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We are accustomed to hearing the old adages, “You do the crime, you do the time" and “You reap what you sow.” I continue to reflect on these words, especially in the context of individuals who have been incarcerated. 

I serve a diverse patient population, and some of them have come in contact with the criminal justice system. I have heard their narratives of trauma and resilience. I have heard them describe the inhumane treatment they received, and how their experience was the antithesis of “rehabilitation.”

Criminal charges do not equate with treating people like caged lepers. If we truly want to decrease recidivism rates and health disparities for individuals in the carceral system, then perhaps we should not strip people of their humanity. I recommend we build on their strengths and provide them with the resources that will help them flourish when they reenter society.

 by Stanley Andrisse, MBA, PhD. His narrative is palpable. I appreciate his authenticity and transparency. It is never too late for the carceral system to have a facelift.

is an outpatient psychiatrist at Prisma Health-Upstate and clinical associate professor at the University of South Carolina School of Medicine, Greenville. He served on the American Psychiatric Association’s Task Force to Address Structural Racism Throughout Psychiatry, and he currently serves as the Diversity and Inclusion section editor and advisory board member for

With so many stories of trauma associated with the criminal justice system, it is time to reexamine how this population is treated.

Trauma, Resilience, and Justice for Those in the Criminal Justice System

MORE FROM THE PAGES OF OUR SPECIAL REPORT: CHILD AND ADOLESCENT PSYCHIATRY

An immigrant’s journey is a leap of faith—and sometimes desperation. The desire to build a better life for oneself and one’s family is a powerful motivator that can make the enormous hardships and risks involved worth the effort. For many, the lure of promise and opportunity draws them to the shores of the United States. For others, 

the need to escape violence, war, and oppression

 leaves them with little choice. No matter what leads them on the path, all immigrants require huge amounts of courage and resilience.

The children who are included on the journey are particularly vulnerable to negative mental health implications associated with migration. Often, they have very little choice or control over the matter, especially when circumstances separate them from caregivers. Growing up with these complex circumstances puts enormous pressure on the mental health of many immigrant children, and this can have far-reaching effects on generations to come. Although stronger government policies are needed to set the proper tone on immigration, the mental health community has an important role to play in the treatment of immigrants, especially children.

, immigrants generally come from countries with poorer health outcomes than the US, and oftentimes they bring with them a lower socioeconomic status.

 When they arrive, they are often subject to intense discrimination and prejudice, which may diminish over time.

 Language barriers and cultural differences can be particularly confusing and disorienting, which can make it extremely difficult to get help for physical or mental health needs as well as to integrate and adapt to a foreign environment.

 push forward and succeed, often outperforming both native citizens and established immigrants while reporting lower rates of depression and anxiety.

 Compared to US natives, immigrants have a lower risk over their lifetime of developing a psychiatric condition such as anxiety, mood, and substance use disorders.

 This curious phenomenon is known as the 

. It is used to describe how recently arrived immigrants are usually in better health than their non-migrant counterparts. Why does this paradox exist? The answer is unclear, but researchers have made a few educated guesses.

One study suggests that strong family ties, cultural strength, religion, and migrant social networks provide protections.

 Another study suggests selective migration as an influence, which favors immigrants who represent a smaller yet healthier subset within a population, one that shows above-average

, motivation, and psychological wellbeing.

Immigrant children younger than 13 years old are commonly referred to as the 1.5 generation. Their migration story, and its effect on their mental health, is slightly different from their parents and older siblings. Because they are immersed in US schools at an earlier age, the 1.5 generation becomes acculturated much faster. While first-generation immigrants might enjoy good mental health, at least in the beginning, these 1.5 generation children are more vulnerable to issues.

For these youth, the immigration process affects them the most during adolescence, when a psychiatric illness is most likely to emerge. Those who need mental health services are often stymied by shifts in government policies, the threat of deportation, and cultural attitudes about mental health. Furthermore, a 2007 study found that immigrant children who experienced early socialization in the US showed risk for mood and impulse-control disorders approaching that of native populations.

 The researchers found risk for mood, impulse control, and 

 started to increase soon after immigration, although adjustments are not necessarily consistent across the disorders.

With the arrival of the second generation (those born in the US to immigrant parents), the protections of the healthy immigrant start to fade. While the first and 1.5 generations register lower rates of mood, anxiety, or

, rates for the second and third generations are on par with the native population. This suggests that exposure to US culture is linked to rates of mental illness.

Regardless of which generation they belong to, the length of time spent in the US can reduce the health immigrant effect. Immigrants who had lived in the US for 13 years or more had a higher lifetime prevalence of psychiatric disorders when compared to recently arrived immigrants. Although the risk for substance use disorders was low the first 10 years after immigration, it increased closer to native levels after that.

During the immigration process, first- and 1.5-generation youth experience a number of upheavals, including separation from family, exposure to traumatic events, 

, loss of social status, and changes in family rules and role.

Although parents may be excited about moving to a new country, the child/adolescent often has little input to the decision. For instance, a 2010 report of Latino youths aged 12 to 19 found that 60.4% had little to no involvement in the decision to migrate.

The researchers found anxiety was the most common condition among youth, with 29% showing symptoms, compared to 13% to 20% among natives. On the other hand, only 7% of youth were symptomatic for depression, which is similar to native youths. Almost a quarter of those surveyed described their migration experience as stressful.

Children whose parents kept them involved and educated about the immigration decisions reported lower levels of anxiety. Although parents can help mitigate concerns before migration, they often have little control over what happens during the transition. Being robbed, injured, or otherwise 

 during migration can create a higher risk of anxiety for an average of 5 years after migration.

In fact, 75% of immigrant children experience separation from a caregiver during the process for a variety of reasons.

Separation during the immigration process can be especially traumatizing for youth, with far-reaching effects. In fact, 75% of immigrant children experience separation from a caregiver during the process for a variety of reasons.

 Perhaps a caregiver traveled ahead to lay a foundation by securing employment and housing. Or, as is the case with many unaccompanied refugee minors from South America, families might intentionally send their children on alone, hopeful that US policy designed to protect children against trafficking might help them secure a court hearing.

In addition, some separation has occurred after families arrived in the US. As a result of the zero-tolerance policy on illegal immigration and to discourage families making the journey, children were intentionally separated from their families at the Mexican border. Among other setbacks, these immigrant children are 35% more likely to experience an education gap compared to their peers.

Once they have arrived, young immigrants must then juggle new stressors, including concerns over their legal status, discrimination, and social marginalization. Thus, youth who are undocumented are at a high risk for experiencing anxiety. This risk is even greater among families in which the parents are documented but the children are not. These children worry they will be sent back to their native country and be separated from their parents. To put this in perspective, about 60% of immigrant Latino youths and their parents lacked documentation when entering the US. In cases in which parents had documents, almost 11% of adolescents did not.

, the experience of discrimination is more closely tied to symptoms of depression. Premigration and the immigration process generated depression levels that fell within normal levels. After arriving, about 42% of Latino youth experienced and perceived discrimination. These experiences can affect first-generation Latinos for up to 4.5 years.

 (ADHD) is the most common psychiatric disorder among youth and children, data on rates among immigrant children are limited. A 2013 report analyzing the National Survey of Children’s Health found that immigrant children were 40% to 90% less likely to be diagnosed with ADHD compared to native-born children.

 Similarly, a 2016 study found a pattern of lower rates of ADHD in ethnic minorities, but this is likely due to underdiagnosis and undertreatment rather than a true difference between different populations.

Rates of schizophrenia in immigrants also show some interesting trends. Although the risk of schizophrenia is about 0.5% to 1% in most countries, it is 2.7 times higher in first-generation immigrants, and 4.5 times higher in second-generation immigrants. Despite these startling statistics, immigrant families were 3 times more likely to drop out of monitoring and treatment programs for early psychosis.

The risk of conduct disorders, especially those with nonaggressive symptoms, were shown to increase significantly with each generation of Mexican immigrants, suggesting that environmental factors rather than genetic ones exerted a greater influence.

 rates differ among various immigrant ethnicities. Afro-Caribbeans, for example, did not experience a significant association between duration of stay in the US and rates of suicide or suicidal ideation. Asian immigrants experienced a modest association.19 But this experience was different for Latinos. Those who had lived in the US for more than 20 years were 4.27 times more likely to attempt suicide and 3 times more likely to engage in suicidal ideation compared to Latinos who had lived there less than 5 years.

For first generation immigrants, the risk of alcohol use disorder is low, but rises exponentially with the number of years spent in the US. Second-generation immigrants have a higher risk, and the risk eventually reaches the native-born levels in subsequent generations.

 are common, and yet they varied across ethnic groups. The most common barrier is lack of insurance; others include stigma around mental health, cost, language, distrust of formal services, embarrassment, cultural incompetence, inaccessibility, being undocumented, and lack of knowledge, among others.

 These barriers are particularly challenging for children, who are often at the mercy of their parents when it comes to receiving professional mental health services.

Considering the amount of potential stress involved in the migration story, it may be surprising to note that immigrants rarely seek out professional mental health services. A 2015 systematic review of 62 articles found that only 6% of Asian and Latino immigrants had ever received mental health care.

 Instead, immigrants are more likely to seek out informal care from family, friends, and religious leaders within their social networks. One study of Korean immigrants found that 52% preferred to seek assistance from family and friends, 40% preferred religious consultation, and only 9% sought out a mental health professional.

 Another study found that 15% of Mexican immigrants sought psychiatric help as opposed to 38% of US-born Mexicans with similar problems.

One study found that more than half of the immigrant families 

 Despite there being several US laws requiring access to interpretation services, barely half of the hospitals provide them, and the situation does not seem to be improving much over time.

Confidentiality between a doctor and a child may be unacceptable to some parents, which could stymie treatment efforts.

One 2019 study found that Chinese immigrant parents viewed social anxiety as a personality or cultural issue rather than a mental health problem. Despite higher rates of suicidal ideation in the Asian American youth, most parents in the study were hesitant to bring up suicidal ideation.

Acculturation, especially for recent immigrant youth, appears to be the quickest way to roll back the potentially negative effects of immigration, allowing them to learn the language of their adopted country and navigate social systems with great ease.

Studies have found that bilingualism and biculturalism may confer significant benefits in terms of cognitive abilities, psychological adjustment, and subjective well-being.

In general, second-generation youth who integrate into their adopted society have the most positive psychological well-being when they also involve themselves in their cultural heritage.

 Studies have found that bilingualism and biculturalism may confer significant benefits in terms of cognitive abilities, psychological adjustment, and subjective well-being.

 Youth who do not tend to their bicultural competence in adulthood may experience increased risks for depression and anxiety.

For some, however, this acculturation can add yet another stress to the immigration experience. First- and 1.5-generation youth eager to assimilate run the risk of abandoning the cultural traditions and familial bonds that previously provided the healthy immigrant protections. This chasm can have further effects. Cultural differences over mental health issues can cause riffs, disagreements, and even 

Schools play a vital role in detecting mental health issues among all children and especially immigrants. Provided they are properly trained and staffed, teachers and school administrators can assess children during the day and, in some cases, refer them to onsite services. School-based interventions would not only make it easier for parents and children to access mental health screenings, they would also do so regardless of the immigrant’s insurance or financial status.

Onsite interventions can be particularly beneficial for unaccompanied refugee minors, who have higher risk for developing

 Refugees tend to take more special classes and receive more in-home counseling, likely because they connected to these resources at school.

One example of school-based service is the ​​Cognitive-Behavioral Intervention for Trauma in Schools, a program designed for immigrant children who experienced violence before, during, or after their migration. It was developed by the RAND Corporation in partnership with the University of California, Los Angeles, and the Los Angeles Unified School District. All 126 students in the pilot program had been a victim of at least 2.8 violent events and witnessed 5.9 violent events just a year earlier. All were experiencing moderate to severe PTSD symptoms. After 3 months, students showed substantial improvement. Compared to a control group that would later go through the program, the initial group reported 86% less-severe PTSD symptoms.

Immigrant children often arrive in the US after experiencing hardships and even trauma, including the immigration process itself. It is therefore important to identify these children and find ways to support them and their families to prevent (further) psychiatric issues and help ensure they get settled in the healthiest way possible. Programs such as those that offer initial assisted assimilation, language and vocational training, and culture-orientation classes can be effective.

While we collectively reflect on the social determinants of mental health, let us not alienate the concept of immigration and how it affects those we serve. After all, most of us are immigrants in one way or another.

 Immigration, citizenship, and the mental health of adolescents.

2. Breslau J, Aguilar-Gaxiola S, Borges G, et al. 

Risk for psychiatric disorder among immigrants and their US-born descendants: evidence from the National Comorbidity Survey Replication.

Comparative studies of acculturative stress.

Acculturation and mental health status among Hispanics. Convergence and new directions for research.

Acculturation and lifetime prevalence of psychiatric disorders among Mexican Americans in Los Angeles.

6. Grant BF, Stinson FS, Hasin DS, et al. 

Immigration and lifetime prevalence of DSM-IV psychiatric disorders among Mexican Americans and non-Hispanic whites in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions.

7. Ortega AN, Rosenheck R, Alegría M, Desai RA. 

Acculturation and the lifetime risk of psychiatric and substance use disorders among Hispanics.

Migration, social support and perinatal health: an origin-destination analysis of Puerto Rican women. 

10. Jasso G, Massey DS, Rosenzweig MR, Smith JP. Immigration, health, and New York City: early results based on the US New Immigrant Cohort of 2003. FRBNY Economic Policy Review. December 2005. Accessed August 30, 2021. 

https://www.newyorkfed.org/medialibrary/media/research/epr/05v11n2/0512jass.pdf

Ages, life stages, and generational cohorts: decomposing the immigrant first and second generations in the United States.

12. Salas-Wright CP, Kagotho N, Vaughn MG. 

Mood, anxiety, and personality disorders among first and second-generation immigrants to the United States.

 Depression and anxiety among first-generation immigrant Latino youth: key correlates and implications for future research.

 The impact of immigration-related separation and reunification on children’s education: evidence from the American Community Survey 2010–2018. 

Health, chronic conditions, and behavioral risk disparities among US immigrant children and adolescents.

16. Coker TR, Elliott MN, Toomey SL, et al. 

Racial and ethnic disparities in ADHD diagnosis and treatment.

Schizophrenia and migration: a meta-analysis and review.

18. Breslau J, Borges G, Saito N, et al. 

Migration from Mexico to the United States and conduct disorder: a cross-national study. 

Duration of US residence and suicidality among racial/ethnic minority immigrants.

20. Salas-Wright CP, Vaughn MG, Clark TT, et al. 

Substance use disorders among first- and second- generation immigrant adults in the United States: evidence of an immigrant paradox?

Mental health service use among immigrants in the United States: a systematic review.

Depressive symptoms and help-seeking behaviors among Korean Americans.

23. Vega WA, Kolody B, Aguilar-Gaxiola S, Catalano R. 

Gaps in service utilization by Mexican Americans with mental health problems.

24. Eldred SM. With scarce access to interpreters, immigrants struggle to understand doctors’ orders. 

August 15, 2018. Accessed August 30, 2021. 

https://www.npr.org/sections/health-shots/2018/08/15/638913165/with-scarce-access-to-medical-interpreters-immigrant-patients-struggle-to-unders

Parent perceptions of mental illness in Chinese American youth. 

Acculturation, discrimination, and adaptation among second generation immigrant youth in Montreal and Paris.

Role of bilingualism and biculturalism as assets in positive psychology: conceptual dynamic GEAR model. 

Trauma without borders: the necessity for school-based interventions in treating unaccompanied refugee minors.

29. Betancourt TS, Newnham EA, Birman D, et al. 

Comparing trauma exposure, mental health needs, and service utilization across clinical samples of refugee, immigrant, and US-origin children.

30. Stein BD, Jaycox LH, Kataoka SH, et al. Helping children cope with violence and trauma: a school-based program that works. RAND Corporation. 2011. Accessed August 30, 2021. 

https://www.rand.org/pubs/research_briefs/RB4557-2.html

State-assisted integration, but not for all: Norwegian welfare services and labour migration from the new EU member states

32. Budiman A. Key Findings about US immigrants. Pew Research Center. August 20, 2020. Accessed August 30, 2021. 

https://www.pewresearch.org/fact-tank/2020/08/20/key-findings-about-u-s-immigrants/

Understanding Psychiatric Implications of Child Immigration

“You can imagine if you're regularly hearing in the media that trans people are risks to other people in bathrooms, that you're a risk to your peers on sports teams, that really you're just confused about your gender identity—over time, you may internalize these ideas and start to have self-hatred or low self-esteem,” said Jack L. Turban, MD, MHS, a Fellow in Child & Adolescent Psychiatry at Stanford University School of Medicine and 

In his session, “Evolving Treatment Paradigms for Transgender Youth,” Turban discussed the evolution of prepubertal transgender youth treatment over the past 2 decades, the current evidence base for pubertal suppression for transgender adolescents, and the rationale for gender-affirming hormone treatment for transgender adolescents.

Transgender youth, Turban explained, have an array of psychiatric morbidities, including mood disorders (12.4 to 64%), anxiety disorders (16.3 to 55%), and prior suicide attempts (9.3 to 30%). Additionally, about 80% have been a victim of bullying.

Another topic Turban found important to approach is the dangers of gender identity conversion therapy. In his research published in 

, Turban took a sample size of more than 27,000 American transgender adults who had spoken to a therapist about their gender identity, and compared those whose therapy involved trying to make them cisgender with those whose therapy did not have any conversion efforts.

 The results showed exposure to conversion efforts before age 10 led to increased suicidal ideation, increased lifetime cigarette use, increased lifetime illicit drug use, as well as more suicide attempts.

“We had a ton of data that trying to change sexual orientation was dangerous, but this is the first study to look at trying to change someone's gender identity and the mental health outcomes,” said Turban.

Furthermore, Turban noted it seems like childhood is particularly vulnerable time period for being exposed to conversion efforts. Conversion therapy is still legal in 29 states and 4 territories,

 and approximately 13.5% of transgender individuals report lifetime exposure to gender identity conversion efforts.

Instead, Turban believes a social transition might be a good idea for a prepubertal child. In a social transition, transgender children or adolescents adopt the name, pronouns, and gender expression (like clothing or haircuts) that match their gender identity.

“Banning social transition is likely dangerous and can send a message to a child that being transgender is bad. This can essentially instill shame and damage relationships between the child and the therapist, and the child in the family,” Turban said.

Research review: gender identity in youth: treatment paradigms and controversies.

2. Turban JL, Beckwith N, Reisner SL, Keuroghlian AS. 

Association between recalled exposure to gender identity conversion efforts and psychological distress and suicide attempts among transgender adults.

3. Movement Advancement Project. Updated 2021. Accessed October 2, 2021. 

https://www.lgbtmap.org/equality-maps/conversion_therapy

4. Turban JL, King D, Reisner SL, Keuroghlian AS. 

Psychological attempts to change a person's gender identity from transgender to cisgender: estimated prevalence across US states, 2015.

Transgender youth are at increased risk for a number of psychiatric morbidities. Gender identity conversion therapy can make them worse. 

Treating Transgender Youth: The Danger of Gender Identity Conversion Therapy 

SPECIAL REPORT: MINORITY MENTAL HEALTH PART 2

It is easy to be overwhelmed with the remarkably complex circumstances when considering American Indian and Alaska Native (AI/AN) communities across the United States and the mental health issues and needs of these tribes and/or individuals. Each tribe has a specific history, traditions, customs, and culture, and knowing something of these will help build an understanding of how mental health problems develop and how they are expressed. In addition to learning about a patient’s tribe, gathering a personal history takes time and effort. Issues of poverty, violence, survival, family morbidity and mortality, alcoholism and drug problems, suicide, racism, and historical trauma are often a part of their story.

It might be tempting to start a problem list and then formulate a treatment plan, as has been done so many times before in Western medicine, but what are the issues in need of treatment? What are the odds of a treatment plan resolving the problems? What is the patient’s home environment? It is important to take time to think about the 

 and why chronic illnesses beset their lives. A historical review sheds light on the causes of behavioral health issues and other chronic medical problems.

The AI/AN population is a heterogeneous group of 574 federally recognized tribes with 324 reservations in the United States. Further, there are 63 state-recognized tribes in 11 states,

 and more than 200 tribal groups without any government recognition.

 As of 2019, the collective AI/AN population was estimated to be 6.9 million individuals, about 2% of the total US population. The AI/AN population is spread across different regions, with 78% living outside identified tribal areas, 22% on reservations or other trust lands, and 60% in metropolitan areas. The Native population is significantly younger than that of non-Hispanic Whites.

 shows a county breakdown of where AI/AN lived according to the US 2010 Census.

Federally recognized AI/AN tribes are provided health and educational assistance through several government agencies, with the Indian Health Service (IHS), the Bureau of Indian Affairs (BIA), and the Substance Abuse and Mental Health Services Administration (SAMHSA) having primary responsibilities. State-recognized and nonrecognized Native groups receive assistance through state-, county-, and city-funded health and social programs.

The IHS, established in 1955, operates a comprehensive health service delivery system for approximately 2.6 million AI/AN individuals. Long underfunded, the IHS provides support for about 46% of the health care needs of Native peoples.

 The BIA focuses on education, housing, family and personal safety, and workforce development, and it promotes Native self-determination.

 Along with providing mental health services to all United States citizens, SAMHSA has many dedicated mental health programs, 

, and behavioral health prevention programs specifically for Native communities.

Although vast improvements have been made over the past 20 years, including as part of federal agency efforts, AI/AN people still have a high prevalence of behavioral health problems and limited access to care relative to the overall US population.

The Human Development Index (HDI) uses collective data on life expectancy, education, and income to measure improvement in individuals’ lives. In a critical paper

 comparing well-being among major US ethnic groups, the HDI reported large gaps. The AI/AN group is lowest in wage earnings and second lowest in both education and life expectancy. Taken together, these findings give AI/AN the lowest Health Index in the United States. The AI/AN population is the only group that had negative improvement over the past 10 years. According to 2018 US Census data, the highest poverty rate by ethnicity is found among AI/AN at 25.4%; the White non-Hispanic rate, by comparison, is 10.1%.

According to data from the Indian Health Service and the Office of the Surgeon General, AI/AN individuals experience serious mental health disparities when compared with the overall US population. Higher rates of addictions, depression, anxiety, and suicide exist. Historical 

, racism, poverty, inadequate education, unemployment, discrimination in the delivery of health services, and cultural differences coexist with the morbidity and mortality findings for this population.

 These observations suggest that social and economic issues connect with mental health problems and affect treatment outcomes (

? Considering the events since the first contact of AI/AN with European explorers and colonizers gives a start in understanding the interrelationship between chronic health issues and social determinants. First, we can look at a series of papal bulls directed to leaders of European monarchies, which encouraged taking possession of lands and Native people in the Americas. The first bull by Pope Nicholas V was issued in 1452 to the Portuguese monarchy, asking Portugal to declare war on all non-Christians worldwide and endorsing conquest, ownership, colonization, and slavery of all non-Christian nations and territories. Forty years later in 1493, shortly following the first voyage of Columbus to the Americas, Pope Alexander VI issued the bull “Inter Caetera” or “The Doctrine of Discovery” to the Spanish monarchy, which gave Spain and Portugal the “right” to vanquish, colonize, convert, and enslave all non-Christian peoples and lands. Ultimately, all European monarchies used these papal bulls as justifications to control lands in the New World.

As the colonies became independent, they modified their governments to incorporate the message of 1493’s papal bull. When the United States declared its independence in 1776, it retained the British right of discovery and also assumed Britain’s power of dominion. In 1823, the US Supreme Court unanimously adopted the theme of the Doctrine of Discovery into federal law, observing that Christian European nations had assumed “ultimate dominion” over the lands of America during the “Age of Discovery.”

 American Indians, therefore, lost their right to complete sovereignty and retained a right to occupy only certain lands. This Supreme Court decision allowed the Federal government to ignore the rights of American Indians and to claim that the non-Christian lands of America rightfully belonged to, first, the “discovering” Christian European nations, then, subsequently, to the US federal government. Indian nations were deemed “domestic dependent nations” that were subject to the federal government’s absolute legislative authority. Between 1778 and 1871, the United States signed 368 treaties related to land cession with various tribes.

The Doctrine of Discovery and later Manifest Destiny became the underlying themes for a multitude of negative events affecting indigenous peoples across North America. Tribes were decimated by 

, disease, ethnic cleansing, and genocide. AI/AN peoples also experienced forced relocation and boarding schools, restrictions of cultural activities, prohibitions on use of their own language, and historical trauma.

 While the Doctrine of Discovery has been rescinded in many churches in the last 2 decades, it is still in place with the Catholic church, and its repercussions echo today.

In a series of studies beginning in the late 1960s and continuing to the present, Sir Michael Marmot, PhD, has pursued the impact of social, economic, and political determinants upon various populations. His work in the World Health Organization concerning Indigenous peoples suggests that health care systems need to 1) promote improved education, 2) promote expanded vocational support and improved working conditions, 3) promote healthy living conditions and adequate housing, 4) give every child the best start in life, 5) advocate to establish an income necessary for a healthy life, and 6) pursue the causes of ill health.

 The chronic health illnesses in AI/AN peoples are directly influenced by social, economic, and racial conditions over 5 centuries. Even today, the social and economic conditions in which many AI/AN people live create a negative impact on their morbidity and mortality.

AI/AN peoples are different from each other and different from the rest of the US population. A long history of social, cultural, and economic struggles has contributed to their increased morbidity and mortality. It is time to address the long-term problems in conjunction with chronic mental health illnesses (

). An integrated partnership with patients and the Native community, focusing on health equity, will go a long way in improving the social determinants of health for this special population. Psychiatrist participation in the process will help us grow in our understanding of the problems, enrich the therapeutic process, and improve treatment outcomes.

is professor of psychiatry emeritus and director of the One Sky Center for American Indian and Alaska Native Behavioral Health at Oregon Health and Science University. His current work draws attention to best practices for the prevention and treatment of addiction and mental health disorders in American Indian populations.

1. Salazar M. State recognition of American Indian tribes. LegisBrief: National Conference of State Legislatures. 2016;24(39). 

https://www.ncsl.org/legislators-staff/legislators/quad-caucus/state-recognition-of-american-indian-tribes.aspx

2. Johnson T. US federally non-recognized Indian tribes—index by state. Updated April 5, 1997. Accessed June 16, 2021. 

http://www.kstrom.net/isk/maps/tribesnonrec.html#:~:text=Active%20states%20%28reservation%20maps%29%20are%20clickable%20here.%20About,whom%20are%20petitioning%20for%20federal%20recognition.%20Page%20buttons

3. Facts for features: American Indian and Alaska Native Heritage Month: November 2020. News
release. United States Census Bureau. September 30, 2020. Accessed June 16, 2021. 

https://www.census.gov/newsroom/facts-for-features/2020/aian-month.html

4. Indian health disparities. Indian Health Service. October 2019. Accessed June 16, 2021. 

https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/factsheets/Disparities.pdf

5. Office of Indian Services. US Department of the Interior Indian Affairs. Accessed June 16, 2021. 

6. Home page. Substance Abuse and Mental Health Services Administration. Accessed June 16, 2021. 

7. Measuring America: ten years and counting. Measure of America. Accessed June 16, 2021. 

http://www.measureofamerica.org/10yearsandcounting/

8. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. National Institutes of Health; 1999. Accessed June 16, 2021. 

9. History resources: The Doctrine of Discovery, 1493: a spotlight on a primary source by Pope Alexander VI. Gilder Lehrman Institute of American History. Accessed June 16, 2021. 

https://www.gilderlehrman.org/history-resources/spotlight-primary-source/doctrine-discovery-1493

Five hundred years of injustice: the legacy of fifteenth century religious prejudice.

American Indian health disparities: psychosocial influences.

13. Marmot M. Boyer Lectures: Sir Michael Marmot highlights health inequalities and ‘causes of the causes.’ ABC Radio National. September 2, 2016. Accessed June 16, 2021. 

https://www.abc.net.au/news/2016-09-03/boyer-lecture-sir-michael-marmot-highlights-health-inequalities/7810382

Each Native American tribe has a specific history, traditions, customs, and culture, and knowing something of these will help build the physician-patient relationship. 

Issues for Psychiatrists: Challenges Facing American Indian and Alaska Native Patients

Previous systematic reviews estimate the 

 of attention-deficit/hyperactivity disorder (ADHD) worldwide as 5.6% to 7.2%.

 that some ethnocultural groups, such as Black individuals, are underrepresented in studies.

 found a higher prevalence of ADHD in Black than white youth, with evidence for a wide range in individual estimates for Black youth.

 Many factors may contribute to this variability.

 conducted a systematic review and meta-analysis to determine the pooled prevalence estimate of ADHD and associated individual, familial, and social factors among Black individuals, toward evidence-based and culturally adapted programs. The authors search PsychInfo, MEDLINE, Embase, Cochrane CENTRAL, CINAHL, ERIC, and Education Source from inception through October 2019. The search was designed by considering previous systematic review search strategies focused on Black participants. The authors included journal articles published in English or French with empirical data on the prevalence of ADHD samples in Black individuals in countries where they are considered a minority population (eg, United States and Canada).

The authors screened 3833 articles by title/abstract, from which they assessed 99 full-text articles for eligibility. Twenty articles met the inclusion criteria, and an additional article was found by manually searching the reference lists of these articles (

). Thus, 21 studies (24 independent samples), including 2 samples of adults, were included in the meta-analysis, all of which came from the United States.Each study was subjected to a quality assessment. Random effects meta-analysis on the proportion of 

The included studies had a combined sample size of 154,818. The pooled prevalence of ADHD was 14.5% (95% CI 10.6%-19.6%), with significant between-study heterogeneity. There was no evidence of publication bias based on a funnel plot and Kendall τ rank-order correlation. A similar pooled prevalence of 13.9% was found after excluding the 2 adult samples. Although some individual studies found sociodemographic (eg, age, sex, socioeconomic status), familial, and environmental risk factors, and risk behaviors, there were inadequate data to perform a moderation analysis, so a narrative review was performed. Some replicated risk factors (reported in 3 or more studies) include male sex, Black (versus other) race, low socioeconomic status, and 

Research on the prevalence of ADHD in Black individuals in the United States highlights the need for future research in this underrepresented group.









Special Populations

Trauma, Resilience, and Justice for Those in the Criminal Justice System

Understanding Psychiatric Implications of Child Immigration

Treating Transgender Youth: The Danger of Gender Identity Conversion Therapy

Issues for Psychiatrists: Challenges Facing American Indian and Alaska Native Patients

Busting Myths About Black Individuals With ADHD

If We Had a Hammer