Recent important mental health policy documents published by The President's New Freedom Commission on Mental Health (The President's New Freedom Commission on Mental Health, 2003
), Institute of Medicine (Committee on the Future of Rural Health Care, 2004
; Institute of Medicine, 2001
; Smedly, Stith, & Nelson, 2003
), U.S. Surgeon General (U.S. Public Health Service Office of the Surgeon General, 2001a
), and NIMH (National Institute of Mental Health, 1999
) call for the reduction of racial and ethnic disparities in mental health care, particularly in rural areas, by decreasing barriers and delivering culturally-relevant services that are evidence based and patient and family driven. Unfortunately, racially and economically marginalized populations in the U.S., including American Indian and Alaska Native youth, continue to bear larger burdens both in terms of higher prevalence of mental health and substance abuse disorders and lack of access to appropriate, quality care.
American Indian and Alaska Native youth embody the resiliency and survival of indigenous Nations and Tribes throughout the United States, and they symbolize the hope, dreams, and cultural continuity for future generations to come. However, they are hindered in their ability to fulfill these important roles by numerous behavioral health disparities and challenges. American Indian and Alaska Native adolescents have the highest rate of suicide among 15 to 24 year-olds in the United States (34 per 100,000 compared to 11 per 100,000 for overall U.S. population), and suicide has been the second leading cause of death for Native American youth ages 15 to 24 for the past 20 years (Health US, 2004
). Furthermore, in a study of 736 American Indian youth ages 10–12, Whitbeck and colleagues found that 23% met the criteria for at least one mental disorder, which suggests not only a current disparity but also a risk for subsequent disparities in terms of predicting later substance use and mental health problems (L.B. Whitbeck, Hoyt, Johnson, & Chen, 2006
Over many years and across different American Indian populations, Beauvais has found that American Indian youth are more likely to have substance abuse risks than non-American Indian youth, including starting to drink at a younger age, drinking more heavily, using drugs in combination with alcohol, and experiencing negative consequences of using substances (Beauvais, 1992
). American Indian youth are also more likely to meet the criteria for alcohol abuse/dependence and to have co-morbid alcohol use and psychiatric disorders (Beals, Novins, Mitchell, Shore, & Manson, 2002
; Beals, et al., 1997
). Alcoholism death rates for Native American youth ages 15 to 24 are 3.7 deaths per 100,000 (compared to 0.3 per 100,000 for overall U.S. population) (American Academy of Child and Adolescent Psychiatry, 2006
Other research on substance abuse among AI/AN youth demonstrates the complexity and severity of this issue. For example, a study of 89 American Indian adolescents in a tribally operated residential substance abuse treatment program found that youth used multiple substances (mean of 5.26) and that 82% had co-morbid psychiatric disorders (most common conduct disorder) (Novins, Fickenscher, & Manson, 2006). There is also research that examines specific trajectories of substance use for American Indian adolescents (Novins & Baron, 2004). They found that risk peaked at age 18, and also that substance use varied by community and season of the year. This variance suggests that policy and practice changes that target youths' environments and communities could have positive impacts on decreasing substance abuse.
Finally, it is important to note that in addition to the disproportionate burden of mental health problems experienced by AI/AN youth, there is a lack of epidemiology and surveillance (U.S. Public Health Service Office of the Surgeon General, 2001b
Even when these data are collected, they are often not sufficiently analyzed or reported, citing the size of the population as rationale. While the term “statistically insignificant” may seem relevant to epidemiologists, it feels dismissive and like an excuse to many. This is critical because it perpetuates the disparities by allowing them to remain “invisible” to funders, policy-makers, and the population as a whole. In order to eliminate these disparities, it is essential to identify their causes and address them, while simultaneously working to improve the behavioral health care system for AI/AN youth.
Our comprehensive review of the literature on the mental health of AI/AN youth highlighted seven focal causes of behavioral health disparities:
1) High levels of violence and trauma exposure and traumatic loss have been linked to PTSD, other forms of psychological distress, and substance abuse among AI/AN youth (Deters, Novins, Fickenscher, & Beals, 2006; Gnanadesikan, Novins, & Beals, 2005; Jones, Dauphinais, Sack, & Somervell, 1997; Kilpatrick, et al., 2000).
2) An emerging literature is beginning to link psychological distress and substance use among American Indian adolescents to past and current oppression, racism, and discrimination (L.B. Whitbeck, Adams, Hoyt, & Chen, 2004; L.B. Whitbeck, Chen, Hoyt, & Adams, 2004; L.B. Whitbeck, Hoyt, McMorris, Chen, & Stubben, 2001; L.B. Whitbeck, McMorris, Hoty, Stubben, & LaFromboise, 2002).
3) Underfunded systems of care for AI/AN behavioral health affect accessibility and quality of care for AI/AN youth. Per capita funding for Native American health care (through the Indian Health Service) is 60% less than is spent on the average American. Furthermore, the U.S. government spends less per capita on health care for Native Americans than it does on Medicaid recipients, prisoners, veterans, or military personnel (U.S. Commission on Civil Rights, 2003). In addition, funding for behavioral health care through Indian Health Service (IHS) is less than $30 per year spent per person served by the system, including hospitalization (MacArthur Foundation Mental Health Policy Research Network, 2008).
4) One of the most fundamental challenges to reducing health disparities and improving behavioral health care for AI/AN youth is the divergence of western and traditional indigenous approaches to mental health care and healing, and the disregard for effective indigenous practices in service provision, policy, and funding. Traditional AI/AN practices and ceremonies have been effective since time immemorial, but federal policies at different times have prohibited them, disregarded them, perpetuated questions about their credibility and validity, and resulted in their loss across generations in some communities. Use of traditional health practices among AI/AN populations (e.g., indigenous herbs, sweat lodges) and traditional spiritual orientations have been linked to positive health outcomes in numerous studies (Buchwald, Beals, & Manson, 2000; Garroutte, et al., 2003; Marbella, Harris, Diehr, Ignace, & Ignace, 1998). Research also suggests that the most resilient Native youth are those who are culturally and spiritually grounded (Gray & Nye, 2001; Rieckmann, Wadsworth, & Deyhle, 2004; Spicer, Novins, Mitchell, & Beals, 2003; L.B. Whitbeck, Chen, et al., 2004; L.B. Whitbeck, et al., 2001; L.B. Whitbeck, et al., 2002; Yoder, Whitbeck, Hoyt, & LaFromboise, 2006).
5) The focus on evidence-based practices (EBPs) in mental health care and substance abuse by treatment federal, state, and local regulatory bodies, reimbursement mechanisms, and other funders has involved an important effort toward ensuring that all people receive quality care that has been scientifically tested and that has demonstrated effectiveness. However, the reliance on and/or exclusive funding of EBPs raises problematic issues when focusing on behavioral health care for AI/AN youth and their families.3 The fundamental concerns are the lack of inclusion of AI/AN participants in behavioral health intervention research (and thus no evidence-base for these populations) and the previously described exclusion of traditional healing practices among these studies (Miranda, et al., 2005; U.S. Public Health Service Office of the Surgeon General, 2001b).
6) The seemingly divergent emphases on traditional indigenous practices and evidence-based practices as well as issues of trust and power related to U.S. mistreatment of AI/AN populations present a challenge to western behavioral health systems and providers in their attempts to provide culturally “competent” care to AI/AN youth. Many Native researchers and providers recognize the lack of cultural competency for AI/AN youth within current systems (Besaw, et al., 2004; E. Duran & Duran, 1995; Faimon, 2004; J.P. Gone, 2004; LaFromboise, 1988).
7) Finally, there are several related barriers to care which impact the mental health of AI/AN youth and their access to care, including geographical remoteness, poverty, transportation, and shortage of qualified treatment providers (American Academy of Child and Adolescent Psychiatry, 2006), as well as the concerns about privacy, quality of care, and communication and trust (B. Duran, Oetzel, J., Lucero, J., and Jiang Y., 2005).
In addition to our comprehensive review of the literature, we conducted advisory meetings with 71 American Indian youth, parents, and elders; surveyed 25 service providers; and engaged in ongoing consultation with four traditional practitioners. Given our concern about the exclusion of indigenous healing practices and perspectives in current research and funding, it was important to engage with multiple sources of information in order to inform our conclusions and recommendations. For a detailed description of our findings, please see Goodkind et al.(2008)
In summary, we found that American Indian/Alaska Native youth face multiple stressors and traumas, including: poverty, current institutional racism, micro-aggressions, and traumatic life events. Furthermore, the current structures and emphases of behavioral health systems of care do not adequately address these challenges or integrate effective indigenous health practices. To redress these limitations of current behavioral health care in the United States, we propose seven policy recommendations.