available on line at ww.ncbi.nlm.nih.gov/pmc/articles/PMC4302883/.
Lancet Global Mental Health Group. (2007). Scale up services for mental disorders:
A call for action. Lancet, 370, 1241e1252.
Lim, Y. H., Kim, H., Kim, J. H., Bae, S., Park, H. Y., & Hong, Y. C. (2012). Air pollution
and symptoms of depression in elderly adults. Environmental Health
18 A.E. Kazdin / Behaviour Research and Therapy 88 (2017) 7e18
Perspectives, 120(7), 1023e1028.
Linnan, L. A., Kim, A. E., Wasilewski, Y., Lee, A. M., Yang, J., & Solomon, F. (2001).
Working with licensed cosmetologists to promote health: Results from the
North Carolina BEAUTY and Health pilot study. Preventive Medicine, 33,
606e612.
Madigan, M. E., Smith-Wheelock, L., & Krein, S. L. (2007). Healthy hair starts with a
healthy body: Hair stylists as lay health advisors to prevent chronic kidney
disease. Preventing Chronic Disease, 4, A64.
Martini, M. G., Hewage, C. T., Nasralla, M. M., Smith, R., Jourdan, I., & Rockall, T.
(2013, July). 3-D robotic tele-surgery and training over next generation wireless
networks. In In Engineering in Medicine and Biology Society (EMBC), 2013 35th
Annual International Conference of the IEEE (pp. 6244e6247).
McGuire, T. G., & Miranda, J. (2008). New evidence regarding racial and ethnic
disparities in mental health: Policy implications. Health Affairs, 27, 393e403.
Merikangas, K. R., He, J. P., Burstein, M., Swendsen, J., Avenevoli, S.,
Case, B., … Olfson, M. (2011). Service utilization for lifetime mental disorders in
US adolescents: Results of the National Comorbidity Surveyeadolescent sup-
plement (NCS-A). Journal of the American Academy of Child & Adolescent Psy-
chiatry, 50(1), 32e45.
Miranda, J., Bernal, G., Lau, A. S., Kohn, L., Hwang, W. C., & LaFromboise, T. (2005).
State of the science on psychosocial interventions for ethnic minorities. Annual
Review of Clinical Psychology, 1, 113e142.
Montreuil, B. (2011). Toward a physical internet: Meeting the global logistics sus-
tainability grand challenge. Logistics Research, 3(2e3), 71e87.
Mun ~ oz, R. F., Bunge, E. L., Chen, K., Schueller, S. M., Bravin, J. I., Shaughnessy, E. A.,
et al. (2016). Massive open online interventions (MOOIs): A novel model for
delivering behavioral health services worldwide. Clinical Psychological Science,
4, 194e205.
Nowakowski, M. E., McCabe, R., Rowa, K., Pellizzari, J., Surette, M., Moayyedi, P., et al.
(2016). The gut microbiome: Potential innovations for the understanding and
treatment of psychopathology. Canadian Psychology. Initial posting 2016 http://
psycnet.apa.org/psycinfo/2016-01249-001/.
Oddy, W. H., Kendall, G. E., Li, J., Jacoby, P., Robinson, M., de
Klerk, N. H., … Stanley, F. J. (2010). The long-term effects of breastfeeding on
child and adolescent mental health: A pregnancy cohort study followed for 14
years. Journal of Pediatrics, 156, 568e574.
Pallavicini, F., Algeri, D., Repetto, C., Gorini, A., & Giuseppe Riva, G. (2009).
Biofeedback, virtual reality and mobile phones in the treatment of generalized
anxiety disorder (GAD): A phase-2 controlled clinical trial. Journal of Cyber-
Therapy & Rehabilitation, 2, 315e327.
Parikh, S. V., & Huniewicz, P. (2015). E-Health: An overview of the uses of the
internet, social media, apps, and websites for mood disorders. Current Opinion
in Psychiatry, 28(1), 13e17.
Patel, V., Maj, M., Flisher, A. J., Silva, M. J., Koschorke, M., Prince, M., … Risco, L.
(2010). Reducing the treatment gap for mental disorders: A WPA survey. World
Psychiatry, 9(3), 169e176.
Patel, V., Weiss, H. A., Chowdhary, N., Naik, S., Pednekar, S.,
Chatterjee, S., … Kirkwood, B. R. (2010). Effectiveness of an intervention led by
lay health counsellors for depressive and anxiety disorders in primary care in
Goa, India (MANAS): A cluster randomised controlled trial. Lancet, 376,
2086e2095.
Patel, V., Weiss, H. A., Chowdhary, N., Naik, S., Pednekar, S.,
Chatterjee, S., … Kirkwood, B. R. (2011). Lay health worker led intervention for
depressive and anxiety disorders in India: Impact on clinical and disability
outcomes over 12 months. British Journal of Psychiatry, 199, 459e466.
Price, M., Yuen, E. K., Goetter, E. M., Herbert, J. D., Forman, E. M., Acierno, R., et al.
(2014). mHealth: A mechanism to deliver more accessible, more effective
mental health care. Clinical Psychology & Psychotherapy, 21(5), 427e436.
Prince, M., Patel, V., Saxena, S., Maj, M., Maselko, J., Phillips, M. R., et al. (2007). No
health without mental health. Lancet, 370, 859e877.
Rabbitt, S. M., Kazdin, A. E., & Scassellati, B. (2015). Integrating socially assistive
robotics into mental healthcare interventions: Applications and recommenda-
tions for expanded use. Clinical Psychology Review, 35, 35e46.
Rahman, A., Malik, A., Sikander, S., Roberts, C., & Creed, F. (2008). Cognitive
behaviour therapy-based intervention by community health workers for
mothers with depression and their infants in rural Pakistan: A cluster-
randomised controlled trial. Lancet, 372, 902e909.
RelaxLine. (2010). Bellybio interactive breathing. Retrieved from http://itunes.apple.
com/us/app/bellybio-interactive-breathing/id353763955?mt¼8.
Rezin, G. T., Amboni, G., Zugno, A. I., Quevedo, J., & Streck, E. L. (2009). Mitochondrial
dysfunction and psychiatric disorders. Neurochemical Research, 34(6),
1021e1029.
Richardson, C. R., Faulkner, G., McDevitt, J., Skrinar, G. S., Hutchinson, D. S., &
Piette, J. D. (2005). Integrating physical activity into mental health services for
persons with serious mental illness. Psychiatric Services, 56, 324e331.
Roine, R., Ohinmaa, A., & Hailey, D. (2001). Assessing telemedicine: A systematic
review of the literature. Canadian Medical Association Journal, 165, 765e771.
Rossignol, D. A., & Frye, R. E. (2015). Mitochondrial dysfunction in psychiatric
disorders. In A. Dietrich-Muszalska, V. Chauhan, & S. Grignon (Eds.), Studies on
psychiatric disorders (pp. 231e244). New York: Springer.
Rotheram-Borus, M. J., Swendeman, D., & Chorpita, B. F. (2012). Disruptive in-
novations for designing and diffusing evidence-based interventions. American
Psychologist, 67(6), 463e476.
Ryder, D. (1988). Minimal intervention: A little quality for a lot of quantity.
Behaviour Change, 5, 100e107.
Sharan, P., Gallo, C., Gureje, O., Lamberte, E., Mari, J. J., Mazzotti, G., … Saxena, S.
(2009). Mental health research priorities in low- and middle-income countries
of Africa, Asia, Latin America and the Caribbean. British Journal of Psychiatry, 195,
354e363.
Singhal, A., Cody, M. J., Rogers, E. M., & Sabido, M. (2003). Entertainment-education
and social change: History, research, and practice. Mahwah, NJ: Lawrence
Erlbaum.
Singhal, A., & Rogers, E. M. (1999). Entertainment-education: A communication
strategy for social change. Mahwah, NJ: Lawrence Erlbaum.
Spek, V., Cuijpers, P. I. M., Nyklícek, I., Riper, H., Keyzer, J., & Pop, V. (2007). Internet-
based cognitive behaviour therapy for symptoms of depression and anxiety: A
meta-analysis. Psychological Medicine, 37, 319e328.
Steel, Z., Marnane, C., Iranpour, C., Chey, T., Jackson, J. W., Patel, V., et al. (2014). The
global prevalence of common mental disorders: A systematic review and meta-
analysis 1980e2013. International Journal of Epidemiology, 43(2), 476e493.
StressEraser. (2012). Portable biofeedback device. Retrieved from http://stresseraser.
com/.
Thompson, A., Issakidis, C., & Hunt, C. (2008). Delay to seek treatment for anxiety
and mood disorders in an Australian clinical sample. Behaviour Change, 25,
71e78. YEA84.
Titov, N., Dear, B. F., Staples, L. G., Bennett-Levy, J., Klein, B., Rapee, R. M., … Purtell, C.
(2015). MindSpot clinic: An accessible, efficient, and effective online treatment
service for anxiety and depression. Psychiatric Services, 66, 1043e1050.
Tolin, D. F., McKay, D., Forman, E. M., Klonsky, E. D., & Thombs, B. D. (2015).
Empirically supported treatment: Recommendations for a new model. Clinical
Psychology: Science and Practice, 22(4), 317e338.
Tomlinson, M., Rotheram-Borus, M. J., Swartz, L., & Tsai, A. C. (2013). Scaling up
mHealth: Where is the evidence? PLoS Medicine, 10(2), e1001382.
United Nations. (2000, September). Resolution adopted by the general Assembly:
United Nations millennium declaration. Available on line at www.un.org/
millennium/declaration/ares552e.pdf.
Walsh, R. (2011). Lifestyle and mental health. American Psychologist, 66, 579e592.
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 disor-
ders in the National Comorbidity Survey Replication. Archives of General Psy-
chiatry, 62(6), 603e613.
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(6), 629e640.
Wells, K. B., Jones, L., Chung, B., Dixon, E. L., Tang, L., Gilmore, J., … Miranda, J. (2013).
Community-partnered cluster-randomized comparative effectiveness trial of
community engagement and planning or resources for services to address
depression disparities. Journal of General Internal Medicine, 28(10), 1268e1278.
Wells, K., Klap, R., Koike, A., & Sherbourne, C. (2001). Ethnic disparities in unmet
need for alcoholism, drug abuse, and mental health care. American Journal of
Psychiatry, 158, 2027e2032.
Whiteford, H. A., Degenhardt, L., Rehm, J., Baxter, A. J., Ferrari, A. J.,
Erskine, H. E., … Burstein, R. (2013). Global burden of disease attributable to
mental and substance use disorders: Findings from the global burden of disease
Study 2010. Lancet, 382(9904), 1575e1586.
Wible, B., Mervis, J., & Wigginton, N. S. (2014, June). Rethinking the global supply
chain. Science, 344(6188), 1100e1103.
Wooton, R. (2003). Telepsychiatry and e-mental health. London: Royal Society of
Medicine Press.
World Health Organization. (2005). Mental health: Facing the challenges, building
solutions. Copenhagen, Denmark: WHO Regional Office for Europe.
World Health Organization. (2008). Task shifting: Global recommendations and
guidelines. Geneva: WHO.
World Health Organization. (2011a). Prevention and control of NCDS: Summary.
Moscow: First Global Ministerial Conference on Healthy Lifestyles and Non-
communicable Disease Control.
World Health Organization. (2011b). Scaling up action against non-communicable
diseases: How much will it cost? Geneva: WHO.
World Mental Health Survey Consortium. (2004). Prevalence, severity, and unmet
need for treatment of mental disorders in the World Health Organization World
Mental Health Surveys. JAMA, 291(21), 2581e2590.
Zhang, Z., Wu, H., Wang, W., & Wang, B. (2010). A smartphone based respiratory
biofeedback system. Biomedical Engineering and Informatics (BMEI), 2, 717e720,
3rd International Conference Proceedings.