Innovative Mental Health Care Research Articles

Social psychiatry in Oxford and its ecological niche, 1959-1988.

This paper reflects on a special edition of the journal History of Psychiatry and a related symposium held at Somerville College, Oxford, exploring the innovations in mental healthcare in Oxfordshire led by Dr Bertram Mandelbrote between 1959 and 1988. I draw on clinical culture, biography, mental health policy and my lived experience to understand Mandelbrote's life and work, and his legacy and lessons for contemporary psychiatrists. I explore the ecological niche that Mandelbrote created and conclude with the probable importance of his relationship with Professor Michael Gelder, who led the University of Oxford Department of Psychiatry at the time.

Mental health providers are inexperienced but interested in telehealth-based virtual reality therapy: survey study.

Virtual reality (VR) is an emerging technology that can enhance experiences and outcomes in mental healthcare. However, mental health therapists have been slow to adopt VR into practice. Implementation of telehealth-based VR therapy (tele-VR) could catalyze adoption and innovation in mental healthcare. To explore therapists' perspectives on tele-VR, we conducted a cross-sectional survey of practicing mental health providers in the United States in June-July 2023. We analyzed 176 completed surveys from therapists, of whom 51.14% had no prior experience with VR, only 6.25% had used VR clinically, and 56.82% had neutral impressions of VR for therapy. Despite therapists' general inexperience with VR, therapists indicated a wide variety of tele-VR simulations (e.g., social situations, flying, heights) and features (e.g., personalized spaces, homework, interactivity) would be moderately to extremely useful for their practices. Therapists also requested additional VR simulations and features for their telehealth clients such as behavioral skills training, exposure therapy, gender identity therapy, and psychological assessments in VR. Therapists rated Health Insurance Portability and Accountability Act compliance, the ability to try VR before buying, affordability for therapists, accessibility for clients, and insurance coverage as the five most influential implementation factors for tele-VR. Overall, therapists were generally inexperienced and neutral about VR for telehealth therapy, but were interested in tele-VR for specific applications. These findings provide actionable directions for future research and collaborative development of therapeutic VR content and features.

Adoption of Digital Healthcare Interventions and Innovations in Reducing Mental Health Stigma: A Perspective on (COVID)-19

Objectives: During the COVID-19 pandemic, Chinese people with mental health difficulties faced a major issue of mental health stigma. The pandemic's constant stress and social isolation intensified the stigma attached to people suffering from mental illnesses. To address this issue, a study was done in China to investigate mental health stigma in the context of digital media arts. Methods: The study involves randomly distributing 1300 questionnaires on a 5-point Likert scale. Only 500 questionnaires, however, were found adequate for data analysis using partial least squares (PLS). Results: Digital health innovation and adoption are crucial for enhancing mental health. The study's focus was confined to the adoption of innovation in mental healthcare in China because this sector received less attention in previous research that sought to establish a link between digital health innovation and digital mental healthcare. Conclusion: The study has important theoretical and practical implications for improving people's lives by strengthening their mental health systems with digital technologies and raising awareness of digital healthcare tools. The findings are important for policymakers to make people aware of the importance of caring for their mental health by digital healthcare tools.

Violence, women, blood(line): Hong Kong films of severe mental illness

ABSTRACT Hong Kong has commendably progressive mental health care for local people with a severe mental illness. Social stigma towards these people, however, remains unyieldingly intense and widespread. This occurs despite Hong Kong’s well-regarded community psychoeducation regime. This study analyses how popular local films contribute to an apparent paradox, whereby a society with innovative mental health care and community psychoeducation retains conspicuously high levels of stigma towards people with a severe mental illness. The study employs a well-tested narrative-cum-discourse analytic approach to reveal how four contemporary local films construct and make sense of the illness, and why they do so in the ways that they do. The analysis finds that, regardless of a film’s social intent or commercial status, it casts local men with severe mental illness as dangerous and macabrely violent. Women are assigned blame for this. The films further justify the removal of people with the illness from everyday society, in line with longstanding Chinese cultural scripts. As a result, the filmic portrayals discursively align with local newspaper reporting on severe mental illness, disregarding the humane principles espoused and embraced by local mental health care and community psychoeducation.

Innovations in treatment of psychosis in southeast europe

AbstractSoutheast Europe (SEE) is home to 70 million people living across 12 countries. These countries share similar socioeconomic background and tradition of healthcare systems, although many differences exist in the organisation of mental health care. The region has been called ‘the blind spot on the global mental health map’ due to lack of research and innovations in mental health care. In recent years European Commission has invested significant resources to improve mental health care of individuals with severe mental disorders in Southeast Europe. Two major, recently completed, projects are Recover-e and Impulse. This presentation will focus on findings from the Impulse study. We will start with an overview of evidence-based, non-pharmacological interventions for individuals with psychosis, with focus on what is offered and implemented in 12 SEE countries. Next, we will present key findings from the hybrid type II effectiveness-implementation psychosocial randomised-controlled trial. We will show an evidence-based approach how to improve psychosocial aspect of treatment of individuals with psychotic disorders. Mental health services that offer a combined-therapy approach, including psychosocial interventions and pharmacotherapy, can ensure holistic care, preferred by patients and their families. Discussion will include the role of implementation science tool in mental health care and sustainability of implemented interventions.Disclosure of InterestNone Declared

The processes and context of innovation in mental healthcare: Oxfordshire as a case study.

This article introduces the four following articles and the Classic Text. They describe the development of a sequence of innovative local mental health services in Oxfordshire, and explore the processes of innovation, led by the humane pragmatism practised by Dr Bertram Mandelbrote, who was Physician Superintendent at Littlemore Hospital in Oxford from 1959 to 1988. The articles describe emerging patterns of therapeutic community practice, and trace the events leading to a set of discrete service developments outside the hospital. Together, they suggest a positive role for chance in these developments, and a focus on the then prevailing national and local regulatory culture. The Classic Text by David Millard provides an overview of the origins of the therapeutic community movement.

Innovation in mental health care: Bertram Mandelbrote, the Phoenix Unit and the therapeutic community approach.

Bertram Mandelbrote was Physician Superintendent and Consultant Psychiatrist at Littlemore Hospital in Oxford from 1959 to 1988. A humane pragmatist rather than theoretician, Mandelbrote was known for his facilitating style of leadership and working across organisational boundaries. He created the Phoenix Unit, an innovative admission unit run on therapeutic community lines which became a hub for community outreach. Material drawn from oral histories and witness seminars reflects the remarkably unstructured style of working on the Phoenix Unit and the enduring influence of Mandelbrote and fellow consultant Benn Pomryn's styles of leadership. Practices initiated at Littlemore led to a number of innovative services in Oxfordshire. These innovations place Mandelbrote as a pioneer in social psychiatry and the therapeutic community approach.

Not as Straight-Forward as that It’s Just ‘An Added Fuss’ – Untangling How Indian Psychiatrists Construe Domestic Human Rights Legislation

After its ratification of the 2006 United Nations Convention on the Rights of People with Disabilities (UNCRPD), the Indian government proceeded to work through a list of laws from various fields – employment, housing, healthcare, personal status – that would need to be amended to guarantee the rights in the UNCRPD. Regarding the healthcare of persons with mental illness, the law-drafters deemed it insufficient to merely amend the existing law and proceeded to draft a new, innovative mental healthcare law. When the Mental Healthcare Act (MHA) was passed in 2017, responses were strongly polarised: On the one hand, it was lauded for staying true to the vision of the UNCRPD (Duffy & Kelly, 2019), while on the other hand, especially psychiatrists heavily criticised that they anticipated the law would adversely affect their ability to treat patients

Organizational Readiness for Implementing an Internet-Based Cognitive Behavioral Therapy Intervention for Depression Across Community Mental Health Services in Albania and Kosovo: Directed Qualitative Content Analysis.

BackgroundThe use of digital mental health programs such as internet-based cognitive behavioral therapy (iCBT) holds promise in increasing the quality and access of mental health services. However very little research has been conducted in understanding the feasibility of implementing iCBT in Eastern Europe.ObjectiveThe aim of this study was to qualitatively assess organizational readiness for implementing iCBT for depression within community mental health centers (CMHCs) across Albania and Kosovo.MethodsWe used qualitative semistructured focus group discussions that were guided by Bryan Weiner’s model of organizational readiness for implementing change. The questions broadly explored shared determination to implement change (change commitment) and shared belief in their collective capability to do so (change efficacy). Data were collected between November and December 2017. A range of health care professionals working in and in association with CMHCs were recruited from 3 CMHCs in Albania and 4 CMHCs in Kosovo, which were participating in a large multinational trial on the implementation of iCBT across 9 countries (Horizon 2020 ImpleMentAll project). Data were analyzed using a directed approach to qualitative content analysis, which used a combination of both inductive and deductive approaches.ResultsSix focus group discussions involving 69 mental health care professionals were conducted. Participants from Kosovo (36/69, 52%) and Albania (33/69, 48%) were mostly females (48/69, 70%) and nurses (26/69, 38%), with an average age of 41.3 years. A directed qualitative content analysis revealed several barriers and facilitators potentially affecting the implementation of digital CBT interventions for depression in community mental health settings. While commitment for change was high, change efficacy was limited owing to a range of situational factors. Barriers impacting “change efficacy” included lack of clinical fit for iCBT, high stigma affecting help-seeking behaviors, lack of human resources, poor technological infrastructure, and high caseload. Facilitators included having a high interest and capability in receiving training for iCBT. For “change commitment,” participants largely expressed welcoming innovation and that iCBT could increase access to treatments for geographically isolated people and reduce the stigma associated with mental health care.ConclusionsIn summary, participants perceived iCBT positively in relation to promoting innovation in mental health care, increasing access to services, and reducing stigma. However, a range of barriers was also highlighted in relation to accessing the target treatment population, a culture of mental health stigma, underdeveloped information and communications technology infrastructure, and limited appropriately trained health care workforce, which reduce organizational readiness for implementing iCBT for depression. Such barriers may be addressed through (1) a public-facing campaign that addresses mental health stigma, (2) service-level adjustments that permit staff with the time, resources, and clinical supervision to deliver iCBT, and (3) establishment of a suitable clinical training curriculum for health care professionals.Trial RegistrationClinicalTrials.gov NCT03652883; https://clinicaltrials.gov/ct2/show/NCT03652883

Community Reintegration of Long-Stay Hospitalised Mental Health Consumers During COVID-19 Pandemic

ABSTRACT Mandatory restrictions on social activities and access to services during the COVID-19 pandemic prevented discharge into the community of consumers from an extended-stay, hospital-based rehabilitation program. This article describes a revised discharge process that overcame the pandemic-related restrictions by replacing the graded and slow discharge process with a one-stage, full-time transition that facilitated the discharge of 16 adult consumers. No adverse mental health outcomes occurred during the process. The change of practice with its positive results reflected therapeutic risk-taking. The COVID-19 pandemic provided scope for creativity and innovation in mental health care and psychiatric rehabilitation. IMPLICATIONS Innovation and collaboration by service providers can promote consumers’ positive risk-taking to return to a life in mainstream society after a prolonged stay in an inpatient rehabilitation unit. Community reintegration of consumers with enduring severe mental illness can occur under adverse public health and social situations like the COVID-19 pandemic with innovative hospital discharge planning.

Why Multi-Family Groups for Transgender Adolescents and Their Parents?

The author presents a therapeutic approach for contemporary families carried out in an innovative mental health care setting. This approach involves receiving both transgender adolescents and their parents. Initially, the adolescents are brought together in a discussion group. Then, the parents of these adolescents are gathered without their children in order to reflect on family relations and social adaptation and to receive support when needed. Both groups are gathered together a couple of times a year in a multi-family meeting. Using a dynamic based on the principle of free association and the interplay of identifications among participants, the author points out how these groups and multi-family gatherings promote mental health and prevent mental disorders and the disruption of family relations.

The influence of concern about COVID-19 on mental health in the Republic of Georgia: a cross-sectional study

BackgroundEarly evidence indicates increased mental health burden arising from COVID-19 and related control measures. The study aim was to examine concern about COVID-19 and its association with symptoms of mental disorders in the Republic of Georgia.A cross-sectional internet-based survey of adults in Georgia using non-probabilistic sampling was used. Questionnaire topics were: (i) demographic and socio-economic characteristics; (ii) level of burden caused by common causes of COVID-19 related concerns; (iii) strategies used in response to concerns about COVID-19; and (iv) symptoms of mental disorders of anxiety (GAD-7), depression (PHQ-9), PTSD (ITQ) and adjustment disorder (ADNM8). Descriptive and multivariate analyses were conducted.ResultsThere were 2088 respondents. High levels of symptoms for mental disorders were observed for anxiety (23.9% women, 21.0% men), depression (30.3% women, 25.27% men), PTSD (11.8% women, and 12.5% men), and adjustment disorder (40.7% women, 31.0% men). Factors significantly associated with increased COVID-19 concern included bad/very bad household economic situation, larger household size, current NCD, symptoms of anxiety, adjustment disorder and PTSD. Response strategies significantly associated with reduced mental disorder symptoms included meditation and relaxation exercises, physical exercise, positive thinking, planning for the future, TV/radio, housework/DIY, and working. Drinking alcohol was associated with a greater probability of increased mental disorder symptoms.ConclusionsHigh levels of mental disorders were recorded, and they were strongly associated with increased concern about COVID-19. A number of response strategies were identified which may help protect against worse mental health and these could be supported by innovations in mental health care in Georgia.

20.D. Skills building seminar: Design for mental health integration through built environment interventions

Abstract Mental illness is associated with social exclusion and stigma more than most other health issues. This affects psychiatric facility provision (Chrysikou et al 2017), prevention and early treatment interventions. The planning and design of services both conceptually (service procedures, experience designs, campaigns and physically (e.g. buildings, products, interiors) could help change that. New approaches could build resilience by increasing access to and acceptance of mental health services and enable recovery as a constant process (Slade et al 2008). This intense skill- building workshop will use a role-game approach with cross-disciplinary methods from experience design and design thinking to foster innovative spatial concepts in a co-creative manner. This helps to build capacity and knowledge on exploring and developing innovative and disruptive concepts for public urban mental health. Focus is on spatial configuration, architectural and design aspects for services and mental health systems. The highly interactive seminar-workshop starts with two 5' presentations to set the theoretical multi-disciplinary stage. A third 5' presentation addresses issues addressed to the participants and presents the locus of the role play, i.e. Crete, chosen for its unique socio-spatial and systemic characteristics. A 5' presentation explains the scenario and stakeholder roles. The group session comprises a 50' long structured series of ideation and analysis methods based on a role-play-like schedule in which delegates act as service provider for a municipal client (Crete) that request an innovative mental health care solution for a specific urban context. Then 10' will be the closing session on the process by mapping the reflections of the process on a collective SWOT diagram. Chrysikou, E., Kostopoulou, E., Savvopoulou, E., Fatah gen. Schieck, A., 2017. Medical Architecture on the Social Valorisation of Psychiatric Patients: Employing transdisciplinary approaches between architecture, physical and mental well-being disciplines. Proceedings of the AAE 2017 Conference, Architecture Connects, 6th -9th September 2017. Oxford Brookes University, UK Slade, Mike; Amering, Michaela; Oades, Lindsay (2008): Recovery: an international perspective. In: Epidemiologia e psichiatria sociale 17 (2), S. 128-137. Key messages Participants will explore participatory design methodologies to help them consider and use building infrastructure as resource for public health and healthcare actions in relation to mental health. Participants will cross disciplinary boundaries exposed to eco- and psychosocial frameworks, i.e, build and social infrastructure, to co-create healthy, vibrant, resilient and equitable communities.

Your Robot Therapist Will See You Now: Ethical Implications of Embodied Artificial Intelligence in Psychiatry, Psychology, and Psychotherapy.

BackgroundResearch in embodied artificial intelligence (AI) has increasing clinical relevance for therapeutic applications in mental health services. With innovations ranging from ‘virtual psychotherapists’ to social robots in dementia care and autism disorder, to robots for sexual disorders, artificially intelligent virtual and robotic agents are increasingly taking on high-level therapeutic interventions that used to be offered exclusively by highly trained, skilled health professionals. In order to enable responsible clinical implementation, ethical and social implications of the increasing use of embodied AI in mental health need to be identified and addressed.ObjectiveThis paper assesses the ethical and social implications of translating embodied AI applications into mental health care across the fields of Psychiatry, Psychology and Psychotherapy. Building on this analysis, it develops a set of preliminary recommendations on how to address ethical and social challenges in current and future applications of embodied AI.MethodsBased on a thematic literature search and established principles of medical ethics, an analysis of the ethical and social aspects of currently embodied AI applications was conducted across the fields of Psychiatry, Psychology, and Psychotherapy. To enable a comprehensive evaluation, the analysis was structured around the following three steps: assessment of potential benefits; analysis of overarching ethical issues and concerns; discussion of specific ethical and social issues of the interventions.ResultsFrom an ethical perspective, important benefits of embodied AI applications in mental health include new modes of treatment, opportunities to engage hard-to-reach populations, better patient response, and freeing up time for physicians. Overarching ethical issues and concerns include: harm prevention and various questions of data ethics; a lack of guidance on development of AI applications, their clinical integration and training of health professionals; ‘gaps’ in ethical and regulatory frameworks; the potential for misuse including using the technologies to replace established services, thereby potentially exacerbating existing health inequalities. Specific challenges identified and discussed in the application of embodied AI include: matters of risk-assessment, referrals, and supervision; the need to respect and protect patient autonomy; the role of non-human therapy; transparency in the use of algorithms; and specific concerns regarding long-term effects of these applications on understandings of illness and the human condition.ConclusionsWe argue that embodied AI is a promising approach across the field of mental health; however, further research is needed to address the broader ethical and societal concerns of these technologies to negotiate best research and medical practices in innovative mental health care. We conclude by indicating areas of future research and developing recommendations for high-priority areas in need of concrete ethical guidance.

A Qualitative Exploration of Mothers' Experiences Receiving Mental Health Services in a Supermarket Setting.

Objectives Innovative mental health care delivery models have been proposed as a method to address disparities in access and utilization. The aim of this study is to characterize patients' perspectives and experiences of participating in one such innovative delivery model, group cognitive behavioral therapy within a supermarket setting. Methods In this qualitative study, 16 mothers were interviewed to explore their experiences and perspectives of receiving group-based cognitive behavioral therapy in a supermarket setting, as part of their participation in an academic-community research collaborative whose mission is to address mental health needs within low-resourced communities. Data from semi-structured interviews were analyzed using inductive coding. Results Five themes related to receiving mental health services in a supermarket setting emerged from the data: (1) Participants reported a convergence of life stressors and their introduction to supermarket-based services; (2) Participants perceived the supermarket setting as convenient; (3) Participants perceived the supermarket setting as less stigmatizing; (4) Participants perceived services in the supermarket as an acceptable form of mental health treatment; and (5) Participants described the program staff as an influential component of their treatment experience. Conclusions Understanding patient experiences of various service delivery models is critical to improving access to treatment and addressing disparities in mental health service utilization and outcomes. This study supports the use of innovative delivery models to increase access to mental health services in low-resourced communities.

What leads to innovation in mental healthcare? Reflections on clinical expertise in a bureaucratic age.

SummaryThis paper considers a witness seminar in which healthcare professionals discussed working on an acute admissions ward run along therapeutic community lines from the 1960s to the 1980s. Participants remarked that older styles of working are 'unimaginable' today. This paper discusses why. Literature from the humanities and social sciences suggest healthcare is reactive, reflecting wider cultural changes, including a preference for a more bureaucratic, standardised, explicit style of reasoning and a high valuation of personal autonomy. Such a reflection prompts questions about the nature of professional expertise, the role of evidence and the importance of the humanities and social sciences.Declaration of interestNone.

Advances in Mental Health Care: Five N = 1 Studies on the Effects of the Robot Seal Paro in Adults With Severe Intellectual Disabilities

ABSTRACTBackground: The evidence base for psychological treatments for autism and mood disorders in people with moderate to severe intellectual disabilities (ID) is limited. Recent promising robot-based innovations in mental health care suggest that robot-based animal assisted therapy (AAT) could be useful to improve social skills and mood in people with moderate to severe ID. This study explores the efficacy of the innovative therapeutic robot seal Paro on alertness and mood in adults with moderate to severe ID. Method: Five N = 1 studies were performed in adults (59–70 years) with moderate to severe ID. During a control phase of four weeks, participants could interact with a plush seal, which was replaced by the robot seal Paro during an equally long treatment phase. Results: In one participant, alertness and mood, as rated by supervisors, improved during the treatment phase as compared to the baseline phase. The other four participants did not improve on either of the outcome measures. Conclusion: We conclude that robot-based AAT does not have clear beneficial effects on alertness and mood in adults with moderate to severe ID, but that positive interactions with the robot seal could be of therapeutic value in itself.

Home-Based Psychiatric Outpatient Care Through Videoconferencing for Depression: A Randomized Controlled Follow-Up Trial.

BackgroundThere is a tremendous opportunity for innovative mental health care solutions such as psychiatric care through videoconferencing to increase the number of people who have access to quality care. However, studies are needed to generate empirical evidence on the use of psychiatric outpatient care via videoconferencing, particularly in low- and middle-income countries and clinically unsupervised settings.ObjectiveThe objective of this study was to evaluate the effectiveness and feasibility of home-based treatment for mild depression through psychiatric consultations via videoconferencing.MethodsA randomized controlled trial with a 6- and 12-month follow-up including adults with mild depression treated in an ambulatory setting was conducted. In total, 107 participants were randomly allocated to the videoconferencing intervention group (n=53) or the face-to-face group (F2F; n=54). The groups did not differ with respect to demographic characteristics at baseline. The F2F group completed monthly follow-up consultations in person. The videoconferencing group received monthly follow-up consultations with a psychiatrist through videoconferencing at home. At baseline and after 6 and 12 months, in-person assessments were conducted with all participants. Clinical outcomes (severity of depression, mental health status, medication course, and relapses), satisfaction with treatment, therapeutic relationship, treatment adherence (appointment compliance and dropouts), and medication adherence were assessed.ResultsThe severity of depression decreased significantly over the 12-month follow-up in both the groups. There was a significant difference between groups regarding treatment outcomes throughout the follow-up period, with better results in the videoconferencing group. There were 4 relapses in the F2F group and only 1 in the videoconferencing group. No significant differences between groups regarding mental health status, satisfaction with treatment, therapeutic relationship, treatment adherence, or medication compliance were found. However, after 6 months, the rate of dropouts was significantly higher in the F2F group (18.5% vs 5.7% in the videoconferencing group, P<.05).ConclusionsPsychiatric treatment through videoconferencing in clinically unsupervised settings can be considered feasible and as effective as standard care (in-person treatment) for depressed outpatients with respect to clinical outcomes, patient satisfaction, therapeutic relationship, treatment adherence, and medication compliance. These results indicate the potential of telepsychiatry to extend access to psychiatric care to remote and underserved populations.ClinicalTrialClinicaltrials.gov NCT01901315; https://clinicaltrials.gov/ct2/show/NCT01901315 (Archived by WebCite at http://www.webcitation.org/6jBTrIVwg)

Innovations in Mental Health Care.

The traditional means of providing mental health care (e.g. delivered in psychiatric facilities in face to face format) are not meeting many patient needs. The World Health Organization’s (WHO) Mental Health Action Plan [1] lists two key objectives for improving mental health care: integrating mental health care into community settings and strengthening information technology. Patients are more likely to see their primary care providers for their psychiatric symptoms, leave psychiatric care due to fear of stigma [2] and may prefer alternative treatment options for their mental illness. As an Advanced Practice Nurse in Psychiatry, I see patients for medication management who sometimes leave treatment for these same reasons. My practice does not have integrated primary and mental health care AND we do not conduct video or telephone appointment with patients. These deficiencies ultimately affect patients’ mental health. The increased use of technology by patients needs to drive all health care delivery systems to develop innovative methods for improving individuals’ access to mental health care and overall social functioning. I am happy to share some new ideas for mental health care delivery in this special issue. This thematic issue includes review and research articles addressing the two WHO mental health care objectives. Three articles describe primary care providers as avenues to improve access to mental health. Patients’ access to mental health services can be problematic due to limited providers. Kverno describes a new education program to increase the number of mental health nurse practitioners in rural environments by targeting primary care nurse practitioners living in these environments and training them to be psychiatric mental health nurse practitioners. McIntosh, Startsman and Perraud reviews the issue of integrated mental health care (combining mental health and somatic medicine) and its implications for a new role in nursing practice. Kriebel-Gasparro discusses how advanced practice nurses can play a significant role in bipolar disorder screening in primary care. The other three articles examine potential interventions to engage and prevent mental illness sequelae: phone technology (Duarte & Thomas), humor use for substance abuse treatment (Canha) and evidence based mindfulness based interventions for at risk adolescents (Rawlett & Scrandis). These articles can lead nurses in clinical practice and research to expand their thinking to improve mental health care and access using ideas different from the historical care delivery system. It is my hope this issue will open a dialogue to address the pressing mental health needs of our global community.

Democratizing Implementation and Innovation in Mental Health Care.

Improvements in the quality of mental health care in the United States depend on the successful implementation of evidence-based treatments (EBT's) in typical settings of care. Unfortunately, there is little evidence that EBT's are used in ways that would approximate their established fidelity standards in such settings. This article describes an approach to more successful implementation of EBT's via a collaborative process between intervention developers and intervention users (e.g. providers, administrators, consumers) called Lead-user Innovation. Lead-user Innovation democratizes the implementation process by integrating the expertise of lead-users in the delivery, adaptation, innovation and evaluation of EBT's.