[1] 24w Internet access is NOT restricted globally to high income countries: So why are evidenced based prevention and treatment programs for mental disorders so rare?

[1] 116w The developed world owns lots of expertise. Some of it is not expensive, nor is it high tech. It should be widely disseminated in low and middle income countries (LAMICs). This paper will present reasons for why and how this can be done. Both authors have a strong interest in improving mental health outcomes for individuals in LAMICs. Over a period of six months Mrs. Watts has volunteered in Kenya, working at public hospital, a school for children with disabilities, and has conducted research into parenting practices and child development. Professor Andrews has collaborated with the World Health Organization (WHO) and as part of this partnership has worked in various hospital and community settings throughout Malaysia.

[2] 106w There are six courses that are clinician prescribed and all courses have been shown to be superior over the waitlist control (mean hedges g = 0.92; range 0.28-1.18; NNT 2) (Robinson et al., 2010;Newby et al., 2013;Williams and Andrews, 2013;Mewton et al., 2012;Watts et al., 2013;Wims et al., 2010;Titov et al., 2011Titov et al., , 2008)). These courses are offered on a non-for-profit basis and allow clinicians, such as primary care physicians or a mental health practitioners, to prescribe the courses for individuals with MDD, social anxiety disorder, panic disorder, generalized anxiety disorder, obsessive compulsive disorder or for people with mixed anxiety and depression (Fig. 1).

[3] 187w There are six lessons in each course and the content is based on CBT principles. Each lesson is akin to reading a comic book story about someone with the disorder who recovers by learning skills that help them to manage their symptoms and stay well. For example, in the course for people with depression patients are introduced to Jess and follow her story through to recovery (refer to Fig. 1). At the start of every lesson the individual completes a measure of psychological distress, the Kessler 10 [K10] (Andrews and Slade, 2001) and this score is monitored, with an alert automatically sent to a clinician if there is a significant increase in distress (refer to Fig. 2 for an example). Clinicians are also asked to make contact with their patients for two reasons, firstly to assess their psychological well being and secondly, because this contact acts to improve treatment adherence. At the end of every lesson, the individual is instructed to carry out homework activities and utilize the additional resources, such as fact sheets on related mental health skills and recovery stories from previous patients (Fig. 2).

[4] 89w In 2010, these courses were made available to primary care physicians and mental health practitioners around Australia on www.thiswayup.org.au/clinic. Since this time over 3000 clinicians have registered and over 7000 patients have enrolled and paid a small fee ($55 AUD) to access the course, as this fee was found to increase adherence. The online programs can be accessed online using a computer and more recently on a smart mobile phone, as we have shown that the depression course remained efficacious when delivered in this modality (Watts et al., 2013).

[5] 87w In order to evaluate the effectiveness of the programs since this time, CRUfAD has completed studies to ensure quality assurance. The first study examined data from 359 patients prescribed the depression course and intent-to-treat marginal model analyses showed significant reductions in depressive symptoms (PHQ9), psychological distress (K10), and impairment (WHODAS-II) with medium-large effect sizes (Cohen's d = .51-1.13) (Williams and Andrews, 2013). The second study examined data from 588 patients who were prescribed the generalized anxiety disorder course and showed similarly significant results (Mewton et al., 2012).

[1] 232w Mental disorders, such as the depressive and anxiety disorders are the primary cause of disability in the world (Whiteford et al., 2013). They are also the most common of the mental disorders and the considerable and harmful consequences are far reaching. For the individual and their family there are significant impacts on their day-to-day functioning, reducing capacity to work, study, develop and maintain relationships. Moreover, the individual is often subject to stigma, discrimination and victimization, with their quality of life and mortality reduced (Sarkar and Gupta, 2013;Whiteford et al., 2013). Yet, while the social and health impacts of mental disorders are often considered, the economic burden to society is frequently overlooked. Recent figures estimate that the cumulative global impact of mental disorders will amount to US$16 trillion over the next twenty years (Bloom et al., 2011). This points to the need to invest in the treatment and prevention of mental disorders and necessitates that resources are allocated appropriately. However, the world's current distribution of the health budget suggests otherwise. In high income countries, 5.1% of the health budget was allocated to the treatment and prevention of mental disorders, while many LAMICs allocated less than 2 or 1%. This discrepancy between spending is highlighted further between low and high income countries, with mental health expenditure per capita more than 200 times greater in high income countries compared with low income countries (WHO, 2011).

[2] 175w The negative economic impacts of mental disorders foreshadow the global epidemiology. For example, in 2010 there were almost 300 million cases of major depressive disorder (MDD) at any point in time (Ferrari et al., 2013). The prevalence rates of MDD from 53 countries showed that prevalence was lower from high income regions than prevalence from low to middle income regions, Mental disorders are widespread and universal. They are frequently accompanied by considerable harmful consequences for the individual and come at a significant economic cost to a community. Yet while effective evidence based prevention and treatment exists, there are a number of barriers to access, implement and disseminate. Cognitive behavior therapy programs, such as those available at www.thiswayup.com.au are widely available using the Internet in high income countries, such as Australia. With the ubiquitous uptake of Internet users globally, it is suggested that low and middle income countries should consider ways to embrace and scale up these cost effective programs. An explanation of why and some suggestions as to how this can be done are presented.

[3] 11w Crown Copyright ß 2014 Published by Elsevier B.V. All rights reserved.

[4] 164w particularly those LAMICs in conflict. More specifically, prevalence was highest in North Africa/Middle East, which included conflict countries such as Kuwait, Iraq and Lebanon, while the Asia Pacific high income region was lowest, which included countries such as Brunei, Japan and Singapore. Given their population size, Asia East and Asia-South (including China and India correspondingly) yielded the highest number of prevalence cases at over 44 million and 62 million cases respectively (Ferrari et al., 2013). These numbers are non trivial. In response, the World Health Assembly has adopted a Comprehensive Health Action Plan 2013-2020 in May 2013 as a commitment by WHO's 194 member states to take specified actions to improve mental health. Two of the four key objectives are to ''provide comprehensive, integrated and responsive mental health and social care services in community-based settings; and implement strategies for promotion and prevention in mental health (WHO, 2013).'' Effective prevention and treatment strategies exist so what are the barriers that are preventing implementation and dissemination?

[5] 84w Feasible, affordable and cost-effective measures are available for preventing and treating depressive disorders for example, medication like selective serotonin reuptake inhibitors (SSRI) and psychotherapy, such as cognitive behavior treatments (CBT). Effective treatment can result in recovery and a normalized life expectancy (Gallo et al., 2013). A meta-analysis of comparisons between medication and CBT showed little difference in the short term outcomes (Cuijpers et al., 2013); however, in the longer term relapse is associated with discontinuation of medication. Consequently, CBT is the treatment of choice.

[6] 154w Traditionally CBT has been delivered face to face by skilled therapists. Yet, resources to meet the needs of those with mental disorders cannot be met using established mental health care systems; and this is not limited to low income countries. Limited access to evidenced based treatment and funding for resources is a global problem. For example, there were 2.15 psychologist graduates per 100,000 of the population in high income countries compared with .02 in low income countries (WHO, 2011). Moreover, the availability of trained health professionals to deliver evidenced based treatment is not only scarce but costly. Another barrier to accessing evidenced treatment may simply be that many individuals may not have the time to access mental health services offered during traditional working hours between nine and five. Lastly, stigma is widespread and remains problematic in ensuring that treatment is sought. It was in an effort to address these challenges that CBT was computerized.

[7] 131w Delivering cognitive behavior therapy using a computer is effective in the treatment of anxiety and depressive disorders (Andrews et al., 2010). Andrews et al. (2010) conducted a metaanalysis of computer based psychological treatments for anxiety and depression and found a mean effect size of 0.88 (NNT 2.13). Similar results have been reported elsewhere (Andersson and Cuijpers, 2009;Cowpertwait and Clarke, 2013;Hedman et al., 2012;Richards and Richardson, 2012). Consequently the UK National Health Service now recommends two computerized programs as first line treatment, one aimed at panic and phobias, 'Fearfighter (Marks et al., 2004)' and the other aimed at depression and anxiety states, 'Beating the Blues (Marks et al., 2004).' Offering individuals access to evidenced based treatment such as CBT via a computer using the Internet offers a cost effective, highly accessible solution.

[8] 131w Yet, with the rising ubiquity of Smartphone use and the ability to access information in 'real time' it would seem sensible to evaluate whether CBT remain efficacious when delivered in this modality. Recent results from a pilot RCT indicate that when delivering a CBT program using a mobile application on a Smartphone clinically significant improvements in outcomes for patients with depression were seen (Watts et al., 2013). Ensuring security using a password login was highlighted as an important feature of this app and interestingly, most participants in this study accessed the mobile application while at home. This may point to the enhanced utility of accessing the program in a private, secure and comfortable environment. Importantly, this setting allows the individual to concentrate and complete the lesson in an uninterrupted, quiet space.

[9] 103w In 2011 the Australian Department of Health and Aging committed $111 million AUD over four years to establish an Internet portal, MindHealthConnect, where people can source help that is evidence based. Yet, despite this investment, health professionals have been slow to engage and utilize this mode of treatment delivery and are still not up to date with how CBT programs work when delivered using a computer. The Clinical Research Unit for Anxiety and Depression (CRUfAD), University of New South Wales (UNSW) at St Vincent's Hospital, Sydney has developed and evaluated clinician prescribed courses, self-help courses, and health and wellbeing courses for school students.

[10] 52w In 2012 as part of the Australian Department of Health and Aging strategy to disseminate evidence based Internet treatments widely, CRUfAD made freely available three self-help courses from https://thiswayup.org.au/self-help/. Three lesson brief versions of the mixed anxiety and depression and social phobia courses; and a newly developed stress management course are offered.

[11] 146w CRUfAD has also developed and evaluated five programs designed to prevent the onset of mental disorders in young people. These health education courses on stress, anxiety, alcohol and alcohol and cannabis are offered to a class of students in a school setting and include resources for teachers and parents. These courses are available from https://thiswayup.org.au/ schools/to schools free of charge and are aimed at students approximately aged between 12 and 15 years of age. The five courses are designed to be easily implemented into a physical and health education program and take between six and eight classroom lessons (of approximately 60 min). Students learn about strategies to avoid illness and optimize their physical and mental health. Importantly, the course is intended for all students in the classroom to complete as this ensures that individual students are not singled out, teased or made to feel any worse.

[12] 116w Evidenced based treatment programs, such as those freely available at CRUfAD could be easily translated. The courses using comic book visuals are easily understood and are simple in content. When people watch Bollywood films the storyline can be understood by those who are not Indian; people don't need to look like you for the meaning to be translated. Marginal costs to translate are negligible, yet the benefits are not. As one patient who recently completed the depression course put it ''Thank you for your help! I have now completed Lesson 6 of the course. I have been impressed with the content as well as the method of the course. I believe the course would benefit everyone!''

[13] 109w There are a number of possible ways that online courses could be implemented and disseminated, from universal prevention to a stand alone treatment, treatment enhancer, or teaching tool. Universal prevention programs, such as the health and wellbeing prevention courses could be rolled out in classroom settings. The lessons could be completed as a group sharing access to one computer or for those schools with greater resources children could complete the lesson on a computer each. The universal prevention model of delivery reduces the likelihood of stigma and discrimination. Moreover, universal prevention promotes the message that it's useful for everyone to learn new skills to manage their health and wellbeing.

[14] 155w Individuals with a mental disorder should have the opportunity to access a stand alone evidenced based, effective treatment that can be simply accessed from the Internet using a computer or mobile phone. For those with doubts about the effectiveness of this form of treatment, then perhaps consider its use as a therapy enhancer. In existing health care settings, the addition of an evidenced based online treatment may act to accelerate current treatment or act to maintain recovery. Internet or mobile phone access is not restricted to high income countries and we believe that access to evidenced based treatment should not be restricted either. The number of Internet users worldwide in 2013 was over 35% (>2 billion) and mobile phone access even higher, estimated at 77% of the global population (5.4 billion) (Plunkett Research, 2013). As such, the ubiquitous uptake in Internet and mobile users should be embraced to cost effectively scale up evidenced based treatment.

[15] 164w Lastly, evidence from a systematic review investigating the effectiveness of psychological treatments delivered by paraprofessionals suggested justifying the development and evaluation of psychological treatments incorporating paraprofessionals (Boer et al., 2005). Computerized CBT programs offer a viable and evidenced based treatment that could be delivered face to face by paraprofessionals, or possibly used as a training tool for health professionals. Where resources are scarce, flexible and creative use of evidenced based strategies needs to be considered while the online delivery ensures treatment fidelity. In sum, it is suggested that specified actions from the World Health Assembly should include the dissemination of evidenced based programs delivered via the computer and mobile phone using the Internet to prevent and treat common mental disorders. It is hoped that this paper has described why and how this can be done. But more importantly, it is our wish that it will encourage readers in countries where these ideas may be new to consider what action they can initiate for change.