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Mental Health Challenges in Caring for American Indians and Alaska Natives
Introduction
Native Americans, encompassing both American Indian and Alaska Native individuals, are descendants of the original inhabitants of the United States and represent an increasingly diverse and expanding demographic. Research indicates that these populations experience reduced life expectancy and a diminished quality of life compared to the broader US population.[1]
In addition to experiencing elevated rates of prevalent medical conditions, including diabetes, obesity, and hypertension, American Indian and Alaska Native individuals also face a significant prevalence of mental health conditions.[2][3] 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 White individuals.[4][5]
Post-traumatic stress disorder (PTSD), violence, suicide, and substance abuse have been identified as some of the more prevalent mental health issues among American Indian and Alaska Native individuals when compared with the general population in the US.[6] Sociodemographic characteristics, including age, education, and income, are likely contributing factors for the number of psychiatric disorders seen in American Indian and Alaska Native individuals compared to other racial groups.[4]
The cumulative emotional and psychological impact of colonization, forced relocation, and cultural disruption contributes to the intergenerational trauma faced by many in various American Indian and Alaska Native communities. This trauma can manifest as depression, anxiety, substance abuse, and other mental health disorders.[7]
Efforts should be intensified to address mental health care disparities among American Indian and Alaska Native populations through culturally sensitive clinical interventions. Pinpointing the existing gaps in mental health care provision and outcomes within these communities is crucial. Identifying mental health disparities directs essential actions for enhancing outcomes and reducing health inequalities.
Issues of Concern
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Issues of Concern
American Indian and Alaska Native individuals experience disproportionately high rates of mental disorders and psychiatric diagnoses such as PTSD, substance use disorder, and suicide compared to other racial and ethnic groups.[4][6]
Posttraumatic Stress Disorder
Research has found a high rate of American Indian and Alaska Native individuals with PTSD and PTSD-related symptoms compared to other races and ethnicities. In the general US population, the prevalence of lifetime PTSD is 4.8% to 6.4%.[8] Among American Indian and Alaskan Native populations, the prevalence of PTSD is estimated somewhere between 16% to 24%.[9][10][11] PTSD is a clinical diagnosis that is often the result of exposure to a severe stressor or a traumatic event.[12] Several risk factors have been identified for PTSD among American Indian and Alaska Native groups, including high exposure to violence, substance use disorders, history of sexual or physical abuse, pre-existing psychiatric disorders, and combat experience.[13]
PTSD manifests through various signs and symptoms, which may include intrusive memories, negative changes in mood and cognition, avoidance of reminders of the traumatic event, and alterations in arousal and reactivity. These symptoms can lead to significant distress or impair daily functioning and need to be present for four or more weeks.[12] Healthcare providers must recognize the signs and symptoms of PTSD to facilitate early intervention and treatment.
A study focusing on American Indian veterans who served in the Vietnam War revealed a remarkably high prevalence of PTSD, with lifetime rates between 40% and 60%. This rate was higher than that of any other racial or ethnic group of Vietnam veterans studied, further emphasizing the significant impact of PTSD on the American Indian and Alaska Native communities.[14]
Substance Use Disorder
Substance use, encompassing both illicit drugs and alcohol, is a critical issue to address when considering the unique mental health care needs of American Indian and Alaska Native individuals. One study involving 489 American Indian females at an Indian Health Service (IHS) institution revealed a lifetime prevalence of over 60% for any substance use disorder.[15] Another study conducted on a group of 89 adolescent American Indians found that an alarming 94% met the criteria for substance use disorder, with a high percentage also meeting the criteria for alcohol use disorder.[16]
Given the high prevalence of substance use disorders among American Indian and Alaska Native individuals, it is essential to routinely screen for alcohol and substance use. There is a known association between substance use disorder and PTSD, with a considerable number of individuals meeting the criteria for both conditions.[17] Alcohol use significantly contributes to the higher rate of premature deaths in American Indian and Alaska Native individuals compared to other races in the US, especially given its legality and ubiquity.[18] The U.S. Preventive Services Task Force has put forth 3 techniques to detect heavy alcohol consumption. These methods include using the Alcohol Use Disorders Identification Test (AUDIT), the AUDIT-C, or a single-question approach which involves asking individuals how frequently they consumed 5 or more drinks in a day (for men) or 4 or more drinks in a day (for women) in the past year.[19]
Heavy alcohol consumption can lead to several conditions, including fatty liver disease or steatosis, alcoholic hepatitis, and, ultimately, cirrhosis. Alcoholic hepatitis, a serious form of alcoholic liver disease, is marked by a sudden onset of jaundice, malaise, tender hepatomegaly, and a systemic inflammatory response. The condition can be identified when jaundice appears within 60 days of heavy alcohol consumption, defined as more than 50 grams per day for at least 6 months. In addition, diagnostic criteria include serum bilirubin levels exceeding 3 mg/dL, aspartate aminotransferase (AST) levels ranging from 50 U/L to 400 U/L, and an AST to ALT (alanine aminotransferase) ratio greater than 1.5.[20]
Suicide
Historically, suicide rates among the American Indian and Alaska Native populations have been higher than those of the overall US population. In 2015, the National Violent Death Reporting System (NVDRS) discovered that in 18 participating states, suicide rates were over 3.5 times higher among American Indian and Alaska Native individuals compared to ethnic groups with the lowest rates.[21] Another study reported rates of completed suicides, attempts, and suicidal ideation were 50% higher for American Indian and Alaska Native individuals than for the non–Hispanic White population. While suicidality is a significant concern across all ethnic and age groups, previous research has identified a disproportionately high risk for suicide among American Indian adolescents.[22]
Compared to other ethnic groups, American Indian and Alaska Native adolescents have been found to experience more severe experiences, such as victimization, substance abuse, and depression, which may contribute to increased suicidality.[23][24] Specifically, American Indian and Alaska Native adolescent males are at the highest risk of completing suicide.[25] In particular, American Indian and Alaska Native adolescent males who are unemployed, uneducated, or have a history of trauma face an even greater risk of suicide.[26][27] In terms of suicide prevention among American Indian and Alaska Native individuals, several factors have been identified as contributing to building resilience against suicide risk. These include fostering meaningful social connections, being mindful of the negative impact one's suicide may have on loved ones, and utilizing available health resources and services.[28]
Early identification and intervention may be useful for American Indian and Alaska Native individuals experiencing suicidality. Suicidal behaviors have also been found to co-occur with substance use, including alcohol and drug use, in many American Indian and Alaska Native communities. Prior research on this topic has pinpointed potential targets for intervention, such as enhancing coping skills, reducing the stigma surrounding mental health services, and establishing a well-organized community infrastructure of healthcare for American Indian and Alaska Native individuals.[28]
Clinical Significance
It is well-established that American Indian and Alaska Native individuals experience a disproportionate burden of various health conditions, including numerous mental health disorders, compared to other ethnic and racial groups. These health disparities among American Indian and Alaska Native individuals can be partially attributed to significant sociodemographic and socioeconomic differences, such as lower levels of educational achievement, income, and overall health status.[5] Improved mental health care can lead to better health outcomes and reduced health disparities. Moreover, early identification and intervention can prevent the worsening of mental health conditions and reduce the risk of suicide and substance use disorder-related complications.
Clinicians and public health officials must acknowledge the demographic and socioeconomic factors contributing to these health inequalities and prioritize further research and efforts to address these disparities. Moreover, it is crucial to understand the role of cultural issues and other risk factors in the high prevalence of mental health disorders among American Indian and Alaska Native individuals. The National Institutes of Health (NIH) has taken the initiative to allocate funding for promoting health and disease prevention in Native American communities, including American Indian and Alaska Native communities. This funding opportunity has led to the launch of multiple projects aimed at improving health outcomes for this population group.[29]
Enhancing Healthcare Team Outcomes
Health disparities for American Indian and Alaska Native individuals have been linked to limited access to healthcare services, education, and poverty.[30] To provide more equitable health care for this population, enhancing the cultural competence of health services and providers is crucial.
Access to Health Services
Improving mental health outcomes among American Indian and Alaska Native individuals requires increased access to healthcare services and facilities. Established in 1955, the Indian Health Service (IHS) is a federal agency serving many Native Americans.[6] IHS offers healthcare services, including behavioral health, to federally recognized American Indian and Alaska Native tribes. Mental health services are among the leading causes of hospitalization and ambulatory visits through IHS.[5] However, there are limitations to this healthcare system. Despite improvements in the overall health status of American Indian and Alaska Native individuals following the introduction of IHS, significant health disparities persist.[30][31]
IHS-funded federal hospitals are the only facilities that can provide coverage for health services. Most of these hospitals are geographically isolated, making it challenging for American Indian and Alaska Native individuals seeking care in urban areas and larger cities with limited IHS-associated facilities.[30][3] Telepsychiatry and teletherapy are important and effective tools to reach rural American Indian and Alaska Native communities, especially when combining evidence-based Western treatment and traditional Native healing.[32]
Cultural Differences
Recognizing cultural differences in health-related values and beliefs is crucial. While various evidence-based treatments and Western models of intervention are widely used to treat mental health disorders, some American Indian and Alaska Native individuals prefer traditional healing and tribal traditions for addressing substance use and other mental health issues. Overcoming the distrust of formal services in Indigenous communities is a significant challenge.[26] Even with a broader range of evidence-based therapies, American Indian and Alaska Native individuals may prefer traditional and informal services over clinic-based interventions.[6] Therefore, it is essential to continue exploring methods for integrating American Indian and Alaska Native cultural values and traditions into clinical practice.[33]
Cultural competence in healthcare means understanding and respecting the diverse cultures of different patient groups and using this knowledge to provide more culturally and linguistically appropriate interventions.[34] Several culturally congruent intervention strategies have been proposed for American Indian and Alaska Native individuals. For instance, historical trauma interventions address the psychological trauma and unresolved grief resulting from generations of discrimination, oppression, genocide, and colonization.[35] Another intervention fosters positive ethnic identity by encouraging culture-specific stress-coping strategies, enabling American Indian and Alaska Native individuals to engage in cultural healing practices and connect with their rich history and traditions.[36][37]
Research
Limited literature is available on mental health disorders and appropriate treatment for American Indian and Alaska Native individuals. Although knowledge about American Indian and Alaska Native mental health problems is growing, little research has been published on treatment efficacy and outcomes. For example, between 1986 and 2005, none of the 10,000 participants in randomized control trials on major mental health disorders were identified as American Indian and Alaska Native.[38] A recent literature search for mental health treatments for American Indian and Alaska Native individuals yielded 3,500 initial citations, but only 2 were controlled clinical trials.[39] Collecting more data and objective evidence on mental health and psychiatric disorders in the American Indian and Alaska Native populations may help reduce mental health disparities.
Summary
Mental health disparities for American Indian and Alaskan Native individuals are linked to limited access to healthcare services, intergenerational trauma, and cultural differences. Enhancing the cultural competence of health services and providers is crucial for equitable healthcare. Telepsychiatry and teletherapy can help reach rural communities, but recognizing and integrating cultural values and beliefs is essential. More research on mental health disorders and appropriate treatments for American Indian and Alaska Native individuals is needed to reduce health disparities. A multidisciplinary team includes clinicians, mid-level practitioners, nurses, pharmacists, lab technicians, medical technicians, physical and occupational therapists, and ancillary staff. Enhancing healthcare standards for the American Indian and Alaska Native populations requires fostering open communication, engaging in collaborative efforts, and demonstrating empathy toward the challenges faced by these patients. By doing so, optimal care can be ensured and overall well-being improved.
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