For American Indians and Alaska Natives, multiple factors influence health outcomes, including historical trauma and a range of social, policy, and economic conditions such as poverty, under-employment, lack of access to health care, lower educational attainment, housing problems, and violence.
These disparities have consequences. Suicide is the second leading cause of death among American Indian and Alaska Native youth ages 8 to 24. Also, while there is general awareness that Native Americans experience higher rates of alcohol and substance use, the scope of these behavioral health problems is not fully understood.
Native communities face service delivery issues that are complicated by personnel shortages, limited health care resources, and distances to obtain services. There also are other issues that inhibit access to appropriate behavioral health services such as referrals from school, detention, court, housing, primary care, child welfare, and other systems
American Indians and Alaska Natives (Indians, Eskimos, and Aleuts) were self-governing people who thrived in North America long before Western Europeans came to the continent and Russians to the land that is now Alaska. American Indians and Alaska Natives occupy a special place in the history of our Nation; their very existence stands as a testament to the resilience of their collective and individual spirit. This chapter first reviews history and the current social contexts in which American Indians and Alaska Natives live and then presents what is known about their mental health needs and the extent to which those needs are met by the mental health care system. (Reprinted From Surgeon General Report)
The history of American Indians and Alaska Natives sets the stage for understanding their mental health needs. Past governmental policies regarding this population have led to mistrust of many government services or care provided by white practitioners. Attempts to eradicate Native culture, including the forced separation of Indian and Native children from parents in order to send them to boarding schools, have been associated with negative mental health consequences Kleinfeld, 1973; Kleinfeld & Bloom, 1977. Some argue that, as a consequence of past separation from their families, when these children become parents themselves, they are not able to draw on experiences of growing up in a family to guide their own parenting (Special Subcommittee on Indian Education, 1969). The effect of boarding school education on American Indian students remains controversial Kunitz et al., 1999; Irwin & Roll, 1995.
The socioeconomic consequences of these historical policies are also telling. The removal of American Indians from their lands, as well as other policies summarized above, has resulted in the high rates of poverty that characterize this ethnic minority group. One of the most robust scientific findings has been the association of lower socioeconomic status with poor general health and mental health. Widespread recognition that many Native people live in stressful environments with potentially negative mental health consequences has led to increasing study and empirical documentation of this link Manson, 1996b, 1997; Beals et al, under review; Jones et al., 1997.
Because American Indians and Alaska Natives comprise such a small percentage of U.S. citizens in general, nationally representative studies do not generate sufficiently large samples of this special population to draw accurate conclusions regarding their need for mental health care. Even when large samples are acquired, findings are constrained by the marked heterogeneity that characterizes the social and cultural ecologies of Native people. There are 561 federally recognized tribes, with over 200 indigenous languages spoken (Fleming, 1992). Differences between some of these languages are as distinct as those between English and Chinese (Chafe, 1962). Similar differences abound among Native customs, family structures, religions, and social relationships. The magnitude of this diversity among Indian people has important implications for research observations. Novins and colleagues provide an excellent illustration of this point in a paper that shows that the dynamics underlying suicidal ideation among Indian youth vary significantly with the cultural contexts of the tribes of which they are members (Novins, et al., 1999). A tension arises, then, between the frequently conflicting objectives of comparability and cultural specificity-a tension not easily resolved in research pursued among this special population.
As widely noted, language is important when assessing the mental health needs of individuals and the communities in which they reside. Approximately 280,000 American Indians and Alaska Natives speak a language other than English at home; more than half of Alaska Natives who are Eskimos speak either Inuit or Yup’ik. Consequently, evaluations of need for mental health care often have to be conducted in a language other than English. Yet the challenge can be more subtle than that implied by stark differences in language. Cultural differences in the expression and reporting of distress are well established among American Indians and Alaska Natives. These often compromise the ability of assessment tools to capture the key signs and symptoms of mental illness Kinzie & Manson, 1987; Manson, 1994, 1996a. Words such as “depressed” and “anxious” are absent from some American Indian and Alaska Native languages (Manson et al., 1985). Other research has demonstrated that certain DSM diagnoses, such as major depressive disorder, do not correspond directly to the categories of illness recognized by some American Indians. Thus, evaluating the need for mental health care among American Indians and Alaska Natives requires careful clinical inquiry that attends closely to culture.
Census 2000 reports a significant increase in the number of individuals who identify, at least in part, as American Indian or Alaska Native. This finding resurrects longstanding debates about definition and identification (Passel, 1996). The relationship of those who have recently asserted their Indian ancestry to other, tribally defined individuals is unknown and poses a difficult challenge. It suggests a newly emergent need to consider the mental health status and requirements of individuals who live primarily within mainstream society, while continuing to build the body of knowledge on groups already defined.
Although not all mental disorders are disabling, these disorders always manifest some level of psychological discomfort and associated impairment. Such symptoms often improve with treatment. Therefore, the presence of a mental disorder is one reasonable indicator of need for mental health care. As noted in previous chapters, in the United States such disorders are identified according to the Diagnostic and Statistical Manual of Mental Disorders(DSM) diagnostic categories established by the American Psychiatric Association (1994).
Unfortunately, no large-scale studies of the rates of mental disorders among American Indian and Alaska Native adults have yet been published. The discussion at this point must rely on smaller, suggestive studies that await future confirmation.
The most recently published information regarding the mental health needs of adult American Indians living in the community comes from a study conducted in 1988 (Kinzie et al., 1992). The 131 respondents were inhabitants of a small Northwest Coast village who had participated in a previous community-based epidemiological study (Shore et al., 1973). They were followed up 20 years later using a well accepted method for diagnosing mental disorders, the Schedule for Affective Disorders and Schizophrenia-Lifetime Version. Nearly 70 percent of the sample had experienced a mental disorder in their lifetimes. About 30 percent were experiencing a disorder at the time of the follow-up.
The American Indian Vietnam Veterans Project (AIVVP) is the most recent community-based, diagnostically oriented psychiatric epidemiological study among American Indian adults to be reported within the last 25 years Beals et al., under review; Gurley et al., 2001; National Center for Post-Traumatic Stress Disorder and the National Center for American Indian and Alaska Native Mental Health Research [NCPTSD/NCAIANMHR], 1996. It was part of a congressionally mandated effort to replicate the National Vietnam Veterans Readjustment Study that had been conducted in other ethnic groups (Kulka et al., 1990).
The AIVVP found that rates of PTSD among the Northern Plains and Southwestern Vietnam veterans, respectively, were 31 percent and 27 percent, current; 57 percent and 45 percent, lifetime. These figures were significantly higher than the rates for their white, black, and Japanese American counterparts. Likewise, current and lifetime prevalence of alcohol abuse and/or dependence among the Indian veterans (more than 70% current; more than 80% lifetime) was far greater than that observed for the others, which ranged from 11 to 32 percent current and 33 to 50 percent lifetime (NCPTSD/NCAIANMHR, 1997).
There are no recent, scientifically rigorous studies that could shed light on the need for mental health care among Alaska Natives. The only systematic studies of Alaska Natives are outdated Murphy & Hughes, 1965; Foulks & Katz, 1973; Sampath, 1974 and not based on the current DSM system of disorders. One study of Alaska Natives seen in a community mental health center indicated that substance abuse is a common reason for men (85% of those seen) and women (65% of those seen) to seek mental health care (Aoun & Gregory, 1998).