CHAPTER 4

Mental Health Care for American Indians and Alaska Natives

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.

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 cover-age; 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 per-cent 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 tar-get 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.