**4. UC Davis telepsychiatric Native American study**

#### **4.1. Overview**

models of care, which similar to above use 'less intensive or expensive interventions' first then

**Model 6:** Asynchronous telepsychiatry. Traditionally, there have been two main types of telemedicine: *synchronous*, which typically relies on live, two-way interactive video to a remote area, and *asynchronous* (store-and-forward), which transmits clinical information via email or web applications for later review by a specialist. Broadly speaking, synchronous communica‐ tion by phone or with video allows synthesis of information and easy exchange of information, with in -the-moment questions by PCPs. *Asynchronous* telemedicine has been commonly used and well-received for pathology, cardiology, radiology, dermatology and other fields. A study of synchronous telepsychiatry, including Native American patients, revealed that PCPs are highly satisfied with the service, with 100% of the respondents noting the consultation as fast as from a regular face-to-face visit, was able to meet their patient's needs and lead to an improvement in the management of their patient; 64% thought the ATP consultant was able to completely meet their patient's needs and the feedback they received over ATP was as good as from a regular face-to-face visit (Yellowlees et al 2010; Butler and Yellowlees 2012).

Ethnicity, culture and language issues affect health (Office of Surgeon General, 2001) and there is often inadequate access to specialists (Moreno et al 2012) —inroads to patient needs and preferences that can be met by telemental health are progressing. A recent study of nearly 40 rural health clinics compared impressions of 25 primary care providers and 32 staff impres‐ sions of factors important to care: using providers who value differences (5.4/7.0), quality of the provider's care (4.9/7.0), access to care in general (4.5/7.0) and availability of trained interpreters for use with patients (4.4/7.0) (Hilty et al 2013). Others are studying the specific needs of Hispanics/Latinos (Moreno et al 2012; Nieves et al 2007, Chong et al 2012), Asians (Ye et al 2011), Native Americans (Weiner et al 2005, Shore et al 2007, Shore et al 2008), Eastern Europeans (Mucic, 2004), and those using sign language (Lopez et al 2004) —all using telepsychiatry for service provision. With patients of different cultural backgrounds, using the patients' primary language allows for a more comfortable atmosphere where they may express

Northern Plains Native Americans were very satisfied and comfortable with telepsychiatric treatment for post traumatic stress disorder (Shore and Manson 2004a; Shore and Manson 2004b; Shore et al 2006). In fact, location, communication, trust, and confidentiality were equally satisfactory for treatment in-person versus videoconferencing. Even Native American

Over the past decade the University of Colorado's Center for American Indian and Alaska Native Health (CAIANH) has collaborated on multiple telepsychiatry services targeted at American Indian and Alaska Native populations (Shore et al 2006; Savin et al 2006; Shore et al

children and families are receptive to telepsychiatric consultation (Savin et al 2006).

if patients fail to improve, 'step it up' to more intensive services, and

**3.4. Telepsychiatry and cultural populations**

their genuine feelings and emotions.

**U. Colorado.**

82 Telemedicine

**3.5. Telepsychiatry to Native Americans**

This article is a description of the patients seen from three California Native American IHS sites using a telepsychiatric consultation program from the academic medical center. Its objectives were to: a) describe the population's demographics and illnesses, b) identify needs of patients and physicians, c) report the services delivered to this patient population, and d) examine the quality of psychopharmacologic services. Patient, clinic, and system factors related to telepsychiatric consultation, which have important implications for federal health policy toward Native Americans, will be noted (Dixon 2001).

#### **4.2. Methods**

The University of California Davis Health System (UCDHS) is based in Sacramento, California, and serves a 33-county area to the Oregon state border. Since 1995, UCDHS has provided telemedical consultations since 1995 in 28 specialties to 42 clinics (26 rural, 16 prisons) between 100 and 350 miles away (Nesbitt et al 2013). The telepsychiatry service has provided over 4,000 consultations, using a variety of models (Hilty et al 2006b).

#### **4.3. Technology**

UCDMC and remote sites use dial-up integrated service digital network (ISDN) lines, transmission speeds of 384 Kbps and a CODEC (COder-DECoder). The hourly rate for lines ranges from \$30-\$60 depending on the distance and long-distance carrier, for each hourly consultation. Round Valley and K'ima:w use Internet Protocol (IP) with transmissions speeds of 384 Kbps, carried over a dedicated link (either Frame Relay or a T-1 connection) into the UC Davis network. The monthly cost is approximately \$500/clinic, but there is no per-use charge as with ISDN. The total capital cost of these units is approximately \$8,000 at all sites.

**Characteristic Study CA IHS**

Prev. attempted 28.8% suicide (1+) 28.8%

Current nicotine users 35.5%

Prev. hospitalized

Characteristics: 2000.

@ (Numbers in thousands)

**Patients**

**IHS Community**

Mental Health Services for California Native Americans — Usual Service Options and a Description…

**Native American IHS Pts.**

**patients**

Not Noted 8.9 6.6%

Unemployed 53.3% 15,829,2024 Not Noted 24.4% 7.0%

1Source: U.S. Census Bureau (USCB), Census 2000 Summary File 1, 100-% Data, DP-1. Profile of General Demographic

Source: USCB, Current Population Survey, 2004 Annual Social and Economic Supplement. Table HI05. Health Insurance

2These numbers reflect total population, inclusive of those under the age of 18. 3Source: USCB, Census 2000 Summary File 3, Matrices PCT1, PCT7, and PCT8.

Coverage Status and Type of Coverage by State and Age for All People: 2003.

5Rural comparison sample of adult patients over same period of time from10 northern rural clinics.

**Table 1.** A Comparison of Patient Characteristics: Study CA IHS vs. All IHS vs. Rural CA vs. General CA.

4Source: USCB, Census 2000 Summary File 3, Matrices P43 and PCT35.

Amer. Indian 80.0% 52.5% 100% 0% 0.8% 0.7% Latino 2.2% 1.4% 0% 3.0% 0.8% 32.4% Afr. Amer. 0% .2% 0% 0.5% 1.6% 7.4% Asian 0% 0% 0% 0% 0% 12.3% Other 0% 26.4% 0% 53.6% 0% 20.1% Gender: % Female 66.7 51.9% 52.9% 50.6% 58.2% 49.3%1 Marital Status 26,076,1633 Married 40.0 39.3% 54.9% Single 28.9 41.8% 30.1% Divorced 17.8 9.0% 9.5% Widowed 4.4 3.3% 5.6%

**Census) Total CA IHS**

**Non-AI CA IHS Pts.**

**Rural Northern CA (eMH) 5**

http://dx.doi.org/10.5772/56569

**CA (via US**

85

#### **4.4. IHS clinics and patients**

K'ima:w Medical Center (Hoopa, Karuk, and Yurok tribes), Round Valley Indian Health Center, Inc. (Round Valley Indian Tribes) and Pit River Health Service, Inc. (Big Bend, Montgomery Creek, Pit River Tribe, Roaring Creek, Smith Camp) receive specialty services from UC Davis Medical Center (UCDMC) and are officially rural areas as defined by nonmetropolitan statistical criteria (Off Tech Assessment 1990). All have a population under 500 and patients travel 3-6 hours for specialty service on roads that are hard to access or treacherous to travel. Each city has an IHS primary care clinic. Most of these clinics have part-time substance abuse/dependence counseling and groups; none have a full-time psychotherapist and there are no mental health clinics or day treatment programs; psychiatric hospitalization is 3-6 hours away. California IHS has used telepsychiatric, tele-endocrinology and tele-ophthalmology since 1999. They use a specialist consulting by video to a primary care provider at the IHS site, who provides the actual care. Consecutive initial and follow-up telepsychiatric consultation from UCDMC to the IHS sites from January 2004 to December 2004 were reviewed. Data from IHS patients around the state, rural Northern California telepsychiatry sites and the California census were used as comparisons (Tables 1 and 2).



1Source: U.S. Census Bureau (USCB), Census 2000 Summary File 1, 100-% Data, DP-1. Profile of General Demographic Characteristics: 2000.

2These numbers reflect total population, inclusive of those under the age of 18.

3Source: USCB, Census 2000 Summary File 3, Matrices PCT1, PCT7, and PCT8.

4Source: USCB, Census 2000 Summary File 3, Matrices P43 and PCT35.

5Rural comparison sample of adult patients over same period of time from10 northern rural clinics.

Source: USCB, Current Population Survey, 2004 Annual Social and Economic Supplement. Table HI05. Health Insurance Coverage Status and Type of Coverage by State and Age for All People: 2003.

@ (Numbers in thousands)

**4.3. Technology**

84 Telemedicine

**4.4. IHS clinics and patients**

census were used as comparisons (Tables 1 and 2).

**Patients**

**Characteristic Study CA IHS**

Age

UCDMC and remote sites use dial-up integrated service digital network (ISDN) lines, transmission speeds of 384 Kbps and a CODEC (COder-DECoder). The hourly rate for lines ranges from \$30-\$60 depending on the distance and long-distance carrier, for each hourly consultation. Round Valley and K'ima:w use Internet Protocol (IP) with transmissions speeds of 384 Kbps, carried over a dedicated link (either Frame Relay or a T-1 connection) into the UC Davis network. The monthly cost is approximately \$500/clinic, but there is no per-use charge

K'ima:w Medical Center (Hoopa, Karuk, and Yurok tribes), Round Valley Indian Health Center, Inc. (Round Valley Indian Tribes) and Pit River Health Service, Inc. (Big Bend, Montgomery Creek, Pit River Tribe, Roaring Creek, Smith Camp) receive specialty services from UC Davis Medical Center (UCDMC) and are officially rural areas as defined by nonmetropolitan statistical criteria (Off Tech Assessment 1990). All have a population under 500 and patients travel 3-6 hours for specialty service on roads that are hard to access or treacherous to travel. Each city has an IHS primary care clinic. Most of these clinics have part-time substance abuse/dependence counseling and groups; none have a full-time psychotherapist and there are no mental health clinics or day treatment programs; psychiatric hospitalization is 3-6 hours away. California IHS has used telepsychiatric, tele-endocrinology and tele-ophthalmology since 1999. They use a specialist consulting by video to a primary care provider at the IHS site, who provides the actual care. Consecutive initial and follow-up telepsychiatric consultation from UCDMC to the IHS sites from January 2004 to December 2004 were reviewed. Data from IHS patients around the state, rural Northern California telepsychiatry sites and the California

**IHS Community**

**Native American IHS Pts.**

**patients**

N 45 7472 4071 3401 122 24,621,8191

18-30 35.5% 30.1% 36.3% 22.7% 27.9% 26.4% 31-45 37.0% 26.6% 28.7% 24.1% 29.5% 32.5% 46-65 20.0% 29.8% 24.7% 35.8% 36.9% 27.2% > 65 6.6% 13.5% 10.3% 17.4% 4.1% 13.8% Ethnicity 33,871,6482 Caucasian 17.8% 19.5% 0% 42.8% 96.7% 63.4%

**Census) Total CA IHS**

**Non-AI CA IHS Pts.**

**Rural Northern CA (eMH) 5**

**CA (via US**

as with ISDN. The total capital cost of these units is approximately \$8,000 at all sites.

**Table 1.** A Comparison of Patient Characteristics: Study CA IHS vs. All IHS vs. Rural CA vs. General CA.


faculty in English. A consultation care model was used, in which the PCP was the provider of mental health services. Patients signed a consent form that described the nature of the consultation, personnel involved, and their option to see someone in person. Patients who presented with a medical emergency (e.g., suicidal or homicidal ideation or acute psychoses) were referred to local mental health services in lieu of telemedicine consultation, unless the presence of a staff member was sufficient to stabilize them for the appointment. If an emer‐ gency developed, the UCDMC clinic called the IHS clinic to have staff and law enforcement assist. An appointment consisted of 45 minutes for the psychiatrist to conduct the patient evaluation and 5-10 minutes for the PCP to join at the end of the evaluation to discuss options

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87

Diagnosis was made by a semi-structured interview, using the mood, anxiety and substance sections of the Structured Clinical Interview for DSM-IV-TR, and supplemented with the following: screening questions for other psychiatric diagnosis(es); history of abuse or domestic violence; hospitalizations; past suicide attempts and present suicidal or homicidal ideation; current and past medication; 1st and 2nd-degree family member history of psychiatric disorders; and the PCP reasons for referring for consultations (diagnostic assessment, medication management, psychological assessment or triage); this is the PCPs' understanding for the referral rather than what turned out to be true by psychiatric evaluation. On the day of the consultation, a one-page fax was sent from the psychiatrist to the rural site to summarize findings and present three treatment options per problem. The PCP would choose what he/she thought was the best option; the others automatically served as back-up plans. A

Data were collected on each consultation from telemedicine staff at the rural site (RPMS above), the patient, the PCP, and the psychiatrist. The IHS community data were retrieved from the IHS Resource and Patient Management System (RPMS). RPMS is a decentralized automated information system of over 50 integrated software applications that supports the provision of healthcare at Indian Health facilities. RPMS is a repository of patient data that can be manip‐ ulated by applications to support healthcare planning, delivery, management, and research. At UCDMC, paper protocols steered research assistants to collect information from patient registration forms, the electronic medical record and additional paper forms to log any data not usually included in a standard interview; the information was de-identified. Patient sociodemographic information included age, ethnicity, gender, marriage status, education, and employment. Comments by patients and staff were logged for informal analysis of themes

Due to numbers, mood disorders were spelled out, but otherwise, broad grouping of diag‐ nostic categories was done due to small numbers and general clustering of the diagnoses, following DSM-IV-TR categorization (e.g., anxiety, psychotic and impulse control disorders). Substance use disorders were differentiated into either alcohol or drug, regardless of abuse or

that arose, in a qualitative sense, in case future evaluation might be indicated.

for treatment.

dictation was sent one week thereafter.

**4.6. Data collection**

**4.7. Diagnostic clustering**

1Rural comparison sample of adult patients over same period of time from 10 northern rural clinics.

2 PTSD nearly 2/3 of all disorders.

3 Provisional

**Table 2.** Primary Diagnosis for Native American Telepsychiatry Consultations.

#### **4.5. Teleconsultation procedures**

Consultations started with a PCP referral, with an assistant faxing a one-page consultation request and, when available, information on the patient's history, medication log, and medical disorders one week prior to the consultation. All consultations were performed by psychiatric faculty in English. A consultation care model was used, in which the PCP was the provider of mental health services. Patients signed a consent form that described the nature of the consultation, personnel involved, and their option to see someone in person. Patients who presented with a medical emergency (e.g., suicidal or homicidal ideation or acute psychoses) were referred to local mental health services in lieu of telemedicine consultation, unless the presence of a staff member was sufficient to stabilize them for the appointment. If an emer‐ gency developed, the UCDMC clinic called the IHS clinic to have staff and law enforcement assist. An appointment consisted of 45 minutes for the psychiatrist to conduct the patient evaluation and 5-10 minutes for the PCP to join at the end of the evaluation to discuss options for treatment.

Diagnosis was made by a semi-structured interview, using the mood, anxiety and substance sections of the Structured Clinical Interview for DSM-IV-TR, and supplemented with the following: screening questions for other psychiatric diagnosis(es); history of abuse or domestic violence; hospitalizations; past suicide attempts and present suicidal or homicidal ideation; current and past medication; 1st and 2nd-degree family member history of psychiatric disorders; and the PCP reasons for referring for consultations (diagnostic assessment, medication management, psychological assessment or triage); this is the PCPs' understanding for the referral rather than what turned out to be true by psychiatric evaluation. On the day of the consultation, a one-page fax was sent from the psychiatrist to the rural site to summarize findings and present three treatment options per problem. The PCP would choose what he/she thought was the best option; the others automatically served as back-up plans. A dictation was sent one week thereafter.

#### **4.6. Data collection**

**N**

Total Axis I Diagnoses <sup>92</sup> 45 patients

Substance (abuse/ dependence)

86 Telemedicine

**Current CA IHS**

2.04 dx/pt.

Depression 22 49% 56 45.9% Bipolar Disorder 9 20.0% 44 36.1%

Cognitive/ Dementia 1 2.2% 5 4.1% Psychosis 5 11.1% 11 9.0% Childhood 0 0% 8 6.6% Somatoform d/o 0 0% 5 4.1% Eating 0 7 5.7% Unknowns 0 0% 0 0% Total Axis II3 Diagnoses 5 11.1% 11 9.0%

Range 50-70

**Table 2.** Primary Diagnosis for Native American Telepsychiatry Consultations.

Total Axis V - GAF Mean = 60.71; SD = 5.040;

2 PTSD nearly 2/3 of all disorders.

**4.5. Teleconsultation procedures**

3 Provisional

Mood <sup>31</sup> 69% <sup>100</sup> 82% (1, N = 167) =

Anxiety2 <sup>25</sup> 55.5% <sup>45</sup> 36.9% (1, N = 167) =

Impulse <sup>5</sup> 11.1% <sup>0</sup> 0% (1, N = 167) =

Alcohol <sup>10</sup> 22.2% <sup>11</sup> 9.0% (1, N = 167) =

Drug <sup>15</sup> 33.3% <sup>11</sup> 9.0% (1, N = 167) =

1Rural comparison sample of adult patients over same period of time from 10 northern rural clinics.

Consultations started with a PCP referral, with an assistant faxing a one-page consultation request and, when available, information on the patient's history, medication log, and medical disorders one week prior to the consultation. All consultations were performed by psychiatric

**<sup>N</sup> Rural CA1 Chi Square**

<sup>203</sup> 122 patients 1.66 dx/pt.

<sup>25</sup> 55.5% <sup>22</sup> 18.0% (1, N = 167) =

Mean = 60.10; SD = 8.756; Range 35-85

**Analysis Significance**

3.92 p < 0.05

4.71 p < 0.05

13.97 p < 0.001

14.79 p < 0.001

5.21 p < 0.05

14.79 p < 0.001

Data were collected on each consultation from telemedicine staff at the rural site (RPMS above), the patient, the PCP, and the psychiatrist. The IHS community data were retrieved from the IHS Resource and Patient Management System (RPMS). RPMS is a decentralized automated information system of over 50 integrated software applications that supports the provision of healthcare at Indian Health facilities. RPMS is a repository of patient data that can be manip‐ ulated by applications to support healthcare planning, delivery, management, and research. At UCDMC, paper protocols steered research assistants to collect information from patient registration forms, the electronic medical record and additional paper forms to log any data not usually included in a standard interview; the information was de-identified. Patient sociodemographic information included age, ethnicity, gender, marriage status, education, and employment. Comments by patients and staff were logged for informal analysis of themes that arose, in a qualitative sense, in case future evaluation might be indicated.

#### **4.7. Diagnostic clustering**

Due to numbers, mood disorders were spelled out, but otherwise, broad grouping of diag‐ nostic categories was done due to small numbers and general clustering of the diagnoses, following DSM-IV-TR categorization (e.g., anxiety, psychotic and impulse control disorders). Substance use disorders were differentiated into either alcohol or drug, regardless of abuse or dependence. Provisional Axis II diagnoses were grouped together due to the fact that few were confirmed on one-time evaluation. Family members' diagnoses were not confirmed; report was considered positive if they had medication treatment, hospitalization or a long history known to family (e.g., social disturbance by alcohol).

services provided were medication management (96%), diagnostic clarification (89%),

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89

The total number of Axis I diagnoses was 92 (range, 0-4), with an average of 2.04 per pa‐ tient (SD = 1.06) (see Table 2). A total of 31 patients were diagnosed with mood disorders (9 bipolar/22 depression); 13 (42%) of those individuals had 1st and 2nd-degree family members with a mood disorder. Fifteen (48.3%) of the patients with mood disorders had comorbid anxiety disorders. Notably, 55% of the patients seen had a current substance abuse/dependence diagnosis, mainly methamphetamine (42% of the 55%) and marijuana (40% of the 55%). Chi-square tests revealed the IHS sample to have higher rates of anxi‐ ety, impulse, alcohol abuse/dependence, and drug abuse/dependence disorders than the rural California samples (Table 2). The average Global Assessment of Function (GAF) was

There appeared to be a significant relationship of diagnoses to past personal and family history. High rates of disorders were found between mood, abuse/trauma, and substances. The overall sexual abuse rate at 22% (10/45) and these patients had high rates of other disorders (see Table 3). Data suggested a relationship between 1st and 2nd-degree family members using substances and patients using alcohol, as well as between mental and emotional abuse and a diagnosis of depression, but statistical differences were not found. Patients with bipolar or substance disorders commonly had a family member with bipolar disorder. As shown in Table 4, the IHS subgroup with mental and emotional abuse also showed higher of depression rates than the

In terms of dosing and dosing adequacy, of the 45 patients, 73% had a medication indicated for their primary disorder; 60% of those were at an adequate dose. When it was looked at per group and medication, antidepressants were given adequately 50.0% of the time and subadequately for 63.3% of patients (Table 5). This was in stark contrast to mood stabilizers and antipsychotics adequately used 23.1% and 25.0%, respectively, mainly being under-dosed more than antidepressants; they were not erroneously prescribed, though. A chi-square analysis found a significant relationship between inadequate dosing of antipsychotics and

Qualitative analysis revealed that patients reported comments in several theme areas: a) gratitude for the availability of care in general, and care without the stigma of mental health services, in particular, as many do not have transportation to urban centers; b) preference for telepsychiatric consultation, since they fear stigma locally and are unsure if confidentiality can be maintained in small rural centers; c) appreciation of their clinics' initiative in helping them; and 4) initial anxiety about using the technology and surprise that it seemed to work. Staff at IHS sites felt positive about care being available, high patient satisfaction, and some frustration about making the clinic schedule "fit" the rural and cultural environment. Staff at the UCDMC Center for Health and Technology reported that IHS sites seemed to value the service as much

gender (women) (p < 0.01). No other biases were found with inadequate dosing.

psychological assessment (36%), and patient triage (18%).

60.71 (SD 5.040).

overall sample.

or more than other rural sites.

#### **4.8. Quality of medication trial**

Dosing was assessed by chart review and in line with national guidelines, with adjustments made for projected age, culture and drug interactions (Depression in Primary Care. Volume 2 1993; APA Practice Guideline 2002; APA Practice Guideline 2006). The criteria vary on dosage vary according to disorder (e.g., depression, paroxetine, initial 10-20mg bedtime, initial 4-week trial, dose increase and so on). The chart was checked for a disorder in which the medication would be used, to determine if it was "Not needed" or "Needed"; since therapy is available in some sites and not others, and if available, usually used no more than one time per month, medication is more needed than not. Ancillary use of medications at low dose (e.g., for sleep) was excluded. Dosage and duration were reviewed per chart and per patient interview of how it was prescribed, in the event that the dosage was changed or new medications were not reflected in the chart. Medication was categorized as adequate, partially adequate (e.g., adequate dosage or too short of a period) or inadequate (e.g., none given, too little given to affect change). Non-adherence with medication, by self-report and by questioning by the telepsychiatrist, was excluded as a confounder.

#### **4.9. Data analysis**

Descriptive statistics and chi-square tests were run for the following: a) IHS vs. other socio‐ demographics; b) IHS vs. others' diagnoses; c) past and present diagnoses; d) present diagnoses (if more than one); e) present diagnoses and family member diagnoses; and f) dosing adequacy and ethnicity, gender, and presence of a diagnosis of substance abuse/dependence.

#### **4.10. IRB approval**

This project was approved by the Committee on the Protection of Human Subjects at UCDMC.

#### **4.11. Results**

Over the one-year period, 45 different IHS patients were seen; 80% were Native American, and 67% were female. Initial evaluations were done for 32 and 13 had follow-up visits from prior initial telepsychiatry consultations. The mean age was 39.71 (SD = 14.83). For comparison, other samples were of similar ages, though the California rural comparison sample was 97% Caucasian and 58% female; overall, Californians were 63.4% Caucasian, 49.3% female (see Table 1).

PCP reasons for consultations were consistent with primary care practice, and included depression and anxiety (40%), general medication evaluation (38%), mood disorders (11%), disability evaluation (4%), and gastric bypass psych evaluation (7%). The most common services provided were medication management (96%), diagnostic clarification (89%), psychological assessment (36%), and patient triage (18%).

dependence. Provisional Axis II diagnoses were grouped together due to the fact that few were confirmed on one-time evaluation. Family members' diagnoses were not confirmed; report was considered positive if they had medication treatment, hospitalization or a long history

Dosing was assessed by chart review and in line with national guidelines, with adjustments made for projected age, culture and drug interactions (Depression in Primary Care. Volume 2 1993; APA Practice Guideline 2002; APA Practice Guideline 2006). The criteria vary on dosage vary according to disorder (e.g., depression, paroxetine, initial 10-20mg bedtime, initial 4-week trial, dose increase and so on). The chart was checked for a disorder in which the medication would be used, to determine if it was "Not needed" or "Needed"; since therapy is available in some sites and not others, and if available, usually used no more than one time per month, medication is more needed than not. Ancillary use of medications at low dose (e.g., for sleep) was excluded. Dosage and duration were reviewed per chart and per patient interview of how it was prescribed, in the event that the dosage was changed or new medications were not reflected in the chart. Medication was categorized as adequate, partially adequate (e.g., adequate dosage or too short of a period) or inadequate (e.g., none given, too little given to affect change). Non-adherence with medication, by self-report and by questioning by the

Descriptive statistics and chi-square tests were run for the following: a) IHS vs. other socio‐ demographics; b) IHS vs. others' diagnoses; c) past and present diagnoses; d) present diagnoses (if more than one); e) present diagnoses and family member diagnoses; and f) dosing adequacy

This project was approved by the Committee on the Protection of Human Subjects at UCDMC.

Over the one-year period, 45 different IHS patients were seen; 80% were Native American, and 67% were female. Initial evaluations were done for 32 and 13 had follow-up visits from prior initial telepsychiatry consultations. The mean age was 39.71 (SD = 14.83). For comparison, other samples were of similar ages, though the California rural comparison sample was 97% Caucasian and 58% female; overall, Californians were 63.4% Caucasian, 49.3% female (see

PCP reasons for consultations were consistent with primary care practice, and included depression and anxiety (40%), general medication evaluation (38%), mood disorders (11%), disability evaluation (4%), and gastric bypass psych evaluation (7%). The most common

and ethnicity, gender, and presence of a diagnosis of substance abuse/dependence.

known to family (e.g., social disturbance by alcohol).

telepsychiatrist, was excluded as a confounder.

**4.9. Data analysis**

**4.10. IRB approval**

**4.11. Results**

Table 1).

**4.8. Quality of medication trial**

88 Telemedicine

The total number of Axis I diagnoses was 92 (range, 0-4), with an average of 2.04 per pa‐ tient (SD = 1.06) (see Table 2). A total of 31 patients were diagnosed with mood disorders (9 bipolar/22 depression); 13 (42%) of those individuals had 1st and 2nd-degree family members with a mood disorder. Fifteen (48.3%) of the patients with mood disorders had comorbid anxiety disorders. Notably, 55% of the patients seen had a current substance abuse/dependence diagnosis, mainly methamphetamine (42% of the 55%) and marijuana (40% of the 55%). Chi-square tests revealed the IHS sample to have higher rates of anxi‐ ety, impulse, alcohol abuse/dependence, and drug abuse/dependence disorders than the rural California samples (Table 2). The average Global Assessment of Function (GAF) was 60.71 (SD 5.040).

There appeared to be a significant relationship of diagnoses to past personal and family history. High rates of disorders were found between mood, abuse/trauma, and substances. The overall sexual abuse rate at 22% (10/45) and these patients had high rates of other disorders (see Table 3). Data suggested a relationship between 1st and 2nd-degree family members using substances and patients using alcohol, as well as between mental and emotional abuse and a diagnosis of depression, but statistical differences were not found. Patients with bipolar or substance disorders commonly had a family member with bipolar disorder. As shown in Table 4, the IHS subgroup with mental and emotional abuse also showed higher of depression rates than the overall sample.

In terms of dosing and dosing adequacy, of the 45 patients, 73% had a medication indicated for their primary disorder; 60% of those were at an adequate dose. When it was looked at per group and medication, antidepressants were given adequately 50.0% of the time and subadequately for 63.3% of patients (Table 5). This was in stark contrast to mood stabilizers and antipsychotics adequately used 23.1% and 25.0%, respectively, mainly being under-dosed more than antidepressants; they were not erroneously prescribed, though. A chi-square analysis found a significant relationship between inadequate dosing of antipsychotics and gender (women) (p < 0.01). No other biases were found with inadequate dosing.

Qualitative analysis revealed that patients reported comments in several theme areas: a) gratitude for the availability of care in general, and care without the stigma of mental health services, in particular, as many do not have transportation to urban centers; b) preference for telepsychiatric consultation, since they fear stigma locally and are unsure if confidentiality can be maintained in small rural centers; c) appreciation of their clinics' initiative in helping them; and 4) initial anxiety about using the technology and surprise that it seemed to work. Staff at IHS sites felt positive about care being available, high patient satisfaction, and some frustration about making the clinic schedule "fit" the rural and cultural environment. Staff at the UCDMC Center for Health and Technology reported that IHS sites seemed to value the service as much or more than other rural sites.

#### **4.12. Discussion of findings**

These clinics of the IHS found more patients to be female and Native American than in other populations, and to have 2+ psychiatric disorders (mainly depression and anxiety). The main services conducted for IHS patients by telepsychiatry are medication management and diagnostic clarification. The adequacy of medication treatment was better for disorders requiring antidepressants than for those requiring mood stabilizers or antipsychotics. Patients with a personal or family history of trauma, mood or substance disorders, had higher rates of psychiatric and specifically substance disorders. As found in a previous study, relationships appear to exist between trauma history, substance abuse/dependence, mental illness, and higher rates of suicide attempts and hospitalizations (Bohn 2003). The sexual abuse rate that we found in our IHS sample–22%–is consistent with national rates estimating that 15-33% of females have experienced sexual abuse (Bohn 2003). Based on national studies, higher rates of substance abuse/dependence in the Native American sample vs. rural California were not unexpected, though this did not generalize into more overall pathology based on GAF scores.

**Subgroups Current / Past Drug Usage**

**Diagnoses**

**Primary Family Members**

Substance Abuse/ Dependence

1 Family defined as 1st and 2nd-degree members.

**Family N = 11 %**

**Sexual Abuse N = 10 %**

Alcohol 100 90.0 25.0 81.1 **64.4** Amphetamines 36.4 50.0 0 27.2 **42.2** Cocaine 18.2 10.0 0 18.3 **8.9** Opioids 36.7 20.0 25.0 27.2 **22.2** Marijuana 45.5 50.0 75.0 50.0 **40.0** Suicide attempts 27.3 30.0 75.0 36.3 **28.8** ? Hospitalizations 27.3 30.0 75.0 28.8 **28.8**

Bipolar 27.3 20.0 0 9.1 **20.0** Depression 63.6 60.0 100 54.5 **49.0** Anxiety 63.6 60.0 25.0 63.6 **55.5** Substance 54.5 30.0 25.0 54.5 **55.5** Alcohol 18.1 30.0 0 18.1 **22.2** Cognitive 0 0 0 0 **2.2** Psychosis 0 20.0 0 2 **11.1**

Bipolar 36.7 20.0 25.0 18.1 **13.3** Depression 18.2 10.0 75.0 9.1 **20.0** Anxiety 9.1 30.0 25.0 27.2 **11.1**

Cognitive 9.1 0 0 0 **6.6** Psychosis 9.1 10.0 0 0 **8.8** Childhood 9.1 10.0 0 18.1 **6.6** Unknown 0 10.0 0 0 **8.8**

**Table 3.** Relationship of Patient Psychiatric Diagnoses with Personal and Family1 Histories.

100.0 30.0 25.0 45.4 **24.4**

**Non-Physical, Emotional Abuse N = 4 %**

Mental Health Services for California Native Americans — Usual Service Options and a Description…

**Physical Abuse N = 11 %**

**Overall Sample N = 45 %**

91

http://dx.doi.org/10.5772/56569

There are many clinical implications of these data, particularly the high rates of comorbidity between mood, anxiety, substance, and other disorders. In particular, bipolar disorder and substance disorders quite commonly co-exist, and a positive family history may be helpful in diagnosis (APA Practice Guideline 2002). Clinicians may need to evaluate Native American patients differently than other rural populations. Treatment plans with a strong biopsychoso‐ cial approach are indicated in light of stress and trauma, but therapy resources are limited. Best practices and Treatment Intervention Protocols to identify and treat comorbidities are available through the Substance Abuse and Mental Health Services Administration (SAM‐ SHA) Center for Substance Abuse Treatment (SAMSHA Subst Treatment 2002), but these protocols are complex and require more resources than many rural sites have available, or the specialist services are again not available.

Rates of medication dosing adequacy upon referral indicate that PCPs are more likely to *not* prescribe than to inaccurately prescribe psychiatric medications, which is consistent with national trends (Hilty and Servis 1999). From a programmatic point of view, if medication dosing is falling short for bipolar and psychotic disorders, disease management interventions may be indicated (Hilty et al 2007b). No major ethnic biases or gender biases were found regarding dosing, except inadequate dosing of antipsychotics in females; numbers were small and should only be interpreted as a trend.

#### **5. Discussion and conclusions**

Native Americans have significant needs for health care and are at significant risk for many health and mental health problems. Without attention to both health and mental health needs, patients and their families face compounded problems of health, money, access and other social problems.

Mental Health Services for California Native Americans — Usual Service Options and a Description… http://dx.doi.org/10.5772/56569 91


1 Family defined as 1st and 2nd-degree members.

**4.12. Discussion of findings**

90 Telemedicine

specialist services are again not available.

and should only be interpreted as a trend.

**5. Discussion and conclusions**

social problems.

These clinics of the IHS found more patients to be female and Native American than in other populations, and to have 2+ psychiatric disorders (mainly depression and anxiety). The main services conducted for IHS patients by telepsychiatry are medication management and diagnostic clarification. The adequacy of medication treatment was better for disorders requiring antidepressants than for those requiring mood stabilizers or antipsychotics. Patients with a personal or family history of trauma, mood or substance disorders, had higher rates of psychiatric and specifically substance disorders. As found in a previous study, relationships appear to exist between trauma history, substance abuse/dependence, mental illness, and higher rates of suicide attempts and hospitalizations (Bohn 2003). The sexual abuse rate that we found in our IHS sample–22%–is consistent with national rates estimating that 15-33% of females have experienced sexual abuse (Bohn 2003). Based on national studies, higher rates of substance abuse/dependence in the Native American sample vs. rural California were not unexpected, though this did not generalize into more overall pathology based on GAF scores.

There are many clinical implications of these data, particularly the high rates of comorbidity between mood, anxiety, substance, and other disorders. In particular, bipolar disorder and substance disorders quite commonly co-exist, and a positive family history may be helpful in diagnosis (APA Practice Guideline 2002). Clinicians may need to evaluate Native American patients differently than other rural populations. Treatment plans with a strong biopsychoso‐ cial approach are indicated in light of stress and trauma, but therapy resources are limited. Best practices and Treatment Intervention Protocols to identify and treat comorbidities are available through the Substance Abuse and Mental Health Services Administration (SAM‐ SHA) Center for Substance Abuse Treatment (SAMSHA Subst Treatment 2002), but these protocols are complex and require more resources than many rural sites have available, or the

Rates of medication dosing adequacy upon referral indicate that PCPs are more likely to *not* prescribe than to inaccurately prescribe psychiatric medications, which is consistent with national trends (Hilty and Servis 1999). From a programmatic point of view, if medication dosing is falling short for bipolar and psychotic disorders, disease management interventions may be indicated (Hilty et al 2007b). No major ethnic biases or gender biases were found regarding dosing, except inadequate dosing of antipsychotics in females; numbers were small

Native Americans have significant needs for health care and are at significant risk for many health and mental health problems. Without attention to both health and mental health needs, patients and their families face compounded problems of health, money, access and other

**Table 3.** Relationship of Patient Psychiatric Diagnoses with Personal and Family1 Histories.


technical, administrative, evaluation, and cultural factors affect telepsychiatric patient care. Research is indicated with regard to help-seeking, diagnosis, treatment, and outcomes of IHS

**Inadequate Treatment Adequate Treatment**

**Needed, given**

Mental Health Services for California Native Americans — Usual Service Options and a Description…

**% of total**

15/30 50.0%

3/13 23.1%

2/8 25.0%

20/41 48.7%

**Needed, time short**

**Appropriate Non-Treatment**

http://dx.doi.org/10.5772/56569

**None needed or given**

N/A

15 45

32 45

37 45

**Total**

93

A delicate issue in dealing with culture and language of patients is the tension between a goal generalizing an approach or the search for "standard" nuances of specific tribes, with the difficulty of stereotyping groups and making clinical errors (Yellowlees et al 2008, Yellowlees et al 2013). Meeting with members of the community, including the health clinic, in advance is recommended to understand cultural issues. In addition, some nuances are best learned "in vivo" (e.g. during a consultation with "real" patients). Ethnocentrism refers to the attitude that one's own culture is the "correct" one, while the relativist approach compares other cultures to one's own in a less punitive way. Adopting a relativist approach to providing e-mental healthcare to individuals from diverse backgrounds is a minimal, essential step toward

Different cultural and ethnic groups value the role and perspective of the individual differently (Yellowlees et al 2008). Certain cultural groups are highly individualistic, such as many individuals in the United States and in many western European countries. Other cultural groups, such as many Asian societies, value instead the goals and needs of the group/society as a whole. With regard to their mental healthcare, they may not see mental health problems as individual challenges that can be successfully treated, but as shameful or burdensome to themselves or to their families. The value of the individual should be a consideration when

Another issue for rural Native Americans is confidentiality in dealing with life's stresses or steps, as well as mental/substance illness/disorders (Yellowlees et al 2008). Our previous work noted that Native Americans had different frameworks for labeling traumas, and in addition,

populations, preferably via randomized controlled trials.

**Table 5.** Adequacy of Medication Care Upon Consultation per Drug Class.

culturally appropriate care.

**Class Needed,**

**None given**

**Needed, dosage low**

Antidepressants 11 1 3 15

Mood Stabilizers 4 3 3 3

Antipsychotics 3 2 1 2

Total 18 6 7 20

planning e-mental health interventions.

**Table 4.** Drug Usage and Comorbidity by Diagnostic Category.

Native Americans in rural settings have significant need for psychiatric care, but have trouble accessing such care. Traditional models of accessing healthcare—often simply what is available locally, in nearby small cities or by travelling to metropolitan areas—have significant limita‐ tions. New models of service delivery like telepsychiatry appear to be suitable. Many clinical,


**Table 5.** Adequacy of Medication Care Upon Consultation per Drug Class.

Native Americans in rural settings have significant need for psychiatric care, but have trouble accessing such care. Traditional models of accessing healthcare—often simply what is available locally, in nearby small cities or by travelling to metropolitan areas—have significant limita‐ tions. New models of service delivery like telepsychiatry appear to be suitable. Many clinical,

**Subgroups Bipolar Depression Anxiety Psychosis Etoh Drug Overall**

**(n = 4) %**

**(n = 10) %**

**(n = 14) %**

**(N =45) %**

**(n = 21) %**

Alcohol 77.8 59.1 28.6 0 100.0 78.6 **64.4** Amphetamines 88.9 22.7 23.8 75.0 60.0 71.4 **42.2** Cocaine 11.1 9.1 4.7 25.0 20.0 21.4 **8.9** Opioids 33.3 18.2 19.0 50.0 40.0 42.8 **22.2** Marijuana 44.4 45.4 23.8 50.0 60.0 64.3 **40.0** Suicide attempts 33.3 27.3 23.8 75.0 40.0 21.4 **28.8** ?Hospitalizations 11.1 31.8 23.8 75.0 40.0 35.7 **28.8**

Bipolar - 0 14.3 0 20.0 35.7 **20.0** Depression 0 - 57.1 0 50.0 35.7 **49.0** Anxiety 30.0 54.5 - 25.0 50.0 35.7 **55.5** Psychosis 0 0 4.8 - 20.0 14.3 **11.1** Alcohol 22.2 22.7 23.8 50.0 - 28.6 **22.2** Drug 55.5 41.7 23.8 50.0 40.0 - **33.3** Cognitive 0 0 0 0 0 0 **2.2**

Bipolar 33.3 4.5 0 0 0 35.7 **13.3** Depression 22.2 27.3 14.3 0 20.0 14.3 **20.0** Anxiety 4.5 9.1 19.0 25.0 10.0 7.1 **11.1** Substance 33.3 31.8 33.3 0 20.0 35.7 **24.4** Cognitive 11.1 9.1 9.5 0 0 0 **6.6** Psychosis 22.2 9.1 14.3 0 10.0 14.3 **8.8** Childhood 0 13.6 4.7 0 0 0 **6.6** Unknown 33.3 0 4.8 25.0 20.0 14.3 **8.8**

**Current / Past Drug Use**

92 Telemedicine

**Cormorbidity**

**Primary Family Members**

**(n = 9) %**

**Table 4.** Drug Usage and Comorbidity by Diagnostic Category.

**(n = 22) %**

> technical, administrative, evaluation, and cultural factors affect telepsychiatric patient care. Research is indicated with regard to help-seeking, diagnosis, treatment, and outcomes of IHS populations, preferably via randomized controlled trials.

> A delicate issue in dealing with culture and language of patients is the tension between a goal generalizing an approach or the search for "standard" nuances of specific tribes, with the difficulty of stereotyping groups and making clinical errors (Yellowlees et al 2008, Yellowlees et al 2013). Meeting with members of the community, including the health clinic, in advance is recommended to understand cultural issues. In addition, some nuances are best learned "in vivo" (e.g. during a consultation with "real" patients). Ethnocentrism refers to the attitude that one's own culture is the "correct" one, while the relativist approach compares other cultures to one's own in a less punitive way. Adopting a relativist approach to providing e-mental healthcare to individuals from diverse backgrounds is a minimal, essential step toward culturally appropriate care.

> Different cultural and ethnic groups value the role and perspective of the individual differently (Yellowlees et al 2008). Certain cultural groups are highly individualistic, such as many individuals in the United States and in many western European countries. Other cultural groups, such as many Asian societies, value instead the goals and needs of the group/society as a whole. With regard to their mental healthcare, they may not see mental health problems as individual challenges that can be successfully treated, but as shameful or burdensome to themselves or to their families. The value of the individual should be a consideration when planning e-mental health interventions.

> Another issue for rural Native Americans is confidentiality in dealing with life's stresses or steps, as well as mental/substance illness/disorders (Yellowlees et al 2008). Our previous work noted that Native Americans had different frameworks for labeling traumas, and in addition,

were worried about seeking services due to concern that in small communities that "everyone would know". Certainly trained professionals do their best on these concerns, but the intro‐ duction of telemedicine facilitated a more open framework for discussing past events. Providers outside the reservation were seen as neutral parties. Attention was paid, of course, to what was disclosed to the local providers, particularly when one covered for another.

Telepsychiatric consultation may help provide psychiatric services with primary care in Native American communities, which is important because substance abuse/dependence, mental health, and medical treatments are often not integrated and communication between clinicians may be rare (Manson 2000). Patients' comments about their preference for telepsychiatric consultation, because of community stigma and uncertainty about confidentiality, may be significant and require further evaluation. The preliminary high satisfaction rates for patients and staff are encouraging, considering rural and cultural factors that may affect service delivery.

An "effective" program considers clinical, technical, administrative, evaluation, and cultural factors, based on conversations with patients, staff, clinicians, administrators and technicians of this project and according to the literature (Table 6) (Hilty et al 2013; Hilty et al 2004a; Darkins 2001). A developmental model of rural telepsychiatry emphasized stages of needs identifica‐ tion, infrastructure survey, partnership organization, structure configuration, pilot imple‐ mentation, and solidification (Shore 2005). In particular, cultural factors that affect helpseeking, diagnosis, treatment, and outcomes need to be measured and explored. In the clinical/ educational realm, it is important to remember the most complex referrals come first. It is important to be patient with these and the process, in building the relationship with the rural team and using them as opportunities to learn about rural patients' needs, or the "holes" in the rural service delivery system (that can be filled as in the case above).

While technology is certainly reported as being highly beneficial in enhancing mental health outcomes, actual access to information technology is extremely variable and such technologies themselves may also be viewed and understood differently by individuals of different ethnic and cultural backgrounds. The issue of disparate access to technology by individuals of different ethnic and cultural backgrounds reveals that access to information technology differs significantly, depending not only on an individual's race or ethnicity, but also their income, their education level, and their geographical location (Mossberger et al 2006). African Ameri‐ can and Hispanic/Latino individuals tend to report more affinity for information technology than whites do, but tended to have lower access to this type of technology, and poorer skills to use it effectively. When poverty and low socioeconomic status were taken into account, only the Hispanic/Latino group in Mossberger and colleagues' study actually had significantly poorer access to technology than the other two groups.

**•** What kind of assessment tools, methods, and measures are needed to assess the patients,

1. Obtain a telepsychiatric champion and provide adequate training for others with regard to the technology, adapt clinical

Mental Health Services for California Native Americans — Usual Service Options and a Description…

http://dx.doi.org/10.5772/56569

95

2. Coordinate timing of consults (i.e., patient is there at the right time, telepsychiatrist has adequate time, and/or referring

4. Documentation: appropriate policy and procedures for consent, forwarding pertinent information in advance (e.g.,

7. Match the type of service (e.g., consultation to spoke physician, triage, psychological testing, management) to the goal and/or request, as well as standard and reasonable practice (e.g., may be hard to manage from afar, who handles

9. For each consult, be certain that the technical quality equipment is appropriately matched to the service and needs of the

12. Match the type of technology to the goal and/or service: video for patient evaluation; secure e-mail or telephone for

15. Obtain overall and financial support of the program from senior leadership of the organization; ensure telemedicine and

3. Adequately train all site coordinators in the technical and procedural aspects of the service, including referral guidelines and

**•** What are the intersections of culture, class, geography, and technology in our current mental health system, and how do these intersections vary across differing racial/ethnic and class

providers, systems, technology, and other important issues?

subculture groups?

*Clinical/Educational*

medications, illnesses).

emergencies). *Technical*

*Administrative*

*Culture*

practice to fit its use, and identifying its limitations.

transfer of patient medical information to the specialist and back to the referral site.

10. Provide regular technical maintenance and prompt trouble-shooting.

13. Do a site visit to spokes to build relationships and trust.

outreach is aligned with spoke�s overall mission of the organization

16. Develop financial stability after start-up funds with grants and/or contracts.

20. Sites: physicians (e.g., education, skill, performance), staff and clinic system.

**Table 6.** Key Issues in Telepsychiatric Consultation to CA Indian Health Sites.

5. Remember, with new services, the most complex of cases often are tried first (i.e., be patient). 6. Integrate telepsychiatric service with spoke on-site care: therapy, substance or cultural.

11. Have a back-up coordinator at spoke sites for unexpected times the primary coordinator is out.

14. Do a thorough needs assessment in the region that the program is planning to serve

17. Patients� data: sociodemographics, medical and psychiatric diagnoses and satisfaction. 18. Outcomes: disorder-specific (e.g., symptoms), adherence and functional (e.g., SF-12). 19. Services: type preferred and used; adherence; boundary with other system�s services; holes.

22. Obtain consultation from spoke and/or hub specialist on Indian culture, history and illness, as indicated. 23. Include a section on documentation (e.g., brief note the day of, the dictation) re: cultural and/or spiritual issues.

providers or staff stop in if desired).

8. Use clinically proven technology.

physician-to-physician consultation.

patient and their condition.

*Evaluation: hub and spoke*

21. Costs: patient, hub and spoke.

More concerted research on intersecting issues of culture, language, social class, ethnicity, geography, and e-mental health (Yellowlees et al 2008). Scientific and policy recommendations from this discussion include:

#### *Clinical/Educational*

were worried about seeking services due to concern that in small communities that "everyone would know". Certainly trained professionals do their best on these concerns, but the intro‐ duction of telemedicine facilitated a more open framework for discussing past events. Providers outside the reservation were seen as neutral parties. Attention was paid, of course, to what was disclosed to the local providers, particularly when one covered for another.

Telepsychiatric consultation may help provide psychiatric services with primary care in Native American communities, which is important because substance abuse/dependence, mental health, and medical treatments are often not integrated and communication between clinicians may be rare (Manson 2000). Patients' comments about their preference for telepsychiatric consultation, because of community stigma and uncertainty about confidentiality, may be significant and require further evaluation. The preliminary high satisfaction rates for patients and staff are encouraging, considering rural and cultural factors that may affect service

An "effective" program considers clinical, technical, administrative, evaluation, and cultural factors, based on conversations with patients, staff, clinicians, administrators and technicians of this project and according to the literature (Table 6) (Hilty et al 2013; Hilty et al 2004a; Darkins 2001). A developmental model of rural telepsychiatry emphasized stages of needs identifica‐ tion, infrastructure survey, partnership organization, structure configuration, pilot imple‐ mentation, and solidification (Shore 2005). In particular, cultural factors that affect helpseeking, diagnosis, treatment, and outcomes need to be measured and explored. In the clinical/ educational realm, it is important to remember the most complex referrals come first. It is important to be patient with these and the process, in building the relationship with the rural team and using them as opportunities to learn about rural patients' needs, or the "holes" in

While technology is certainly reported as being highly beneficial in enhancing mental health outcomes, actual access to information technology is extremely variable and such technologies themselves may also be viewed and understood differently by individuals of different ethnic and cultural backgrounds. The issue of disparate access to technology by individuals of different ethnic and cultural backgrounds reveals that access to information technology differs significantly, depending not only on an individual's race or ethnicity, but also their income, their education level, and their geographical location (Mossberger et al 2006). African Ameri‐ can and Hispanic/Latino individuals tend to report more affinity for information technology than whites do, but tended to have lower access to this type of technology, and poorer skills to use it effectively. When poverty and low socioeconomic status were taken into account, only the Hispanic/Latino group in Mossberger and colleagues' study actually had significantly

More concerted research on intersecting issues of culture, language, social class, ethnicity, geography, and e-mental health (Yellowlees et al 2008). Scientific and policy recommendations

the rural service delivery system (that can be filled as in the case above).

poorer access to technology than the other two groups.

from this discussion include:

delivery.

94 Telemedicine

1. Obtain a telepsychiatric champion and provide adequate training for others with regard to the technology, adapt clinical practice to fit its use, and identifying its limitations.

2. Coordinate timing of consults (i.e., patient is there at the right time, telepsychiatrist has adequate time, and/or referring providers or staff stop in if desired).

3. Adequately train all site coordinators in the technical and procedural aspects of the service, including referral guidelines and transfer of patient medical information to the specialist and back to the referral site.

4. Documentation: appropriate policy and procedures for consent, forwarding pertinent information in advance (e.g., medications, illnesses).

5. Remember, with new services, the most complex of cases often are tried first (i.e., be patient).

6. Integrate telepsychiatric service with spoke on-site care: therapy, substance or cultural.

7. Match the type of service (e.g., consultation to spoke physician, triage, psychological testing, management) to the goal

and/or request, as well as standard and reasonable practice (e.g., may be hard to manage from afar, who handles emergencies).

*Technical*

8. Use clinically proven technology.

9. For each consult, be certain that the technical quality equipment is appropriately matched to the service and needs of the patient and their condition.

10. Provide regular technical maintenance and prompt trouble-shooting.

11. Have a back-up coordinator at spoke sites for unexpected times the primary coordinator is out.

12. Match the type of technology to the goal and/or service: video for patient evaluation; secure e-mail or telephone for

physician-to-physician consultation.

*Administrative*

13. Do a site visit to spokes to build relationships and trust.

14. Do a thorough needs assessment in the region that the program is planning to serve

15. Obtain overall and financial support of the program from senior leadership of the organization; ensure telemedicine and outreach is aligned with spoke�s overall mission of the organization

16. Develop financial stability after start-up funds with grants and/or contracts.

*Evaluation: hub and spoke*

17. Patients� data: sociodemographics, medical and psychiatric diagnoses and satisfaction.

18. Outcomes: disorder-specific (e.g., symptoms), adherence and functional (e.g., SF-12).

19. Services: type preferred and used; adherence; boundary with other system�s services; holes.

20. Sites: physicians (e.g., education, skill, performance), staff and clinic system.

21. Costs: patient, hub and spoke.

*Culture*

22. Obtain consultation from spoke and/or hub specialist on Indian culture, history and illness, as indicated.

23. Include a section on documentation (e.g., brief note the day of, the dictation) re: cultural and/or spiritual issues.

**Table 6.** Key Issues in Telepsychiatric Consultation to CA Indian Health Sites.


**•** To what extent can technology be used to increase access to high-quality mental health services, and how will confounding/mediating) variables such as geography, poverty, education, and socioeconomic status prevent effective care?

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[2] AACAP Practice Parameter for Telepsychiatry with Children and AdolescentsJ Am

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[9] Beals, J, Piasecki, J, Nelson, S, Jones, M, Keane, E, & Dauphinais, P. Red Shirt R, Sack W, Manson SM. Psychiatric disorder among American Indian adolescents: Preva‐ lence in Northern Plains youth. J Am Academy Child Adol Psychiatry, (1997). , 36,

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