Mental Health Challenges In Caring For American Indians and Alaska Natives

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Continuing Education Activity

Mental health conditions are highly prevalent amongst the American Indian and Alaskan Native populations. Compared to other ethnic groups, this population has a high rate of post-traumatic stress disorder, substance use disorder, and suicidality. This activity reviews the role of the interprofessional team in improving care for patients with these conditions.

Objectives:

  • Describe the challenges to the management of mental health disorders amongst American Indians and Alaskan Natives.
  • Summarize the common mental health disorders in American Indians and Alaskan Natives.
  • Identify specific risk factors for increased suicidality in American Indians and Alaskan Natives.
  • Explain the importance of cultural competence in health care.

Introduction

American Indians (AI) and Alaska Natives (AN), descendants of the indigenous people, are a diverse population group growing in number every year. Studies have shown that American Indians and Alaska Natives (AI/ANs) have a decreased life expectancy, higher mortality rate, and lower quality of life than the general US population.[1][2]

In addition to having higher rates of general medical conditions such as diabetes, obesity, and high blood pressure, there is a high prevalence of mental health problems and psychiatric comorbidity amongst American Indians and Alaska Natives (AI/ANs).[3][4] A national study comparing the prevalence of mental health disorders and associated treatment-seeking results showed higher rates of psychiatric disorders in American Indians and Alaska natives than non-Hispanic whites.[5][6] 

Post-traumatic stress disorder (PTSD), violence, suicide, and substance use have been identified as some of the more prevalent mental health issues among AI/ANs when compared with the general population in the United States.[7] Sociodemographic characteristics, including age, education, and income, are likely contributing factors for the number of psychiatric disorders seen in American Indians and Alaska Natives than other racial groups.[5] 

There should be an increased effort to improve AI/AN mental health care disparities through culturally competent clinical interventions. In working towards this goal, it is important to identify the existing disparities in mental health care delivery and outcomes among AI/ANs. This will then help guide the steps that are necessary for improved outcomes and reduction in health disparities.

Issues of Concern

American Indians and Alaskan natives have been associated with high rates of mental disorders and psychiatric diagnoses such as post-traumatic stress disorder, substance use disorder, and suicidal behaviors compared to other ethnic and racial groups.[5][7] The scientific community needs to continue to research the prevalence of mental health challenges for AI/ANs to determine the specific needs and current limitations of mental health care for this group of people.

PTSD

Research has found a high rate of American Indians and Alaskan natives with PTSD and PTSD-related symptoms compared to other races and ethnicities. In the general U.S. population, the prevalence of lifetime PTSD is 4.8% to 6.4%.[8] Among American Indian and Alaskan Native populations, the prevalence of PTSD estimates somewhere between 16% to 24%.[9][10][11] Post-traumatic stress disorder is a clinical diagnosis that is often the result of exposure to a severe stressor or a traumatic event.[12][13] For example, being exposed to death, threatened death, warfare, or sexual violence. High exposure to violence, substance use disorders, history of sexual or physical abuse, pre-existing psychiatric disorder, combat experience were identified as possible risk factors for PTSD among AI/AN groups. Studies have also shown a higher incidence of mental health problems among AI/AN veterans.[14] 

For a long time now, AI/ANs have served in the US Armed Forces at high rates, and this may be one of the contributing factors for the high prevalence of PTSD among this group.[7] One study highlighted the high prevalence of PTSD among American Indian veterans who had served in the Vietnam War. Of those who participated in the study, the lifetime prevalence for PTSD was between 40 and 60%, which was higher than any other ethnic or racial group of Vietnam veterans studied.[15][7] 

Substance Use Disorder 

High rates of substance use which includes both illicit drugs and alcohol use, is another major issue that should be recognized when addressing the specific needs in caring for mental health in AI/ANs. In one study which screened a group of 489 American Indian females at an Indian Health Service (IHS) institution, the lifetime prevalence for any substance use disorder was greater than 60%.[16] Another study was conducted on a group of 89 adolescent American Indians found that 94% of the group met the criteria for substance use disorder. In this study, a high percentage of participants met the criteria for cannabis use, alcohol use disorder, or both.[17]

Given the high number of adolescent AI/ANs with substance use disorders, it may help explore different interventions that may help prevent the early initiation of substance use. Of note, alcohol use was a large contributing factor for the significantly higher rate of premature deaths in AI/ANs than other races in the United States.[18] There is a known association between substance use disorder and PTSD, and a significant number of individuals who meet criteria for one condition will meet criteria for the other as well.[19] Therefore, it may be beneficial to explore specific trauma-focused interventions when reducing the risk of substance use amongst AI/ANs. 

Suicide

Suicide rates have historically been higher amongst the AI/AN population compared to the total US population. In 2015, the National Violent Death Reporting System (NVDRS) found that the suicide rates in the 18 participating states were more than 3.5 times higher than when compared to ethnic groups with the lowest suicide rates.[20] Another article reported the rate of completed suicide, attempts, and suicidal ideation were 50% higher for AI/ANs than the non-Hispanic White population. While suicidality is a major concern amongst all ethnic and age groups, past studies have found a disproportionate risk for suicide amongst AI adolescents.[21] 

Compared to other ethnic groups, AI/AN adolescents were found to have more severe negative experiences such as victimization, substance abuse, and depression and may contribute to increased suicidality.[22][23][22] Specifically, AI/AN adolescent males have been studied to have the highest risk for suicide.[24] Particularly, young AI/AN males who are unemployed, uneducated, or have a history of trauma were at greater risk of suicide.[25][26][27] Regarding suicide prevention among AI/ANs, several factors were identified as playing a role in building resilience to suicide risk. These included building meaningful social connections with others, being mindful about the negative effect one’s suicide may have on their loved ones, and utilizing available health resources and services.[28] 

There may be some utility in early identification and intervention amongst AI/ANs who experience suicidality. Suicidal behaviors have also been found to co-occur with substance use, including alcohol and drug use, in many AI/AN communities. Previous research on this topic has identified potential targets for intervention, including increasing coping skills, reducing the stigma of mental health services, and building an organized community infrastructure for health care for AI/ANs.

Clinical Significance

It has been well established that American Indians and Alaska Natives are disproportionately affected by different health conditions, including many mental health disorders compared to other ethnic and racial groups. The health disparities among this population group may in part be explained by the numerous sociodemographic and socioeconomic differences, including lower educational achievement, income, and health status.[6]

It is important for clinicians and public health officials to recognize these demographic and socioeconomic determinants of health inequalities and prioritize further research and efforts towards combating these disparities. Besides, it is also important to realize that there are cultural issues and other risk factors that may contribute to the high prevalence of mental health disorders among AI/ANs. The National Institute of Health (NIH) has taken the initiative to provide funding towards promoting health and disease prevention in Native Americans, including American Indians and Alaska Natives. Through this funding opportunity, multiple projects to improve health outcomes in this population group have been launched.[29]

Continued research relevant to the surveillance, prevention, and treatment of mental health disorders is necessary so that there may be further development of culturally appropriate interventions, and ultimately a reduction in the existing health disparities.

Enhancing Healthcare Team Outcomes

Health disparities for American Indians and Alaskan Natives have been attributed to limited access and availability of health services, education, and poverty.[30] It is also important to work towards creating more culturally competent health services for AI/ANs.

Access to Health Services

One way to improve mental health outcomes amongst American Indians and Alaskan Natives is to increase access to available healthcare services and facilities. The Indian Health Service (IHS), a federal agency established in 1955, is one of the main health care systems created to serve a large proportion of the Native Americans.[7] IHS provides health care services, including behavioral health services to AI/AN tribes that are federally recognized. One of the leading causes of hospitalization and ambulatory visits through IHS includes mental health services.[6] However, there are limitations to this health care system. While the overall health status of (AI/ANs) improved with the IHS introduction, significant health disparities persist for this population group.[30][31] 

Only federal hospitals that IHS funds may provide coverage for health services, and a large majority of these hospitals are located in areas that are geographically isolated. This makes it challenging for AI/AN seeking care in more urban areas and larger cities where there is a limited number of IHS-associated facilities.[30][4] With a growing population of AI/AN living in urban settings, it is important to incorporate this population into research studies. Historically, there has been minimal empirical data and research published on AI/AN in this setting.[32] 

Cultural Differences

It is important to recognize that there are cultural differences when it comes to health-related values and beliefs. There are various evidence-based treatments and western models of intervention that have been largely utilized by society in approaching the treatment of mental health disorders. However, even with these established treatment models, some AI/ANs prefer traditional healing and tribal traditions to address substance use and other mental health issues. There is the challenge of overcoming the distrust of formal services that may exist in Indigenous communities.[25] Even if there was a wider range of evidence-based therapies (EBTs) available to AI/AN communities, there is a high likelihood that AI/ANs may prefer traditional and informal services versus clinic-based interventions.[7] Therefore, it is important to continue to seek methods to integrate AI/AN cultural values and traditions into clinical practice.[33] 

Recognizing the importance of cultural competence may help to reduce health care disparities among AI/ANs. Cultural competence in health care means understanding and respecting the various cultures of different patient groups then using the knowledge to tailor health care to provide more culturally and linguistically appropriate interventions for different patient groups.[34] There have already been several proposed intervention strategies that are more culturally congruent for this population group. For example, the implementation of historical trauma interventions focused on addressing the psychological trauma and the subsequent unresolved grief that has cumulated from multiple generations of discrimination, oppression, genocide, and colonization history.[35] Another proposed intervention focuses on the development of positive ethnic identity by encouraging culture-specific stress-coping strategies. This intervention provides an opportunity for AI/ANs to engage in their traditional cultural healing practices and identify with their culture.[36][37]

Research

There is still a limited amount of available literature on mental health disorders and appropriate treatment, specifically regarding the American Indian and Alaska Native populations. While the amount of knowledge about AI/AN mental health problems is growing, little research specific to treatment efficacy and outcomes among AI/AN has been published. To put this into context, within a set of randomized control trials on major mental health disorders between 1986 through 2005, none of the 10,000 participants were identified as American Indian or Alaskan natives.[38] Likewise, a recent literature search for mental health treatments for AI/ANs yielded 3,500 initial citations. However, only two of them were controlled clinical trials.[39] As more data and objective evidence is collected on mental health and psychiatric disorders, specifically in the AI/AN population, it may be possible to reduce the mental health disparities for American Indians and Alaska Natives.

Summary

Improving the availability and quality of care for Native American populations will require the efforts of an interprofessional healthcare team, both in terms of providing the care and also recognizing the unique challenges that confront this population. This team includes all personnel from every discipline, including clinicians, mid-level practitioners, nurses, pharmacists, lab and other medical technicians, physical and occupation therapists, and even ancillary staff. It requires open communication, collaborative effort, and empathy regarding the challenges present in these patients so optimal care can be rendered and bring healthcare in the AI/AN population up to standard. [Level 5]


Article Details

Article Author

Sherry Kwon

Article Editor:

Abdolreza Saadabadi

Updated:

10/17/2021 7:35:43 PM

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