The occasional case against broad dissemination and implementation: Retaining a role for specialty care in the delivery of psychological treatments.

Abstract

Mental illness imposes a staggering public health burden in the United States. Although the past 40 years have witnessed tremendous advances in the identification of evidence-based practices (EBPs) in psychological treatments, gaps persist between treatment in experimental settings and services available in the community. In response, considerable attention and large financial commitments have focused in recent years on broad dissemination and implementation efforts designed to improve the quality of psychological services delivered by a variety of generalist practitioners across practice settings. Increasingly, under the influence of the Patient Protection and Affordable Care Act, it is envisioned that these generalists will practice in integrated primary care settings. These advances hold enormous potential, and yet, given the tremendous diversity of mental health problems and human suffering, broad dissemination and implementation efforts to generalists alone may not be sufficient to adequately address the burden of mental illness. Some EBPs may prove too complex for universal dissemination, and the time and expense required for quality dissemination and implementation preclude large-scale training in the treatment of low base rate disorders. As dissemination and implementation efforts work to ensure a quality generalist mental health care workforce, herein we highlight the vital need for available specialty care in the delivery of psychological treatments. Given traditional barriers that interfere with the accessibility of specialty care, we propose the transformative potential of a specialty behavioral telehealth care workforce, transacting with the generalist practitioner workforce to collectively ensure the highest quality and timely delivery of needed treatments to affected individuals.

Post-training Beliefs, Intentions, and Use of Prolonged Exposure Therapy by Clinicians in the Veterans Health Administration

“…Clinicians not in PTSD specialty programs also reported less frequent use of PE. This is consistent with Comer and Barlow's (2014) observation that mental health generalists, who must juggle many competing responsibilities, may have difficulty dedicating sufficient time to highly specialized evidencebased psychotherapies.…”

Using Synchronous Videoconferencing to Deliver Family-Based Mental Healthcare

“…Mental health workforce shortages, particularly in rural and other remote regions, limit treatment availability for large numbers of children and adolescents in need of care (see Kazdin and Blasé 2011;Flaum 2013). When providers are regionally available, insufficient dissemination and inadequate implementation of supported programs (see Sandler et al 2005;Comer and Barlow 2013) impinge of the quality of available care. Workforce turnover, poor infrastructure, and inadequate agency support at community mental health clinics interfere with the sustainability of broad dissemination efforts (Atkins et al 2003;Glisson et al 2008;Stirman et al 2012), and long waiting lists at overburdened clinics interrupt the timeliness of provided care.…”

“…The use of electronic media to facilitate the provision of children's mental healthcare has grown considerably in popularity over the past decade (American Academy of Child and Adolescent Psychiatry Work Group on Quality Issues 2008; Comer and Barlow 2013;Myers and Turvey 2013), particularly given: 1) The portability of such care; 2) expanded Internet access and improved technological literacy across the general population; 3) the ability for technology-mediated formats to overcome key issues of transportation, convenience, and regional expertise; 4) the advantage of teleconferencing formats for overcoming issues of stigma about attending a mental health clinic; and 5) the ability for technologymediated formats to work with families in their natural settings, which can improve the ecological validity of care and may enhance generalizations of gains (Khanna et al 2007;Comer and Barlow 2013).…”

Critical Concerns When Incorporating Telepractice in Outpatient Settings and Private Practice

“…The second common reason is to reach new markets. For example, the practitioner might have a reputation for expertise in treating a particular problem or in working with specific patient populations, and technology might enable that practitioner to reach a wider number of individuals who would benefit from the specific expertise (see Comer and Barlow 2014). Other reasons might prompt practitioners to consider adding telepractice services as well.…”