title: Designing Psychological Treatments for Scalability: The PREMIUM Approach.
abstract: BACKGROUND
  Lack of access to empirically-supported psychological treatments (EPT) that are contextually appropriate and feasible to deliver by non-specialist health workers (referred to as 'counsellors') are major barrier for the treatment of mental health problems in resource poor countries. To address this barrier, the 'Program for Effective Mental Health Interventions in Under-resourced Health Systems' (PREMIUM) designed a method for the development of EPT for severe depression and harmful drinking. This was implemented over three years in India. This study assessed the relative usefulness and costs of the five 'steps' (Systematic reviews, In-depth interviews, Key informant surveys, Workshops with international experts, and Workshops with local experts) in the first phase of identifying the strategies and theoretical model of the treatment and two 'steps' (Case series with specialists, and Case series and pilot trial with counsellors) in the second phase of enhancing the acceptability and feasibility of its delivery by counsellors in PREMIUM with the aim of arriving at a parsimonious set of steps for future investigators to use for developing scalable EPT.
  
  
  METHODS
  The study used two sources of data: the usefulness ratings by the investigators and the resource utilization. The usefulness of each of the seven steps was assessed through the ratings by the investigators involved in the development of each of the two EPT, viz. Healthy Activity Program for severe depression and Counselling for Alcohol Problems for harmful drinking. Quantitative responses were elicited to rate the utility (usefulness/influence), followed by open-ended questions for explaining the rankings. The resources used by PREMIUM were computed in terms of time (months) and monetary costs.
  
  
  RESULTS
  The theoretical core of the new treatments were consistent with those of EPT derived from global evidence, viz. Behavioural Activation and Motivational Enhancement for severe depression and harmful drinking respectively, indicating the universal applicability of these theories. All the steps of both phases in PREMIUM contributed to the development of the final EPT. However, if there were significant resource constraints, the steps can be limited to workshops with international and local experts in the first phase, and case series with specialists, and case series and pilot trial with counsellors in the second phase.
  
  
  CONCLUSIONS
  Integrating global evidence with local knowledge and practices are complementary and feasible goals to contribute to the development of contextually appropriate and feasible EPT in resource poor country settings. The emerging EPT share similar theoretical frameworks to those described in the global evidence. The PREMIUM method has relevance for any setting where populations have poor access to EPT as its explicit goal is to develop scalable treatments.
authors.affiliation: Centre for Control of Chronic Conditions, Public Health Foundation of India, New Delhi, India.
authors.forename: Sukumar
authors.initials: S
authors.lastname: Vellakkal
authors.affiliation: Centre for Control of Chronic Conditions, Public Health Foundation of India, New Delhi, India; Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; Sangath, Goa, India.
authors.forename: Vikram
authors.initials: V
authors.lastname: Patel
mesh_terms: D015276:Health Care Rationing; D006801:Humans; D008605:Mental Health Services / Q000458:organization & administration*