Addressing Depression Among American Indians and Alaska

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Addressing Depression Among American Indians and Alaska

Transcript Of Addressing Depression Among American Indians and Alaska

Urban Indian Health Institute
A Division of the Seattle Indian Health Board

Addressing Depression Among American Indians and Alaska Natives: A Literature Review
August 2012

This report was prepared by Megan Fairweather MA, Julie Loughran MPH, Caleb Dunlap BA, Emma Strick BA and Emma Robson BA.
Recommended Citation: Urban Indian Health Institute, Seattle Indian Health Board. (2012). Addressing Depression Among American Indians and Alaska Natives: A Literature Review. Seattle, WA: Urban Indian Health Institute.


Addressing Depression Among American Indians and Alaska Natives: A Literature Review








Depression and Common Mental Disorders


Current Prevalence of Depression and Associated Factors







Implications for Care


Activities and Programs



Review and Considerations





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Urban Indian Health Institute
A Division of the Seattle Indian Health Board

The UIHI would like to thank all those who dedicate their lives to improving the emotional, spiritual, social and physical well-being of urban American Indians and Alaska Natives. We know that this report does not capture all of the important work that you do but we hope this report can benefit your ongoing efforts.
A special thanks to Dr. Bonnie Duran for her assistance and guidance in developing this report. Bonnie M. Duran Dr.P.H. is an Associate Professor at the University of Washington (UW)-School of Public Health, Department of Health Services and Director of the Center for Indigenous Health Research at the UW Indigenous Wellness Research Institute.
This publication was made possible by Grant Number MPCMP101055-01-00 from the Department of Health and Human Services, Office of Minority Health. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Office of Minority Health.

Addressing Depression Among American Indians and Alaska Natives: A Literature Review


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Addressing Depression Among American Indians and Alaska Natives: A Literature Review

The purpose of this report is to highlight and review literature, programs and activities focused on depression and other common mental health conditions in American Indian and Alaska Native (AI/AN) communities in the United States. In 2010 the Urban Indian Health Institute (UIHI) initiated its Health Equity Project in order to examine the health disparities affecting urban AI/AN communities. This report represents a synthesis of academic (articles in scholarly, typically peer-reviewed journals) and grey literature (from a variety of sources including websites, online documents, government reports and presentations). This combination of findings is uncommon in typical reviews of depression and mental health among AI/ANs, which tend to focus on peer-reviewed academic literature.
This report provides background information on the prevalence of and factors associated with depression and common mental health conditions in AI/ANs as well as a description of mental health care standards, utilization trends and barriers to care. The procedures and inclusion criteria used in this literature review are detailed in the methods section. Due to the limited availability of outcomes and evaluation information in the sources identified, the results here do not present evidenced-based or best practices for depression but rather focus on the themes identified regarding implications for care as well as descriptions of programs in practice and useful resources. For organizations serving urban AI/ANs, it is intended that this information be useful for program planning purposes and proposal development.
BACKGROUND While there is not a definitive assessment of the prevalence of depression and other common mental health conditions among all AI/ANs, available data point to disproportionately high rates of depression in AI/ANs compared other ethnic groups. Psychological distress, as evidenced by poor mental health and depression, is associated with historical and intergenerational trauma. The highly prevalent nature of emotional trauma helps explain the disproportionate rate of psychological distress in AI/AN communities. Serious co-occurring conditions including alcohol or substance abuse and greater incidence of chronic illness like diabetes are associated with an increased number of poor mental health days.
The Indian Health Service (IHS) provides screening guidelines for depression as one of the quality measures used for the Government Performance and Results Act. For those who screen positive for depression, the IHS suggests several treatment options. However, the barriers to accessing mental health care that AI/ANs face are complicated. Complex factors play a role in the disparity of utilization of mental health services among AI/ANs including insufficient resources, socio-economic factors (e.g., poverty, unemployment, housing stability, access to transportation), adequate availability of culturally relevant treatment sources and cultural preferences. While the prevalence of depression and co-occurring conditions is recognized and screening is recommended, the system of care to address these mental health conditions is often lacking.
METHODS UIHI project staff developed search terms to obtain relevant and comprehensive search results in consultation with a reference librarian at the University of Washington. These search terms defined the population of interest (AI/ANs in the United States), the conditions of interest (depression, mental disorders, mental illness, mood disorder and anxiety) and the type of

Addressing Depression Among American Indians and Alaska Natives: A Literature Review


information sought (programs, activities and evaluations). In October and November of 2011, UIHI project staff conducted initial searches of both academic and grey literature databases. The searches resulted in a high volume of sources, which staff then reviewed and eliminated systematically, based on previously determined inclusion criteria.

RESULTS Original academic and grey literature searches identified 1413 sources; 591 were found through academic databases and 822 were found through grey source databases or search engines. An additional seven sources included in this report were referred to in the original searches. Of the 1420 sources identified, 299 sources were excluded as duplicates and 1042 sources were excluded based on review criteria, for a total of 79 sources listed in this review.
The results of this environmental scan identified eight common themes regarding implications for improving depression and mental health care for AI/ANs. These themes included: 1) focusing on family and community, 2) incorporating traditional knowledge and practices into care, 3) emphasizing active skills building, 4) integrating and linking prevention and treatment care systems, 5) expanding cultural competency of both providers and health care systems, 6) developing flexible provider-client/patient relationships with adaptive treatment approaches, 7) implementing environmental and structural changes to affect surrounding conditions, and 8) developing policies, systems, and advocating for adequate funding to improve health care and economic opportunities for AI/AN people.
Additionally, these results include program or activity descriptions. Many of the programs and activities identified demonstrated these themes in practical application. Lastly, the review identified resources on depression, suicide prevention and mental health care for AI/AN communities. These resources are listed at the end of the results section.

DISCUSSION Considerations regarding the overall report are highlighted including limitations and recommendations. Key recommendations and items for consideration include:
 The shortcomings of the mental health care system along with systemic and cultural barriers to care impede service utilization and access for AI/ANs.
 Discord exists between Western mental health care services and culturally based approaches for both research studies and in public health practice. This discord may be eased by increasing support for traditional or culturally-based treatment approaches by recognizing these strategies as reimbursable services. Additionally, both Western and traditional approaches require increased evidence of effectiveness through research and evaluation of practices in the field.
 Future research is required to address gaps in public health knowledge about mental health care among AI/ANs, especially research focused on pathways and barriers to care, financial infrastructure for AI/AN mental health care and testing of mental health programs and interventions in AI/AN communities.
 Investments must be made in providing evaluation of activities already in use among urban AI/ANs to establish practice-based evidence rather than expecting evidencebased practices that were not developed or tested in AI/AN communities to work effectively.


Addressing Depression Among American Indians and Alaska Natives: A Literature Review

 A systems approach featuring collaborative efforts, integration of services and support mechanisms needs to be advanced through local, state and national policy.
 Socioeconomic factors impacting AI/ANs and their mental health status need to be addressed through policy changes, economic opportunities, and social supports that provide integrated prevention, treatment and follow-up care as well as ancillary services such as life-skills building, economic opportunities and stable housing resources.
 In summary, the striking disparities in the prevalence of depression and common mental health conditions among AI/ANs require more comprehensive, systematic approaches than just the implementation of best practices through medical clinics. A health care system is needed that provides a new perspective on integrating the concept of mental health with holistic well-being including family, community, socioeconomic, and social supports.

Addressing Depression Among American Indians and Alaska Natives: A Literature Review



The goal of this report is to provide an overview of behavioral health programs for American Indians and Alaska Natives (AI/ANs) that address depression and other common mental health conditions. This report highlights findings from research, case studies, and mental health experts from the field. It is our hope that describing eight themes that have implications for care will support health care providers, policy makers and advocates in promoting effective mental health services for urban AI/ANs with the overall objective of achieving health equity for all AI/ANs.

Responding to the persistent inequities in health outcomes among urban AI/ANs, the Urban Indian Health Institute (UIHI) launched its Health Equity Project in 2010. With support from the U.S. Office of Minority Health, the project focuses on identifying and disseminating culturally appropriate successful models of care in urban AI/AN communities to prevent and reduce disease. The Health Equity Project focuses on two diseases identified by Healthy People 2020 as critical focal areas for health improvement in urban AI/AN communities: cardiovascular disease and depression. In addition a third health topic, chemical dependency and substance abuse, was identified by Urban Indian Health Organizations as a priority. The Health Equity Project provides tools, trainings, information and facilitates partnerships to support Urban Indian Health Organizations in delivering promising programs to their clients.

The importance of documenting and recognizing effective, culturally appropriate efforts to reduce morbidity and mortality in minority communities is essential to achieve Healthy People 2020 goals and to realize the overall outcome of health equity for all.

The critical health focus area of this report is on depression and other common mental health
conditions. Depression is not just a case of “feeling blue” or sad for a time; depression can
impact a person’s ability to function, maintain relationships and enjoy life for an extended period
of time. Depression may also reoccur throughout a person’s lifetime, even after successful
treatment of earlier episodes. Untreated depression is the leading cause of suicide, which is alarmingly high among AI/ANs.3 An estimated 90% of individuals who die by suicide have a mental illness, a substance abuse disorder or both.4 AI/AN communities suffer from higher rates of depression and co-occurring conditions than any other ethnic group.5-7

Socioeconomic status, social support, cultural preferences for care and historical traumas, play a role in depression as well as in the perception of illness and treatment decisions. A Native concept of health traditionally embodies a holistic perspective in which mental health is viewed as a part of the overall health and well-being of the individual. One example to illustrate this point is the Medicine Wheel (Figure 1). The Medicine Wheel represents balance, harmony and interrelatedness of the physical, the mental, the emotional and the spiritual aspects of life. In contrast, Western mental health approaches typically use a more categorical, segmented and individualistic view of mental and physical health. These disparate health perspectives create incongruity in approaches to health between the mental health care

Figure 1. Medicine Wheel


Addressing Depression Among American Indians and Alaska Natives: A Literature Review

system and the AI/AN clients it intends to serve. In addition, a great disparity exists in accessing mental health care among AI/ANs fueled by cultural insensitivities and barriers to care created by the current mental health system infrastructure for AI/ANs.
This report was developed by the Urban Indian Health Institute primarily for the Urban Indian Health Organizations and others serving the health needs of urban Indians in the United States. These organizations and groups are described here in more detail. A general overview of mental health care for AI/ANs begins in the background section of this report.
American Indians and Alaska Natives (AI/ANs) living in urban areas are a diverse and growing population. Over the past three decades, AI/ANs have increasingly relocated from rural communities and reservations to urban centers. Urban AI/ANs are a very diverse group and include members, or descendents of members, of many different tribes. Represented tribes may or may not be federally recognized. Individuals may or may not have historical, cultural or religious ties to their tribal communities. Because urban Indians may not be connected to their tribal communities, their mental health may be impacted more by this disconnect. The population as a whole is highly mobile; individuals may travel back and forth between their tribal communities or reservations on a regular basis. Others may feel the loss of not having a reservation home. Generally, urban AI/ANs are spread out within the urban center rather than localized within one or two neighborhoods. Thus they are often not easily seen or recognized by the wider U.S. population. This “invisible” population makes up more than 67% of all AI/ANs living in the United States.8
Numerous treaties, court cases, Executive Orders and laws such as the Snyder Act of 1921 and the Indian Health Care Improvement Reauthorization and Extension Act of 2009, define and affirm the U.S. federal governments’ responsibility to provide health care services to members of federally recognized Indian tribes and Native Entities of Alaska, regardless of whether they live in urban or reservation areas. This responsibility has been delegated to the Indian Health Services (IHS), an agency within the federal Department of Health and Human Services. The IHS is divided into three distinct health delivery models characterized as the I/T/U. The “I” refers to hospitals and clinics run directly by the Indian Health Service. The “T” applies to individual tribes or consortia of tribes that operate tribally managed hospitals and clinics under Indian selfdetermination and self-governance. The “U” signifies a discrete program created to assist urban Indian communities in building capacity to improve access to health care for urban Indians. In 2010, Tribally-run health services and IHS facilities received approximately 53% and 43% of the IHS budget respectively, while urban programs received only 1%.9 This funding discrepancy contributes to a number of factors limiting AI/AN access to health services. Additionally, eligibility criteria for IHS and Tribally-run services are more limiting than at Urban facilities, often excluding urban AI/ANs who are either not enrolled in tribes, are members of State-recognized tribes, or are members of tribes that are not recognized by the U.S. federal government.

Addressing Depression Among American Indians and Alaska Natives: A Literature Review


Urban Indian Health Organizations (UIHOs) are private, non-profit corporations that serve American Indian and Alaska Native people in select cities by providing a range of health and social services, from outreach and referral to full ambulatory care. UIHOs are funded in part under Title V of the Indian Health Care Improvement Act and receive limited grants and contracts from the federal Indian Health Service (IHS). UIHOs are located in 19 states serving individuals in approximately 100 U.S. counties, in which over 1.2 million AI/ANs reside, according to the 2010 U.S. Census. UIHOs provide traditional health care services, cultural activities and a culturally appropriate place for urban AI/ANs to receive health care.
The UIHI was established as a division of the Seattle Indian Health Board to study and document the striking health disparities affecting the urban AI/AN population. The UIHI is one of 12 tribal epidemiology centers (TECs) and the only TEC providing surveillance, research and analysis of data focused on the nationwide urban AI/AN population. The UIHI provides data and technical assistance to 33 UIHOs across the country. The mission of the UIHI is to support the health and well-being of urban Indian communities through information, scientific inquiry and technology.
The UIHI recognizes that there are many information sources regarding health promotion efforts in AI/AN communities beyond academic or peer-reviewed journals. In an effort to comprehensively capture those practices and lessons learned in AI/AN communities we included both databases of academic literature as well as “grey” literature (on-line, open source, government reports, etc.). Additionally, some organizations that have done innovative work in preventing and treating depression and other common mental conditions among AI/ANs may not be captured in this report due to limitations of the methods as well as limited dissemination of these novel efforts.
The remainder of this report is organized into several main sections. The background provides an overview of depression as well as the factors influencing AI/AN mental health, including prevalence and current barriers to care. The methods section outlines the process and sources used for the literature review. The results from this extensive review of the available literature include expert opinions, research findings, activities and programs. The discussion highlights themes from the literature review in addition to recommendations for future practices, policies and research projects. A companion UIHI report describes the current work of UIHOs across the county, and the important role of the UIHOs in meeting the behavioral health needs of the communities they serve. This companion report is titled, “A Profile of Urban Indian Health Organization Programming to Support Behavioral Health.”


Addressing Depression Among American Indians and Alaska Natives: A Literature Review
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