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.

Pilot of a screening, brief intervention and referral to treatment process for symptoms of trauma among primary care patients.

BACKGROUND: For populations with high rates of trauma exposure yet low behavioural health service use, identifying and addressing trauma in the primary care setting could improve health outcomes, reduce disability and increase the efficiency of health system resources. OBJECTIVE: To assess the acceptability and feasibility of a screening, brief intervention and referral to treatment (SBIRT) process for trauma and symptoms of posttraumatic stress disorder (PTSD) among American Indian and Alaska Native people. We also examine the short-term effects on service utilization and the screening accuracy of the Primary Care Posttraumatic Stress Disorder Screen. METHODS: Cross-sectional pilot in two tribal primary care settings. Surveys and interviews measured acceptability among patients and providers. Health service utilization was used to examine impact. Structured clinical interview and a functional disability measure were used to assess screening accuracy. RESULTS: Over 90% of patient participants (N = 99) reported the screening time was acceptable, the questions were easily understood, the right staff were involved and the process satisfactory. Ninety-nine percent would recommend the process. Participants screening positive had higher behavioural health utilization in the 3 months after the process than those screening negative. The Primary Care Posttraumatic Stress Disorder Screen was 100% sensitive to detect current PTSD with 51% specificity. Providers and administrators reported satisfaction with the process. CONCLUSIONS: The SBIRT process shows promise for identifying and addressing trauma in primary care settings. Future research should explore site specific factors, cost analyses and utility compared to other behavioural health screenings.

An Internet-Based Therapeutic Tool for American Indian/Alaska Native Adults With Posttraumatic Stress Disorder: User Testing and Developmental Feasibility Study.

BACKGROUND: Posttraumatic stress disorder (PTSD) is a major public health concern among American Indian and Alaska Native populations. Primary care clinics are often the first point of contact for American Indian and Alaska Natives seeking health care and are feasible locations for trauma-focused interventions. OBJECTIVE: Web-based therapeutic interventions have the potential to reduce PTSD symptoms by offering psychoeducation and symptom self-management tools. We investigated the feasibility of a culturally adapted Web-based therapeutic intervention in two American Indian and Alaska Native-serving primary care sites. We developed and tested a self-guided Web-based therapeutic intervention aimed at improving knowledge and awareness of, and provision of guidance, support, and symptom-management for, PTSD symptoms. METHODS: A community-based participatory research process was used to refine adaptations to the veteran's administration's PTSD Coach Online, to develop new content, and to guide and interpret the results of the feasibility pilot. This process resulted in a 16-guide intervention "Health is Our Tradition: Balance and Harmony after Trauma" website. The feasibility pilot included 24 American Indian and Alaska Natives aged 18 years and older who scored positive on a primary care PTSD screener. Enrolled participants completed a demographic questionnaire, an experience with technology questionnaire, and baseline behavioral health measures. Once measures were complete, research staff described weekly text messages, minimum study expectations for website use, and demonstrated how to use the website. Feasibility measures included self-reported website use, ratings of satisfaction and perceived effectiveness, and website metrics. Feasibility of obtaining measures for an effectiveness trial was also assessed to include behavioral health symptoms and service utilization through self-report instruments and electronic health record queries. Self-reported measures were collected at enrollment and at 6 and 12 weeks post enrollment. Electronic health records were collected from 12 months before study enrollment to 3 months following study enrollment. Changes between enrollment and follow-up were examined with paired t tests, analysis of variance or logistic regression, or the Wilcoxon signed rank test for nonnormally distributed data. RESULTS: The culturally adapted website and associated text message reminders were perceived as satisfactory and effective by participants with no differences by age or gender. The majority of participants (86%, 19/24) reported use of the website at 6 weeks and nearly all (91%, 20/22) at 12 weeks. At 6 weeks, 55% (12/22) of participants reported using the website at the recommended intensity (at least three times weekly), dropping to 36% (8/22) at 12 weeks. Participant use of modules varied from 8% (2/24) to 100% (24/24), with guide completion rates being greater for guides that were only psychoeducational in nature compared with guides that were interactive. There were no significant changes in patterns of diagnoses, screening, medications, or service utilization during exposure to the website. CONCLUSIONS: "Health is Our Tradition: Balance and Harmony after Trauma" shows promise for an effectiveness pilot.

Attitudes Towards Evidence-Based Practice in Substance Use Treatment Programs Serving American Indian Native Communities.

The objective of this paper was to compare attitudes towards evidence-based practice (EBP) of substance use disorder treatment (SUDT) center employees' serving American Indian and Alaskan Native (AIAN) populations to those serving non-AIAN populations. Survey data on the openness and divergence subscales of the Evidence-Based Practice Attitude Scale (EBPAS) were collected and analyzed. Independent samples T tests were performed to compare the two samples. For all comparisons, except the divergence subscale between counselors, the SUDT employees serving AIANs had significantly lower mean openness scores and higher mean divergence scores than those serving non-AIANs. This study suggests that employees of SUDT centers serving AIAN population hold less positive attitudes towards the adoption and use of EBP than non-AIAN.

Disseminating Information on Trauma Screening, Brief Intervention, and Referral to Treatment in a Tribal Health Setting: A Case Study.

Exposure to trauma is consistently associated with co-occurrence of behavioral health disorders. Primary care settings are opportune places to screen for traumatic experiences and symptoms, as they are often the initial point of care for behavioral health concerns by the Alaska Native and American Indian (AN/AI) population. In this case study, we examine results dissemination activities at the SCF Research Department-hosted 2016 Alaska Native Health Research Forum (Forum) of a pilot study of a trauma-focused screening, brief intervention, and referral to treatment (T-SBIRT) process for AN/AI adults in primary care. Feedback included audience responses to the presentation delivered at the Forum and recommendations to guide future community dissemination of T-SBIRT results. Attendees (N = 31) found the presentation clear, interesting, and included the right amount of detail. Four broad dissemination themes were identified in discussion groups: 1) share results with everyone; 2) share results in ways that reach all AN audiences; 3) provide a summarized status update at each stage of the study; and 4) use results to improve care for trauma and related symptoms.

Correlates of Motivational Interviewing Use Among Substance Use Treatment Programs Serving American Indians/Alaska Natives.

Motivational interviewing (MI) offers a treatment modality that can help meet the treatment needs of American Indians/Alaska Natives (AI/ANs) with substance use disorders. This report presents results from a national survey of 192 AI/AN substance abuse treatment programs with regard to their use of MI and factors related to its implementation, including program characteristics, workforce issues, clinician perceptions of MI, and how clinicians learned about MI. Sixty-six percent of programs reported having implemented the use of MI in their programs. In the final logistic regression model, the odds of implementing MI were significantly higher when programs were tribally owned (OR = 2.946; CI95 1.014, 8.564), where more than 50% of staff were Certified Alcohol and Drug Counselors (CADCs) (OR = 5.469; CI95 1.330, 22.487), and in programs in which the survey respondent perceived that MI fit well with their staff's expertise and training (OR = 3.321; CI95 1.287, 8.569).

National Overview of Medication-Assisted Treatment for American Indians and Alaska Natives With Substance Use Disorders.

OBJECTIVE: American Indians and Alaska Natives (AI/ANs) experience higher rates of substance use disorders and less access to high-quality care compared with other racial-ethnic groups. The objective of this study was to better understand the use of medication-assisted treatment (MAT) of substance use disorders for AI/ANs and barriers to broader implementation. METHODS: Representatives of 192 substance abuse treatment programs completed a survey about their use of MAT. On the basis of implementation science frameworks, the authors examined survey items about program structure, workforce, and other services provided in order to develop logistic regression models that explored significant associations between workforce and program characteristics and use of MAT. RESULTS: Of the 192 programs, 28% reported implementing MAT. Multivariate logistic regression models indicated that programs with staff that perceived MAT to be consistent with their program's treatment approach and philosophy and programs reporting that MAT fit with staff expertise and training were more likely to implement MAT. Programs with nurses on staff and those reporting a perceived gap in the use of evidence-based treatments (EBTs) were less likely to implement MAT. CONCLUSIONS: Low rates of MAT implementation suggest racial disparities in access to MAT among AI/ANs, a population with historically high rates of substance use disorders. Study findings also highlight the important role of treatment culture and organizational fit in the implementation of MAT in treatment programs serving AI/AN populations. Results also speak to the importance of adapting existing EBTs in a culturally competent way to best serve the needs of the AI/AN community.

Development of a Screening and Brief Intervention Process for Symptoms of Psychological Trauma Among Primary Care Patients of Two American Indian and Alaska Native Health Systems.

American Indian and Alaska Native (AI/AN) people experience high rates of acute, chronic, and intergenerational trauma. Traumatic experiences often increase the risk of both medical and behavioral health problems making primary care settings opportune places to screen for trauma exposure or symptomology. The objective of this study was to determine considerations and recommendations provided by patients, health care providers, health care administrators, and tribal leaders in the development of an adult trauma screening, brief intervention, and referral for treatment process to pilot at two large AI/AN primary care systems. A qualitative and iterative data collection and analysis process was undertaken using a community-based participatory research approach guided by a cross-site steering committee. Twenty-four leaders and providers participated in individual interviews, and 13 patients participated in four focus groups. Data were thematically analyzed to select a trauma screening instrument, develop a screening process, and develop brief intervention materials. The nature of traumas experienced in the AI/AN community, the need to develop trusting patient-provider relationships, and the human resources available at each site drove the screening, brief intervention, and referral process decisions for a future trauma screening pilot in these health systems.

A National Study of American Indian and Alaska Native Substance Abuse Treatment: Provider and Program Characteristics.

American Indians and Alaska Natives (AIANs) experience major disparities in accessing quality care for mental health and substance use disorders. There are long-standing concerns about access to and quality of care for AIANs in rural and urban areas including the influence of staff and organizational factors, and attitudes toward evidence-based treatment for addiction. We conducted the first national survey of programs serving AIAN communities and examined workforce and programmatic differences between clinics located in urban/suburban (n=50) and rural (n=142) communities. We explored the correlates of openness toward using evidence-based treatments (EBTs). Programs located in rural areas were significantly less likely to have nurses, traditional healing consultants, or ceremonial providers on staff, to consult outside evaluators, to use strategic planning to improve program quality, to offer pharmacotherapies, pipe ceremonies, and cultural activities among their services, and to participate in research or program evaluation studies. They were significantly more likely to employ elders among their traditional healers, offer AA-open group recovery services, and collect data on treatment outcomes. Greater openness toward EBTs was related to a larger clinical staff, having addiction providers, being led by directors who perceived a gap in access to EBTs, and working with key stakeholders to improve access to services. Programs that provided early intervention services (American Society of Addiction Medicine level 0.5) reported less openness. This research provides baseline workforce and program level data that can be used to better understand changes in access and quality for AIAN over time.

Use of evidence-based treatments in substance abuse treatment programs serving American Indian and Alaska Native communities.

BACKGROUND: Research and health surveillance activities continue to document the substantial disparities in the impacts of substance abuse on the health of American Indian and Alaska Native (AI/AN) people. While Evidence-Based Treatments (EBTs) hold substantial promise for improving treatment for AI/ANs with substance use problems (as they do for non-AI/ANs), anecdotal reports suggest that their use is limited. In this study, we examine the awareness of, attitudes toward, and use of EBTs in substance abuse treatment programs serving AI/AN communities. METHODS: Data are drawn from the first national survey of tribal substance abuse treatment programs. Clinicians or clinical administrators from 192 programs completed the survey. Participants were queried about their awareness of, attitudes toward, and use of 9 psychosocial and 3 medication EBTs. RESULTS: Cognitive Behavioral Therapy (82.2%), Motivational Interviewing (68.6%), and Relapse Prevention Therapy (66.8%) were the most commonly implemented psychosocial EBTs; medications for psychiatric comorbidity was the most commonly implemented medication treatment (43.2%). Greater EBT knowledge and use were associated with both program (e.g., funding) and staff (e.g., educational attainment) characteristics. Only two of the commonly implemented psychosocial EBTs (Motivational Interviewing and Relapse Prevention Therapy) were endorsed as culturally appropriate by a majority of programs that had implemented them (55.9% and 58.1%, respectively). CONCLUSIONS: EBT knowledge and use is higher in substance abuse treatment programs serving AI/AN communities than has been previously estimated. However, many users of these EBTs continue to have concerns about their cultural appropriateness, which likely limits their further dissemination.

How do providers serving American Indians and Alaska Natives with substance abuse problems define evidence-based treatment?

Rates of substance abuse remain high in American Indian and Alaska Native (AI/AN) populations. While there are many evidence-based treatments (EBTs) for substance use problems, no studies exist describing how directors of treatment programs serving AI/ANs perceive and use EBTs. Twenty-one key informant interviews with program administrators and 10 focus groups with clinicians were conducted at 18 treatment programs for AI/ANs with substance use problems. Demographic data were not collected to protect participant privacy. Transcripts were coded to identify relevant themes. A majority of participants correctly defined an EBT using the key terms "effective" and "research" found in standard definitions of the phrase. More detailed descriptions were uncommon. Prevalent themes related to attitudes about EBTs included concerns about cultural relevance, external mandates to use EBTs, and their reliance on western conceptualization of substance abuse. While most administrators and clinicians who treat AI/AN clients for substance abuse had a basic understanding of what constitutes an EBT, there was little consensus regarding their relevance for use with AI/ANs. Recognizing that broad geographic and tribal diversity among AI/AN populations may impact conclusions drawn about EBTs, several factors may enhance the abilities of program staff to identify EBTs most appropriate for local implementation. These include gaining a more detailed understanding of how an EBT is developed and how to assess its scientific grounding, as well as utilizing definitions of EBTs that include not only research evidence, but also clinical expertise and judgment, and fit with consumer choice, preference, and culture.

Walking on: celebrating the journeys of Native American adolescents with substance use problems on the winding road to healing.

High rates of substance use and related problems have been long recognized as critical health issues for Native American adolescents. Unfortunately, no manualized interventions address the specific needs of Native American adolescents in a culturally appropriate manner. In 2006, the Cherokee Nation partnered with the University of Colorado to employ a community-based participatory research process to develop an intervention for Native American adolescents with substance use problems. The resulting intervention, Walking On, is an explicit blend of traditional Cherokee healing and spirituality with science-based practices such as cognitive behavioral therapy and contingency management and is designed to address the specific needs and worldviews of Native American adolescents with substance use problems and their families. Each individual and family session includes a brief assessment, a skill-building component, and a ceremony. A Weekly Circle (multifamily group) promotes sobriety and builds a community of healing. Early pilot study results suggest that Walking On is feasible for use in tribal substance abuse treatment programs. While Walking On shows early promise, the intervention will require further study to examine its efficacy.

A framework for conducting a national study of substance abuse treatment programs serving American Indian and Alaska native communities.

BACKGROUND: Because of their broad geographic distribution, diverse ownership and operation, and funding instability, it is a challenge to develop a framework for studying substance abuse treatment programs serving American Indian and Alaska Native communities at a national level. This is further complicated by the historic reluctance of American Indian and Alaska Native communities to participate in research. OBJECTIVES AND METHODS: We developed a framework for studying these substance abuse treatment programs (n ≈ 293) at a national level as part of a study of attitudes toward, and use of, evidence-based treatments among substance abuse treatment programs serving AI/AN communities with the goal of assuring participation of a broad array of programs and the communities that they serve. RESULTS: Because of the complexities of identifying specific substance abuse treatment programs, the sampling framework divides these programs into strata based on the American Indian and Alaska Native communities that they serve: (1) the 20 largest tribes (by population); (2) urban AI/AN clinics; (3) Alaska Native Health Corporations; (4) other Tribes; and (5) other regional programs unaffiliated with a specific AI/AN community. In addition, the recruitment framework was designed to be sensitive to likely concerns about participating in research. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: This systematic approach for studying substance abuse and other clinical programs serving AI/AN communities assures the participation of diverse AI/AN programs and communities and may be useful in designing similar national studies.

Problems with non-adherence to antipsychotic medication in Samoan New Zealanders: a literature review.

This paper explores what is known about adherence to antipsychotic medications in general and the possible reasons for non-adherence in Samoan New Zealanders. Samoan New Zealanders are either Samoan-born immigrants or their descendents born in New Zealand. Clinicians recognize a high prevalence of non-adherence among Samoan New Zealanders. The authors hypothesize that traditional Samoan beliefs play a prominent role in problems with adherence. To investigate this hypothesis, a review of the literature on adherence in Samoan New Zealanders was undertaken. Documents from the Ministry of Health support the hypothesis. To investigate this issue, the Ministry of Health initiated a qualitative research project to examine the nature of Samoan traditional beliefs. The results of this study are summarized. No research had previously been undertaken on adherence in Samoan New Zealanders. In general, there is a lack of research on all aspects of the mental health of Pacific peoples in New Zealand. Literature reviews of adherence research consistently show that interventions that improve adherence address the beliefs, behaviours, and relationships surrounding adherence. This finding supports the author's hypothesis that traditional beliefs play an important role in the problem of adherence. Further definitive study with Samoan New Zealanders is required.

Malignant Narcissism: from fairy tales to harsh reality.

INTRODUCTION: Malignant Narcissism has been recognized as a serious condition but it has been largely ignored in psychiatric literature and research. In order to bring this subject to the attention of mental health professionals, this paper presents a contemporary synthesis of the biopsychosocial dynamics and recommendations for treatment of Malignant Narcissism. METHODS: We reviewed the literature on Malignant Narcissism which was sparse. It was first described in psychiatry by Otto Kernberg in 1984. There have been few contributions to the literature since that time. We discovered that the syndrome of Malignant Narcissism was expressed in fairy tales as a part of the collective unconscious long before it was recognized by psychiatry. We searched for prominent malignant narcissists in recent history. We reviewed the literature on treatment and developed categories for family assessment. RESULTS: Malignant Narcissism is described as a core Narcissistic personality disorder, antisocial behavior, ego-syntonic sadism, and a paranoid orientation. There is no structured interview or self-report measure that identifies Malignant Narcissism and this interferes with research, clinical diagnosis and treatment. This paper presents a synthesis of current knowledge about Malignant Narcissism and proposes a foundation for treatment. CONCLUSIONS: Malignant Narcissism is a severe personality disorder that has devastating consequences for the family and society. It requires attention within the discipline of psychiatry and the social science community. We recommend treatment in a therapeutic community and a program of prevention that is focused on psychoeducation, not only in mental health professionals, but in the wider social community.

The existential way to recovery.

This paper explores the essential features of recovery and the need for an existential approach in psychiatry. The biopsychosocial model often fails to sufficiently validate the existential suffering of patients. We review the major principles of recovery and the philosophical and psychiatric principles of existentialism. The ontological or intrinsic existential issues of death, isolation, freedom and meaninglessness are described and their manifestations are explored in clinical syndromes. When ultimate existential concerns are recognised, patients have an opportunity to understand their life on a deeper level that is not defined as a medical disorder but as a part of human existence. Understanding that existential concerns underlie a great deal of human behaviour helps to free patients from the stigma of psychiatric labels. An existential approach is a humanistic way toward recovery.

Bipolar disorder: from psychoeducational to existential group therapy.

OBJECTIVE: The aim of this study was to assess the importance of addressing psychoeducational and existential issues in group therapy for patients with bipolar disorder. METHOD: The group consisted of 10 bipolar patients. Group sessions were held for 2 hours weekly for 3 months and then monthly up to 2 years. Group topics focused on psychoeducation, cognition and existential issues. RESULTS: Over 2 years, two members had a minor relapse that did not require hospitalization. Adherence with pharmacotherapy and follow up was 100%. All members reported significant improvements in family and social function and nine members remained employed in full-time jobs. There was a high level of satisfaction with the group process. CONCLUSION: Addressing existential and psychosocial issues in bipolar disorder group therapy may improve outcome. This approach deserves further thorough investigation.

Early intervention in first episode psychosis: hope for a better future.

In the last two decades the clinical and research focus in psychotic disorders has shifted to first episode psychosis, early detection of the prodromal phase of psychosis and an effective integrated treatment model known as "Early Intervention". The first five years of psychosis that is described as a "critical period" is the most important time for recognition and treatment. Services for Early Intervention should be easily accessible, non-threatening and non-stigmatising. Effective treatment is based on successful engagement and the development of trust between patients, their families and the mental health professionals assisting them. Psychosocial interventions have a fundamental place in early treatment. They provide a humane basis for acute and continuing care, prevention or resolution of the secondary consequences of psychosis and the promotion of recovery. Antipsychotic medication is considered effective and is recommended by evidence based research in the treatment of first episode psychosis. A program of extensive public education and specific education forteachers, general health and mental health professionals about the prodrome and nature of first episode psychosis can reduce the duration of untreated psychosis and improve treatment outcome. Countries that do not have services for Early Intervention should seriously consider implementing this model.

An investigation of the field trip model as a method for teaching breastfeeding to pediatric residents.

Pediatricians in training are underexposed to breastfeeding issues and as a result are not fully prepared to promote breastfeeding and support the breastfeeding mother. This study is a pre-post evaluation of the effectiveness of a pilot breastfeeding curriculum. Using the "field trip model," pediatric residents participated in 4 half-day teaching sessions at community sites, including a visit to a La Leche League home meeting, a Kaiser lactation consultant clinic, hospital-based lactation rounds, and a children's hospital-based referral clinic. The objective of this study was to evaluate the effectiveness of this curriculum using a modified version of a previously published questionnaire that assesses knowledge about (70 items), attitude toward (6 items), and experience with breastfeeding (11 items). Residents enrolled in the field trip model of breastfeeding instruction exhibited significant increases in attitude and experience scores and self-reported high levels of satisfaction compared to controls.

Linking nursing home working conditions to organizational performance.

Exploring selected working conditions and performance in nursing homes suggests that high and low performers can be determined based on both quantitative and qualitative findings.