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Introduction

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.

The U.S. Census Bureau estimates that 4.1 million American Indians and Alaska Natives lived in the United States in 2000 1 . This represented less than 1.5 percent of the total U.S. population (U.S. Census Bureau, 2001). However, between 1960 and 2000, the recorded population of this minority group increased by over 250 percent, largely due to better data collection by the Census Bureau, an increasing number of individuals who identify themselves as American Indians or Alaska Natives, and an increase in the birth rate of this population. Alaska Natives comprise approximately 4 percent of the combined population of American Indians and Alaska Natives (Population Reference Bureau, 2000). But numbers alone tell little of this population, for it is the social and political history of Native people 2 and their relationship to the U.S. Government that define their distinctive place in American life.

Historical Context

American Indians

As members of federally recognized sovereign nations that exist within another country, American Indians are unique among minority groups in the United States. Ever since the European "discovery" and colonization of North America, the history of American Indians has been tied intimately to the influence of European settlers and to the policies of the U.S. Government.

Early European contact in the 17th century exposed Native people to infectious diseases from which their natural immunity could not protect them, and the population of American Indians plummeted. In 1820, as European settlers pushed westward, Congress passed the Indian Removal Act to force Native Americans west of the Mississippi River. Brutal marches of Native people, sometimes in the dead of winter, ensued. Later, as colonists moved farther westward to the Great Plains and beyond, the U.S. Government sent many tribes to live on reservations of marginal land where they had little chance of prospering. Treaties between the tribes and the U.S. Government were signed, then broken, and struggles for territory followed. The Plains Indian Wars raged until the end of the 19th century, punctuated by whole-sale slaughter of American Indian men, women, and children. As the settlers migrated toward the Pacific Ocean, the U.S. Congress passed legislation that effectively made Native Americans wards of the state.

Even as American Indians were being killed or forced onto reservations, some Americans protested the destruction of entire Indian "nations" (tribes and tribal confederacies). In 1887, after the bloodiest of the Indian Wars ended, Congress passed the Dawes Severalty Act, which allotted portions of reservation land to Indian families and individuals. The government then sold the leftover reservation land at bargain prices. This Act, which intended to integrate American Indians into the rest of U.S. society, had disastrous consequences. In addition to losing surplus tribal lands, many Natives lost their allotted lands as well and had little left for survival. By the early 1900s, the population of American Indians reached its lowest point, an incredible 5 percent of the original population estimated at first European contact (Thornton, 1987).

The Federal Indian Boarding School Movement began in earnest in 1875. By 1899, there were 26 off-reservation schools scattered across 15 states. The emphasis within the Indian educational system later shifted to reservation schools and public schools, but boarding schools continued to have a major impact into the next century because they were perceived as "civilizing" influences on American Indians. During the 1930s and 1940s, nearly half of all Indian people who received formal education attended such schools.

American Indians experienced both setbacks and progress during the 20th century. In June 1924, Congress granted American Indians U.S. citizenship. The Indian Citizenship Act later was amended to include Alaska Natives Deloria, 1985; Thornton, 1987. The subsequent passage of the Indian Reorganization Act (1934) placed great emphasis on civilizing Native people and teaching them Christianity. To this end, many more Native American children were sent to learn "American ways" at government- or church-run boarding schools that were often thousands of miles from the "detrimental influences" of their home reservations.

The era of American Indian educational reform began in the 1920s. Public criticism of Indian Bureau policies and practices culminated in an in-depth investigation of Indian affairs by the Brookings Institution in 1926. Its report, The Problem of Indian Administration, concluded: The first and foremost need in Indian education is a change in point of view. Whatever may have been the official government attitude, education for the Indian in the past has proceeded on the theory that it is necessary to remove the Indian child as far as possible from his home environment; whereas the modern point of view in education and social work lays stress on upbringing in the natural setting of home and family life. Although some children did well in these settings, other did not. Reports of harsh discipline were widespread (Brookings, 1971).

Even worse, the National Resource Center on Child Sexual Abuse (1990) cites evidence that many Native American children were sexually abused while attending boarding schools (Horejsi et al., 1992).

One positive result of the collective experience of boarding school students is that it gave rise to a shared social consciousness across previously disparate tribes, thereby fueling political change. One lesson from the boarding school era is that tribal peoples have encountered tremendous adversity yet survived-politically, culturally, linguistically, and spiritually (Hamley, 1994).

Near the end of World War II, Congress began to withdraw Federal support and to abdicate responsibility for American Indian affairs. Whereas earlier assimilationists had envisioned a time when tribes and reservations would vanish as Native Americans became integrated into U.S. society, the proponents of "termination" decided to legislate such entities out of existence. As a consequence, over the following two decades, many Federal services were withdrawn, and Federal trust protection was removed from tribal lands.

One policy from this era was an attempt by the U.S. Government to extinguish Native spiritual practices. A government prohibition on participation in traditional spiritual ceremonies continued until the American Indian Religious Freedom Act of (1978). Despite the prohibitions and the Christianizing efforts by various churches, indigenous culture and spirituality have survived and are widely practiced (Bryde, 1971). Even in areas where many Native people practice Christianity, traditional cultural views still heavily influence the way in which Native people understand life, health, illness, and healing (Todd-Bazemore, 1999).

In the 1970s, American Indians and Alaska Natives began to demand greater authority over their own lives and communities, encouraged by the 1969 publication of the report of the Congressional Committee on Labor and Public Welfare: Indian Education: A National Tragedy- A National Challenge.Current Federal policy encourages tribal administration of the government's health, education, welfare, law enforcement, and housing programs for Native Americans. Local communities have responded to this in a variety of ways that reflect the continuing diversity of their experiences and perspectives.

Alaska Natives

The history of Alaska Natives is similar to the history of their American Indian cousins to the south, yet differs in some important ways. Similar to American Indians, Alaska Natives are culturally diverse. Inupiats settled the Arctic coasts from the Chukchi Sea as far east as Greenland. In interior Alaska, along the Yukon and Tanana rivers, live Athabascan Indians; their link to the Navajo and Apache of Arizona and New Mexico is evident in the similarity of their languages. In southeast Alaska, Tlingit, Haida, Tsimshian, and Eyak Indians live by the sea; their arts and crafts have been well known for over 200 years. The coast of northeast Alaska and the deltas of the Yukon and Kuskokwim rivers are home to some 20,000 Yup'ik and Cup'ik Eskimos, the greatest concentration of Eskimos in the world. They still depend on hunting, fishing, and gathering. On the Pribilof Islands and the Aleutian chain, the Aleuts, kin to the Yup'ik, maintain their cultural identity even though decimated by a century and a half of Russian occupation (Berger, 1985). The Aleuts share with American Indians a history of devastation as a result of diseases introduced by white men. Their peak population, estimated at 80,000 just prior to European contact, dwindled to 25,000 by 1909. The early Russian invaders took control of the native Aleut and Inuit people and forced them to hunt for furs. In 1867, the United States bought Alaska from Russia, and the Treaty of Cession stated that the "uncivilized [Native] tribes will be subject to such laws and regulations as the United States may, from time to time, adopt in regard to aboriginal tribes of that country" (Treaty of Cession, Article III). Although the U.S. Government had legal control over Alaskan land from that point on, Alaska Natives were not forced to move to reservations. In fact, the Federal Government did not create reservations in Alaska until 1891, and, even then, it established only a few for a small percentage of the Alaska Native population.

In 1971, upon the discovery of huge oil deposits on Alaska's North Slope and the wish to clear the area for construction of the Alaska Pipeline, Congress passed the Alaska Native Claims Settlement Act (ANCSA). This Act organized Alaska Natives into regional and village corporations and gave them control over more than 44 million acres of land and almost $1 billion. In exchange, Alaska Natives waived all claims to many of their original lands.

In the 1970s, more and more Alaska Natives petitioned for the right to self-government, and traditional institutions such as tribal courts and councils re-emerged. The U.S. Census Bureau now recognizes 200 Native communities in Alaska; more than half have state-chartered municipal governments, and 69 have elected Native Councils (Douglas K. Mertz, personal communication). The sheer number of these governments and councils reflects a rich and diverse Alaskan heritage (Berger, 1985).

Current Status

Geographic Distribution

Most American Indians live in Western States, including California, Arizona, New Mexico, South Dakota, Alaska, and Montana, with 42 percent residing in rural areas, compared to 23 percent of whites (Rural Policy Research Institute, 1999). The number of American Indians who live on reservations and trust lands (areas with boundaries established by treaty, statute, and executive or court order) has decreased substantially in the past few decades. For example, in 1980, most American Indians lived on reservations or trust lands; today, only 1 in 5 American Indians live in these areas, and more than half live in urban, suburban, or rural nonreservation areas.

Family Structure

Consistent with a national trend, the proportion of American Indian families maintained by a single female increased between 1980 and 1990. However, the Native American increase of 27 percent was considerably larger than the national figure of 17 percent. In 1990, 6 in 10 American Indian and Alaska Native families were headed by married couples; in contrast, about 8 in 10 of the Nation's other families were headed by married couples (U.S. Census Bureau, 1993). In 1993, American Indian families were slightly larger than the average size of all U.S. families (3.6 versus 3.2 persons per family) (U.S. Census Bureau, 1993). An even more telling insight into the family structure of American Indians follows from consideration of the dependency index, which compares the proportion of household members between the ages of 16 and 64 to those younger than 16 years of age combined with those 65 years of age and older. Here the assumption is that the former are more likely to contribute economically to a household, and the latter are not, thus the dependency of one on the other. In this regard, households in many American Indian communities exhibit much higher dependency indices than other segments of the U.S. population and are more comparable to impoverished Third World countries (Manson & Callaway, 1988).

Education

In 1990, 66 percent of American Indians and Alaska Natives 25 years old and over had graduated from high school or achieved a higher level of education; in contrast, only 56 percent had done so in 1980. Despite this advance, the figure was still below that for the U.S. population in general (75%). American Indians and Alaska Natives were not as likely as others in the United States to have completed a bachelor's degree or higher (U.S. Census Bureau, 1993). Data suggest that Indian students achieve on a par with or beyond the performance of non-Indian students in elementary school and show a crossover or decline in performance between fourth and seventh grades (Barlow & Walkup, 1998). Explanations for this crossover vary. Indian children may have a culturally rooted way of learning at odds with teaching methods currently used in public education. Several researchers cite differences between Indian cognitive styles and Western teaching styles. For example, Indian children are primarily visual learners, rather than auditory or verbal learners. Indian youngsters tend to excel at nonverbal performance scales of development and fall below national averages on verbal scales (Yates, 1987). Verbal learners are favored by modes of mainstream public education and testing (Yates, 1987). Linguistic experts have observed that Native languages stress keen descriptive observation and form rather than the verbal or conceptual abstractions that are common in English, which may make learning in English-language schools difficult (Basso, 1996).

Regardless of the reasons for lower academic achievement, negative consequences often ensue. The academic crossover is paralleled by a similar trend in mental health status, as extrapolated from rates of child and adolescent outpatient treatment. Specifically, one study noted that Indian youth enter mental health treatment at a sharply increased rate during the same period, fourth to seventh grades, and that the rate dramatically exceeds their non-Indian counterparts, with a continuously widening gap into late adolescence (Beiser & Attneave, 1982). Subsequent work by Beiser and colleagues clearly underscores the contribution of cultural dynamics in the classroom to these outcomes (Beiser et al., 1998).

Income

Following the devastation of these once-thriving Indian nations, the social environments of Native people have remained plagued by economic disadvantage. Many American Indians and Alaska Natives are unemployed or hold low-paying jobs. Both men and women in this population were roughly twice as likely as whites to be unemployed in 1998 (Population Reference Bureau, 2000). From 1997 to 1999, about 26 percent of American Indians and Alaska Natives lived in poverty; this percentage compares with 13 percent for the United States as a whole and 8 percent for white Americans (U.S. Census Bureau, 1999b).

Physical Health Status

With some exceptions, the health of this ethnic minority group has begun to improve, and the gap in life expectancy rates between Native Americans and others has begun to close. For instance, the infant mortality rate of American Indians decreased from 22 per 1,000 live births in 1972-1974 to 13 in 1990 and 9 in 1997 (Indian Health Service, 1997). Still, American Indians and Alaska Natives have the second highest infant mortality rate in the Nation (National Center for Health Statistics, 1999) and the highest rate of sudden infant death syndrome (DHHS, 1998). The death rates among American Indians ages 15 to 24 are also higher than those for white persons in the same age group (Grant Makers in Health, 1998). American Indians and Alaska Natives are five times more likely to die of alcohol-related causes than are whites, but they are less likely to die from cancer and heart disease (Indian Health Service, 1997). The rate of diabetes for this population group is more than twice that for whites. In particular, the Pima tribe of Arizona has one of the highest rates of diabetes in the world. The incidence of end-stage renal disease, a known complication of diabetes, is higher among American Indians and Alaska Natives than for both whites and African Americans.

Nationally, one-third of American Indians and Alaska Natives do not have a usual source of health care, that is, a doctor or clinic that can provide regular preventive and medical care (Brown et al., 2000). In 1955, the U.S. Government established the Indian Health Service (IHS) within the Department of Health and Human Services (DHHS). The IHS mission is to provide a comprehensive health service delivery system for American Indians and Alaska Natives "‥ with opportunity for maximum Tribal involvement in developing and managing programs to meet their health needs" (IHS, 1996). The IHS is responsible for working to provide health delivery programs run by people who are cognizant of entitlements of Native people to all Federal, State, and local health programs, in addition to IHS and tribal services. The IHS also acts "as the principal Federal health advocate for the American Indian and Alaska Native people in the building of health coalitions, networks, and partnerships with Tribal nations and other government agencies as well as with non-Federal organizations [such as] academic medical centers and private foundations" (IHS, 1996).

Although the goal of the IHS is to provide health care for Native Americans, IHS clinics and hospitals are located mainly on reservations, giving only 20 percent of American Indians access to this care (Brown et al., 2000). Furthermore, IHS-eligible American Indians are less likely than others with private health insurance coverage to have obtained the minimum number of physician visits 3 for their age and health status.

More than half of American Indians and Alaska Natives live in urban areas (U.S. Census Bureau, 1990). Title V of Public Law 94-437 of the Indian Health Care Improvement Act authorizes the appropriation of funds for urban Indian health programs. Presently, there are 34 such programs across 41 sites, independently operated through grants and contracts offered by the IHS. Though there is little data available regarding the health needs and access to care among urban Native Americans, the constellation of problems is similar to that of rural communities and includes serious mental illness, alcohol and substance abuse, alcohol and substance dependence, and suicidal ideation (Novins, 1999). An Urban Indian Epidemiology Center was recently funded by the IHS to address this important knowledge gap (Indian Health Service, 2001).

Even where the IHS is active, health service systems in general fail to meet the wide-ranging needs of indigenous populations, especially in remote and isolated regions of the United States. This includes rural, "bush" Alaska, which is divided into 12 Native regions that encompass several villages whose languages, dialects, and cultural connections are only somewhat similar (Reimer, 1999). For example, ethnographic studies in two Pacific Northwest Indian tribal communities document the lack of trust between American Indians and the IHS. Many community members felt they were not receiving appropriate care. Furthermore, holistic education programs to address health needs across the lifespan were considered lacking. Overall, many community members reported that they felt unheard and trapped in a system of care over which they have no control (Strickland, 1999).

Today, the IHS remains the primary entity responsible for the mental health care of American Indians and Alaska Natives. Until 1965, the delivery of mental health services was sporadic. That year, the first Office of Mental Health was opened on the Navajo Reservation. It remained severely understaffed and underfunded until its dissolution in 1977. Legislation to authorize comprehensive mental health services for tribes has been enacted and amended several times, but Congress consistently failed to appropriate funds for such initiatives (Nelson & Manson, 2000). Financial inadequacies have resulted in four IHS service areas without child or adolescent mental health professionals. Fragmented Federal, State, tribal, private foundation, and national nonprofit attempts to meet such obvious needs have led to isolation, difficult work conditions, cultural differences, and high turnover rates that dilute efforts to provide mental health services (Barlow & Walkup 1998; Novins, Fleming, et al., 2000).

The Need for Mental Health Care

Historical and Sociocultural Factors That Relate to Mental Health

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.

Key Issues for Understanding the Research

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.

Mental Disorders

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).

Adults

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).

Children and Youth

Two recent studies examined the need for mental health care among American Indian youth. The Great Smoky Mountain Study assessed psychiatric disorders among 431 youth ages 9 to 13 (Costello et al., 1997). Children were defined as American Indian if they were enrolled in a recognized tribe or were first- or second-generation descendants of an enrolled member. Overall, American Indian children were found to have fairly similar rates of disorder (17%) in comparison to white children from surrounding counties (19%). Lower rates of tics (2 vs. 4%) and higher rates of substance abuse or dependence (1 vs. 0.1%) were found in American Indian children as compared with white children. The difference in substance abuse is almost totally accounted for by alcohol use among 13-year-old Indian children (Costello et al., 1997). Rates of anxiety disorders, depressive disorders, conduct disorders, and attention-deficit/hyperactivity disorder (AD/HD) were not significantly different for American Indian and white children. Yet, for white children, poverty doubled the risk of mental disorders, whereas poverty was not associated with increased risk of mental disorders among the American Indian children. Overall, these American Indian children appeared to experience rates of mental disorders similar to those for white children.

The second study reported a followup of a school-based psychiatric epidemiological study involving Northern Plains youth, 13 to 17 years of age (Beals et al., 1997). Of 109 adolescents, 29 percent received a diagnosis of at least one psychiatric disorder. Altogether, more than 15 percent of the students qualified for a single diagnosis; 13 percent met criteria for multiple diagnoses. In terms of the broad diagnostic categories, 6 percent of the sample met criteria for an anxiety disorder, 5 percent for a mood disorder (either major depressive disorder or dysthymia), 14 for one or more of the disruptive behavior disorders, and 18 percent for substance abuse disorders. Only 1 percent was diagnosed with an eating disorder. The five most common specific disorders were alcohol dependence or abuse (11%), attention- deficit/hyper-activity disorder (11%), marijuana dependence or abuse (9%), major depressive disorder (5%), and other substance dependence or abuse (4%). Considerable comorbidity among disorders was observed. More than half of those with a disruptive behavior disorder also qualified for a substance use disorder. Similarly, 60 percent of those youth diagnosed with any depressive disorder had a substance use disorder as well.

Beals and colleagues compared their findings with those reported for nonminority children drawn from the population at large Lewinsohn et al., 1993; Shaffer et al., 1996. The American Indian youth were diagnosed with fewer anxiety disorders than the nonminority children in the Shaffer sample. However, American Indian adolescents were much more likely to be diagnosed with AD/HD and substance abuse or substance dependence disorders. The rates of conduct disorder and oppositional defiant disorder were also elevated in the American Indian sample. Rates of depressive disorders were essentially equivalent. This latter finding was consistent with a study published in 1994 (Sack et al., 1994) that reported clinical depression among youth from several reservations below 1 percent, "a prevalence rate compatible with other studies in white populations, which typically varies from 1 to 3 percent" (Fleming & Offord, 1990). When compared with the Lewinsohn sample, American Indian adolescents in the study by Beals and colleagues demonstrated statistically significant higher 6-month prevalence rates than did the nonminority children for lifetime prevalence of ADHD and alcohol abuse/dependence. In addition, the American Indian youth had higher 6-month rates of simple phobias, social phobias, overanxious disorder, and oppositional defiant and conduct disorders than the nonminority children's lifetime rates for those disorders.

At present, there are no published estimates of the rates of mental disorders among Alaska Native youth. One study of Eskimo children seen in a community mental health center in Nome, Alaska, indicated that substance abuse, including alcohol and inhalant use, and previous suicide attempts are the most common types of problems for which these children receive mental health care (Aoun & Gregory, 1998). An earlier study found a high need for mental health care among Yup'ik and Cup'ik adolescents who were in boarding schools (Kleinfeld & Bloom, 1977), but current DSM diagnostic categories were not used.

Box 4-1:

Charlie (age 9); Mike (father, age 29)

Charlie frequently argued with teachers and started fights with other children. Charlie's schoolteacher recommended him for counseling because of his acting out in school.

Charlie had lived all his life with his mother and two younger siblings on their Southwestern reservation. Charlie's father, Mike, lived in the home until Charlie was 3 years old, when he was sent to prison for attempted murder of Charlie's mother. Mike was a chronic alcoholic who frequently battered his wife when their arguments became heated. Charlie often witnessed violence between his mother and father and was aware of the circumstances leading to his father's imprisonment. During Mike's incarceration, Charlie visited him in prison and maintained regular contact by mail and phone. At the time of Charlie's referral, Mike had been out of prison for one year and had just returned home from a 30-day alcohol rehabilitation program.

Mike had been the youngest of eight children; his mother, the primary caretaker, sent Mike away to boarding school because she was unable to care for him. Mike never had contact with his father, whom he described as "an alcoholic and a womanizer." Although Mike recognized the economic hardship his mother faced after his father left, he nonetheless felt abandoned by her and frequently wondered why she had had him in the first place.

Mike described boarding school as a constant struggle. On the weekends and holidays, Mike rarely went home; his family did not visit him. Over the years, Mike felt great sadness over his childhood loss and great anger toward his mother for her complete abandonment of him.

In addition to being physically abusive toward his wife, Mike frequently fought other men. He often felt great rage and was easily provoked

Mike was a talented artist who created pottery and woodwork designs that were derived from traditional practices within his tribe. He was a full-blooded member of his tribe. Though raised on the reservation, he spent most of his life shuttling between it and various institutions, such as boarding school, prison, and alcohol rehabilitation facilities.

In talking about his childhood, Mike was confused and incoherent, especially about his parents. He sometimes needed to leave the therapeutic setting because he had become so agitated by these feelings. Mike was preoccupied with the sense that he had been dealt a bad lot in life. This contributed to his quickness to see that others were betraying him and thus needed to be dealt with swiftly and harshly without forgiveness.

At the time of Charlie's referral, Mike was newly committed to being a parent. Mike wanted to teach his children about his art and culture, to play sports with them, and to guide them in ways that he had not been guided. Mike acknowledged that the problems Charlie was having were not unlike the problems he had as a child. He had not appreciated the impact that the rage rooted in his own childhood experience of abandonment had on Charlie's development. In witnessing the violence that his father let explode on his mother, Charlie had learned to fear his father and to feel powerless to protect his mother. Charlie appears to be making up for this powerlessness at home by dominating his peers through his own acts of violence. ( Adapted from Christensen & Manson, 2001)

Older Adults

Although large-scale studies of mental disorders among older American Indians are lacking, Manson (1992) found that over 30 percent of older American Indian adults visiting one urban IHS outpatient medical facility reported significant depressive symptoms; this rate is higher than most published estimates of the prevalence of depression among older whites with chronic illnesses (9 to 31%) (Berkman et al., 1986). In another clinic-based investigation, nearly 20 percent of American Indian elders who received primary care reported significant psychiatric symptoms (Goldwasser & Badger, 1989), with rates increasing as a function of age. These findings are consistent with a survey of older, community-dwelling, urban Natives in Los Angeles, among whom more than 10 percent reported depression, and an additional 20 percent reported sadness and grieving (Kramer, 1991).

A recent study of 309 Great Lakes American Indian elders revealed that 18 percent of the sample scored above a traditional cutoff for depression on the Center for Epidemiology Studies Depression Scale (CES-D) (Curyto et al., 1998, 1999). However, upon further examination of that data, the factor structure of the CES-D was found to be different in this population as compared to available norms (Chapleski, Lamphere, et al., 1997). Therefore, the concern remains that the CES-D may not accurately measure depressive symptoms in this population. Nonetheless, depressive symptoms were strongly associated with impaired functioning (Chapleski, Lichtenberg, et al., 1997), which is in keeping with past findings (Baron et al., 1990) and underscores the burden posed by such distress, as well as the need for intervention (Manson & Brenneman, 1995).

Mental Health Problems

Symptoms

Although little is known about rates of psychiatric disorders among American Indians and Alaska Natives in the United States, one recent, nationally representative study looked at mental distress among a large sample of adults (Centers for Disease Control and Prevention, 1998). Overall, American Indians and Alaska Natives reported much higher rates of frequent distress-nearly 13 percent compared to nearly 9 percent in the general population. The findings of this study suggest that American Indians and Alaska Natives experience greater psychological distress than the overall population.

Somatization

The distinction between mind and body common among individuals in industrialized Western nations is not shared throughout the world Manson & Kleinman, 1998; Manson, 2000. Many ethnic minorities do not discriminate bodily from psychic distress and may express emotional distress in somatic terms or bodily symptoms. Relatively little empirical research is available concerning this tendency among American Indians and Alaska Natives. However, a sample of 120 adult American Indians belonging to a single Northwest Coast tribe was screened using the Center for Epidemiologic Studies Depression Scale, which includes both psychological and somatic symptoms. Analyses showed that somatic complaints and emotional distress were not well differentiated from each other in this population (Somervell et al., 1993). Other inquiries into the psychometric properties of the CES-D and other measures of depressive symptoms among American Indians have yielded similar findings, providing some evidence of the lack of such distinctions within this population Ackerson et al., 1990; Manson et al., 1990.

Culture-Bound Syndromes

A large body of ethnographic work reveals that some American Indians and Alaska Natives, who may express emotional distress in ways that are inconsistent with the diagnostic categories of the DSM, may conceptualize mental health differently. Many unique expressions of distress shown by American Indians and Alaska Natives have been described Trimble et al., 1984; Manson et al., 1985; Manson 1994; Nelson & Manson, 2000. Prominent examples include ghost sickness and heartbreak syndrome (Manson et al., 1985). The question becomes how to elicit, understand, and incorporate such expressions of distress and suffering within the assessment and treatment process of the DSM-IV.

Suicide

Given the lack of information about rates of mental disorders among American Indian and Alaska Native populations, the prevalence of suicide often serves as an important indicator of need. The Surgeon General's 1999 Call to Action to Prevent Suicide indicates that from 1979 to 1992, the suicide rate for this ethnic minority group was 1.5 times the national rate. The suicide rate is particularly high among young Native American males ages 15 to 24. Accounting for 64 percent of all suicides by American Indians and Alaska Natives, the suicide rate of this group is 2 to 3 times higher than the general U.S. rate May, 1990; Kettle & Bixler, 1991; Mock et al., 1996. In another survey of American Indian adolescents (n = 13,000), 22 percent of females and 12 percent of males reported having attempted suicide at some time; 67 percent who had made an attempt had done so within the past year (Blum et al., 1992). Furthermore, an analysis of Bureau of Vital Statistics death certificate data from 1979 to 1993 found that "Alaska Native males had one of the highest documented suicide rates in the world" (1997). Alaska Natives, in general, were more likely to commit suicide than non-Natives living in Alaska (Gessner, 1997). It is important to note that violent deaths (unintentional injuries, homicide, and suicide) account for 75 percent of all mortality in the second decade of life for American Indians and Alaska Natives (Resnick et al., 1997).

High-Need Populations

American Indians and Alaska Natives are the most impoverished ethnic minority group in the United States. Although no causal links have yet been demonstrated, there is good reason to suspect that the history of oppression, discrimination, and removal from traditional lands experienced by Native people has contributed to their current lack of educational and economic opportunities and their significant representation among populations with high need for mental health care.

Individuals Who Are Homeless

American Indians and Alaska Natives are overrepresented among people who are homeless. Although they comprise less than 1 percent of the general population, American Indians and Alaska Natives constitute 8 percent of the U.S. homeless population (U.S. Census Bureau, 1999a). It is not clear that homeless American Indians and Alaska Natives are at greater risk of mental disorder than their non-Native counterparts. In one study, American Indian veterans who were homeless had fewer psychiatric diagnoses than did white veterans who were homeless (Kasprow & Rosenheck, 1998), although these differences were relatively small. Nevertheless, because there are more individuals with mental disorders among the homeless population than among the general population (Koegel et al., 1988), this finding likely points to a substantial number of Native people with a high need for mental health care.

Individuals Who Are Incarcerated

In 1997, an estimated 4 percent of racially identified American Indian and Alaska Native adults were under the care, custody, or control of the criminal justice system. Also, 16,000 adults in this group were held in local jails (Bureau of Justice Statistics, 1999). Although research specific to rates of mental disorders among American Indian and Alaska Native adults in jails is not available, a recent study has evaluated disorders among incarcerated adolescents. Rates of mental disorders among those held in a Northern Plains reservation juvenile detention facility were examined (Duclos et al., 1998). Among the 150 youth evaluated, nearly half (49%) had at least one alcohol, drug, or mental health disorder. The most common problems detected were substance abuse, conduct disorder, and depression.

These rates were higher than those found in Indian adolescents in the community, indicating that incarcerated American Indians are likely to be at high need for mental health and substance abuse interventions.

Individuals with Alcohol and Drug Problems

Actual rates of alcohol abuse among American Indian adults are difficult to estimate, yet indirect evidence suggests that a substantial proportion of this population suffers from this problem. For example, the estimated rate of alcohol-related deaths for Indian men is 27 percent and for Indian women 13 percent (May & Moran, 1995). Rates appear to vary widely among different tribes. Although the topic of substance abuse is beyond the scope of this Supplement, alcohol problems and mental disorders often occur together in American Indian and Alaska Native populations Westermeyer, 1982; Whittaker, 1982; Westermeyer & Peake, 1983; Kinzie et al., 1992; Beals et al., 2001. A recent study, which sought to understand the link between alcohol problems and psychiatric disorders in American Indians, included over 600 members of three large families (Robin et al., 1997a). More than 70 percent qualified for a lifetime diagnosis of alcohol disorders. Among both men and women, those who were alcohol-dependent were also more likely to have psychiatric disorders, as were those who engaged in binge-drinking behavior. This finding underscores the likelihood that American Indians with alcohol disorders are at high risk for concomitant mental health problems.

Given the high rates of alcohol abuse among some American Indians and Alaska Natives, fetal alcohol syndrome is an important influence on mental health needs (May et al., 1983). The Centers for Disease Control and Prevention (1998) monitored the rate of fetal alcohol syndrome (FAS), identifying cases based on hospital discharge diagnoses collected from more than 1,500 hospitals across the United States between 1980 and 1986. The overall rate of FAS was 2.97 per 1,000 for Native Americans, 0.6 per 1,000 for African Americans, 0.09 for Caucasians, 0.08 for Hispanics, and 0.03 for Asians (Chavez et al., 1988). As might be expected given the fact that physicians often do not identify this disease, these rates are much lower than those found in clinic-based investigations (Stratton et al., 1996). Fetal alcohol syndrome now is recognized as the leading known cause of mental retardation in the United States (Streissguth et al., 1991), surpassing Down's syndrome and spina bifida. Fetal alcohol syndrome is not just a childhood disorder; predictable long-term progression of the disorder into adulthood includes maladaptive behaviors such as poor judgment, distractibility, and difficulty perceiving social cues. Consequently, American Indians and Alaska Natives with fetal alcohol syndrome are likely to have high need for intervention to facilitate the management of their disabilities.

Drinking by American Indian youth has been more thoroughly studied than drinking by American Indian adults. Ongoing school-based surveys have shown that, although about the same proportion of Indian and non-Indian youth in grades 7 to 12 have tried alcohol, Indian youth who drink appear to drink more heavily than do youth of other ethnicities Plunkett & Mitchell, 2000; Novins et al., under review. They also experience more negative social consequences from their drinking than do their non-Indian counterparts Oetting et al., 1989; Mitchell et al., 1995. Although drinking and mental disorders may be less linked for youth than for adults, those adolescents with serious drinking problems are likely to be at risk for mental health problems as well (Beals et al., 2001).

Individuals Exposed to Trauma

Lower socioeconomic status is associated with an increased likelihood of experiencing undesirable life events (McLeod & Kessler, 1990). As a result of lower socioeconomic status, American Indians and Alaska Natives are also more likely to be exposed to trauma than members of more economically advantaged groups. Exposure to trauma is related to the development of subsequent mental disorders in general and of post-traumatic stress disorder (PTSD) in particular (Kessler et al., 1995). Recent evidence suggests that American Indians may be at high risk for exposure to trauma.

An investigation of Northern Plains youth ages 8 to 11 found that 61 percent of them had been exposed to some kind of traumatic event. These children were reported to have more trauma-related symptoms, but not substantially higher rates of diagnosable PTSD (3%) (Jones et. al., 1997). According to the Bureau of Justice Statistics (1999), the rate of violent victimization of American Indians is more than twice as high as the national average. Indeed, the data regarding reported child abuse in Native communities indicate that this phenomenon has increased 18 percent in the last 10 years (Bureau of Justice Statistics, 1999). Another study noted a high prevalence of trauma exposure (e.g., car accidents, deaths, shootings, beatings) and PTSD within those in the family study mentioned above (Robin et al., 1997c). Of those studied, 82 percent had been exposed to one traumatic event, and the prevalence of PTSD was 22 percent. Because American Indians probably are similar to non-Indians in their likelihood of developing PTSD after a traumatic exposure (Kessler et al., 1995), the substantially higher prevalence of the disorder (22% for AI/AN vs. 8% in the general community) does not signal greater vulnerability to PTSD, but rather higher rates of traumatic exposure.

Maltreatment and neglect have been shown to be relatively common among older urban American Indian and Alaska Native patients in primary care. A chart review of 550 Native adults 50 years of age or older seen at one of the country's largest, most comprehensive, urban Indian health programs during one calendar year revealed that 10 percent met criteria for definite and probable physical abuse or neglect (Buchwald et al., 2000). After controlling for other factors in a logistic regression model, patient age, female gender, alcohol abuse, domestic violence, and current depression remained significant correlates of physical abuse or neglect of these Native elders.

The previously mentioned American Indian Vietnam Veterans Project (AIVVP) replicated the National Vietnam Veterans Readjustment Study that examined psychiatric disorders among African American, Latino, and white veterans (Kulka et al., 1990). Between 1992 and 1995, researchers evaluated random samples of Vietnam combat veterans drawn from three Northern Plains reservations (n = 305) and one Southwest reservation (n = 316). Approximately one-third of the Northern Plains (31%) and Southwestern (27%) American Indian participants had PTSD at the time of the study. Approximately half had experienced the disorder in their lifetimes (57% and 45%, respectively). This rate is far in excess of rates of current PTSD for white veterans (14%) and for black veterans (21%) (Kulka et al., 1990). The excess rates, however, were largely attributable to the fact that American Indian veterans had been exposed to more combat-related traumas than their non-Indian peers National Center for Post-Traumatic Stress Disorder and the National Center for American Indian and Alaska Native Mental Health Research, 1996; Beals et al., under review.

Box 4-2

John : Vietnam Combat Veteran (age 45)

John is a 45-year-old, full-blood Indian, who is married and has 7 children. The family lives in a small, rural community on a large reservation in Arizona. John served as a Marine Corps infantry squad leader in Vietnam during 1968-1969. He most recently was treated through a VA medical program, where he participates in a post-traumatic stress disorder (PTSD) support group. John suffers from alcoholism, which began soon after his initial patrols in Vietnam. These involved heavy combat and, ultimately, physical injury. He exhibits the hallmark symptoms of PTSD, including flashbacks, nightmares, intrusive thoughts on an almost daily basis, marked hypervigilance, irritability, and avoidant behavior.

Some 10 years after his return from Vietnam, John began cycling through several periods of treatment for his alcoholism in tribal residential programs. It wasn't until one month after he began treatment for his alcoholism at a local VA facility that a provisional diagnosis of PTSD was made. Upon completing that treatment, he transferred to an inpatient unit specializing in combat-related trauma. John left the unit against medical advice, sober but still experiencing significant symptoms.

John speaks and understands English well; he also is fluent in his native language, which is spoken in his home. John is the descendant of a family of traditional healers. Consequently, the community expected him to assume a leadership role in its cultural and spiritual life. However, boarding school interrupted his early participation in important aspects of local ceremonial life. His participation was further delayed by military service and then forestalled by his alcoholism. During boarding school, John was frequently harassed by non-Indian staff for speaking his native language, for wearing his hair long, and for running away. Afraid of similar ridicule while in the service, he seldom shared his personal background with fellow infantrymen. Yet John was the target of racism, from being selected to act as point on patrol because he was an Indian to being called "Chief" and "blanket ass."

Until recently, tribal members had never heard of PTSD, but now frequently refer to it as the "wounded spirit." His community has long recognized the consequences of being a warrior, and indeed, a ceremony has evolved over many generations to prevent as well as treat the underlying causes of these symptoms. Within this tribal worldview, combat-related trauma upsets the balance that underpins someone's personal, physical, mental, emotional, and spiritual health. The events in John's life (the Vietnam war, his father's death, and his impairment due to PTSD and alcoholism) conspired to prevent his participation in this and other tribal ceremonies.

John attends a VA-sponsored support group, comprised of all Indian Vietnam veterans, which serves as an important substitute for the circle of "Indian drinking buddies" from whom he eventually separated as part of his successful alcohol treatment. John reports having left the VA's larger PTSD inpatient program because of his discomfort with its non-Native styles of disclosure and expectations regarding personal reflection. Through the VA's Indian support group, he joined a local gourd society that honors warriors and dances prominently at pow-wows. His sobriety has been aided by involvement in the Native American Church, with its reinforcement of his decision to remain sober and its support for positive life changes.

Though John has a great deal of work ahead of him, he feels that he is now ready to participate in the tribe's major ceremonial intended to bless and purify its warriors. His family, once alienated but now reunited, is busily preparing for that event. (Adapted from Manson, 1996).

Children in Foster Care

Studies have consistently indicated that children who are removed from their homes are at increased risk for mental health problems (e.g., Courtney & Barth, 1996), as well as for serious subsequent adult problems such as homelessness (Koegel et al., 1995). By the mid-1970s, many American Indian children were experiencing out-of-home placements. In Oklahoma, four times as many Indian children were either adopted or in foster care as non-Indian children. In New Mexico, twice as many Indian children were in foster care than any other minority group. Estimates suggest that as many as 25 to 30 percent of American Indian children have been removed from their families (Cross, et al., 2000). As a result, Congress passed the Indian Child Welfare Act in 1978 to protect American Indian children. The Congressional investigation that led to the passage of the act concluded families that "a pattern of discrimination against American Indians is evident in the area of child welfare, and it is the responsibility of Congress to take whatever action is within its power to see that Indian communities and their are not destroyed" (Fischler, 1985). Accordingly, in 1999, the number of American Indian and Alaska Native children in foster care had decreased to 1 percent of all children in foster care in the United States (DHHS, 1999). Yet the mental health consequences for the children, now adults, who were placed out of their homes, especially those placed in non-Indian homes, during this lengthy period of mass cultural dislocation is not known Nelson et al., 1996; Roll, 1998.

Availability, Accessibility, and Utilization of Mental Health Services

The historical and current socioeconomic factors presented highlight several elements that may affect the use of mental health services by American Indians and Alaska Natives. Foremost, given the history of this ethnic group's relationship with the U.S. Government, many American Indian and Alaska Native people may not trust institutional sources of care and may be unwilling to seek help from them. Second, mental health services are quite limited in the rural and isolated communities where many Indian and Native peoples live. Alaska Natives, in particular, have little mental health care available to them, as is the case of Alaskans generally (Rodenhauser, 1994). Although little is known about the role of mental health care within American Indian and Alaska Native life, there is some evidence regarding their use of such services.

Availability of Mental Health Services

There is little information to indicate whether American Indians and Alaska Natives are more likely to seek care if it is available from ethnically similar, as opposed to dissimilar providers. Although there is likely to be great variability regarding this preference, given the historical relationships between Native people and white authorities, a proportion of the population is likely to prefer ethnically matched providers (Haviland et al., 1983). However, the fact is that few American Indian and Alaska Native mental health professionals are available. Approximately 101 American Indian and Alaska Native mental health providers (psychiatrists, psychologists, social workers, psychiatric nurses, and counselors) are available per 100,000 members of this ethnic group; this compares with 173 per 100,000 for whites (Manderscheid & Henderson, United States, 1998). The scarcity of American Indian and Alaska Native psychiatrists is particularly striking. In 1996, only an estimated 29 psychiatrists in the United States were of Indian or Native heritage. The same scarcity exists among other physicians as well, whereas American Indians and Alaska Natives make up close to 1 percent of the population, only .0003 percent of physicians in the United States identify themselves as American Indians or Alaska Natives.

Accessibility of Mental Health Services

As noted earlier, the Federal Government has responsibility for providing health care to the members of over 500 federally recognized tribes through the Indian Health Service (IHS). However, only 1 in 5 American Indians reports access to IHS services (Brown et al., 2000). IHS services are provided largely on reservations; consequently, Native people living elsewhere have quite limited access to this care. Furthermore, American Indian tribes that are recognized by their State, but not by the Federal Bureau of Indian Affairs, are ineligible for IHS funding (Brown et al., 2000).

In addition, according to a recent report based on national data, only about half of American Indians and Alaska Natives have employer-based insurance coverage; this is in contrast to 72 percent of whites. Medicaid is the primary source of coverage for 25 percent of American Indians and Alaska Natives, particularly for the poor and near poor; 24 percent of American Indians and Alaska Natives do not have health insurance (Brown et al., 2000).

These circumstances are compounded by the dramatic change which the IHS is undergoing as a consequence of tribal options to self-administer Federal functions under the contracting or compacting provisions of P. L. 93-638. The attendant downsizing of Federal participation in Indian health care has diminished local ability to recover Medicaid, Medicare, and private reimbursement, leading to fewer resources to support health care delivery to Native people.

Recent policy changes enable tribes to apply directly for substance abuse block-grant funds, independent of the states in which they reside. No such provision is available with respect to mental health block grants, but it is the subject of increasing discussion. It is not known, however, if these changes in policy have or will have increased Federal support of relevant programs at the local level.

Utilization of Mental Health Services

Community Studies

Representative community studies of American Indians and Alaska Natives have not been published, so little is known about the use of mental health services among those with established need. A previously mentioned study that examined the relationship of substance abuse and psychiatric disorders among family members (Robin et al., 1997b) also considered their use of mental health services. Of those with a mental disorder, only 32 percent had received mental health or substance abuse services. Although the special design of this study does not permit generalization of its findings to the community at large, it is noteworthy that very low rates of service use were observed among those most in need of care.

The use of mental health services by American Indian children with mental disorders has been the subject of several recent studies. For instance, the Great Smoky Mountain Study examined mental health service use among Cherokee and non-Indian youth living in adjacent western North Carolina communities (Costello et al., 1997). Among Cherokee children with a diagnosable DSM-III-R psychiatric disorder, 1 in 7 received professional mental health treatment. This rate is similar to that for the non-Indian sample. However, Cherokee children were more likely to receive this treatment through the juvenile justice system and inpatient facilities than were the non-Indian children. Similarly, in a small study of Plains Indian students in the north-central United States, more than one-third (39%) of those with psychiatric disorders (21%) used services at some time during their lives (Novins, et al., 2000). Two-thirds of those who received services were seen through school; just one adolescent was treated in the specialty mental health system. Among those youth with a psychiatric disorder who did not receive services, over half were recognized as having a problem by a parent, teacher, or employer.

Finally, the use of mental health services by incarcerated American Indian youth also has been considered in the literature (Novins, et al., 1999). The previously described study in a Northern Plains reservation juvenile detention facility found that about one-third of the youth suffering from a mental disorder reported having received treatment at some point in their lives, and 40 percent of those with a substance abuse disorder had done so. Overall, service use was greater among these detained youth than among their counterparts in the community. However, substantial unmet need was still evident. While services for substance-related problems were most commonly provided in residential settings, services for emotional problems typically were delivered through outpatient settings. Traditional healers and pastoral counselors provided more than one-quarter of the services received by these youth.

Mental Health Systems Studies

When data regarding the use of services by individuals who suffer from mental disorders is as limited as it is for American Indians and Alaska Natives, data generated by the overall health system may provide insight into how effective the mental health sector is in meeting the needs. However, in the case of Native people, there are two problems with this approach. First, rates of service use are related to the prevalence of mental illness in the target group. Given that American Indians and Alaska Natives may differ from white Americans in their respective rates of mental disorder, comparisons of this nature may not accurately identify differences in unmet need for care. Second, as noted in the initial SGR, less than one-third of adults with a diagnosable mental disorder receive care within a year. Therefore, disparities in care received must be interpreted in light of differences in the use of services by those in need, which appears to vary by ethnicity. With these cautions in mind, what does the available evidence suggest?

An evaluation of national data from 1980 to 1981 found that American Indians and Alaska Natives were admitted to state and county hospitals at higher rates than whites (Snowden & Cheung, 1990). This pattern was true for psychiatric services at non-Federal hospitals and at Veterans Administration (VA) medical centers. At private psychiatric hospitals, however, American Indians and Alaska Natives were admitted at a lower rate than whites. With all the rates combined, there were more American Indian and Alaska Natives than whites in inpatient psychiatric units, with even greater rates of admission if IHS hospitals were included (Snowden & Cheung, 1990). Conversely, data from 1983 (Cheung & Snowden, 1990) and again from 1986 (Breaux & Ryujin, 1999) suggested that American Indians used inpatient facilities at rates equal to their proportion in the general population.

These same studies also looked at use of outpatient mental health services Cheung & Snowden, 1990; Breaux & Ryujin, 1999. In both, American Indians and Alaska Natives were found to use outpatient mental health services at a rate similar to their representation in the U.S. population. Yet, two smaller studies of use of outpatient care in Seattle found greater than expected use by American Indians and Alaska Natives Sue, 1977; O'Sullivan et al., 1989. Just as important, fewer than half of the American Indian clients who were seen returned after the initial contact, which was a significantly higher nonreturn rate than was observed for African American, Asian, Hispanic, and white clients. The picture with respect to mental health service use by American Indians and Alaska Natives is inconsistent and puzzling. But there is a clear indication of significant need equal to, if not greater than, the need of the general population.

Complementary Therapies

Several targeted studies suggest that in many cases American Indians and Alaska Natives use alternative therapies at rates that are equal to or greater than the rates for whites. For example, 62 percent of Navajo patients interviewed at a rural IHS clinic in New Mexico had used native healers, and 39 percent reported using native healers on a regular basis (Kim & Kwok, 1998). In another study, 38 percent of the individuals interviewed in an urban clinic in Wisconsin (representing at least 30 tribal affiliations) reported concurrent use of a native healer. Of those who were not currently seeing a native healer, 9 out of 10 would consider seeing one in the future (Marbella et al., 1998). A third study at one of the country's largest, most comprehensive urban primary care programs for Indians in Seattle, Washington, revealed that two-thirds of the 871 patients sampled employed traditional healing practices regularly and felt that such practices significantly improved their health status (Buchwald, et al., 2000). Use was strongly associated with cultural affiliation, poor functional status, alcohol abuse, dysphoria, and trauma, but not with specific medical problems (except for musculoskeletal pain). In all these studies, alternative therapies and healers were generally used to complement care received by mainstream sources, rather than as a substitute for such care.

In a study of mental health service utilization by American Indian veterans in two tribes, use of both traditional Native American and mainstream medical services was markedly apparent (Gurley et al., 2001). Overall, they used services much less for mental health problems than for physical health problems. IHS facilities were equally available to both tribes, but VA services were available more readily to one of them. Within the tribe with less access to VA services, more traditional healing services were used, so that similar amounts of care were received. This demonstrates that need drives service utilization, although local availability of care dictates the forms that such service may assume.

Appropriateness and Outcomes of Mental Health Services

During the past decade, many guidelines for treating mental disorders have been offered to ensure the provision of evidence-based care. Even though few American Indians or Alaska Natives were included in the studies that led to their development, such professional practice guidelines offer the clearest, most carefully considered recommendations available regarding appropriate treatment for this population. They therefore warrant special attention.

The DSM-IV, both within the main text and in its "Outline for Cultural Formulation," does provide clear guidelines for addressing cultural matters, including those specific to this population, in the assessment and treatment of mental health problems Manson & Kleinman, 1998; Mezzich et al., 1999. A growing body of case material demonstrates the utility of applying these guidelines to American Indian children (Novins et al., 1997), as well as to adults Fleming, 1996; Manson, 1996; O'Nell, 1998.

Novins and colleagues (1997) critically analyzed the extension of the "Outline for Cultural Formulation" to American Indian children. Drawing upon rich clinical material, they demonstrated the merits and utility of this approach for understanding the emotional, psychological, and social forces that often buffet Native children. However, Novins and his colleagues underscored the importance of obtaining the perspectives of adult family members and teachers, as well as the children themselves, which is not explicitly considered in the formulation.

No studies have been published regarding the outcomes associated with standard psychiatric care for American Indians and Alaska Natives. Hence, it is not known if practitioners accurately diagnose the mental health needs of American Indians and Alaska Natives, nor whether they receive the same benefits from guideline-based psychiatric care as do whites. For this we must await related studies of treatment outcome, studies that venture beyond the limitations of current thinking with respect to intervention technology and best practices.

Mental Illness Prevention and Mental Health Promotion

Up to this point, the chapter has focused on the prevalence, risk, assessment, and treatment of mental illness among American Indian and Alaska Native youth and adults. The public health model that guides this Supplement stresses the importance of preventive and promotive interventions as well. Indeed, virtually any serious dialogue at both local and national levels about mental health and well-being among American Indians and Alaska Natives underscores the central place of preventive and promotive efforts in the programmatic landscape (Manson, 1982).

Preventing Mental Illness

Among Indian and Native people, efforts to prevent mental illness have been overshadowed by a much more aggressive agenda in regard to preventing alcohol and drug abuse (May & Moran, 1995). The research literature mirrors a similar emphasis on interventions intended to prevent or ameliorate developmental situations of risk, with special emphasis on family, school, and community Manson, 1982; Beiser & Manson, 1987; U.S. Congress, 1990.

As discussed earlier, poverty and demoralization combine with rapid cultural change to threaten effective parenting in many Native families. This can lead to increased neglect and abuse and ultimately to the removal of children into foster care and adoption (Piasecki et al., 1989). Poverty, demoralization, and rapid culture change also increase the risk for domestic violence, spousal abuse, and family instability, with their attendant negative mental health effects Norton & Manson, 1995; Christensen & Manson, 2001. The preventive interventions that have emerged in response to such deleterious circumstances in American Indian communities are particularly creative, in form as well as in reliance upon cultural tradition. One example is the introduction of the indigenous concept of the Whipper Man, a nonparental disciplinarian, into a Northwest tribe's group home for youth in foster care (Shore & Nicholls, 1975). This unique mechanism of social control, coupled with placement counseling and intensive family outreach, significantly enhanced self-esteem, decreased delinquent behavior, and reduced off-reservation referrals (Shore & Keepers, 1982). Another example is a developmental intervention that targeted Navajo family mental health (Dinges et al., 1974). This effort sought to improve stress resistance in Navajo families whose social survival was threatened and to prepare their children to cope with a rapidly changing world. It focused on culturally relevant developmental tasks and the caregiver-child interactions thought to support or increase mastery of these tasks. Delivered through home visits by Navajo staff, the intervention promoted cultural identification, strengthened family ties, and enhanced child and caregiver self-images (Dinges, 1982).

Fueled by longstanding concern regarding the disruptive nature of boarding schools for the emotional development of Indian youth, early prevention programs focused largely on social and cultural enrichment. The most widely known of these early efforts is the Toyei Model Dormitory Project, which improved the ratio of adult dormitory aides to students, replaced non-Navajo houseparents with tribal members, and trained them to be both caretakers and surrogate parents (Goldstein, 1974). As a result, youth in the Toyei model dormitory showed accelerated intellectual development, better emotional adjustment, and superior performance on psychomotor tests. The promise of this approach was slow to be realized, however, in part because of a change in Federal policy away from boarding school education for American Indians and Alaska Natives, and in part because local control over educational settings in Indian communities was rare until recently (Kleinfeld, 1982). Schoolwide interventions only now are emerging in Native communities, as successful litigation and legislative change in funding mechanisms transfer to tribes the authority to manage health and human services, including education (Dorpat, 1994).

Targeted prevention efforts have flourished in tribal and public schools. Most have centered on alcohol and drug use, but a growing number of programs are being designed and implemented with a specific mental health focus, typically suicide prevention Manson et al., 1989; Duclos & Manson, 1994; Middlebrook et al., 2001. These preventive interventions take into account culture-specific risk factors: lack of cultural and spiritual development, loss of ethnic identity, cultural confusion, and acculturation. Careful evaluation of their effects, though still the exception, illustrates, as in the case of the Zuni Life Skills Development Curriculum, the significant gains that can accompany such investments (LaFromboise & Howard-Pitney, 1994).

With increasing frequency, entire Indian and Native communities have become both the setting and the agent of change in attempts to ameliorate situations of risk and to prevent mental illness. Among the earliest examples is the Tiospaye Project on the Rosebud Sioux Reservation in South Dakota, which entailed organizing a series of community development activities that were cast as the revitalization of the tiospaye, an expression of traditional Lakota lifestyle based on extended family, shared responsibility, and reciprocity (Mohatt & Blue, 1982). More recent ones include the Blue Bay Healing Project among the Salish-Kootenai of the Flathead Reservation (Fleming, 1994) and the Western Athabaskan "Natural Helpers" Program (Serna et al., 1998). Both of these community-based interventions marshaled local cultural resources consistent with long-held tribal traditions, albeit in quite different ways that reflected their distinct orientations. Other nationwide initiatives, such as those mentioned earlier in this chapter, are likewise deeply steeped in the emphasis on community solutions to community problems.

Promoting Mental Health

Indian and Native people are quick to observe that the prevention of mental illness-with its goals of decreasing risk and increasing protection-is defined by a disease-oriented model of care. Although this approach is valued, professionals are encouraged by Indian and Native people to move beyond the exclusive concern with disease models and the separation of mind, body, and spirit, to consider individual as well as collective strengths and means in the promotion of mental health.

There is less clarity about and little common nomenclature for such strengths, their relationship to mental health, and technologies for promoting them than there is for risk, mental illness, and prevention. Even less data exist upon which to base empirical discussions about targets for promotion and outcomes, but there are relevant intellectual histories that suggest this is no quixotic quest. For example, the contemporary literature on psychological well-being has its roots in past work on dimensions of positive mental health and the related concept of happiness Jahoda, 1958; Bradburn, 1969, which have evolved into the closely related constructs of competence, self-efficacy, mastery, empowerment, and communal coping David, 1979; Swift & Levin, 1987; Sternberg & Kolligian, 1990; Bandura, 1991. Clear parallels exist between these ideas and central themes for organizing life in Native communities. Consider, for example, the concept of hozhq in the Navajo worldview: Kluckhohn identified hozhq as the central idea in Navajo religious thinking. But it is not something that occurs only in ritual song and prayer; it is referred to frequently in everyday speech. A Navajo uses this concept to express his happiness, health, the beauty of his land, and the harmony of his relations with others. It is used in reminding people to be careful and deliberate, and when he says good-bye to someone leaving, he will say hozhqqgo naninaa doo "may you walk or go about according to hozhq." (Witherspoon, 1977)

Hozhq encompasses the notions of connectedness, reciprocity, balance, and completeness that underpin contextually oriented views of health and well-being (Stokols, 1991). Although the terms of reference vary, this orientation is commonly held across Indian and Native communities. The American Indian and Alaska Native experience may lead to the rediscovery of the fundamental aspects of psychological and social well-being and the mechanisms for their maintenance.

In this regard, as noted in Chapter 1, recent years have seen the development of sophisticated theoretical formulations of the relationships among spirituality, religion, and health. Most work in this area has focused on populations raised in Judeo-Christian traditions and, consequently, measurement approaches generally remain contained within this cultural horizon (The Fetzer Institute & National Institute on Aging, 1999). American Indian and Alaska Native populations, on the other hand, often participate in very different spiritual and religious traditions, which require expanded notions of spirituality and religious practice Reichard, 1950; Gill, 1982; Hultkrantz, 1990; Vecsey, 1991 Beauvais, 1992; Harrod, 1995; Tafoya & Roeder, 1995; Csordas, 1999. Especially notable here are the importance in many Native traditions of private religious and spiritual practice, an emphasis on individual vision and revelation, ritual action in a world inhabited by multiple spiritual entities, and complex ceremonies that are explicitly oriented to healing. Moreover, many American Indian and Alaska Native people participate in multiple traditions. Traditional tribal and pan-Indian beliefs and practices continue to be influential, especially in help-seeking Kim & Kwok, 1998; Csordas, 1999; Buchwald et al., 2000; Gurley et al., 2001. Christian religions are also quite important in many Indian communities (Spangler et al., 1997). There is mounting evidence that many Indian people do not see Christianity and traditional practices as incompatible (Csordas, 1999). This dynamic is probably most evident in the Native American Church (NAC), where Christian and Native beliefs coexist Aberle, 1966; Pascarosa et al., 1976; Vecsey, 1991.

More explicit attention to the connections between spirituality and mental health in Native communities is especially warranted given the nature and type of problems described previously.

Conclusions

As evidenced through history and current socioeconomic realities, American Indian and Alaska Native nations have withstood the consequences of colonialism and of subsequent subjugation by the U.S. Government. Many members of this minority population are regaining control of their lives and rebuilding the health of their communities.

1. Although relatively little evidence is available, the existing data suggest that American Indian and Alaska Native youth and adults suffer a disproportionate burden of mental health problems compared with other Americans. Because of the unique and painful history of this minority group, many of its members are quite vulnerable. Given the high rates of suicide documented among some segments of this population, they are likely to experience increased need for mental health care as compared with white Americans. Yet, in sharp contrast to other minority groups and the general population, there is a lack of epidemiology and surveillance. This information is needed to understand the nature, extent, and sources of burden to mental health, as well as concomitant disparities. This is true across the developmental lifespan.

2. Those who are homeless, incarcerated, and victims of trauma are particularly likely to need mental health care. Indian and Native people are overrepresented in these vulnerable groups. It is not known whether they receive mental health care within the institutions intended to serve them, but there appears to be considerable unmet need. Research is needed to understand the paths by which American Indians and Alaska Natives reach these points. Just as important, methods for detecting and managing their mental health are needed in related institutional settings through culturally appropriate ways that both ameliorate their present burden and protect them from the future consequences of adversity.

3. There is significant comorbidity in regard to mental and substance abuse disorders, notably alcoholism, among both Native youth and adults. There is some indication that disorders occurring together are unlikely to be addressed by most mental health or substance abuse treatment settings. This underscores an important unmet need. Neither philosophies of treatment nor funding streams should preclude the timely and culturally appropriate treatment of such comorbidities, which otherwise threaten successful, lasting intervention.

4. Little is known about either the use of mental health services by American Indians and Alaska Natives, or whether those who need treatment actually obtain it. However, the available research has important implications. First, practical considerations, such as availability of culturally sensitive providers and accessibility of services through insurance or geographic location, are extremely important for this ethnic group. Second, services for those in greatest need of care may best be provided within targeted settings, such as those serving the homeless, incarcerated, or alcohol dependent. Medical services that provide care for victims of trauma or older primary care patients also hold promise for meeting the needs of a significant portion of this population.

5. Major changes in the financing and organization of mental health care are underway in American Indian and Alaska Native communities as a consequence of relatively recent policies regarding self-determination. There is limited understanding of these changes, their implications for resources, the resulting continuum of care, or the quality of services. Thus, it is imperative that organizational and financing changes be closely examined with an eye toward the best interests of Native people. It would be a sad legacy to conclude 20 years from now that the assimilationist pressures that proved so devastating in the past have been unwittingly repeated.

6. The knowledge base underpinning treatment guidelines for mental health care have been built with little specific analysis of their benefit to ethnic minority groups. The evidence behind them is an extrapolation from largely majority clinical populations. This is in spite of the fact that cultural forces are known to be at work in virtually every aspect of psychopathology, from risk to onset, presentation, assessment, treatment response, and relative burden. Moreover, the efficacy of treatment alternatives that may be especially relevant to this population has not yet been examined. Accordingly, clinical research needs to be undertaken to shed light on the applicability and outcomes of treatment recommendations for American Indians and Alaska Natives.

7. Though long-suppressed by social and political forces, traditional healing practices and spirituality are strongly evident in the lives of American Indians and Alaska Natives. They usually complement, rather than compete with, medical care. The challenge is to find ways to support and strengthen their respective contributions to the health and well-being of those in need. How well this is accomplished depends on advances in the science by which healing practices and spirituality are conceptualized and examined.

8. Despite the mental health problems that plague Indian and Native people, the majority, though at risk, are free of mental illness. Thus, prevention should remain a high priority. Native voices are clear and unequivocal in this regard; preventive and promotive approaches strike a resonant chord in the hearts of these individuals and their communities. Abundant evidence attests to the creativity of intervention strategies mounted in an attempt to ameliorate situations of developmental risk for mental health problems among American Indians and Alaska Natives. Unfortunately, the current limits of science, notably the conceptualization and measurement of both the culturally defined and relevant points of intervention as well as outcomes, impede the evaluation of these strategies. Here the challenge is to understand how preventive interventions developed in other populations work for the American Indian and Alaska Native population in order to determine what adaptations must be made to improve their cultural fit and effectiveness. Conversely, the country as a whole has a great deal to gain by attending to advances in prevention among American Indians and Alaska Natives, for the lessons learned in these instances may have broader application to all Americans.

9. Lastly, the individual and collective strengths of Native communities warrant closer, systematic attention. Interventions are needed to promote the strengths, resiliencies, and other psychosocial resources that characterize full, productive, meaningful lives and contribute to their maintenance. New perspectives need to be explored, bending our scientific tools to the task.

American Indian and Alaska Native people speak about a journey as beginning with its initial steps. With respect to mental health, this journey already has begun. Some paths have been well traveled and feel familiar; some paths are new and intriguing; some paths have yet to be marked. It is clear that the Nation can serve as a guide for hastening this journey along certain paths. It is equally clear that the Nation would also do well to watch carefully and follow Native people along the paths that they have emblazoned.

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1

This figure includes people identifying themselves as Hispanic and/or multiracial members of this group. Those identifying solely as American Indian or Alaska Native comprise just less than 1 percent of the U.S. population.

In 1977, the National Congress of American Indians and the National Tribal Chairmen's Association issued a joint resolution indicating that in the absence of specific tribal designations, the preferred reference to people indigenous to North America is American Indian and/or Alaska Native. A variety of other referents are apparent in the professional literature, including Native Americans, First Americans, and Natives. In keeping with the 1977 resolution, this report adopts American Indian and/or Alaska Native except in limited instances where, editorially, Native people or Native American is used as a general term to refer to both American Indians and Alaska Natives.

Minimum number of visits set by the Kaiser Commission are at least one physician visit in the past year for children ages 0-5 and in the past two years for children ages 6-17 (as recommended by the American Academy of Pediatrics in Pediatrics, 96, 712), and in the past year for adults in fair or poor health and in the past two years for adults in good or excellent health (Kaiser Commission on Medicaid and the Uninsured, 2000).

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