From Part 1 of This Special Report
Frank A. Clark, MD
Geoffrey Z. Liu, MD; Margaret Cheng Tuttle, MD
María José Lisotto, MD; Andrés Martin, MD, MPH
Each Native American tribe has a specific history, traditions, customs, and culture, and knowing something of these will help build the physician-patient relationship.
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
Demographics
Frank A. Clark, MD
Geoffrey Z. Liu, MD; Margaret Cheng Tuttle, MD
María José Lisotto, MD; Andrés Martin, MD, MPH
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,1 and more than 200 tribal groups without any government recognition.2 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.3 The
Health Care and Social Services
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.4 The BIA focuses on education, housing, family and personal safety, and workforce development, and it promotes Native self-determination.5 Along with providing mental health services to all United States citizens, SAMHSA has many dedicated mental health programs,
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.
Morbidity and Mortality
Erica Richards, MD, PhD
The Human Development Index (HDI) uses collective data on life expectancy, education, and income to measure improvement in individuals’ lives. In a critical paper7 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%.7
Alarming Statistics
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
Doctrine of Discovery
What has caused these
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.”10 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.10
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
Social Determinants of Health
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.12 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.13
Conclusions
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 (
Dr Walker 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.
References
1. Salazar M. State recognition of American Indian tribes. LegisBrief: National Conference of State Legislatures. 2016;24(39).
2. Johnson T. US federally non-recognized Indian tribes—index by state. Updated April 5, 1997. Accessed June 16, 2021.
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.
4. Indian health disparities. Indian Health Service. October 2019. Accessed June 16, 2021.
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.
8. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. National Institutes of Health; 1999. Accessed June 16, 2021.