Population Health: Behavioral and Social Science Insights

By Alan E. Kazdin

Abstract

Remarkable progress has been made in developing psychosocial interventions for a broad range of psychiatric disorders and domains of social, emotional, and behavioral impairment for children, adolescents, and adults. At this time, over 340 interventions have been identified as evidence based in light of rigorously controlled studies, replication of treatment effects, and other criteria. The vast majority of these interventions are delivered in one-to-one, in-person sessions provided by a mental health professional. This model of delivery cannot begin to reach the large numbers of individuals in need of services. Multiple models and novel models of delivery are needed to provide interventions on a large scale in order to reduce the burdens of mental illness. Novel models of treatment delivery are presented that have emerged from global health care, business, economics, and the media and are well outside of mainstream mental health professions. Two models (task-shifting and best-buy interventions) illustrate how different ways of delivering treatment are essential to reach large and diverse groups of unserved individuals. Translational research is presented as a broad framework to convey the scope of the research agenda from basic treatment research to large-scale community applications.

Introduction

The development of psychosocial interventions for the treatment of psychiatric dysfunction and related domains of impairment has made remarkable gains. Currently, there are many psychotherapies or psychosocial treatments that have strong research support and are designated as evidence based. In this chapter, the term psychosocial interventions refers to procedures based on psychological methods that alter functioning by focusing on affect, cognition, and behavior. These are distinguished here from more biologically based interventions (e.g., diet, medication, brain stimulation). The interventions focus on the full range of psychiatric disorders but also on multiple domains that may not focus on a diagnosis (e.g., stress, bereavement) where there is impairment in daily functioning. Psychosocial interventions that are supported by evidence have been designated with many different terms, including empirically supported treatments, empirically validated treatments, evidence-based treatments, evidence-based psychotherapies, and others.^1,2 For this chapter, I will use the term evidence-based psychotherapies to cover the full range of interventions that draw on psychological methods to effect change.

The criteria to define treatment as evidence based vary among multiple disciplines (e.g., psychology, psychiatry, social work), professional organizations within and among countries (e.g., in the Evidence-Based Psychotherapies: Novel Models of Delivering Treatment Americas, European Union), and private and public agencies within a given country. Although there is no single consensus definition of evidence-based psychotherapy (EBP), most of these criteria are commonly invoked:

1. Careful specification of the patient population.
2. Random assignment of participants to intervention and comparison or control conditions.
3. Use of treatment manuals that document the procedures.
4. Statistically significant differences at the end of the intervention period between treatment and control or comparison conditions.
5. Replication of outcome effects, ideally by an independent investigator or research team.

There is no single count of the accumulated treatments given the varied definitions. Yet, one U.S. government agency has identified over 340 such interventions for mental health and substance abuse disorders.³ EBPs encompass interventions for children, adolescents, and adults, although some populations (e.g., ethnic minorities) and developmental stages (e.g., adolescents, elderly) tend to be less well studied. Among the critical issues are extending EBPs to patient care and to do so on a scale sufficient to have impact on the personal and social burdens of mental illness. There are multiple challenges, but they begin with recognition that in the United States, and also worldwide, most people in need of mental health services do not receive them.

The purpose of this chapter is to convey next steps in moving from models of treatment (what techniques are used to alter clinical dysfunction) to models of delivery (how that treatment is provided so that it reaches people in need and on a large scale). The chapter begins by highlighting the dominant model of applying EBPs and how that model is evolving to expand service delivery. The main focus of the chapter is on what is needed to reach large numbers of individuals and novel models of treatment delivery that are available from multiple disciplines. The chapter ends with a discussion of translational research as a framework to help conceptualize the challenges and the next steps in research.

Background: Dominant Model and New Variations of Administering Treatment

EBPs encompass many different therapy techniques and procedures (e.g., mindfulness, cognitive therapy for depression, graduated exposure for anxiety), and these have been developed and evaluated for a period now extending decades. A pervasive consistency in developing EBPs has been the model through which the techniques are delivered. The dominant model has been administration of treatment by a highly trained (e.g., doctoral, Master's level) mental health professional in one-to-one, in-person sessions with a client.^a The model applies to well-developed EBPs as well as the much larger number of interventions yet to be evaluated empirically. The one-on-one, in-person model has been enduring, is in demand, and can deliver several EBPs. Indeed, the now vast research on EBPs not only supports scores of specific interventions, but by implication is the dominant model through which they are delivered.

There are several lines of work that have altered facets of the dominant model. First, within the past decade efforts have expanded to take advantage of technology and online versions of treatment that draw on the Internet and other media, including video, texting, application software ("apps"), and feedback of various types via smartphone, smart watches, tablets, and related devices. These variations can extend one-to-one treatment to places (e.g., rural areas, across country borders) where services might not otherwise be available,⁴ and many of these address a range of significant clinical problems. For example, "apps" are available for treating anxiety, preventing suicide, and helping individuals recovering from alcohol abuse.⁵

Second and related, other extensions of the model of delivery include self-help interventions and a vast array of techniques (e.g., online interventions, expressive writing techniques) that are available 24/7 and require little or no assistance from a trained professional.⁶ Several Internet, computer-based, and self-help psychological interventions are evidence based, achieve outcome effects on par with treatment administered in person by a trained mental health professional, and are high in client adherence and satisfaction.^7-9 Use of technology and self-help interventions are important developments and part of the solution of reaching the community that is otherwise unserved.

Third, recent changes in how EBPs are conceived have implications for delivery of treatment. The development of EBPs has focused on matching treatments to specific psychiatric dysfunctions, such as anxiety disorders, major depression, bipolar disorder, and a few hundred more.^10,11 An alternate view to disorder-specific treatments has emerged and involves two interrelated areas: transdiagnosis and transtreatment, and it serves as a model for understanding clinical dysfunction, underlying processes, and intervention. Transdiagnosis refers to the study of processes that span many different manifestations of clinical dysfunction.^12,13 Several factors have served as the impetus for a transdiagnostic conceptualization of psychopathology, including findings that:

• There are high rates of comorbidity so that individuals (children or adults) who meet criteria for one disorder are likely to meet criteria for at least one other disorder as well.^14,15
• Underlying processes that maintain "different disorders" often are quite similar.^16,17
• Several disorders share common biological underpinnings as reflected in brain structures, neurotransmitters, and genes.^18,19
• A number of EBPs (e.g., cognitive behavior therapy, mindfulness) are effective across a range of disorders, suggesting some common mechanisms or core processes (e.g., working memory, emotion regulation).²⁰
• Broad characteristics such as a general psychopathology factor (a "p factor"), neuroticism, perfectionism, and tolerance of uncertainty might serve as underlying or mediating characteristics of many different disorders.^{21– 24}

Transdiagnostic conceptualizations have altered treatment and treatment research. Rather than adding to the burgeoning list of EBPs for specific disorders, attention is now being directed to the search for transdiagnostic treatments. Terms such as transdiagnostic treatment, unified treatment protocol, and unified cognitive behavior therapy are increasingly evident in the treatment literature. It is likely that research will continue to explore treatments that are broad in applicability and study basic biological and psychological processes on which these treatments depend.^25–27

Finally, another effort is designed to facilitate training of clinicians and delivery of EBPs. With hundreds of EBPs now recognized, which ones do we train? In mental health graduate and professional training programs (e.g., psychology, psychiatry, social work), it is rare to provide training in even one or two EBPs. Possible solutions have been advanced and implemented.^28–30 These include identifying a few components of treatments or modules that can be more readily and fluidly used as clinical cases require. A few modules might be widely applicable to the range of disorders and comorbidities that are seen in clinical practice.³¹ Also, with a limited number of modules, rather than a long list of EBPs, training clinicians in practice is much more feasible. A smaller set of treatments or modules that can be flexibly deployed raises the prospect of more readily placing EBPs in the hands of clinicians.

These variations of treatment highlighted here, including the use of technology, self-help, transdiagnostic treatments, and modular-type treatments, are critical topics in their own right and can only be mentioned in passing. However, many of them retain core features of the dominant model, i.e., one-to-one treatment by a therapist. Overall, it is still the case that most psychotherapy services, evidence based or not, transdiagnostic or not, and modular or not are administered in the one-to-one model of treatment delivery.

Novel and Expanded Models of Delivery Are Needed

Although the dominant model can deliver EBPs, several findings have emerged to make it increasingly obvious that the model cannot begin to address the challenge of reducing the burdens of mental illness.³² Among the factors are:

• High rates of psychiatric disorders in community samples, as evident from major epidemiological studies.
• The absence of mental health services for most individuals in need of treatment.
• Paucity of services for populations with some of the greatest needs (e.g., children and elderly individuals, individuals from ethnic minority groups, and those who live in rural areas).
• A limited number of mental health professionals both in developing and developed countries who are available to deliver services.

To make these points more concrete, approximately 25 percent of children, adolescents, and adults living in the community in the United States meet criteria for at least one psychiatric disorder.^33,34 Currently, that would amount to approximately 80 million people. Apart from prevalence, the personal and social burdens of mental disorders are astounding. Mental disorders are more impairing than common chronic medical disorders.³⁵ For example, in 2004, the burden of depressive disorders (e.g., years of good health lost because of disability) was ranked third on the list of mental and physical diseases worldwide.³⁶ By 2030, depression is projected to be the number one cause of disability, ahead of cardiovascular disease, traffic accidents, chronic pulmonary disease, and HIV/AIDS.³⁷

Most people in need of services do not receive any treatment or care. In the United States, approximately 70 percent of individuals in need of treatment do not receive services.³⁸ The significance of this is difficult to overstate. It means that if all clinicians began using EBPs tomorrow, it still would not be pertinent to the majority of individuals who do not receive treatment. As I have noted elsewhere, "treatment as usual" in the United States but also worldwide has another name, namely, "no treatment."³⁹

Perhaps an increase in the workforce of trained mental health professionals would address the problem of providing care with the dominant model. Yet the geographical distribution, interests, and composition of the highly trained professional workforce convey why sheer numbers alone will not mitigate the problem of reaching many unserved individuals in need.⁴⁰ In the United States, mental health professionals are concentrated in highly populated, affluent urban areas, which limits the ability to reach large numbers of people (e.g., those in rural areas, small towns). In addition, most mental health professionals do not provide care to populations for clinical problems where there is a great need (children, adolescents) and an increasing need (the elderly) need.^41,42 Too few mental health professionals are trained to provide services to these groups. Finally, disproportionately few mental health professionals reflect the cultural and ethnic characteristics of those in need of care. Merely expanding the workforce with additional mental health professionals would not bring treatment to the community on a sufficient scale to have a major impact on the burdens of mental illness. One-to-one, in-person treatment, while useful as a model of delivery, is not very helpful as the dominant or primary model if there is going to be any palpable reduction in the burdens of mental illness. New ways of delivering services are sorely needed.

Requirements to Reach People in Need of Services

We already have proven we can develop interventions, but we have not established that we can extend them very widely in a given country or throughout the world. As a point of departure, it would be valuable to begin by considering what would be the key characteristics or requirements of a model of delivery that could in fact reach people. Table 1 lists several characteristics that, if met, could reach and have impact on large numbers of people.

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

Multiple models have emerged from global health care, business, economics, and the media—all well outside of traditional psychological and psychiatric care.^32,43 Table 2 presents several models of delivery and their key characteristics. 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 EBPs well established in the dominant model (individual, one-to-one treatment by a mental health professional) are delivered by nonprofessional individuals. This is a case of little or no change in the intervention (e.g., cognitive behavior therapy) but in how or in this case who provides the treatment. In other models, the distinction between models of technique and delivery is blurred because they are connected, and the technique is not at all like one of the traditional or evidence-based treatments. Best buy is an example where advertising and imposition of taxes on products are among viable interventions to address clinical problems, as highlighted below.

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

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.^32,43

Illustrations

Table 2 provides key characteristics of several delivery models, but in general the models are not widely familiar among mental health researchers and practitioners. I highlight two examples mentioned previously to illustrate their novelty and departure from the dominant model of delivery.

Task-Shifting

Task-shifting is a method to strengthen and expand the health care workforce by redistributing the tasks of delivering services to a broad range of individuals with less training and fewer qualifications than traditional health care workers (e.g., doctors, nurses).³⁷ This redistribution allows an increase in the total number 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.^60,61

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 non-communicable disease (e.g., cardiovascular disease, diabetes, cancer, respiratory disease) and improving living conditions and education.^49,62–64 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., HIV/AIDS) are acute. Empirical evaluations have shown task-shifting to rapidly increase access to services, reach large numbers of individuals in need, yield good health outcomes, and have high levels of patient and counselor satisfaction.³⁷

Task-shifting was extended to mental health problems because of (1) its ability to be scaled up to provide services to individuals who otherwise did not have access to care and (2) 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.^43,65 More than 2,700 individuals with depression or anxiety (being served by 24 public and private facilities) 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 2-month training course. Medication was available, as was specialist attention (health professional) for suicidal patients. At 6 and 12 months after treatment, the intervention 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 administer interventions with fidelity, 313 and that their interventions reduced the rates of disorder in a large sample. This is an excellent example of extending EBPs developed in controlled research settings to community applications but with a change in the model of delivery of those treatments. An EBP, 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 is typically 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 schizophrenia.^66,67 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 followup, among other features.

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.^68,69 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, reduced 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, particularly the control of chronic diseases globally.⁶¹

Best buy refers to an intervention for which, "there is compelling evidence that it is not only highly cost effective, but also feasible, low cost (affordable), and appropriate to implement within the constraints of a local health system."⁴⁹ 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 buy interventions was conceived as an economic tool to help countries assess 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, among other variables.^48,68,70 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.⁴⁹ 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 interventions can vary for a given disorder and country because of the cost of delivering a particular intervention in light of varied health care resources and infrastructure.

Best-buy interventions for physical diseases often focus on domains 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 feasibility. Excessive alcohol use was identified as a best buy for reducing the incidence of cardiovascular diseases and cancers, but it also extends to other burdensome conditions (e.g., cirrhosis of the liver, depression, traffic injuries and deaths).⁴⁹ 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.⁴⁸ 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.⁴⁸ Direct tests are critical 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 or adherence to a specific treatment protocol by therapists. Of course, taxes and advertising have 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.

General Comments

My illustrations do not do full justice to the interventions and models of delivery. Yet the purpose in noting these was to convey that "novel models of delivery" is not an abstraction or a class with no members. Rather, there is already evidence for some of the models (Table 2) that in fact they can be applied, achieve the desired outcomes, and be scaled to meet the enormous and still unmet need for services.

The importance of addressing mental illness has been well recognized in its own right. Yet, accelerated attention emerged from global health initiatives to treat physical disease (e.g., chronic, infectious).^61,68 Initiatives to provide physical health care services revealed gaps in mental health services. Moreover, it has become increasingly clear that mental and physical health are inextricably intertwined, with bidirectional, reciprocal, and comorbid relations. Reducing the burdens of physical health cannot neglect mental health, as reflected in the oft-cited statement there is "no health without mental health."^71,72

Several models or strategies for delivering treatment and preventive interventions emerged to address physical diseases. Many barriers for delivering care for physical health care to large numbers of individuals in need, particularly in developing countries, were recognized to be similar to the barriers encountered in providing mental health care.^73,74 Consequently, models for delivering treatment proved to be applicable to both mental and physical health services. What remains to be accomplished is moving these models of delivery to mainstream applications of services.

Stepped Care: How to Deploy Treatments and Models

Determining how the different models and treatments within the range of available models will be deployed is related to expanding the models into mainstream care. That is, treatments and models of delivery vary along several dimensions, and some guidance would be needed for their application. Stepped care provides a useful point of departure for considering both treatments and delivery models.

Stepped care is the notion that we should begin with less intensive and less costly interventions that are more easily disseminated, and then move to more aggressive, costly, and specialized treatment as needed. The concept of stepped care has been around for some time and continues to be advocated as a model for providing treatment.^75–79 Also, earlier in this chapter I mentioned one example in which stepped care was used.^43,64

Currently, cognitive therapy and interpersonal psychotherapy are two EBPs for individuals seeking treatment for depression. Typically, these are individually administered by a professional in a clinic setting. Yet, stepped care raises the question, "Are there opportunities to intervene to reduce and treat depression effectively without moving to these individually based therapies at least as an initial point of departure?" Stepped care would consider a range of interventions that could be applied as needed if a less costly intervention did not achieve change.

Where can we begin with low-cost interventions that might reach large numbers of individuals and be effective? Two come to mind, merely to make the point and again in the context of depression. First, a psychoeducational intervention might be systematically tried. This would consist of telling people about depression and what they can do about it on their own, including activities in which they could engage. We know already that information and education in relation to the treatment of disorders (or as behavior-change techniques more generally) typically are weak in the magnitude of change and number of individuals affected as interventions go. Yet, in a stepped-care model that is not necessarily problematic at all. It is likely that some number of individuals in need of treatment would be helped sufficiently with systematic efforts to provide psychoeducation. Psychoeducation can be delivered widely through many media (e.g., smartphone, TV, brochures, the Web), provided where people are in everyday life (e.g., grocery stores, shopping malls, doctors' offices), adapted culturally (e.g., language, customs, use of photos or illustrations of population-specific or –neutral individuals on the medium); made available 24/7, and if necessary, disseminated by lay individuals rather than professionals.

As another possibility, physical exercise might be promoted as a first or early line of attack to intervene for depression (and for other domains of mental disability as well). There is already evidence about its effectiveness clinically in nonhuman models to suggest the mechanisms through which it operates.^50,80,81 Also, exercise can take many different forms to suit individual tastes and preferences, and it can vary across the developmental spectrum (e.g., childhood through old age). Incentives to exercise could be integrated in schools, the workplace, or at public events (e.g., warm-up with the players before athletic events to receive a monetary rebate on the ticket) as part of combined preventive and treatment strategies. Again, exercise would not be expected to eliminate clinical depression for all or even most individuals. Yet the benefits would be expected to reduce the incidence and prevalence of depression, leaving aside the enormous individual and societal benefits related to physical health. Will psychoeducation or exercise "cure" or "eliminate" depression? That is not the appropriate stepped-care question. Rather, can these interventions, and others like them (less costly, more easily disseminated) be deployed and be effective with a subgroup of individuals in need as an initial line of attack, and can they reduce the need for more intensive and costly interventions?

Stepped care develops as a sequence of interventions that vary in effort and cost. A given client might not necessarily go through the sequence in order. So, we do not take a depressed, suicidal patient and say, "Let us see what a couple of brochures could do for you." Moderator research might well be helpful in deciding where in a stepped-care sequence of treatment would be an optimal place to begin with this client. What is missing now is stepped-care thinking in routinely providing services and developing EBPs to serve that overall model. It is true currently that most people receive the least costly intervention, i.e., nothing. (Actually, with emergency room visits and physical health correlates and consequences of mental illness, "no treatment" is probably very expensive.) Much could be done to treat and reduce the burden of mental illness by moving to expanded, more easily disseminated, and stepped-care models of providing interventions.

Stepped care involves dual considerations of not only the treatment technique, but also the model of delivery. And, as we learned from best-buy interventions, treatment options might need to vary with local conditions (e.g., resources, health delivery infrastructure). Yet the initial goal is to move beyond the current dominant EBP treatment model. Considering options among the treatments and among the models of delivery and adapting these to local conditions would mean that adopting stepped care is not straightforward. Understandably, in deciding which interventions to apply, the best-buy model has relied on mathematical modeling to help with many of these complexities for making initial treatment recommendations.⁴⁸

General Comments

Novel models, as illustrated by task-shifting and best-buy interventions, address many of the characteristics noted previously, such as reach, scalability, and cost. They add to the dominant model and increase the likelihood of reaching more people who are not being served but are in need of mental health care. Those who are unserved within a country or among different countries are heterogeneous in culture, ethnicity, geography, resources, infrastructure for providing and receiving care, and many other characteristics that can influence treatment delivery. Any one model will miss key segments of the population in need of services. But multiple models, particularly those that begin with the characteristics that are needed to provide treatment on a large scale, are likely to have the needed impact.

The cultural sensitivity issue warrants further comment. Many of the EBPs have been developed, evaluated, and implemented largely in Western cultures and could readily vary in applicability and effectiveness among diverse cultures. It is true that many EBPs do not vary in effectiveness across the few ethnic cultural groups (out of thousands internationally) to which they have been extended.⁸² Add to that a small number of EBPs that began with the cultural and ethnic groups of interest as a basis for developing treatment.⁸³

The novel models I have mentioned begin with a different and complementary point of departure for developing ethnically and culturally sensitive interventions. They begin with a 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 the intervention. in task-shifting, for example, lay members 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 which interventions are likely to be appropriate is determined by local conditions and resources (e.g., government, political, likely impact) and, in that sense, are also 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 these may not be an effective way to exert influence 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.

Translational Research: Conceptualizing the Research Terrain

An obstacle in moving to novel models of treatment delivery may be the absence of a broader framework that places current work into a larger context and also points to needed directions. Current research evaluates and develops EBPs in the model of delivery I mentioned and in well-controlled treatment trials. The needed work I have outlined is to develop models of delivery that can provide treatment on a larger scale. The now familiar concept of translational research includes concepts that provide a useful framework. Moreover, translational research spans areas of science and technology (e.g., medicine, agriculture, engineering) where there is interest in moving findings from the lab to application.^b

Definitions of translational research vary in the kinds of research that qualify and their emphases.^84,85 Critical concepts from translational research that help cast the challenges for EBPs are bench, bedside, and community and the movement from one to the other. The phrase "bench to bedside" refers to the translation of research under well-controlled laboratory situations (where "bench" is equivalent to "laboratory" or "basic" research) to patient care (where "bedside" is direct application).

Although "bench to beside" is the key phrase that characterizes translational research, community conveys a broader thrust and a special challenge for EBPs. Translational research includes "bedside to community," which refers to bringing the findings and applications to others on a larger scale. This means taking bedside findings, i.e., research that can help individual patients or groups of patients in relatively small studies to the level of the community. Community here refers to interventions that can be scaled up perhaps at the level of public health. Vaccinations may be among the most familiar examples to convey the full range from bench and bedside to community in which very basic studies are done (e.g., nonhuman animal studies, evaluations of underlying processes), next these are moved to small scale or isolated applications to monitor their effects with individuals or small groups, and eventually they move to community-wide applications.

Bench to Bedside

EBP research by and large has been exemplary at the "bench" level, as it comprises well-controlled trials in laboratory-like rather than clinical practice settings. For some of the treatments, the bench part includes studies using animal models (e.g., to evaluate extinction of anxiety or reduction of depression),^79,86 and that qualifies as the usual meaning of "bench" in discussions of translational research. Yet, let us begin at the level of randomized controlled trials that have been the core focus of developing EBPs. What is accepted as routine and indeed exemplary treatment research involves careful screening of the sample using inclusion and exclusion criteria to recruit clients, development of manuals that specify the treatment, extensive training and supervision of therapists to administer treatment, and so on. Although this is not animal laboratory research, it has a "bench" feature because of the highly controlled, small-scale application. Patients can get better in such trials of course, so the research extends beyond a "proof of concept" demonstration. Yet, the high levels of experimental control when added to the dominant model make the treatment not very applicable beyond the confines of the study. This is the bench part.

Currently a major research priority is to extend treatment from the highly controlled conditions of the lab to "bedside" (patient care). The challenges of extending EBP findings from bench to clinical practice while retaining the effectiveness of treatment are enormous. Current efforts to disseminate EBPs is exactly that step, namely get the treatments in the hands of clinicians so that patient care benefits from the research.

Clinicians often integrate EBPs into their practice based on continuing education or workshop experiences. Typically, these training experiences are not up to the challenge of imparting the skill sets that many EBPs require. Understandably, without this training or supervision, one cannot expect EBPs to be optimally effective when clinicians try to adopt them. A now well-established finding is that when EBPs are used in clinical practice, their effectiveness drops sharply from what the results show in controlled treatment studies.^30,87 The standard explanation for why treatment effects are diminished has been that in clinical practice patients are more severely impaired and diverse than the "pure" cases seen in controlled trials. There are enough exceptions with direct applications of EBPs to patients with multiple comorbidities to challenge this interpretation.^88–90 Even so, it remains the case that many if not most studies with EBPs do not include clinically referred samples, or they are conducted in clinical practice settings. There may be many reasons why treatment outcome effects drop off when bench-to-bedside extensions are made. Among the likely candidates is the lack of training of the practitioners, dilution of the treatment (e.g., fewer sessions, combined with other treatments), and overall fidelity of the treatment in practice, compared to highly controlled research settings.

Bedside to Community

Bench-to-bedside remains important and is the incubator of interventions that may include principles and practices that serve as the bases for larger-scale interventions. Yet, current EBPs are not likely to have much impact as they are developed, studied, and disseminated at the present time. As I have mentioned, the problem with current EBPs is the dominant model of treatment delivery. Now it is critical to attend to the larger community of individuals in need of services and what we can do to deliver available treatments or draw on new ones.

The move from bedside to community does not merely require scaling up an intervention in the usual way. Scaling introduces special features that change the very nature of the task. In treatment, very well trained and supervised therapists are usually part of a clinical trial (bench), and training and supervision are two of the components that fall down in extensions to clinical practice (bedside). Scaling up now involves many more individuals administering treatment, under the most diverse circumstances. This is not a matter of doing more of the same but changing the model of delivery. Problems and challenges to administering treatment effectively are new, different, and formidable when providing an intervention on scale, even when the treatment is really well specified, clear, and not so difficult to administer (e.g., polio vaccinations). It was for this reason that my discussion began by considering the requirements of what is needed to provide a treatment that is to be administered on a large scale.

Translational research emphasizes bench, bedside, and community, but the progression need not be unidirectional and move from bench, to bedside, to community. There would be enormous value to beginning in the community with interventions that can be administered on scale and that seem to be working. These interventions can also be moved to the bench to evaluate critical features (e.g., mechanisms, mediators).

General Comments

Key concepts of bench, bedside, and community help convey the different levels of interest and our foci. Each type of work is ctitical to reduce the burden of mental illness. We want laboratory, experimental, and controlled studies (bench), and we want tests of how and whether a treatment is effective when extended to more routine practice settings (clinical work and patient care). These facets (bench, bedside) are being studied.

What is missing is more concern about extending treatment on scale. It is important to conceptualize critical goals of treatment with the community as an end point of our efforts. We develop treatments to have impact on the burden of mental illness. This goes beyond identifying EBPs alone but also ensuring that at some point, we are extending these in such a way that they will have impact on the scale as does the impact of mental illness.

It is useful in this conceptualization to begin with identifying the demands of models of delivery that can meet community needs. This does not begin at the bench level but rather looks at community needs, resources, and options. The ability of the model to scale up treatment, bring treatment to those in need, expand the workforce, and address other dimensions mentioned previously (e.g., scalability, affordability) are not currently considered in the context of bench and bench-to-bedside research of psychosocial treatments. Not only do we need different models of delivery, we also need a different mindset in our research efforts. The current mindset is to demonstrate the effectiveness of a one-to-one delivered treatment and see if it can be generalized (extended to clinic settings). That part already has its own obstacles (e.g., training clinicians in large numbers, ensuring the integrity of treatment, preventing the decline in treatment effects) that remain to be resolved. The central reason to raise translational research has been to turn attention to the need to scale up interventions to the community. Even if bench to bedside were to be successful, there is little inherent in that process to help the community, i.e., the large and diverse population in need of care, in diverse contexts, settings, and cultures and for whom individual one-to-one, in person (or Web-based) treatment is not likely to be an option.

Conclusions

EBPs represent an enormous research advance. The comments in this chapter are not a challenge to that at all. Indeed, we are now at the first point in history where behavioral and social sciences have established a large set of treatments (a few hundred and growing) with rigorous scientific evidence supporting those treatments. This accomplishment has to be savored as an evolutionary leap that allows us to consider what is needed for the next breakthrough.

The vast majority of EBPs rely on a model of providing mental health services that is one-to-one, in-person treatment delivered by a mental health professional. This model has proven itself as a platform for effective treatments. What is clear now is that multiple models of treatment delivery are needed to ensure that the large and diverse numbers of individuals needing care can be reached.

In this chapter, I have discussed novel models of delivering treatment that are not merely "potential" options that could be used; in actuality, they are being used now in different contexts but not very often to deliver mental health services. The models draw on advances from multiple disciplines beginning with those in delivering physical health care but also drawing on health care, business, economics, and the media—all well outside of traditional psychological and psychiatric care. I listed several models and illustrated two (task-shifting, best buy), both of which have emerged in the context of providing physical health care but have also entered into mental health care.

The diverse models begin with the requirements of scaling up and sensitivity to local conditions (e.g., resources, geography, culture) that may influence care delivery. It is not just one model of delivery that is needed; indeed, elsewhere I have argued for a portfolio of delivery models to ensure coverage and multiple opportunities to reach those in need.⁴³ Thus, no single model among those I have noted (Table 2) is intended to be the new "dominant" model. Also, there is no need to replace or eliminate the dominant model of one-to-one, in-person therapy administered by a mental health professional. That model is quite fine, but it is limited, in that it reaches very few of those in need of services.

In addition to different models, I conveyed the importance of stepped care, i.e., providing both the intervention and model of delivery in such a way that those interventions involving less effort and cost would be administered first when possible, and then the next stage or step of treatment would be administered if that did not work or was not likely to work. Introducing treatments in a stepped-care fashion raises its own set of research questions. However, stepped care is already being used and studied selectively (e.g., psychoeducation, then an evidence-based treatment) in some studies.^44,75 As with novel models, the task is making stepped care more fully integrated in contemporary treatment research and then application.

In conclusion, I discussed the use of translational research to provide a framework that could help to integrate the type of work we as researchers have been doing to develop and establish treatments as evidence based. The development of EBPs in well-controlled settings reflects enormous success for the "bench" part of our research. Now we are innovating and struggling to get the treatments to clinicians and patient care, the "bedside" part of our work. These are efforts to breakdown and simplify treatment (e.g., modules) or develop individual treatments that can be applied widely (transtreatment) so that it is more feasible for training individuals currently in or being trained for private practice. Yet in all of this we have pretty much neglected the "community" part of the work. In this context, extension to the community refers to the large numbers of individuals in the population who are in need of services but receive no intervention.

Current "bench" based EBPs rely on a model of individual one-on-one therapy administered by a mental health professional. This is a viable model to be sure, but it cannot reach the many people in need. Multiple other models are required that begin with the need to reach the community. Actually, several models are available (Table 2), but they are not mainstream within the mental health professions (psychiatry, psychology, social work). The challenges of reducing the burdens of mental illness within a country and worldwide will require attending to novel ways of scaling up treatment and collaborating with other disciplines, as well as with governments, third-party payers, and policymakers.

There is a huge need worldwide for interventions that reduce the personal and social burdens of mental illness. With the success of EBPs in highly controlled settings (bench), it important to focus on models of delivering treatment that can have impact beyond the small proportion of individuals who have access to care (bedside). Which of our interventions can be used to make a difference on a large scale (community)? The advances in EBPs have made this gap in our knowledge more salient, and perhaps that will make it more likely to be addressed in the coming years.

Acknowledgments

The author is not aware of any affiliations, funding, or financial holdings that would influence comments or positions taken in this chapter. Preparation of this chapter was not supported by any funding agency. The opinions presented in this chapter are those of the author and should not be construed as the official position of the Agency for Healthcare Research and Quality, the National Institutes of Health, or the U.S. Department of Health and Human Services.

Author's Affiliation

Alan E. Kazdin, PhD, is Sterling Professor of Psychology, Professor of Child Psychiatry, and Director of the Yale Parenting Center, New Haven, CT.

Address correspondence to: Alan E. Kazdin, Department of Psychology, 2 Hillhouse Avenue, Yale University, New Haven, CT 06520-8205; email: alan.kazdin@yale.edu

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^a. Some therapies focus on groups (e.g., 8-10 individuals, families, or couples) and involve more than one individual. Typically, these units are seen individually, in person by a mental health professional. The scope and use of these treatments are not such that they alter the central thesis of the chapter or materially alter the impact of the dominant model of delivering treatment.

^b. With translational research, a major concern is that findings from basic research take a long time, often decades, to move from the lab to helping people in everyday life. Translational research emerged in an effort to move findings from the lab to clinics more systematically and quickly. This is slightly different from the move to novel models of delivery, but key concepts from translational research are useful in casting the challenge for moving forward. Another area of work closely related to translational research is called Implementation Science (www.fic.nih.gov/News/Events/implementation-science/Pages/faqs.aspx). Implementation science focuses on the movement from EBPs to application (e.g., how to do that, what implementation strategies are effective, how to adapt findings from controlled research to "real" world settings). Sometimes this is characterized as "research to programs" and "research to policy." Although the topic is beyond the goals of this chapter, the delineation of implementation science conveys the attention and concern in moving findings from research to application.

Alan E. Kazdin, PhD, is Sterling Professor of Psychology, Professor of Child Psychiatry, and Director of the Yale Parenting Center, a service for children and families. While at Yale, he has been Chairman of the Psychology Department, Director of the Yale Child Study Center at the School of Medicine, and Director of Child Psychiatric Services at Yale-New Haven Hospital. Previously, he was on the faculty of The Pennsylvania State University and the University of Pittsburgh School of Medicine. He has received the Outstanding Research Contribution by an Individual Award and Lifetime Achievement Awards from the Association of Behavioral and Cognitive Therapies, the Outstanding Lifetime Contributions to Psychology Award and Distinguished Scientific Award for the Applications of Psychology from the American Psychological Association, and the James McKeen Cattell Award from the Association for Psychological Science. In 2008, Dr. Kazdin served as president of the American Psychological Association.