Effectiveness of proactive video therapy for problematic alcohol use on treatment initiation, compliance, and alcohol intake: a randomised controlled trial in Denmark

BACKGROUND

Few people with problematic alcohol use reach treatment and dropout is frequent. Therapy for problematic alcohol use delivered via video conference (e-alcohol therapy) might overcome treatment barriers. In this randomised study, we tested whether proactive e-alcohol therapy outperformed face-to-face alcohol therapy (standard care) regarding treatment initiation, compliance, and weekly alcohol intake at 3-month and 12-month follow-up.

METHODS

In this two-arm randomised controlled trial, we recruited individuals who had problematic alcohol use, defined as a score of 8 or more on the Alcohol Use Disorders Identification Test; were 18 years or older; and had access to a personal computer, smartphone, or tablet with internet access in Denmark through online advertisements. Participants were assigned to receive alcohol therapy delivered either face-to-face or via video conference. The number, frequency, and duration of therapy sessions were individualised in both groups. Data analysis was conducted using masked data. Primary analyses were based on an intention-to-treat sample. The study is registered with ClinicalTrials.gov (NCT03116282).

FINDINGS

Between Jan 22, 2018, and June 29, 2020, 816 individuals signed up for the trial and 502 (63%) were assessed for eligibility. We randomly assigned 379 to proactive e-alcohol therapy (n=187) or standard care (n=192), of which, 170 (48%) participants were female and 186 (52%) were male. In the intervention group, more participants initiated treatment (155 [88%] of 177 vs 96 [54%] of 179; odds ratio [OR] 6·3; 95% CI 2·8 to 13·8; p<0·0001 at 3 months; 151 [85%] of 177 vs 115 [64%] of 179; OR 3·2; 95% CI 1·6 to 6·2; p=0·0007 at 12 months) and complied with treatment (130 [73%] of 177 vs 74 [41%] of 179; OR 4·0; 95% CI 2·2 to 7·2; p<0·0001 at 3 months; 140 [79%] of 177 vs 95 [53%] of 179; OR 3·4; 95% CI 1·8 to 6·3; p=0·0002 at 12 months). Weekly alcohol intake was significantly lower in the intervention group only after 3 months (13·0 standard drinks per week vs 21·3 standard drinks per week; adjusted difference -6·7; 95% CI -12·3 to -1·0; p=0·019).

INTERPRETATION

Proactive e-alcohol therapy was associated with increased treatment initiation and compliance and is promising as an easily accessible and effective alcohol treatment for individuals with problematic alcohol use.

FUNDING

TrygFonden.

The impact of COVID-19 on trends in alcohol use disorder treatment in Veterans Health Administration

BACKGROUND AND AIMS

The COVID-19 pandemic disrupted health-care provision in the United States and prompted increases in telehealth-delivery of care. This study measured alcohol use disorder (AUD) treatment trends across visit modalities before and during COVID-19.

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

We conducted a national, retrospective cohort study with interrupted time-series models to estimate the impact of COVID-19 on AUD treatment in the Veterans Health Administration (VHA) in the United States during pre-COVID-19 (March 2019 to February 2020) and COVID-19 (March 2020 to February 2021) periods. We analyzed monthly trends in telephone, video and in-person visits for AUD treatment and compared patient and treatment characteristics of patients receiving AUD treatment between the pre-COVID-19 and COVID-19 periods. AUD was defined using International Classification of Diseases, 10th revision (ICD-10) codes for alcohol abuse (F10.1) and alcohol dependence (F10.2), which have previously been used to study AUD in VHA.

FINDINGS

The predicted percentage of VHA patients with an AUD diagnosis receiving any AUD treatment at the beginning of the pre-COVID period was 13.8% (n = 49 494). The predicted percentage decreased by 4.3% (P = 0.001) immediately at the start of the COVID-19 period due to a decline in AUD psychotherapy. Despite an increase of 0.3% per month (P = 0.026) following the start of COVID-19, the predicted percentage of VHA patients with an AUD diagnosis receiving any AUD treatment at the end of the study period remained below the pre-COVID-19 period. In February 2021, AUD psychotherapy visits were primarily delivered by video (50%, 58 748), followed by in-person (36.6%, 43 251) and telephone (13.8%, 16 299), while AUD pharmacotherapy visits were delivered by telephone (38.9%, 3623) followed by in-person (34.3%, 3193) and video (26.8%, 2498) modalities. Characteristics of VHA patients receiving AUD treatment were largely similar between pre-COVID-19 and COVID-19 periods.

CONCLUSIONS

Despite increased telehealth use, the percentage of United States Veterans Health Administration patients with an alcohol use disorder (AUD) diagnosis receiving AUD treatment declined during COVID-19 (March 2020 to February 2021) mainly due to a decrease in psychotherapy.

The Evolution of Telepsychiatry for Substance Use Disorders During COVID-19: a Narrative Review

Purpose of Review

This article aims to review and synthesize the current research evidence regarding the efficacy of telepsychiatry-delivered substance use disorder treatment using a narrative review with a focus on the effects of remote healthcare delivery within the substance abuse treatment space.

Recent Findings

The COVID-19 pandemic exerted substantial pressures on all levels of society. Social isolation, loss of employment, stress, physical illness, overburdened health services, unmet medical needs, and rapidly changing pandemic restrictions had particularly severe consequences for people with mental health issues and substance use disorders. Since the start of the pandemic, addiction treatment (and medical treatment overall) using remote health platforms has significantly expanded to different platforms and delivery systems. The USA, in particular, reported transformational policy developments to enable the delivery of telehealth during the COVID-19 pandemic. However, systemic barriers such as a widespread lack of internet access and insufficient patient and provider digital skills remain.

Summary

Overall, telepsychiatry is a promising approach for the treatment of substance use disorders, but more randomized controlled trials are needed in the future to assess the evidence base of available interventions.

Determinants of preference for telehealth versus in-person treatment for substance use disorders: A discrete choice experiment

INTRODUCTION

Access to substance use disorder (SUD) treatment remains a significant issue in the United States. Telehealth has potential for increasing access to services; however, it is underutilized in SUD treatment compared to mental health treatment. This study uses a discrete choice experiment (DCE) to examine stated preferences for telehealth (videoconferencing, text-based + video, text only) versus in-person SUD treatment (community-based, in-home) and the attributes (location, cost, therapist choice, wait time, evidence-based practices) most important when choosing between modalities. Subgroup analyses are reported about preference differences based on type of substance and substance use severity.

METHODS

Four hundred participants completed a survey containing a DCE with eighteen choice sets, the alcohol use disorders inventory test, drug abuse screening test, and a brief demographic questionnaire. The study collected data between April 15, 2020, and April 22, 2020. Conditional logit regression provided a measure of strength for participant preferences for technology-assisted treatment compared to in-person care. The study provides willingness to pay estimates as a real-world measure for the importance of each attribute in participants' decision-making.

RESULTS

Telehealth options that include a video conference option were equally preferrable to in-person care modalities. Text-only treatment was significantly less preferable to all other modalities of care. The ability to choose one's own therapist was a significant driver of treatment preference beyond modality, while wait time did not appear significant in making decisions. Participants with the most severe substance use differed in that they were open to text-based care without video conferencing, did not express a preference for evidence-based care, and valued therapist choice significantly more than those with only moderate substance use.

CONCLUSIONS

Telehealth for SUD treatment is equally preferable to in-person care offered in the community or at home, signifying preference is not a barrier for utilization. Text-only modalities may be enhanced by offering videoconference options for most individuals. Individuals with the most severe substance use issues may be willing to engage in text-based support without synchronous meetings with a provider. This approach may offer a less intensive method to engage individuals in treatment who may not otherwise access services.

Patient evaluation of a smartphone application for telehealth care of opioid use disorder

Background

People with opioid use disorder (OUD) face barriers to entering and remaining in life-saving treatment (e.g., stigma, detrimental interactions with health care, and privacy concerns). Telehealth and related technology can reduce barriers to entering and staying in care. Patient feedback is critical to the development of these newer treatment approaches to ensure they are usable and do not inadvertently recreate treatment barriers.

Purpose

Evaluate the perceived usability of existing and planned features of a mobile application (app) that facilitates delivery of OUD treatment via telehealth.

Methods

People with current or prior experience with OUD treatment were eligible for the study. Participants (n = 31; 55% women) provided feedback on an interactive prototype demonstration via individual qualitative interviews and completed a quantitative survey on the app’s perceived usability. Descriptive statistics summarized the usability survey. We analyzed qualitative interview transcripts to elicit common themes.

Results

Participants were primarily white (77%) with a mean age of 42.2 years (range 22–69). Participants rated the six major features of the current app as helpful (median response 5 out of 5) and appreciated the flexibility of conducting a visit from a place of their choosing. Participants regarded the five proposed components of the app, such as daily affirmations and medication treatment-related reminders (e.g., pick up medication at pharmacy, medication schedule), as useful features with medians 5 out of 5, and reported they would recommend the app to others for OUD care. Participant qualitative interviews provided additional information on perceived usability of existing and proposed app features.

Conclusion

Our study suggests that an appealing, easy-to-use app—with tools and features that effectively support care—could circumvent existing barriers and foster sustained recovery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-022-00331-4.

Comparing efficacy of telehealth to in-person mental health care in intensive-treatment-seeking adults

The heightened acuity in anxiety and depressive symptoms catalyzed by the COVID-19 pandemic presents an urgent need for effective, feasible alternatives to in-person mental health treatment. While tele-mental healthcare has been investigated for practicability and accessibility, its efficacy as a successful mode for delivering high-quality, high-intensity treatment remains unclear. This study compares the clinical outcomes of a matched sample of patients in a private, nation-wide behavioral health treatment system who received in-person, intensive psychological treatment prior to the COVID-19 pandemic (N = 1,192) to the outcomes of a distinctive group of patients who received telehealth treatment during the pandemic (N = 1,192). Outcomes are measured with respect to depressive symptoms (Quick Inventory of Depressive Symptomatology-Self-Report; QIDS-SR) and quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire; Q-LES-Q). There were no significant differences in admission score on either assessment comparing in-person and telehealth groups. Patients in the partial hospitalization level of care stayed longer when treatment was remote. Results suggest telehealth as a viable care alternative with no significant differences between in-person and telehealth groups in depressive symptom reduction, and significant increases in self-reported quality of life across both groups. Future research is needed to replicate these findings in other healthcare organizations in other geographical locations and diverse patient populations.

Increased Attendance During Rapid Implementation of Telehealth for Substance Use Disorders During COVID-19 at the Largest Public Hospital System in the United States

OBJECTIVE

The objective of this study is to examine differences between; telehealth and in-person visits during COVID-19 and in a pre-COVID-19 reference period; COVID-19 televisit completion for patients with varying engagement in treatment during the reference period.

METHODS

Electronic medical record data were collected and analyzed with chi-squared or t-tests to compare patient demographics. Generalized estimating equations for estimating the odds of outcomes were used, controlling for demographics.

RESULTS

Patients were 3.34 and 1.74 times more likely to complete a telehealth visit (n = 11,839) compared with an in-person visit during (n = 7,917) and prior (n = 15,497) to COVID-19. For patients on buprenorphine, patients with no prior in-person visits during the pre-televisit period were 2.26 more likely to complete televisits compared with patients with two or more prior in-person visits. For all patients, those with two or more prior in-person visits in the reference period were 1.27 times more likely to complete a televisit compared with a patient with no in-person visits during the pre-televisit period. There was no significant difference when comparing with patients who had only one prior in-person visit to those patients with no prior visits.

CONCLUSIONS

In this study, outpatient substance use disorder (SUD) telehealth appointments were associated with higher odds of visit completion compared with in-person visits during and prior to COVID-19. Patients receiving buprenorphine, without prior in person visits, were more likely to attend if they did not have in-person visits prior to COVID-19. Regulators should consider permanently adopting telehealth flexibilities for SUD treatment once the federal emergency status has ended.

The Impact of COVID-19 on Provider Perceptions of Telemental Health

The present study was designed to assess mental health provider attitudes and perceptions of telemental health (TMH) prior to and during the COVID-19 Pandemic, as well as the nature of their TMH utilization. The study aimed to gather information about positive and negative attitudes towards TMH, perceptions and correlates based on the modality of care, and beliefs about the overall effectiveness of TMH as compared to face-to-face care. The current study is part of a larger mixed methods project utilizing a repeated cross-sectional design. An online survey was administered to a sample of 1448 mental health providers and included demographic and professional information, experiences with and perceptions of TMH prior to and during the COVID-19 Pandemic, as well as a brief measure of pandemic-related stress. The COVID-19 Pandemic resulted in an increased use of TMH in the study sample. During COVID-19, providers reported increased agreement with TMH being necessary, important, and effective for care delivery. Providers who primarily used video, compared with telephone, reported that TMH was more useful, satisfying, and effective. While negative attitude towards TMH was predicted only by prior attitudes and belief in TMH effectiveness, positive attitude towards TMH was also predicted by female sex and current level of pandemic related stress. TMH use during the pandemic was predicted by primary use of video platform and previous TMH use. The 2020 COVID-19 Pandemic resulted in increased use of TMH and significantly increased positive perceptions about TMH among mental health providers.

An explanatory sequential investigation of the working alliance as a change process in videoconferencing psychotherapy

OBJECTIVES AND DESIGN

Debate exists as to patient experience, and the importance, of the working alliance (WA) in videoconferencing psychotherapy (VCP). This study used a two-phase explanatory sequential design to investigate the WA as a change process in VCP.

METHODS

Phase I: sessional VCP outcome and WA data were analysed using multilevel modelling (n = 46). Phase II: participants (n = 12) from Phase I were recruited to semi-structured interviews, analysed using thematic framework analysis.

RESULTS AND CONCLUSIONS

Results demonstrate: (1) a significant correlation between WA and outcome (F(1, 15.19) = 25.01, p < 0.001), (2) previous session WA significantly predicted outcome in the next session (F(1, 355.61) = 4.47, p < 0.05), and (3) previous session outcome significantly predicted next session WA (F(1, 55.3) = 15.19, p < 0.001), with three core themes explaining patient experience (engaging with the medium, connection with the therapist, and working via the medium). Results are discussed and future research recommended.

Patient Satisfaction With Medications for Opioid Use Disorder Treatment via Telemedicine: Brief Literature Review and Development of a New Assessment

Telemedicine is increasingly being used to treat patients with opioid use disorder (OUD). It has particular value in rural areas of the United States impacted by the opioid crisis as these areas have a shortage of trained addiction medicine providers. Patient satisfaction significantly impacts positive clinical outcomes in OUD treatment and thus is of great clinical interest. Yet little is known regarding patient satisfaction with the increasingly important platform of telemedicine-delivered medications for opioid use disorder (tMOUD). The goal of this review is to provide a summary of the existing literature regarding patient satisfaction with tMOUD. We also submit a novel survey based on an existing framework designed to assess tMOUD satisfaction, and present pilot data (N = 14) acquired from patients engaged in rural tMOUD care. Telemedicine provides a feasible method for delivering MOUD in rural areas, and our survey provides a useful assessment to measure patient satisfaction with tMOUD. In light of the pressing need for innovative and technology-driven solutions to the opioid epidemic (especially in light of the COVID-19 pandemic), future research should focus on the development and refinement of tools to assess the important implementation goal of patient satisfaction.

An integrated videoconferencing intervention for chronic pain and heavy drinking among patients in HIV-care: a proof-of-concept study

Chronic pain and heavy drinking are common comorbid conditions among people living with HIV/AIDS (PLWHA). An integrated approach to address these co-occurring conditions in a manner that facilitates treatment utilization would represent an important advance in HIV-care. This study examined the acceptability and feasibility of a tailored, videoconferencing intervention to reduce chronic pain and heavy drinking among PLWHA. Participants in HIV-care (n = 8) completed baseline assessments and an in-person intervention session followed by 6 videoconferencing sessions. Acceptability and feasibility were assessed with patient satisfaction ratings and interview responses 8 weeks following baseline along with videoconferencing use during the intervention period. Treatment satisfaction and comprehensibility ratings were high and supported by interview responses indicating the value of the intervention content, treatment alliance, and format. All participants successfully enabled videoconferencing on their own smartphones and completed a median number of 4.5 (out of 6) video-sessions. Changes in heavy drinking and pain provided additional support for the potential utility of this approach. Results suggest that this videoconferencing intervention is an acceptable and feasible method of addressing chronic pain and heavy drinking among PLWHA. Findings provide the basis for future work to examine the efficacy of this approach in a Stage 1b trial.

Telemedicine-delivered treatment interventions for substance use disorders: A systematic review

With increased negative impacts from opioid and other substance use disorders in the US, it is important for treatments to not only be effective, but also accessible to patients. Treatment delivery via telemedicine, specifically, the use of videoconferencing, which allows real time communication between a patient and a clinician at a distant site, has been shown to be an effective approach for increasing reach and access to treatments for mental health disorders and other chronic illnesses. This systematic review identified and summarized studies examining the effectiveness of telemedicine interventions to deliver treatment for patients with substance use disorders. Out of 841 manuscripts that met our search criteria, 13 studies met the inclusion criteria. Studies covered interventions for nicotine, alcohol and opioid use disorders. They varied widely in size, quality, and in the comparison groups examined. Studies examined both delivery of psychotherapy and medication treatments. Most studies suggested telemedicine interventions were associated with high patient satisfaction and are an effective alternative, especially when access to treatment is otherwise limited. However, there were substantial methodological limitations to the research conducted to date. Further studies are needed, including larger scale randomized studies that examine different models of telemedicine that can be integrated into existing healthcare delivery settings, to increase the use of effective treatments for patients with substance use disorders.

Evidence for telehealth group-based treatment: A systematic review

Background

Interest in the use of telehealth interventions to increase access to healthcare services is growing. Group-based interventions have the potential to increase patient access to highly needed services. The aim of this study was to systematically review the available literature on group-based video teleconference services.

Methods

The English-language literature was searched using Ovid MEDLINE, PubMed, PsycINFO and CINAHL for terms related to telehealth, group therapy and support groups. Abstracts were reviewed for relevance based on inclusion criteria. Multiple study types were reviewed, including open-label, qualitative and randomised controlled trial study designs. Data were compiled regarding participants, study intervention and outcomes. Specific areas of interest were the feasibility of and satisfaction with telehealth technology, as well as the effect of video teleconference delivery on group dynamics, including therapeutic alliance.

Results

Forty published studies met the inclusion criteria and were included in the review. Six were randomised controlled trials. Among the studies, there was a broad range of study designs, participants, group interventions and outcome measures. Video teleconference groups were found to be feasible and resulted in similar treatment outcomes to in-person groups. However, few studies were designed to demonstrate noninferiority of video teleconference groups compared with in-person groups. Studies that examined group process factors showed small decreases in therapeutic alliance in the video teleconference participants.

Conclusions

Video teleconference groups are feasible and produce outcomes similar to in-person treatment, with high participant satisfaction despite technical challenges. Additional research is needed to identify optimal methods of video teleconference group delivery to maximise clinical benefit and treatment outcomes.

Patient Satisfaction With Videoconferencing-based Treatment for Alcohol Use Disorders

OBJECTIVES

The objectives of this study are (1) to compare the satisfaction between patients who have received treatment as usual face-to-face (TAU group) and patients who have received optional videoconferencing-based treatment for alcohol use disorders (TAU+I group); and (2) to elaborate on the TAU+I group's satisfaction with the treatment in general and the technical equipment.

METHODS

The design consisted of mixed methods: a survey and a qualitative study. Data consisted of self-reported data from questionnaires filled out by both groups and semistructured interviews with the TAU+I group. Data from the questionnaires were analyzed statistically using Stata. The semistructured interviews were analyzed using a general inductive approach.

RESULTS

The survey indicated that the TAU+I group and TAU group were equally satisfied with the elements in the treatment. The interview indicated that the TAU+I group seemed to have a high satisfaction with most elements in the treatment. Patients who used videoconferencing were satisfied with establishing the videoconferencing connection and with the picture quality but less satisfied with the sound quality.

CONCLUSIONS

Overall, the patients were satisfied with the treatment. We saw a nonsignificant tendency that the TAU+I group were more satisfied with the treatment in general, compared with the TAU group. It is a possibility that patients in this group felt more satisfied with the treatment as they had the opportunity to choose videoconferencing. Offering videoconferencing-based treatment may be a positive feature in the treatment and lead to improved outcomes of the treatment courses. The technical equipment and routine using it should be improved in future studies or during implementation.

Pilot Study of a Telehealth-Delivered Medication-Augmented Exposure Therapy Protocol for PTSD

Posttraumatic stress disorder (PTSD) is a serious condition, with certain occupations at increased risk due to greater trauma exposure. These same individuals face multiple barriers to care. This study aimed to investigate the feasibility of conducting a research trial with exposure therapy delivered via videoconferencing. Eleven adults working in occupations at risk with PTSD enrolled and seven completed 12 to 15 sessions. Individuals were randomized to receive the cognitive enhancer D-cycloserine or placebo, and participants provided saliva samples for genetic analysis. Treatment completers demonstrated decreases in PTSD and depressive symptomatology (measured by CAPS [p < 0.001, d = 2.79] and BDI-II [p = 0.004, d = 0.92]). Participants reported high therapeutic alliance, treatment satisfaction, and telehealth satisfaction. There were no significant technical, medication, or safety issues, and no clinical emergencies. The results suggest that it may be feasible to conduct clinical research using telehealth for PTSD and to use telehealth to increase access to care.

Opioid use disorder patients' perceptions of healthcare delivery platforms

OBJECTIVES

To assess the acceptability and quality of web-based videoconferencing telemedicine consultation platform in the treatment of opioid use disorder at TrueNorth Medical Centre.

METHODS

We conducted an interview based quality improvement initiative using an investigator-designed questionnaire. The questionnaire consisted of 17 Agree/Disagree questions, measured on a 7-point Likert scale and 2 questions where patients had the ability to elaborate qualitatively on their perceptions and experiences with their telemedicine service. Content-style analysis was performed on qualitative responses.

RESULTS

The majority of patients (n=14; 47%) preferred face-to-face over telemedicine consultations. The number of patients that preferred telemedicine consultations over face-to-face consultations was lower (n=6; 20%). A notable number of patients (n=10; 33%) indicated no specific preference for either telemedicine or face-to-face consultations. Patients preferring face-to-face consultations rated their clinical outcome and patient-physician relationship following telemedicine consultations similarly as those who preferred telemedicine consultations. Patients preferring telemedicine rated their experience and overall perceptions of the service significantly higher than those preferring face-to-face consultations. Patients who preferred telemedicine consultations identified the efficient and timesaving nature of telemedicine consultations as primary advantages whereas those preferring face-to-face consultations reported lower levels of empathy from their physician during telemedicine consultations as a major disadvantage.

CONCLUSIONS

The majority of patients at TrueNorth Medical Centre viewed telemedicine consultations as an acceptable treatment modality. Patients preferring telemedicine consultations and those preferring face-to-face consultations evaluated the majority of the measured indices of care in a similar fashion.

Trends in telemedicine use in addiction treatment

Introduction

Telemedicine use in addiction treatment and recovery services is limited. Yet, because it removes barriers of time and distance, telemedicine offers great potential for enhancing treatment and recovery for people with substance use disorders (SUDs). Telemedicine also offers clinicians ways to increase contact with SUD patients during and after treatment.

Case description

A project conducted from February 2013 to June 2014 investigated the adoption of telemedicine services among purchasers of addiction treatment in five states and one county. The project assessed purchasers’ interest in and perceived facilitators and barriers to implementing one or more of the following telemedicine modalities: telephone-based care, web-based screening, web-based treatment, videoconferencing, smartphone mobile applications (apps), and virtual worlds.

Discussion and evaluation

Purchasers expressed the most interest in implementing videoconferencing and smartphone mobile devices. The anticipated facilitators for implementing a telemedicine app included funding available to pay for the telemedicine service, local examples of success, influential champions at the payer and treatment agencies, and meeting a pressing need. The greatest barriers identified were: costs associated with implementation, lack of reimbursement for telemedicine services, providers’ unfamiliarity with technology, lack of implementation models, and confidentiality regulations. This paper discusses why the project participants selected or rejected different telemedicine modalities and the policy implications that purchasers and regulators of addiction treatment services should consider for expanding their use of telemedicine.

Conclusions

This analysis provides initial observations into how telemedicine is being implemented in addiction services in five states and one county. The project demonstrated that despite the considerable interest in telemedicine, implementation challenges exist. Future studies should broaden the sample analyzed and track technology implementation longitudinally to help the research and practitioner communities develop a greater understanding of technology implementation trends and practices.

Methodology for conducting the children's attention-deficit hyperactivity disorder telemental health treatment study in multiple underserved communities

BACKGROUND

Children living in nonmetropolitan communities are underserved by evidence-based mental health care and are underrepresented in clinical trials.

PURPOSE

In this article, we describe lessons learned in conducting the Children's Attention-Deficit Hyperactivity Disorder (ADHD) Telemental Health (TMH) Treatment Study (CATTS), a randomized controlled trial testing the effectiveness of TMH in improving outcomes of children with ADHD living in underserved communities.

METHODS

Children were referred by primary care providers (PCPs). The test intervention group received six telepsychiatry sessions with each session followed by an caregiver behavior training session delivered in-person by a local therapist. A secure website was used to support decision making by the telepsychiatrists and to facilitate real-time collaboration between the telepsychiatrists and community therapists. The control group received a single telepsychiatry consultation. Questionnaires tapping ADHD symptoms and other outcomes were administered to parents and teachers online through a secure portal from personal computers.

RESULTS

total of 88 PCPs in seven communities referred the 223 children who participated in the trial. Attrition in treatment sessions and research assessments was very low. Lessons learned TMH proved to be a viable means of providing evidence-based pharmacological services to children and training to local therapists. Recruitment was enhanced by offering the control group a telepsychiatry consultation. Site-specific strategies were needed to meet recruitment targets.

CONCLUSIONS

The CATTS trial used methods designed to optimize inclusion of children living in multiple dispersed and underserved areas. The study will serve as a model for other research projects aiming at reducing geographic disparities in access to quality mental health care.

Avatar therapy: where technology, symbols, culture, and connection collide

The topic of "e-therapy" is of great research and clinical interest in 2012. This article presents a case study that examines several elements of psychotherapy, as administered in the "Second Life" virtual environment. In this case, psychotherapy took place primarily via text messaging between two avatars (client and therapist) who "sat" in a virtual office. The therapist resided in the United States and provided therapy to an individual from a developing nation who was currently residing in another more developed Middle Eastern country for work and to escape political atrocities being committed in his home country. This case example raises many issues that could be explored, including the ethics of providing such therapy, cultural competence, technological details, and providing therapy across national lines. However, due to the complicated and multifaceted nature of providing therapy in a virtual environment, this case presentation focuses on technical issues, such as the basics of providing therapy in Second Life. Given that the patient in this case used multiple avatars (cartoon-like representations of himself) in therapy, the topic of the avatar as the expression of internal representations and conflicts is also examined. This case report also discusses the patient's presenting problems and elements of the therapeutic alliance such as transference and countertransference. Finally, suggestions for future research are made. The author posits that mental health professionals can now reach at-risk patients (e.g., refugees residing in other countries) whom they were not previously able to treat and suggests that mental health practitioners may have an ethical duty to research and provide these kinds of services so that certain underserved populations may be treated. (Journal of Psychiatric Practice 2012;18:451-459).

Telemedicine interventions for substance-use disorder: a literature review

A literature review was conducted to identify research into multiple-contact (i.e. extended) telemedicine interventions for substance-use disorder. The goals were: (1) to describe the methodology used to evaluate telemedicine interventions; (2) to identify the range of interventions which have been formally evaluated; and (3) to summarize the findings. Fourteen databases and Google Scholar were searched, as well as bibliographies of relevant papers and online conference abstracts. There were 50 studies which met the inclusion criteria, of which 50% were randomized controlled trials. The studies most frequently reported the effect on substance use and 61% of those findings fully supported telemedicine interventions. Although the studies reported persistent challenges in sustaining participation, 76% of the studies reporting on satisfaction indicated that participants were enthusiastic supporters of telemedicine. Only 30% of reviewed studies addressed the effect on resource utilization. The majority of studies reported evidence of clinical effectiveness, which justifies continued research in the field.

Current Directions in Videoconferencing Tele-Mental Health Research

The provision of mental health services via videoconferencing tele-mental health has become an increasingly routine component of mental health service delivery throughout the world. Emphasizing the research literature since 2003, we examine: 1) the extent to which the field of tele-mental health has advanced the research agenda previously suggested; and 2) implications for tele-mental health care delivery for special clinical populations. Previous findings have demonstrated that tele-mental health services are satisfactory to patients, improve outcomes, and are probably cost effective. In the very small number of randomized controlled studies that have been conducted to date, tele-mental health has demonstrated equivalent efficacy compared to face-to-face care in a variety of clinical settings and with specific patient populations. However, methodologically flawed or limited research studies are the norm, and thus the research agenda for tele-mental health has not been fully maximized. Implications for future research and practice are discussed.

VA telemental health: suicide assessment

The Department of Veterans Affairs (VA) encompasses one of the largest telemental health networks in the world, with over 45,000 videoconferencing and over 5,000 home telemental health encounters annually. Recently, the VA designated suicide prevention as a major priority, with telehealth modalities providing opportunities for remote interventions. Suicide risk assessments, using videoconferencing, are now documented in the literature, as are current studies that find telemental health to be equivalent to face-to-face treatment. Remote assessment of suicidality, however, involves complex legal issues: licensing requirements for remote delivery of care, legal procedures for involuntary detainment and commitment of potentially harmful patients, and liability questions related to the remote nature of the mental health service. VA best practices for remote suicide risk assessment include paradigms for establishing procedures in the context of legal challenges (licensing and involuntary detainment/commitment), for utilizing clinical assessment and triage decision protocols, and for contingency planning to optimize patient care and reduce liability.

Empirical evidence on the use and effectiveness of telepsychiatry via videoconferencing: implications for forensic and correctional psychiatry

A growing body of literature now suggests that use of telepsychiatry to provide mental health services has the potential to solve the workforce shortage problem that directly affects access to care, especially in remote and underserved areas. Live interactive two-way audio-video communication-videoconferencing-is the modality most applicable to psychiatry and has become synonymous with telepsychiatry involving patient care, distance education, and administration. This article reviews empirical evidence on the use and effectiveness of videoconferencing in providing diagnostic and treatment services in mental health settings that serve child, adolescent, and adult populations. Descriptive reports, case studies, research articles, and randomized controlled trials related to clinical outcomes were identified and reviewed independently by two authors. Articles related to cost-effectiveness, technological issues, or legal or ethical aspects of telepsychiatry were excluded. The review of the evidence broadly covers mental health service provision in all settings, including forensic settings. Given the sparse literature on telepsychiatry in forensic settings, we discuss implications for mental health care across settings and populations and comment on future directions and potential uses in forensic or correctional psychiatry.

Consultation-liaison psychiatry: how far have we come?

This article takes stock of how far the field of consultation-liaison psychiatry has come since its inception in the 20th century. In order to do this, we review its past in terms of its knowledge base in psychosomatic medicine and in terms of its practice at the bedside in the general hospital setting. We also offer a contemporary account of the field and finish with a subjective view of the opportunities and pitfalls faced during the next phase of consultation-liaison psychiatry in the 21st century.