title: 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.
authors.affiliation: Center for Anxiety and Related Disorders.
authors.forename: Jonathan S
authors.initials: JS
authors.lastname: Comer
authors.affiliation: Center for Anxiety and Related Disorders.
authors.forename: David H
authors.initials: DH
authors.lastname: Barlow
mesh_terms: D055317:Evidence-Based Practice; D006301:Health Services Needs and Demand; D006801:Humans; D001523:Mental Disorders / Q000628:therapy*; D008605:Mental Health Services; D058991:Patient Protection and Affordable Care Act; D011320:Primary Health Care; D011787:Quality of Health Care; D014481:United States
references.citation: J Am Acad Child Adolesc Psychiatry. 2008 Apr;47(4):369-373
references.pmid: 18356704
references.citation: J Child Fam Stud. 2010 Oct 1;19(5):654-668
references.pmid: 20877583
references.citation: Eur Child Adolesc Psychiatry. 2012 Jan;21(1):5-13
references.pmid: 22038343
references.citation: US Statut Large. 1996 Aug 21;110:1936-2103
references.pmid: 16477734
references.citation: Implement Sci. 2012 Mar 14;7:17
references.pmid: 22417162
references.citation: J Consult Clin Psychol. 2004 Dec;72(6):1050-62
references.pmid: 15612851
references.citation: Cyberpsychol Behav. 2002 Apr;5(2):95-105
references.pmid: 12025884
references.citation: J Am Acad Child Adolesc Psychiatry. 2012 Feb;51(2):192-201.e5
references.pmid: 22265365
references.citation: Am J Psychiatry. 2011 Oct;168(10):1057-65
references.pmid: 21799067
references.citation: Psychiatry Res. 2011 Oct 30;189(3):407-12
references.pmid: 21684018
references.citation: Child Adolesc Psychiatr Clin N Am. 2005 Apr;14(2):351-66, x
references.pmid: 15694790
references.citation: Gen Hosp Psychiatry. 2008 May-Jun;30(3):208-25
references.pmid: 18433653
references.citation: J Affect Disord. 2009 Nov;118(1-3):60-8
references.pmid: 19217669
references.citation: Adm Policy Ment Health. 2008 Mar;35(1-2):124-33
references.pmid: 18080741
references.citation: J Consult Clin Psychol. 2004 Apr;72(2):276-87
references.pmid: 15065961
references.citation: J Clin Psychiatry. 2011 Jan;72(1):43-50
references.pmid: 20816036
references.citation: Arch Gen Psychiatry. 2007 Oct;64(10):1180-8
references.pmid: 17909130
references.citation: Gen Hosp Psychiatry. 2007 Sep-Oct;29(5):379-87
references.pmid: 17888803
references.citation: J Consult Clin Psychol. 2000 Aug;68(4):549-55
references.pmid: 10965629
references.citation: Eur Psychiatry. 2011 Oct;26(7):428-35
references.pmid: 21306876
references.citation: Psychiatr Serv. 2009 Jul;60(7):898-907
references.pmid: 19564219
references.citation: J Consult Clin Psychol. 1998 Jun;66(3):484-92
references.pmid: 9642886
references.citation: J Behav Ther Exp Psychiatry. 2005 Jun;36(2):79-97
references.pmid: 15814078
references.citation: Child Adolesc Psychiatr Clin N Am. 2012 Jul;21(3):607-19
references.pmid: 22800997
references.citation: J Consult Clin Psychol. 2008 Apr;76(2):282-97
references.pmid: 18377124
references.citation: Am Psychol. 2004 Dec;59(9):869-878
references.pmid: 15584821
references.citation: Depress Anxiety. 2009;26(3):235-42
references.pmid: 19212970
references.citation: J Consult Clin Psychol. 1999 Feb;67(1):82-94
references.pmid: 10028212
references.citation: Am J Community Psychol. 1993 Oct;21(5):607-33
references.pmid: 8192124
references.citation: Pediatrics. 2012 Feb;129(2):e370-6
references.pmid: 22232310
references.citation: Am Psychol. 2012 Sep;67(6):463-76
references.pmid: 22545596
references.citation: J Emot Behav Disord. 2011 Sep;19(3):182-192
references.pmid: 27182190
references.citation: Arch Gen Psychiatry. 2005 Jun;62(6):617-27
references.pmid: 15939839
references.citation: Arch Gen Psychiatry. 2005 Jun;62(6):603-13
references.pmid: 15939838
references.citation: Behav Ther. 2012 Sep;43(3):666-78
references.pmid: 22697453
references.citation: J Consult Clin Psychol. 2009 Jun;77(3):383-96
references.pmid: 19485581
references.citation: Adm Policy Ment Health. 2011 Nov;38(6):504-17
references.pmid: 21416160
references.citation: Cyberpsychol Behav Soc Netw. 2010 Feb;13(1):29-35
references.pmid: 20528290
references.citation: Am J Psychiatry. 2006 Sep;163(9):1561-8
references.pmid: 16946181
references.citation: J Affect Disord. 2008 Jan;105(1-3):261-5
references.pmid: 17521743
references.citation: Telemed J E Health. 2004 Spring;10(1):13-25
references.pmid: 15104911
references.citation: Psychiatr Serv. 2008 Jul;59(7):738-46
references.pmid: 18586990
references.citation: J Med Internet Res. 2002 Dec;4(3):E14
references.pmid: 12554545
references.citation: Clin Psychol Rev. 2012 Jun;32(4):343-57
references.pmid: 22504491
references.citation: Arch Gen Psychiatry. 2012 Mar;69(3):274-82
references.pmid: 22065252
references.citation: J Abnorm Child Psychol. 2004 Jun;32(3):263-71
references.pmid: 15228175
references.citation: J Am Acad Child Adolesc Psychiatry. 2010 Jan;49(1):13-23
references.pmid: 20215922
references.citation: J Consult Clin Psychol. 2002 Dec;70(6):1303-6
references.pmid: 12472302
references.citation: Perspect Psychol Sci. 2011 Jan;6(1):21-37
references.pmid: 26162113
references.citation: J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):1001-10
references.pmid: 20855045
references.citation: J Consult Clin Psychol. 2010 Apr;78(2):200-11
references.pmid: 20350031
references.citation: Behav Res Ther. 2006 Dec;44(12):1821-9
references.pmid: 16466688
references.citation: Arch Gen Psychiatry. 2005 Jun;62(6):629-40
references.pmid: 15939840
references.citation: JAMA. 2002 Jul 24-31;288(4):423-5
references.pmid: 12132953
references.citation: J Consult Clin Psychol. 2005 Feb;73(1):106-15
references.pmid: 15709837
references.citation: Ann N Y Acad Sci. 1993 Dec 31;703:226-35; discussion 235-7
references.pmid: 8192299
references.citation: Arch Gen Psychiatry. 2005 Jun;62(6):593-602
references.pmid: 15939837
references.citation: J Am Acad Child Adolesc Psychiatry. 2007 Apr;46(4):469-478
references.pmid: 17420681
references.citation: Clin Psychol (New York). 2010 Mar;17(1):1-30
references.pmid: 20877441
references.citation: J Am Acad Child Adolesc Psychiatry. 2013 Jan;52(1):26-36
references.pmid: 23265631
references.citation: Psychiatr Serv. 2012 Jul;63(7):660-5
references.pmid: 22549401
references.citation: N Engl J Med. 2010 Dec 9;363(24):2332-8
references.pmid: 21142535
references.citation: J Psychosom Res. 2009 Dec;67(6):475-83
references.pmid: 19913651
references.citation: J Stud Alcohol Drugs. 2009 Jan;70(1):101-5
references.pmid: 19118398
references.citation: J Am Acad Child Adolesc Psychiatry. 2006 Jun;45(6):749-56
references.pmid: 16721326
references.citation: Cognit Ther Res. 2012 Oct 1;36(5):427-440
references.pmid: 23459093
references.citation: J Psychiatr Res. 2008 Jul;42(9):708-16
references.pmid: 18331741
references.citation: Br J Psychiatry. 2004 Jul;185:55-62
references.pmid: 15231556
references.citation: J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):1043-52
references.pmid: 20855049
references.citation: N Engl J Med. 2011 Sep 15;365(11):973-5
references.pmid: 21848453
references.citation: J Consult Clin Psychol. 2003 Apr;71(2):251-60
references.pmid: 12699020
references.citation: Am J Psychiatry. 2009 Mar;166(3):311-9
references.pmid: 19074978
references.citation: J Clin Child Adolesc Psychol. 2014;43(1):74-87
references.pmid: 24295036
references.citation: J Consult Clin Psychol. 2009 Apr;77(2):270-80
references.pmid: 19309186
references.citation: Behav Res Ther. 2009 Nov;47(11):946-53
references.pmid: 19643395
references.citation: J Clin Child Adolesc Psychol. 2003 Sep;32(3):419-29
references.pmid: 12881030
references.citation: Cogn Behav Pract. 2010 Feb;17(1):88-101
references.pmid: 33762811
references.citation: Am J Community Psychol. 2005 Jun;35(3-4):127-42
references.pmid: 15909790
references.citation: J Am Acad Child Adolesc Psychiatry. 2007 Dec;46(12):1532-72
references.pmid: 18030077
references.citation: Am Psychol. 2005 Sep;60(6):628-48
references.pmid: 16173895
references.citation: Depress Anxiety. 2010;27(1):78-89
references.pmid: 19569060
references.citation: Cogn Behav Pract. 2012 Feb 1;19(1):68-82
references.pmid: 24653642
references.citation: Am J Geriatr Psychiatry. 2011 Apr;19(4):347-56
references.pmid: 21427643
references.citation: Cogn Behav Pract. 2009 Aug 1;16(3):317-331
references.pmid: 21935300
references.citation: Psychiatry Res. 2011 Feb 28;185(3):421-6
references.pmid: 20546922
references.citation: J Clin Psychiatry. 1999 Jul;60(7):427-35
references.pmid: 10453795
references.citation: J Anxiety Disord. 2012 Jan;26(1):40-9
references.pmid: 21917417
references.citation: N Engl J Med. 2008 Dec 25;359(26):2753-66
references.pmid: 18974308
references.citation: Behav Ther. 2016 Nov;47(6):838-853
references.pmid: 27993336
references.citation: J Stud Alcohol Drugs. 2012 Mar;73(2):216-25
references.pmid: 22333329
references.citation: J Am Acad Child Adolesc Psychiatry. 2008 Dec;47(12):1468-83
references.pmid: 19034191
references.citation: Psychiatr Serv. 2009 Oct;60(10):1315-22
references.pmid: 19797370
references.citation: J Consult Clin Psychol. 2009 Jun;77(3):397-409
references.pmid: 19485582
references.citation: Behav Res Ther. 2009 Nov;47(11):910-20
references.pmid: 19647230
references.citation: Am J Psychiatry. 2010 Dec;167(12):1456-63
references.pmid: 20686187
references.citation: J Consult Clin Psychol. 2000 Aug;68(4):564-72
references.pmid: 10965631
references.citation: Behav Res Ther. 2005 Jul;43(7):869-84
references.pmid: 15896284
references.citation: Am Psychol. 2010 Feb-Mar;65(2):73-84
references.pmid: 20141263
references.citation: J Clin Psychiatry. 2008 Aug;69(8):1276-80
references.pmid: 18557666
references.citation: Cogn Behav Pract. 2009 Aug 1;16(3):294-303
references.pmid: 20161063
references.citation: J Clin Child Psychol. 1998 Mar;27(1):34-45
references.pmid: 9561935