An equivalence analysis of provider education in youth mental health care.

OBJECTIVE: To test for equivalence between providers with and without advanced degrees in multiple domains related to delivery of evidence-based treatment. DATA SOURCE: Provider and client data from an effectiveness trial of Alternatives for Families: A Cognitive Behavioral Therapy (AF-CBT) in a major metropolitan area in the United States. STUDY DESIGN: We tested for equivalence between providers (N = 182) with and without advanced degrees in treatment-related knowledge, practices, and attitudes; job demands and stress; and training engagement and trainer-rated competence in AF-CBT. We also conducted exploratory analyses to test for equivalence in family clinical outcomes. DATA COLLECTION: Providers completed measures prior to randomization and at 6-month follow-up, after completion of training and consultation in AF-CBT. Children and caregivers completed assessments at 0, 6, 12, and 18 months. PRINCIPAL FINDINGS: Providers without advanced degrees were largely non-inferior to those with advanced degrees in treatment-related knowledge, practices, and attitudes, while findings for job demands and stress were mixed. Providers without advanced degrees were non-inferior to providers with advanced degrees in consultation attendance (B = -1.42; confidence interval (CI) = -3.01-0.16; margin of equivalence (Δ) = 2), number of case presentations (B = 0.64; CI = -0.49-1.76; Δ = 2), total training hours (B = -4.57; CI = -10.52-1.37; Δ = 3), and trainer-rated competence in AF-CBT (B = -0.04; CI = -3.04-2.96; Δ = 4), and they were significantly more likely to complete training (odds ratio = 0.66; CI = 0.10-0.96; Δ = 30%). Results for clinical outcomes were largely inconclusive. CONCLUSIONS: Provider-level outcomes for those with and without advanced degrees were generally comparable. Additional research is needed to examine equivalence in clinical outcomes. Expanding evidence-based treatment training to individuals without advanced degrees may help to reduce workforce shortages and improve reach of evidence-based treatments.

Accuracy Requirements for Cost-effective Suicide Risk Prediction Among Primary Care Patients in the US.

Importance: Several statistical models for predicting suicide risk have been developed, but how accurate such models must be to warrant implementation in clinical practice is not known. Objective: To identify threshold values of sensitivity, specificity, and positive predictive value that a suicide risk prediction method must attain to cost-effectively target a suicide risk reduction intervention to high-risk individuals. Design, Setting, and Participants: This economic evaluation incorporated published data on suicide epidemiology, the health care and societal costs of suicide, and the costs and efficacy of suicide risk reduction interventions into a novel decision analytic model. The model projected suicide-related health economic outcomes over a lifetime horizon among a population of US adults with a primary care physician. Data analysis was performed from September 19, 2019, to July 5, 2020. Interventions: Two possible interventions were delivered to individuals at high predicted risk: active contact and follow-up (ACF; relative risk of suicide attempt, 0.83; annual health care cost, $96) and cognitive behavioral therapy (CBT; relative risk of suicide attempt, 0.47; annual health care cost, $1088). Main Outcomes and Measures: Fatal and nonfatal suicide attempts, quality-adjusted life-years (QALYs), health care sector costs and societal costs (in 2016 US dollars), and incremental cost-effectiveness ratios (ICERs) (with ICERs ≤$150 000 per QALY designated cost-effective). Results: With a specificity of 95% and a sensitivity of 25%, primary care-based suicide risk prediction could reduce suicide death rates by 0.5 per 100 000 person-years (if used to target ACF) or 1.6 per 100 000 person-years (if used to target CBT) from a baseline of 15.3 per 100 000 person-years. To be cost-effective from a health care sector perspective at a specificity of 95%, a risk prediction method would need to have a sensitivity of 17.0% or greater (95% CI, 7.4%-37.3%) if used to target ACF and 35.7% or greater (95% CI, 23.1%-60.3%) if used to target CBT. To achieve cost-effectiveness, ACF required positive predictive values of 0.8% for predicting suicide attempt and 0.07% for predicting suicide death; CBT required values of 1.7% for suicide attempt and 0.2% for suicide death. Conclusions and Relevance: These findings suggest that with sufficient accuracy, statistical suicide risk prediction models can provide good health economic value in the US. Several existing suicide risk prediction models exceed the accuracy thresholds identified in this analysis and thus may warrant pilot implementation in US health care systems.

CE: Opioid Use Disorder: Pathophysiology, Assessment, and Effective Interventions.

Opioid use disorder (OUD) is a chronic, relapsing disease. Genetic variability, dysregulated stress system response, and history of opioid experimentation or escalating exposure all contribute to the likelihood of developing OUD, which produces complex brain changes that make it difficult to stop opioid use. Understanding the neurobiology of OUD helps nurses anticipate the behaviors of patients with OUD and approach them with empathy. Here, the authors discuss the pathophysiology of OUD, available screening tools, medical treatments, and behavioral interventions that have demonstrated efficacy in reducing substance use.

Process Evaluation of the BearStand Behavioral Intervention: A Social Cognitive Theory-Based Approach to Reduce Occupational Sedentary Behavior.

OBJECTIVE: Describe the process evaluation of the behavioral intervention group of a multicomponent workplace intervention, BearStand, to reduce employees' sitting time using sit-stand workstations and behavioral strategies. METHODS: Process evaluation metrics: dose delivered, dose-received exposure, dose-received satisfaction, and context were collected using an online survey. Participants included employees of a US university. RESULTS: Overall, 38 of 52 participants completed the process evaluation. The majority were satisfied (53%) with the intervention. Participants' interactions with intervention materials decreased over time (73.7%, week 1, to 52.6%, week 13), and 42% and 33% of participants used suggested videos and apps, respectively. Participants found goal setting and self-regulation strategies to be the most helpful and identified workplace-related contextual barriers that impacted intervention engagement. CONCLUSIONS: Future interventions should incorporate more engaging materials for participants, reduce contextual barriers, and facilitate use of apps and videos.

The 2018 UK NHS Digital annual report on the Improving Access to Psychological Therapies programme: a brief commentary.

This commentary examines publicly available information on 2017-2018 outcomes in the UK government's Improving Access to Psychological Therapies (IAPT) programme, a National Health Service (NHS) primary care mental health programme in England. In that year there were 1.4 million referrals into IAPT and over 500,000 people completed a course of treatment. The IAPT database collects routine session-by-session outcome monitoring data for this population, including outcomes for depression and anxiety in a stepped care model which includes a range of psychological therapies, among them Cognitive Behavioural Therapy (CBT) and Person-centred Experiential Therapy, known in the IAPT programme as Counselling for Depression (CfD).In 2017-18, 32% of all referrals were for anxiety and stress disorders, 26% for depression, and 35% were unspecified. The definition of treatment completion is receipt of 2 sessions or more and on this basis 60% of all referrals in 2017-18 did not complete treatment, predominantly because they failed to attend the initial appointment, or ended after only one session. Four years of data on outcomes for CBT and CfD suggests these therapies are broadly comparable in terms of both recovery rate and average number of sessions, though the number of referrals to each therapy varied widely. Data on treatment choice and satisfaction was favourable but there were issues with low return rates and invalid data. Information on outcomes for ethnicity, sexual orientation, disability and religion, as well as a measure of local economic deprivation, indicate lower outcomes for a number of patient groups. Data on employment status outcomes suggest little overall change, including for the category of those on benefits payments.The data published alongside the annual IAPT reports mean there is an increasing amount of information in the public domain about IAPT performance, but it is time consuming to extract and evaluate. This report highlights a number of points of concern which suggest the need for improvement on multiple axes. We suggest that improved researcher access to the huge IAPT dataset can allow for more detailed evaluations of IAPT that can inform policy/decision-making to improve outcomes for clients.

Long-Term Outcomes of a Therapist-Supported, Smartphone-Based Intervention for Elevated Symptoms of Depression and Anxiety: Quasiexperimental, Pre-Postintervention Study.

BACKGROUND: Depression is one of the most common mental health disorders and severely impacts one's physical, psychological, and social functioning. To address access barriers to care, we developed Ascend-a smartphone-delivered, therapist-supported, 8-week intervention based on several evidence-based psychological treatments for depression and anxiety. A previous feasibility study with 102 adults with elevated depression reported that Ascend is associated with a postintervention reduction in depression symptoms. OBJECTIVE: We aimed to examine whether Ascend is associated with a reduction in symptoms of anxiety, and importantly, whether reductions in symptoms of depression and anxiety are maintained up to 12-months postintervention. METHODS: We assessed whether the previously reported, end-of-treatment improvements seen in the 102 adults with elevated symptoms of depression extended up to 12 months posttreatment for depression symptoms (measured by the Patient Health Questionnaire-9 [PHQ-9]) and up to 6 months posttreatment for anxiety symptoms (added to the intervention later and measured using the Generalized Anxiety Disorder-7 [GAD-7] scale). We used linear mixed effects models with Tukey contrasts to compare time points and reported intention-to-treat statistics with a sensitivity analysis. RESULTS: The intervention was associated with reductions in symptoms of depression that were maintained 12 months after the program (6.67-point reduction in PHQ-9 score, 95% CI 5.59-7.75; P<.001; Hedges g=1.14, 95% CI 0.78-1.49). A total of 60% of the participants with PHQ-9 scores above the cutoff for major depression at baseline (PHQ≥10) reported clinically significant improvement at the 12-month follow-up (at least 50% reduction in PHQ-9 score and postprogram score <10). Participants also reported reductions in symptoms of anxiety that were maintained for at least 6 months after the program (4.26-point reduction in GAD-7 score, 95% CI 3.14-5.38; P<.001; Hedges g=0.91, 95% CI 0.54-1.28). CONCLUSIONS: There is limited evidence on whether outcomes associated with smartphone-based interventions for common mental health problems are maintained posttreatment. Participants who enrolled in Ascend experienced clinically significant reductions in symptoms of depression and anxiety that were maintained for up to 1 year and 6 months after the intervention, respectively. Future randomized trials are warranted to test Ascend as a scalable solution to the treatment of depression and anxiety.

Promoting the Mental Health of Adolescents through Cognitive Behavior Group Therapy and Family Psychoeducation.

The aim of this study was to examine the effects of cognitive behavior group therapy (CBGT) and family psychoeducation (FPE) in promoting and maintaining adolescent mental health. This quantitative study used a quasi-experiment method, pre- and post-testing with a control group design. A total of 86 adolescents were selected using the purposive sampling method and allocated into two groups that were administered different types of intervention. The first intervention group was provided with mental health education and adolescent developmental stimulation only, which was carried out with individual exercises of stimulation. The second intervention group was provided with mental health education and adolescent developmental stimulation in addition to CBGT and FPE. A mental health continuum short-form questionnaire was used to determine mental health scores. The results showed that most of the adolescents received flourishing mental health scores. These scores significantly increased after receiving mental health education and developmental stimulation, as well as CBGT and FPE. Our results indicate that mental health education and developmental stimulation can be used to promote and maintain good mental health. CBGT and FPE can be used not only to treat mental health problems but also to promote flourishing mental health.

Strengthening competence of therapists-in-training in the treatment of health anxiety (hypochondriasis): Validation of the Assessment of Core CBT Skills (ACCS).

Although the observation and assessment of psychotherapeutic competences are central to training, supervision, patient care, quality control, and life-long practice, structured instruments are used only occasionally. In the current study, an observation-based tool for the Assessment of Core CBT Skills (ACCS) was translated into German and adapted, and its psychometric properties were pilot evaluated. Competence of therapists-in-training was assessed in a random sample of n = 30 videos on cognitive behavioural therapy including patients diagnosed with hypochondriasis. Two of three raters independently assessed the competences demonstrated in the entire, active treatment sessions (n = 60). In our sample, internal consistency was excellent, and interrater reliability was good. Convergent validity (Cognitive Therapy Scale) and discriminant validity (Helping Alliance Questionnaire) were within the expected ranges. The ACCS total score did not significantly predict the reduction of symptoms of hypochondriasis, and a one-factorial structure of the instrument was found. By providing multiple opportunities for feedback, self-reflection, and supervision, the ACCS may complement current tools for the assessment of psychotherapeutic competences and importantly support competence-based training and supervision.

MENOS4 trial: a multicentre randomised controlled trial (RCT) of a breast care nurse delivered cognitive behavioural therapy (CBT) intervention to reduce the impact of hot flushes in women with breast cancer: Study Protocol.

BACKGROUND: Women who have been treated for breast cancer may identify vasomotor symptoms, such as hot flushes and night sweats (HFNS), as a serious problem. HFNS are unpleasant to experience and can have a significant impact on daily life, potentially leading to reduced adherence to life saving adjuvant hormonal therapy. It is known that Cognitive Behavioural Therapy (CBT) is effective for the alleviation of hot flushes in both well women and women who have had breast cancer. Most women with breast cancer will see a breast care nurse and there is evidence that nurses can be trained to deliver psychological treatments to a satisfactory level, whilst also maintaining treatment fidelity. The research team will assess whether breast care nurses can effectively deliver a CBT intervention to alleviate hot flushes in women with breast cancer. METHODS: This study is a multi-centre phase III individually randomised controlled trial of group CBT versus usual care to reduce the impact of hot flushes in women with breast cancer. 120-160 women with primary breast cancer experiencing seven or more problematic HFNS a week will be randomised to receive either treatment as usual (TAU) or participation in the group CBT intervention plus TAU (CBT Group). A process evaluation using May's Normalisation Process Theory will be conducted, as well as practical and organisational issues relating to the implementation of the intervention. Fidelity of implementation of the intervention will be conducted by expert assessment. The cost effectiveness of the intervention will also be assessed. DISCUSSION: There is a need for studies that enable effective interventions to be implemented in practice. There is good evidence that CBT is helpful for women with breast cancer who experience HFNS, yet it is not widely available. It is not yet known whether the intervention can be effectively delivered by breast care nurses or implemented in practice. This study will provide information on both whether the intervention can effectively help women with hot flushes and whether and how it can be translated into routine clinical practice. TRIAL REGISTRATION: ISRCTN 12824632 . Registered 25-01-2017.

What Are Effective Psychological Interventions for Veterans With Sleep Disturbances? A Rapid Evidence Assessment.

BACKGROUND: Insomnia and related sleep disturbances commonly occur in veterans, with prevalence rates as high as 90% reported in some studies. Military-specific factors such as sleep disturbances during military training and deployment, as well as a higher prevalence of post-traumatic stress disorder (PTSD), which is known to poorly impact sleep, may contribute to higher insomnia rates in veterans. Although evidence-based guidelines for the treatment of insomnia exist, the unique nature of veterans sleep problems means they may differ in their response to treatment. The aim of this study was to review the evidence for interventions for veterans with sleep disturbances. METHODS: This literature review used a rapid evidence assessment methodology, also known as rapid review. The rapid evidence assessment methodology involves rigorously locating, appraising, and synthesising the evidence while making concessions to the breadth or the depth of the process in order to significantly decrease the length of the process. EMBASE, MEDLINE (PubMed), PsychINFO, Cochrane, Clinical Guidelines Portal (Australia), and the National Guideline Clearinghouse (United States) were searched for peer-reviewed literature and guidelines published from 2004 to August 2015 that investigated psychological interventions for veterans with sleep disturbances. The literature was assessed in terms of strength (quality, quantity, and level of evidence), direction, and the consistency, generalizability, and applicability of the findings to the population of interest. These assessments were then collated to determine an overall ranking of level of support for each intervention: "Supported" (clear, consistent evidence of a beneficial effect), "Promising" (evidence suggestive of a beneficial effect but further research is required), "Unknown" (insufficient evidence of beneficial effect and further research is required), and "Not Supported" (clear consistent evidence of no effect or negative harmful effect). FINDINGS: From an initial yield of 1,131 articles, 18 studies met the inclusion criteria for review. The majority of the studies investigated the effectiveness of cognitive behavioral therapy for insomnia (CBTi; n = 10). Five studies investigated CBTi with an adjunctive psychotherapy, typically for PTSD-related sleep disturbances. One further study investigated sleep hygiene education (a component of CBTi) with pharmacotherapy. Two final studies investigated hypnotherapy and mind-body bridging, respectively. Overall, the quality of the studies was mixed, with some high and some poor quality studies. DISCUSSION: There was sufficient evidence to support CBTi with adjunctive psychotherapy for veterans with PTSD-related sleep disturbances, although the evidence for CBTi in the treatment of general sleep disturbance for veterans was ranked as "promising." This indicates a beneficial effect, but more research is needed to confidently establish efficacy in a veteran population. There is currently insufficient evidence to support the use of sleep hygiene education and pharmacotherapy, hypnotherapy, or mind-body bridging. Further research dismantling the components of CBTi is needed to identify which are the critical components. Such research has the potential to lead to brief, targeted, and accessible treatments that overcome the time and stigma-related barriers to care that veterans often face.

Community-based implementation of trauma-focused interventions for youth: Economic impact of the learning collaborative model.

This study investigated the economics of the learning collaborative (LC) model in the implementation of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT), an evidence-based intervention for traumatic stress in youth. We evaluated the cost-effectiveness of the LC model based on data from 13 LCs completed in the southeastern United States. Specifically, we calculated cost-effectiveness ratios (CERs) for 2 key service outcomes: (a) clinician TF-CBT competence, based on pre- and post-LC self-ratings (n = 574); and (b) trauma-related mental health symptoms (i.e., traumatic stress and depression), self- and caregiver-reported, for youth who received TF-CBT (n = 1,410). CERs represented the cost of achieving 1 standard unit of change on a measure (i.e., d = 1.0). The results indicated that (a) costs of $18,679 per clinician were associated with each unit increase in TF-CBT competency and (b) costs from $5,318 to $6,548 per youth were associated with each unit decrease in mental health symptoms. Thus, although the impact of LC participation on clinician competence did not produce a favorable CER, subsequent reductions in youth psychopathology demonstrated high cost-effectiveness. Clinicians and administrators in community provider agencies should consider these findings in their decisions about implementation of evidence-based interventions for youth with traumatic stress disorders. (PsycINFO Database Record

Behavioral Rehearsal for Analogue Fidelity: Feasibility in a State-Funded Children's Mental Health Initiative.

A substantial number of evidence-based treatments (EBTs) are available, but are delivered infrequently in public mental health. To improve the quality of care, some states and systems have focused on EBT training; however, these efforts have rarely included objective measurement of clinician fidelity because of feasibility issues. The primary goal of the current study was evaluating the feasibility of the behavioral rehearsal (BR) method to assess "analogue fidelity" in a children's mental health quality improvement initiative. Results indicated low-but representative-clinician participation. Participants demonstrated greatest improvement at post-training with maintenance or decreases at 6-months (post-consultation). Implications for future use of BR are discussed.

Development and psychometric evaluation of the Assessment of Core CBT Skills (ACCS): An observation-based tool for assessing cognitive behavioral therapy competence.

This article outlines the development and psychometric evaluation of the Assessment of Core CBT Skills (ACCS) rating scale. The ACCS aims to provide a novel assessment framework to deliver formative and summative feedback regarding therapists' performance within observed cognitive-behavioral treatment sessions, and for therapists to rate and reflect on their own performance. Findings from 3 studies are outlined: (a) a feedback study (n = 66) examining content validity, face validity and usability; (b) a focus group (n = 9) evaluating usability and utility; and (c) an evaluation of the psychometric properties of the ACCS in real world cognitive behavioral therapy (CBT) training and routine clinical practice contexts. Results suggest that the ACCS has good face validity, content validity, and usability and provides a user-friendly tool that is useful for promoting self-reflection and providing formative feedback. Scores on both the self and assessor-rated versions of the ACCS demonstrate good internal consistency, interrater reliability, and discriminant validity. In addition, ACCS scores were found to be correlated with, but distinct from, the Revised Cognitive Therapy Scale (CTS-R) and were comparable to CTS-R scores in terms of internal consistency and discriminant validity. In addition, the ACCS may have advantages over the CTS-R in terms of interrater reliability of scores. The studies also provided insight into areas for refinement and a number of modifications were undertaken to improve the scale. In summary, the ACCS is an appropriate and useful measure of CBT competence that can be used to promote self-reflection and provide therapists with formative and summative feedback. (PsycINFO Database Record

[Prognostic modelling and proactive intervention in psychosis: efficacy and cost-effectiveness]. / Prognostisch modelleren en proactieve interventie bij psychose: effectiviteit en kosteneffectiviteit.

BACKGROUND: Diagnoses have heterogeneous outcomes, varying from good to extremely poor. There is a need to single out an ultra-high-risk group of individuals who have illnesses that might well end unfavourably or who might later develop serious psychopathology.
AIM: To devise a screening instrument that can identify a group of individuals who run a very high risk of developing a first-episode psychosis, and to create a type of intervention that can modify the course of the illness.
METHOD: We developed a short screening instrument (PQ-16) and were able to ascertain its predictive value. We also tested an intervention that could influence risk factors and deal with emerging symptoms thereby achieving a better outcome for the patient.
RESULTS: We developed a two-step detection instrument with a positive predictive value of 44%. The intervention, involving cognitive behavioural therapy for ultra-high-risk patients, was effective and led to a risk reduction of about 50%. Using the ultra-high-risk group of patients, we were able to model three prognostic profiles, each carrying a 4%, 13%, and 70% risk of subsequently developing psychosis. The intervention was cost-effective, reducing the financial burden on the health care services and on society as a whole.
CONCLUSION: Prognostic modelling and proactive intervention can achieve improvements in health at lower costs.

A feasibility study of the clinical effectiveness and cost-effectiveness of individual cognitive behavioral therapy for panic disorder in a Japanese clinical setting: an uncontrolled pilot study.

BACKGROUND: In Japan, cognitive behavioral therapy (CBT) for panic disorder (PD) is not well established. Therefore, a feasibility study of the clinical effectiveness and cost-effectiveness of CBT for PD in a Japanese clinical setting is urgently required. This was a pilot uncontrolled trial and the intervention consisted of a 16-week CBT program. The primary outcome was Panic Disorder Severity Scale (PDSS) scores. Quality of life was assessed using the EuroQol's EQ-5D questionnaire. Assessments were conducted at baseline, 8 weeks, and at the end of the study. Fifteen subjects completed outcome measures at all assessment points. RESULTS: At post-CBT, the mean reduction in PDSS scores from baseline was -6.6 (95 % CI 3.80 to -9.40, p < 0.001) with a Cohen's d = 1.77 (95 % CI 0.88-2.55). Ten (66.7 %) participants achieved a 40 % or greater reduction in PDSS. By calculating areas under the curve for EQ-5D index changes, we estimated that patients gained a minimum of 0.102 QALYs per 1 year due to the CBT. CONCLUSIONS: This study demonstrated that individual CBT for PD may be useful in Japanese clinical settings but further randomized control trials are needed. TRIAL REGISTRATION: UMIN-CTR UMIN000022693 (retrospectively registered).

A New Scale for the Assessment of Competences in Cognitive and Behavioural Therapy.

BACKGROUND: Scales for assessing competence in CBT make an important contribution to research and practice. AIMS: To develop a novel scale. METHOD: A new structured assessment tool is described, which draws on a widely-used CBT competence framework to identify relevant areas of clinical practice. RESULTS: Scale content was clarified through piloting and review by a range of stakeholders. CONCLUSION: Pending formal testing of the psychometric properties, the scale is ready for use to assess competences in cognitive and behavioural therapy.

Internet-supported versus face-to-face cognitive behavior therapy for depression.

Major depression and depressive symptoms are highly prevalent and there is a need for different forms of psychological treatments that can be delivered from a distance at a low cost. In the present review the authors contrast face-to-face and Internet-delivered cognitive behavior therapy (ICBT) for depression. A total of five studies are reviewed in which guided ICBT was directly compared against face-to-face CBT. Meta-analytic summary statistics were calculated for the five studies involving a total of 429 participants. The average effect size difference was Hedge's g = 0.12 (95% CI: -0.06-0.30) in the direction of favoring guided ICBT. The small difference in effect has no implication for clinical practice. The overall empirical status of clinician-guided ICBT for depression is commented on and future challenges are highlighted. Among these are developing treatments for patients with more severe and long-standing depression and for children, adolescents and the elderly. Also, there is a need to investigate mechanisms of change.

Increasing access to Cognitive Behaviour Therapy in Low and Middle Income Countries: A strategic framework.

Cognitive Behaviour Therapy has been demonstrated to be an effective intervention in outpatient and inpatient settings for a wide range of presenting mental health problems including depression, Obsessive Compulsive Disorder, Post traumatic Stress Disorder, Social Anxiety Disorder, Panic Disorder and Somatorform Disorder. There is likely to be an unmet need for this therapeutic approach in most Low and Middle Income Countries (LMIC). However, the training of therapists to deliver this intervention has historically been a lengthy and expensive process, with already highly trained staff such as psychiatrists and psychologists undertaking additional training of up to one year duration in order to develop expertise in this area. This paper proposes that a model where training, supervision, leadership and service evaluation is provided by a small number of highly trained staff to front-line non-specialist staff who will then deliver manualised therapy. These front-line staff may also be conceptualised as part of a stepped care model where self-help and manualised therapy approaches are used in the first instance. Where patient functioning does not improve there is then the possibility of being stepped-up for treatment by a more specialised and highly trained therapist. This approach may help in meeting the huge mental health treatment gap in LMIC. This paper also suggests that lessons learnt from the dissemination of behaviourally informed parenting interventions internationally can be applied to the dissemination of this therapeutic approach.