Review of American Indian veteran telemental health

Scoping review of telehealth use by Indigenous populations from Australia, Canada, New Zealand, and the United States

INTRODUCTION

Telehealth has the potential to address health disparities experienced by Indigenous people, especially in remote areas. This scoping review aims to map and characterize the existing evidence on telehealth use by Indigenous people and explore the key concepts for effective use, cultural safety, and building therapeutic relationships.

METHODS

A search for published and gray literature, written in English, and published between 2000 and 2022 was completed in 17 electronic databases. Two reviewers independently screened retrieved records for eligibility. For included articles, data were extracted, categorized, and analyzed. Synthesis of findings was performed narratively.

RESULTS

A total of 321 studies were included. The most popular type of telehealth used was mHealth (44%), and the most common health focuses of the telehealth interventions were mental health (26%) and diabetes/diabetic retinopathy (13%). Frequently described barriers to effective telehealth use included concerns about privacy/confidentiality and limited internet availability; meanwhile, telehealth-usage facilitators included cultural relevance and community engagement. Although working in collaboration with Indigenous communities was the most frequently reported way to achieve cultural safety, 40% of the studies did not report Indigenous involvement. Finally, difficulty to establish trusting therapeutic relationships was a major concern raised about telehealth, and evidence suggests that having the first visit-in-person is a potential way to address this issue.

CONCLUSION

This comprehensive review identified critical factors to guide the development of culturally-informed telehealth services to meet the needs of Indigenous people and to achieve equitable access and positive health outcomes.

Adaptation models, barriers, and facilitators for cultural safety in telepsychiatry: A systematic scoping review

Introduction: Indigenous peoples, and racial and ethnic minorities around the world experience significant mental health inequities. Telepsychiatry can contribute to addressing these inequities among these populations. However, it is first crucial to ensure the cultural safety of this tool as a critical step toward health equity. This review aimed to collate evidence regarding cultural adaptations, barriers, opportunities, and facilitators for telepsychiatry services supporting minority groups. Method: Using the PRISMA extension for scoping reviews (PRISMA-ScR) guideline, we conducted a systematic scoping review and thematic analysis. Six databases were searched using the PICO framework, i.e., population, intervention, comparison, and outcomes.. Additional literature was identified through reference lists screening. We developed a table for data extraction, and the extracted data were further analyzed following Braun and Clarke's approach for thematic analysis. Results: A total of 1514 citations were screened with a final total of 58 articles included in the review. The themes related to telepsychiatry cultural adaptations emphasize the crucial role of community involvement and quality service delivery. Identified barriers were associated with service and infrastructure, and service users' socioeconomic and cultural contexts. Opportunities and facilitators for telepsychiatry were enhanced access and rapport, and multi-organizational collaborations and partnerships. Discussion: This review identified factors that can guide the adaptation of telepsychiatry evidence-based interventions to meet the needs of Indigenous peoples and racial and ethnic minorities. Telepsychiatry programs must be specifically designed for the population they seek to serve, and this review offers emerging insights into critical factors to consider in their development.

Culturally Centered Implementation of Video Telehealth for Rural Native Veterans

Introduction: Native American Veterans are the most rural and experience heightened risk for mental health (MH) challenges while facing significant health care inequities and access barriers. Rural Native Veterans (RNVs) have experienced historical loss and racial discrimination, contributing to mistrust of Veterans Health Administration (VHA) and other Federal systems. Telemedicine, including video telehealth (VTH), can improve access to MH care for RNVs by addressing barriers. Understanding the cultural context and existing community resources can improve engagement and implementation efforts with RNVs. Objective: This article describes a model of culturally centered MH care and a flexible implementation approach, Personalized Implementation of Virtual Treatments for Rural Native Veterans (PIVOT-RNV), used to disseminate the model. Methods: Participants included four VHA sites serving large RNV populations where PIVOT-RNV was applied to expand the availability of virtual solutions, including VTH, for RNVs. A mixed methods formative evaluation tracked VTH utilization and used provider and RNV feedback to inform iterative process improvements. Results: Where PIVOT-RNV was used, number of providers using VTH with RNVs, number of unique RNVs receiving MH care through VTH, and number of VTH encounters with RNVs grew annually. Provider and RNV feedback highlighted the importance of addressing the unique barriers and cultural context of RNVs. Conclusions: PIVOT-RNV demonstrates promise for improving implementation of virtual treatments and access to MH care for RNVs. The integration of implementation science within a cultural safety framework helps address specific barriers to adoption of virtual treatments for RNVs. Next steps include expanding PIVOT-RNV efforts at additional sites.

Evaluating Native Youth: Issues and Considerations in Clinical Evaluation and Treatment

This article provides an overview of the clinical evaluation and clinical treatment on multiple levels of American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander youth, and their families. Included are basic cultural beliefs and practices shared among multiple tribes and nations within this diaspora, where the most important concept is balance and harmony in healing. Readers are provided with current practice approaches to core issues of substance abuse, anxiety, depression, and suicidal ideation including case examples, psychopharmacology, and therapy.

Barriers and facilitators of videoconferencing psychotherapy implementation in veteran mental health care environments: a systematic review

BACKGROUND

Whilst treatment for mental health issues has traditionally been conducted in-person, advances in technology has seen a recent growth in the use of online video therapy services to help overcome access-to-care barriers faced by those living in rural locations and those unable to travel. These barriers are particularly apparent in the case of veteran populations, which is the focus of this review. Whilst the research investigating the efficacy of online video therapy to treat mental health issues among veterans is promising, widespread adoption and utilisation of this modality remains low with efforts often failing to progress past the pilot phase to implementation. This review focuses on the implementation of online video therapy in veteran mental health care settings and aims to identify the potential barriers and facilitators relevant to implementing the modality in military organisations.

METHODS

A systematic search of three databases (PsycInfo, PubMed, and Web of Science) was conducted. To be eligible for inclusion, studies had to investigate the challenges, lessons learnt, or factors operating as barriers and/or facilitators to the implementation of online video therapy in veteran health care systems.

RESULTS

The initial search revealed a total of 202 articles. This was reduced to 133 when duplicates were removed. After screening the titles and abstracts a further 70 articles were excluded leaving 63 to be retrieved for full review. A total of 10 studies were included in this review. The most commonly reported barriers were related to clinician concerns, logistical problems, and technology. Other barriers included access to resources as well as challenges posed by collaborations, policy and recruitment. Facilitators included experience using the modality and having dedicated staff responsible for promoting and managing the new service (e.g., on-site champions and telehealth technicians).

CONCLUSIONS

This review suggests that numerous barriers must be identified and addressed before attempting to implement an online video therapy service in veteran organisations. Further research is needed to establish best practice for implementation, particularly across geographically dispersed sites. It is hoped that the findings of this review will be used to help inform future implementation efforts and research initiatives in this space.

Telepsychiatry in an Alaska Native Residential Substance Abuse Treatment Program

Introduction: Alaska Native communities experience high rates of alcohol and substance abuse and face challenges accessing quality, culturally appropriate treatment. Telepsychiatry could help bridge this gap, but no publications have examined its impacts for alcohol and substance abuse treatment directed at Alaska Native communities. This study explores one telepsychiatry clinic's impact on a residential substance abuse treatment serving the Alaska Native community in Anchorage, Alaska. Methods: Using a matched case - control design, 103 cases receiving telepsychiatry services between 2007 and 2012 were matched with 103 controls who did not. Outcome measures included length of stay, discharge plans, emergency room visits, and hospital admissions; clinical history, including previous suicide attempts, history of violence, and trauma history; social stressors such as current legal issues, unemployment, and homelessness; mental health, medical, and substance abuse diagnoses; and number of telepsychiatry appointments and nature of telepsychiatry services rendered. Results: Both groups exhibited high rates of mental and medical illness, socioeconomic challenges, and substance abuse. However, the telepsychiatry group demonstrated a significantly higher rate of post-traumatic stress disorder, history of violence, ongoing legal issues, and children in outside custody. It also remained engaged in treatment longer, had fewer discharges against medical advice, and was more likely to complete treatment. Discussion/Conclusions: Our study highlights this telepsychiatry clinic's real-world difference serving the complex substance abuse treatment needs of Alaska Native individuals. It also reinforces telepsychiatry's promise in serving other communities facing a high burden of addiction and mental illness yet facing barriers to high-quality, culturally competent services.

Videoconferencing Psychotherapy in the Public Sector: Synthesis and Model for Implementation

BACKGROUND

Videoconferencing psychotherapy (VCP) is a growing practice among mental health professionals. Early adopters have predominantly been in private practice settings, and more recent adoption has occurred in larger organizations, such as the military. The implementation of VCP into larger health service providers in the public sector is an important step in reaching and helping vulnerable and at-risk individuals; however, several additional implementation challenges exist for public sector organizations.

OBJECTIVE

The aim of this study was to offer an implementation model for effectively introducing VCP into public sector organizations. This model will also provide practical guidelines for planning and executing an embedded service trial to assess the effectiveness of the VCP modality once implemented.

METHODS

An iterative search strategy was employed, drawing on multiple fields of research across mental health, information technology, and organizational psychology. Previous VCP implementation papers were considered in detail to provide a synthesis of the barriers, facilitators, and lessons learned from the implementation attempts in the military and other public sector settings.

RESULTS

A model was formulated, which draws on change management for technology integration and considers the specific needs for VCP integration in larger organizations. A total of 6 phases were formulated and were further broken down into practical and measurable steps. The model explicitly considers the barriers often encountered in large organizational settings and suggests steps to increase facilitating factors.

CONCLUSIONS

Although the model proposed is time and resource intensive, it draws on a comprehensive understanding of larger organizational needs and the unique challenge that the introduction of VCP presents to such organizations.

Disagreement in Satisfaction Between Patients and Providers in the Use of Videoconferences by Depressed Adults

Aim: To evaluate whether there was a difference in satisfaction scores between providers and patients in the use of videoconferences (VCs) by depressed adults. Method: This study was a subanalysis of the joint European project, MasterMind, and participants were recruited from 15 pilot studies in 11 different countries. The Client Satisfaction Questionnaire (CSQ)-3 was used as assessment tool, and scores were summed to give total scores. The questionnaire consists of three items evaluating general satisfaction, fulfillment of needs in treatment, and usability. Results: A total of 362 respondents, 201 patients and 161 providers, completed the questionnaire. Providers had a mean total CSQ-3 score of 9.17 (95% confidence interval [CI] = 8.90-9.45), whereas patients had a mean of 9.70 (95% CI = 9.44-9.98). Mean scores for item 1 (the extent to which VCs had met the needs of the participants): patients 3.19, providers 2.93 (p = 0.00048); for item 2 (general satisfaction): patients 3.22, providers 3.08 (p = 0.083); and item 3 (whether participants wanted to use VCs again): patients 3.28 providers 3.16 (p = 0.045). Conclusion: The results showed that total satisfaction scores were higher in patients than in providers. The differences between patients and providers were significant for items 1 and 3 (p < 0.05), but we did not find a significant difference regarding item 2.

Best Practices in Tele-Teaming: Managing Virtual Teams in the Delivery of Care in Telepsychiatry

PURPOSE OF THE REVIEW

To review and organize best practices around management of virtual teams for psychiatrists working in team-based telepsychiatry services.

RECENT FINDINGS

An early but evolving literature in telepsychiatric team-based care is beginning to examine the importance of team function. Psychiatrists will increasingly have opportunities to engage in team-based telepsychiatry in evolving models that improve outcomes, enhance quality, and expand access to behavioral health treatments. While the literature is limited in psychiatry and medicine on virtual teams, there is a growing literature from applied psychology and business. This article synthesizes these findings along with lessons learned from the field to provide recommendations for psychiatrists involved in team-based telepsychiatry. Providing this type of care involves mastering the management of virtual teams. Psychiatrists are well positioned to play a distinctive and central leadership role for team-based telepsychiatry.

Methodology for Evaluating Models of Telemental Health Delivery Against Population and Healthcare System Needs: Application to Telemental Healthcare for Rural Native Veterans

Background: Rural American Indian and Alaska Native (AI/AN) Veterans face exceptional barriers to receiving quality mental healthcare. We aimed to identify models of in-person and telemental health service delivery with promise for adaptation and wide dissemination to rural AI/AN Veterans. Methods: Our method for matching specific populations with models of care includes (1) selecting frameworks that represent the healthcare organization's goals, (2) identifying relevant service delivery models for the target population(s), (3) assessing models against the selected frameworks, and (4) summarizing findings across models. We applied this approach to rural AI/AN Veteran populations. Results: Searches identified 13 current models of service delivery for rural AI/AN Veteran, rural AI/AN, and general rural Veteran populations. These models were assessed against four frameworks-the U.S. Department of Veterans Affairs' Office of Rural Health's Promising Practices, Veterans Health Administration's Guide to Mental Health Services, the Institute for Healthcare Improvement's Triple Aim Framework, and the American Indian Telemental Health Clinic framework. Discussion: The one model used for service delivery for rural AI/AN Veterans increases access and is patient-centered but lacks operational feasibility. Models for rural AI/ANs also increase access and are patient-centered but generally lack effectiveness evaluations. Models for rural Veterans demonstrate beneficial effects on mental health outcomes but do not emphasize cultural adaptations to diverse populations. Conclusions: Our approach to selecting models of service delivery considers the needs of operational partners as well as target populations and emphasizes large-scale implementation alongside effectiveness. Pending further testing, this approach holds promise for wider application.

Review of key telepsychiatry outcomes

AIM

To conduct a review of the telepsychiatry literature.

METHODS

We conducted a systematic search of the literature on telepsychiatry using the search terms, "telepsychiatry", "telemental health", "telecare", "telemedicine", "e-health", and "videoconferencing". To meet criteria for inclusion, studies had to: (1) be published in a peer-reviewed journal after the year 2000; (2) be written in English; (3) use videoconferencing technology for the provision of mental health assessment or treatment services; and (4) use an adequately-powered randomized controlled trial design in the case of treatment outcome studies. Out of 1976 studies identified by searches in PubMed (Medline database), Ovid medline, PsychInfo, Embase, and EBSCO PSYCH, 452 met inclusion criteria. Studies that met all inclusion criteria were organized into one of six categories: (1) satisfaction; (2) reliability; (3) treatment outcomes; (4) implementation outcomes; (5) cost effectiveness; and (6) and legal issues. All disagreements were resolved by reassessing study characteristics and discussion.

RESULTS

Overall, patients and providers are generally satisfied with telepsychiatry services. Providers, however, tend to express more concerns about the potentially adverse of effects of telepsychiatry on therapeutic rapport. Patients are less likely to endorse such concerns about impaired rapport with their provider. Although few studies appropriately employ non-inferiority designs, the evidence taken together suggests that telepsychiatry is comparable to face-to-face services in terms of reliability of clinical assessments and treatment outcomes. When non-inferiority designs were appropriately used, telepsychiatry performed as well as, if not better than face-to-face delivery of mental health services. Studies using both rudimentary and more sophisticated methods for evaluating cost-effectiveness indicate that telepsychiatry is not more expensive than face-to-face delivery of mental health services and that telepsychiatry is actually more cost-effective in the majority of studies reviewed. Notwithstanding legal concerns about loss of confidentiality and limited capacity to respond to psychiatric emergencies, we uncovered no published reports of these adverse events in the use of telepsychiatry.

CONCLUSION

A large evidence base supports telepsychiatry as a delivery method for mental health services. Future studies will inform optimal approaches to implementing and sustaining telepsychiatry services.

Telepsychiatry Today

The use of video-based telepsychiatry is increasing in response to consumer demand for convenient, inexpensive, and readily accessible services; improved financial reimbursement; and a robust body of evidence-based literature. Telepsychiatry leads to high patient and provider satisfaction ratings, and outcomes equivalent to in-person care, while younger generations often prefer telepsychiatry over face-to-face encounters. The evidence base for telepsychiatry is especially strong with respect to the treatment of post-traumatic stress disorder (PTSD), depression, and ADHD, while its use in underserved ethnic groups is well described in the American Indian, Hispanic, and Asian populations. Despite this, telepsychiatry barriers still persist. These include personal bias-especially in leadership-and insufficient training; the challenging business environment and legislative processes; and inconsistent reimbursement, licensing, and prescription policies. Technology is now less of a barrier, and it is clear that telepsychiatry overall is flourishing and changing the way that providers are working and patients are being treated.

Tribal Veterans Representative (TVR) training program: the effect of community outreach workers on American Indian and Alaska Native Veterans access to and utilization of the Veterans Health Administration

American Indians and Alaska Natives serve at the highest rate of any US race or ethnic group, yet are the most underserved population of Veterans and do not take advantage of the Department of Veterans Affairs (VA) benefits and services. Barriers to seeking care include stigma, especially for mental health issues; distance to care; and lack of awareness of benefits and services they are entitled to receive. In response to this underutilization of the VA, an innovative program--the Tribal Veterans Representative (TVR) program--was developed within the VA to work with American Indians and Alaska Natives in rural and remote areas. The TVR goes through extensive training every year; is a volunteer, a Veteran and tribal community member who seeks out unenrolled Native Veterans, provides them with information on VA health care services and benefits, and assists them with enrollment paperwork. Being from the community they serve, these outreach workers are able to develop relationships and build rapport and trust with fellow Veterans. In place for over a decade in Montana, this program has enrolled a countless number of Veterans, benefiting not only the individual, but their family and the community as well. Also resulting from this program, are the implementation of Telemental Health Clinics treating Veterans with PTSD, a transportation program helping Veterans get to and from distant VA facilities, a Veteran Resource Center, and a Veteran Tribal Clinic. This program has successfully trained over 800 TVRs, expanded to other parts of the country and into remote areas of Alaska.

A systematic review of telecounselling and its effectiveness in managing depression amongst minority ethnic communities

Telecounselling--the provision of counselling services by telephone, videoconferencing or Internet media--can assist with disparities in the treatment and management of depression for minority ethnic groups. We therefore reviewed the evidence examining the effectiveness of telecounselling for this population. This involved a search of electronic databases, the grey literature and two peer-reviewed journals. Study quality was examined using the Oxford Centre for Evidence Based Medicine guidelines. Cohen's d effect sizes were additionally calculated for between-study comparisons. The final sample comprised eight independent studies, with a total of 498 adults of Asian, African-American or Spanish origin. None of the studies met the criteria for the highest methodological rating (Level 1) and there were five studies at Level 2. Significant short-term treatment effects were associated with telephone- and Internet-mediated services, including moderate to large improvements across measures of depression, anxiety, quality of life and psychosocial functioning reported. Longer-term treatment effects were also reported, although these results were based on very limited data. The results highlight the need for additional rigorous research to determine the clinical efficacy of telecounselling as a treatment option for depression among minority communities.

Posttraumatic stress disorder and symptoms among American Indians and Alaska Natives: a review of the literature

PURPOSE

American Indians and Alaska Natives (AI/ANs) experience high rates of trauma and posttraumatic stress disorder (PTSD). We reviewed existing literature to address three interrelated questions: (1) What is the prevalence of PTSD and PTSD symptoms among AI/ANs? (2) What are the inciting events, risk factors, and co-morbidities in AI/ANs, and do they differ from those in the general U.S. population? (3) Are studies available to inform clinicians about the course and treatment of PTSD in this population?

METHODS

We searched the PubMed and Web of Science databases and a database on AI/AN health, capturing an initial sample of 77 original English-language articles published 1992–2010. After applying exclusion criteria, we retained 37 articles on prevalence of PTSD and related symptoms among AI/AN adults. We abstracted key information and organized it in tabular format.

RESULTS

AI/ANs experience a substantially greater burden of PTSD and related symptoms than U.S. Whites. Combat experience and interpersonal violence were consistently cited as leading causes of PTSD and related symptoms. PTSD was associated with bodily pain, lung disorders, general health problems, substance abuse, and pathological gambling. In general, inciting events, risk factors, and co-morbidities appear similar to those in the general U.S. population.

CONCLUSIONS

Substantial research indicates a strikingly high incidence of PTSD in AI/AN populations. However, inciting events, risk factors, and co-morbidities in AI/ANs, and how they may differ from those in the general population, are poorly understood. Very few studies are available on the clinical course and treatment of PTSD in this vulnerable population.

Using technology in the delivery of mental health and substance abuse treatment in rural communities: a review

Rural communities face tremendous challenges in accessing mental health and substance abuse treatment services. Some of the most promising advancements in the delivery of rural health care services have been in the area of telecommunication technology. These applications have the potential to reduce the disparities in the delivery of substance abuse and mental health services between urban and rural communities. The purpose of this inquiry was to explore the advances and uses of telecommunications technology, and related issues, in the delivery of mental health and substance abuse treatment services within rural areas. A review of the academic literature and other relevant works was conducted and the content was organized into four major themes: (a) advantages of telehealth and applications to rural practice, (b) barriers to implementation in rural practice, (c) utilization in rural areas, and (d) areas for further research.