Telepsychiatry in an Alaska Native Residential Substance Abuse Treatment Program

Abstract

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.

Introduction

Alaska Native communities experience significantly higher rates of alcohol and substance misuse than other U.S. communities and suffer disproportionately from their physical and emotional consequences.^1

–7 These disparities are amplified by the limited availability of high-quality, culturally competent substance abuse services and the challenges of accessing existing services.^3,8

–12 Over the past two decades, however, telepsychiatry has emerged as a safe, cost- and clinically effective intervention that can traverse these barriers across a range of settings, treatment models, and populations.^13
–15 It has specifically brought acceptable and culturally appropriate psychiatric services to American Indian and Alaska Native communities^16

–21 and facilitated addiction treatment by creating teams of virtual and onsite staff to provide evidence-based addition care.^22
–24 However, the literature regarding telepsychiatry for addiction treatment has been limited to descriptive reports, and there have been no publications examining the use of telepsychiatry for alcohol and substance abuse treatment in Alaska Native communities in particular.

Since 2007, the University of Colorado Centers for American Indian and Alaska Native Health (CAIANH) has operated a telepsychiatry clinic run by two psychiatrists This clinic serves the Ernie Turner Center (ETC), an innovative residential substance abuse treatment program located in Anchorage, Alaska. The clinic is operated by the Cook Inlet Tribal Council (CITC), a nonprofit organization serving Alaska Native people in the Cook Inlet region of Alaska. Drawing on a Therapeutic Community approach to substance abuse treatment,²⁵ the program provides a participative, group-based approach to substance abuse and other mental illness treatment based on milieu therapy and group psychotherapy.^26,27 The ETC also integrates traditional Alaska Native culture (such as beading, a sweat, music, and hunting/fishing) into treatment services, resulting in a clinical program that they describe as a “Village of Care.”²⁸

Given telepsychiatry's potential to provide effective, culturally competent mental health and substance abuse treatment, we conducted a retrospective chart review to examine the impact of the University of Colorado telepsychiatry clinic at the ETC. We compared clinical characteristics related to health care service utilization, completion of treatment at ETC, psychiatric diagnoses, and medical comorbidities and we characterized the nature of telepsychiatry services. We hypothesized the following regarding individuals receiving telepsychiatry services when compared with individuals who did not: They would face a greater burden and severity of medical and mental illness; similarly high rates of trauma, socioeconomic problems, and substance abuse; but that because of their access to telepsychiatric services they would remain engaged in treatment longer. By describing this unique model of telepsychiatric care embedded within a culturally oriented substance abuse treatment program, we hoped to describe diagnostic status, socioeconomic and demographic characteristics, and treatment patterns of patients receiving services at a residential substance abuse treatment program for Alaska Native people; to demonstrate the overall impact of a telepsychiatry clinic operating within this unique treatment structure; and, ultimately, to facilitate the development of similar telepsychiatry clinics for Alaska Native people and other underserved populations.

Methods

Participants/Study Sample

After receiving approval from the CITC and approvals including waivers of informed consent from The Colorado Multiple Institutional Review Board and the Alaska Area Institutional Review Board, we identified all individuals receiving telepsychiatric services at ETC from 2007 to 2012. We then established a control group of 103 individuals who did not receive telepsychiatry services. Match criteria were based on gender, age (±5 years), and closest date of admission to the residential treatment program (±6 months). For five telepsychiatric participants for whom we were unable to identify matches based on these strict criteria, we maintained the gender and age criteria and chose controls who met these two criteria and had the closest date of admission (median = 16 months).

Setting

ETC is a 6-month, 12-bed residential inpatient substance abuse treatment program that relies on the Village of Care model. Participants receive mental health and substance abuse counseling, group therapy, case management services, and daily work therapy. Participants become part of the ETC “Family” within a Village philosophy where sobriety involves the whole person, and spiritual needs are addressed as part of recovery. Participants actively contribute to the daily running of the program and serve on a village council, working with the clinical team to shape and structure the environment and treatment. Through this approach persuasion is privileged over confrontation. Cultural elements include the village council model itself, steam baths and saunas, cultural outings and activities, traditional art, and family engagement.

Begun in 2007, the ETC telepsychiatry clinic is led by two board-certified psychiatrists based at the University of Colorado with active Alaska medical licenses. Each psychiatrist leads a weekly 2–3-h clinic using secure teleconferencing systems and entering clinical information into the ETC electronic medical system via secure remote access. Telepsychiatric patient care services include diagnostic assessment, medication management, and treatment planning; whereas staff and structural support include supervision, training, case coordination and planning, and program development. Psychiatrists remain in regular contact with staff via phone and periodic in-person visits at ETC to provide bi-directional feedback and education about environmental, milieu, and cultural issues and to foster collaborative relationships. Psychiatrists have extensive experience working with both American Indian and Alaska Native communities and extensive cross-cultural work experience and formal training through programs and projects at CAIANH.

Telepsychiatry Clinic Patient Identification

Patients for the telepsychiatry clinic are enrolled patients from the ETC residential treatment program. The ETC staff identify patients in need of psychiatric services through the telepsychiatry clinic. Patients who have the following characteristics are strongly considered for referral to psychiatric service: psychiatric diagnosis on admission, other than substance abuse; indication of psychiatric symptomatology based on clinical assessment; current medication treatment but unable to continue with current physician while at ETC; previous history of psychiatric treatment; and behavioral problems as evidenced at ETC. Once a patient is identified, an initial assessment is scheduled. Treatment through the telepsychiatry clinic is voluntary.

Experimental Design and Task:

As part of a quality improvement project approved by the CITC, we completed a preliminary chart review of 10 cases from the UC telepsychiatry clinic at the ETC to assess the range and depth of data available in these charts and the optimal methods for their extraction and analysis. While this preliminary review indicated the feasibility of gathering meaningful clinical information, it also revealed the limited availability of common data sources and variables and high rates of missing data. Based on these findings, we created a data abstraction tool to direct the coder to extract accurate, available information including, but not limited to, length of stay and discharge plans; medical, psychiatric, and social histories; and psychiatric diagnoses and substances of abuse. For the telepsychiatry cases, we also identified the nature of services rendered and the medications prescribed. The data abstraction tool provided clear descriptions of each variable and directed the coder to the most likely sources of accurate information to reduce bias and ambiguity.

Variables

Many of the clinical and other variables carry self-evident definitions, whereas others warrant clearer definitions. Emergency room visits or hospital admissions referred to all such events taking place during the ETC admission or 30 days before admission for both psychiatric and substance-related issues. Trauma history was defined by a history of physical, verbal, or sexual trauma/abuse; and current legal issues, according to whether an individual was presently on probation, on parole, or court-ordered into treatment. Employment indicated employment at the time of their admission into the program, whereas homelessness was defined as currently living transiently, with friends, or in a shelter. Children in outside custody was defined by whether the individual had ever lost custody of children. Mental health and substance abuse diagnoses were based on criteria from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. Chronic medical conditions included a current diagnosis of diabetes, hypertension, heart disease, or cancer; whereas chronic medical conditions related to alcohol/substance abuse was defined by the presence of liver disease, gastroesophageal reflux, esophageal varices, or withdrawal seizures. For the telepsychiatry variables, medication management denoted whether or not the psychiatrist prescribed medication or recommended it as a part of treatment. Coordinating care with outside providers meant the psychiatrist coordinated care with outside providers, such as primary care physicians, psychologists, neurologists, or other psychiatrists, as a part of telepsychiatry services.

Data Collection

Data were collected from January 2014 to September 2015. The data abstraction tool was used to extract clinical information directly from the ETC online medical record, which is accessed off site via a password-protected virtual private network that is HIPAA compliant. All members of the research team received access to the ETC online medical record, through approval from the CITC. The primary investigator, who is a licensed and board-certified psychiatrist, created the data abstraction tool, extracted and verified the clinical and service utilization information. Though we had a single extractor, the first, fourth, and senior authors worked together during the pilot phase to achieve consensus regarding how to extract and rate consistently. The resultant database was stored on a secured server at the University of Colorado to maintain participant confidentiality.

Statistical Analysis

Using a method outlined by Grandits and Neuhaus,²⁹ cases and controls were matched by using SAS version 9.4. Chi-square tests for categorical data and t-tests for continuous data were used to examine differences between those who received telepsychiatry and those who did not. A linear regression model was constructed to explore the relationships between length of stay in treatment and selected patient demographic and health characteristics. In addition, a logistic regression model was developed to examine these relationships relative to treatment completion. We selected variables for these regressions that had univariate associations with length of stay and treatment completion of p ≤ 0.25.³⁰ Then, we used backward elimination to remove variables from both models until all remaining variables were either themselves significant at p ≤ 0.05 or belonged to a set of variables in which at least one was significant. Because controls had sections of missing data for history of suicide, violence, and trauma, the multiple regression analyses were run in MPlus, which applies the full information maximum likelihood missing data estimation approach as recommended in the literature.^31,32

Results

Demographic and Clinical Characteristics

The study sample included 103 individuals in the telepsychiatry group and 103 matched individuals in the control group (Table 1). The mean age for the telepsychiatry group was 38.6 (standard deviation [SD] 11.5), and 38.7 (SD 10.9) for the control group. There were 43 men and 60 women in each group.

Table 1.

Demographics and Clinical Characteristics

CHARACTERISTIC	TELEPSYCHIATRY (N = 103)		NO TELEPSYCHIATRY (N = 103)		p
CHARACTERISTIC	N	%	N OR MEAN	%	p
Demographics
Age, mean ± SD	38.6 ± 11.5		38.7 ± 10.9		0.957
Male	43	41.8	43	41.8	1.000
Female	60	58.3	60	58.3	1.000
Psychiatric history
Past suicide attempt	42	40.8	33	32.0^a	<0.001
History of violence	52	50.5	42	40.8^b	<0.001
History of trauma	84	81.2	68	77.3^a	<0.001
Social history
Ongoing legal issues	69	67.0	48	46.6^c	0.004
Unemployed	95	92.2	97	94.2^d	0.568
Homeless	84	81.6^d	86	83.5	0.855
Children in outside custody^e	41	39.8	22	21.4	0.011
Psychiatric diagnoses
Depression	35	34.0	27	26.5	0.225
Bipolar	13	12.6	6	5.8	0.092
PTSD	58	56.3	15	14.6	<0.001
Other	37	35.9	24	23.3	0.047
Substances of abuse
Alcohol	84	81.6	87	84.5	0.578
Cannabis	44	42.7	41	39.8	0.671
Cocaine	31	30.1	29	28.2	0.759
Opiates	28	27.2	21	20.4	0.252
Stimulants/amphetamines	14	13.6	9	8.7	0.269
Chronic medical condition	47	45.6	54	52.4	0.329
Sequelae of alcohol/substance abuse^f	41	40.6	31	30.1	0.117

n = 88.

n = 89.

n = 99.

n = 102.

Eighty participants with no children or adult children only are excluded.

Chronic medical condition related to alcohol or substance abuse, including liver disease, gastroesophageal reflux, esophageal varices, and withdrawal seizures.

OR, odds ratio; PTSD, post-traumatic stress disorder; SD, standard deviation.

Comparisons of the telepsychiatry and control group are summarized in Table 1. The two groups shared did not differ in terms of rates of suicide attempts, trauma, unemployment, homelessness, chronic medical conditions, and medical sequelae of substance abuse. The telepsychiatry group reported significantly higher rates of violence histories, legal issues, children in outside legal custody, and post-traumatic stress disorder (PTSD). Individuals receiving telepsychiatry also remained engaged in treatment longer and were more likely to complete treatment (Table 2). Both groups reported similarly high rates of hospitalizations or emergency room visits, speaking to their significant medical needs (50–60%).

Table 2.

Service Utilization

CHARACTERISTIC	TELEPSYCHIATRY (N = 103)		NO TELEPSYCHIATRY (N = 103)		p
CHARACTERISTIC	N	%	N	%	p
LOS
Average stay, days, mean ± SD	154.8 ± 69.5		110.3 ± 76.3		<0.001
<90	22	21.4	43	42.8	0.001
>90	81	78.6	60	58.3	0.001
Discharge plan
Left against medical advice	26	65.0	39	68.4	0.724
Completed treatment	62	60.2	46	44.7	0.026
Emergency room visits/hospitalizations^a	50	48.5^b	60	58.3^c	0.282

During admission or in the 30 days before admission; for psychiatric or substance-related issue.

n = 101.

n = 100.

LOS, length of stay.

Tables 3 and 4 report findings from two multivariate regression analyses that we conducted. In the linear regression model exploring relationships between length of stay in treatment and patient demographic and health characteristics, there was a significant relationship between length of stay and membership in the group who received telepsychiatry and with age. Patients in the telepsychiatry group stayed 43.8 days longer than those who did not receive telepsychiatry. Moreover, for every 1 year older a patient was, their stay in treatment was 1.2 days longer. A significant regression equation was found [F(1,201) = 13.58, p = 0.020], with an R ² of 0.119.

Table 3.

Predictors of an Increased Length of Stay Among Patients Receiving Behavioral Health Services

CHARACTERISTIC	ESTIMATE	SE	p
Received telepsychiatry	43.82	10.11	<0.0001
Age	1.16	0.4517	0.0108

Results are from a linear regression. Saturated model included: received telepsychiatry, cocaine abuse, opiate abuse, stimulant abuse, age, gender, legal problems, employment, homeless, lost custody of children, depression, PTSD, bipolar, other behavioral health condition, chronic medical condition, and sequelae.

SE, standard error.

Table 4.

Predictors of Treatment Completion Among Patients Receiving Behavioral Health Services

CHARACTERISTIC	OR	95% CI	p
Received telepsychiatry	1.993	1.116–3.559	0.0198
Age	1.052	1.024–1.082	0.0002

Results are from a logistic regression. Saturated model included: received telepsychiatry, cocaine abuse, opiate abuse, stimulant abuse, age, gender, legal problems, employment, homeless, lost custody of children, depression, PTSD, bipolar, other behavioral health condition, chronic medical condition, and sequelae.

CI, confidence interval; OR, odds ratio.

The logistic regression model examined associations between the dichotomous treatment completion variable and patient demographic and health characteristics. The odds of treatment completion were 99% greater for patients in the telepsychiatry group than those in the control group (odds ratio [OR] = 1.993, 95% confidence interval [CI] = 1.116–3.559, p = 0.020). Age was also significantly associated with treatment completion. For every 1 year older a patient was, their odds of treatment completion increased by 5% (OR = 1.052, 95% CI = 1.024–1.082, p < 0.001).

Telepsychiatry Services

Table 5 characterizes the nature of telepsychiatry visits, including the emphasis on prescribing or recommending medication (79%) with some coordination of care with other providers (19%). The mean number of visits was 6.1 (SD 4.3), and antidepressants were the most commonly prescribed psychotropic medication (66; 62.3%), a finding consistent with the predominance of PTSD and depression diagnoses.

Table 5.

Telepsychiatry Services (n = 103)

CHARACTERISTIC	N OR MEAN	%
Number of visits, mean ± SD	6.1 ± 4.3
Medication management
MD prescribed medication	69	64.5
MD suggested medication but patient refused	12	11.2
Coordination of care	20	18.9
Prescribed medications
Antidepressant	66	62.3
Antipsychotic	12	11.3
Mood stabilizer	4	3.8
Other medication	30	28.0
Prazosin	13	12.1
Hydroxyzine	4	3.7
Naltrexone	3	2.8
Melatonin	3	2.8
Clonazepam	2	1.9
Buspirone	2	1.9
Acamprosate	2	1.9
Atomoxetine	1	1.0

Discussion

To our knowledge, this study is the first to examine telepsychiatry services for alcohol and substance abuse treatment programs in Alaska Native communities. This is also the first study to present outcomes data for use of telepsychiatry in alcohol and substance abuse treatment for any population. We hypothesized that individuals receiving telepsychiatry services, when compared with those who did not, would face a greater severity of mental illness. The significantly higher rate of PTSD and history of violence among the former supported our hypothesis. However, we found equally high rates of medical and other forms of mental illness. Our hypothesis about similarly high rates of trauma, socioeconomic problems, and substance abuse held true. Notably, however, individuals receiving telepsychiatry services were more likely to be experiencing ongoing legal issues and to have children in custody, suggesting a greater severity of social stressors. The greater burden of illness facing the individuals in the telepsychiatry group was matched by greater treatment engagement, as indicated by longer lengths of stay and fewer discharges against medical advice. Further, the odds of treatment completion was 99% greater in the telepsychiatry group. Therefore, our study endorses telepsychiatry's real-world effectiveness in serving the complex substance-abuse treatment needs of Alaska Native individuals, as well as its ability to traverse barriers to high-quality, culturally informed care. It also suggests its potential to reach individuals with greater treatment needs and to retain them in treatment longer and until completion.

These outcomes reinforce a burgeoning literature demonstrating telepsychiatry's promise in serving communities facing barriers to culturally sensitive, high-quality care. Several studies, for example, have demonstrated telepsychiatry's feasibility in providing psychiatric consultation to ethnic immigrants in diverse settings.^33

–36 One study comparing 167 low-income Hispanic individuals receiving depression treatment through video webcam or treatment as usual additionally found better outcomes in the former. Specifically, the webcam group rated their alliance and visit satisfaction significantly higher, used antidepressants far more frequently, and experienced a faster decrease in depression severity.³⁷ Similar to our study, the clinicians providing mental health services in these studies were linguistically and culturally compatible with the patients they served, thereby highlighting the importance of culturally competence in providing effective telemental health care. Lessons from our study can also be applied to low-income countries, where telepsychiatry has been postulated as a potential solution to the high burden of mental illness and the corresponding dearth of mental health resources, including a few psychiatrists in-country and scarce training opportunities.^38

–42 Finally, our findings expand the limited literature about leveraging telepsychiatry for substance abuse treatment and provide guidance for successful implementation of one particular model.^22
–24

Because we conducted a retrospective chart review, we were unable to randomize the telepsychiatry and nontelepsychiatry groups and to control for known and unknown prognostic factors. Nonetheless, we did match both groups according to age, gender, and date of admission to treatment. Limitations in the availability of consistent data precluded our assessment of improvement in mental health and substance abuse symptomatology or long-term follow-up as outcome variables. As a result, we were unable to assess the longer-term impacts of the telepsychiatry intervention. Future studies could build on our findings by replicating our model of telepsychiatry services embedded within a culturally relevant substance abuse treatment setting serving other American Indian and Alaska Native populations. Replicating our telepsychiatry services within a general-population focused treatment center could help determine the degree to which culturally informed substance abuse treatment affects care treatment engagement and outcomes.

Conclusions

Telepsychiatry has the potential to bring effective and culturally appropriate mental health treatment services to Alaska Native communities. Our finding that individuals receiving telepsychiatry services face a higher burden of mental illness and social distress yet are more likely to complete treatment and remain engaged in treatment longer speaks to its real-world effectiveness in addressing Alaska Native communities’ addition and mental health needs. Our study also reinforces telepsychiatry's promise in bringing high-quality, culturally relevant mental health treatment, including substance abuse treatment and particularly to underserved populations.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

Support for this research was provided through the American Psychiatric Association, Minority Fellowship Program (T06 SM-11-005).

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