By Spero M. Manson, Ph.D.
Distinguished Professor of Public Health and Psychiatry; Director, Centers for American Indian and Alaska Native Health; and The Colorado Trust Chair in American Indian Health and Associate Dean for Research at the Colorado School of Public Health, University of Colorado Denver
Over the past 20 years, as research on alcohol, drug, and mental health disorders has advanced, scientific inquiry among American Indian and Alaska Native (AI/AN) people has shifted from a primary focus on describing the prevalence of such problems to explorations of ways to address well-documented health disparities.
One example involves detecting and managing depression and subsequent alcohol and substance abuse, risk of suicide, and, more recently, trauma among patients in large primary care settings operated by tribal health programs. In 2001, the Southcentral Foundation’s Primary Care Center in Anchorage, Alaska, initiated Screening, Brief Intervention, and Referral for Treatment (SBIRT) among Alaska Native patients age 18 and older.1 Their efforts, which integrated masters-level behavioral health clinicians within the care teams, demonstrated that such evidence-based practices could be tailored to this population in scientifically sound and clinically meaningful ways.2 Over a 5-year period beginning in 2004, 55 percent of the 8,000 patients who scored positive for alcohol use disorder agreed to follow-up treatment. Thanks to those results, the state of Alaska authorized Medicaid reimbursement for SBIRT, leading to the service becoming fully self-sustainable. This approach has been expanded to other tribal primary care settings in Alaska and in rural, reservation, and urban clinics in the lower 48 states. It now includes AI/AN youth ages 12 to 17 and covers other conditions, notably suicide risk and trauma.3
A second example arose in response to the widespread lack of access to mental healthcare in rural, isolated Native communities. In 1999, I co-developed a pilot project with funding from the Veterans Health Administration that deployed real-time, interactive videoconferencing to increase tribal veterans’ access to treatment resources.4 The effort proved remarkably successful and was singled out by Telehealth Magazine as one of the 10 best telemedicine programs in the United States, well before use of such technologies to address the mental health needs of disadvantaged populations became common. Research sponsored by the National Institute on Minority Health and Health Disparities documented the effort’s organization, process, clinical reliability, treatment, and cost outcomes and justified its expansion across the country.5 The U.S. Department of Veterans Affairs now funds 12 telepsychiatry clinics co-located in tribal veterans centers and Indian Health Service primary care clinics that serve hundreds of patients and family members.
A third example reflects increasing attention to the role of anxiety, depression, and trauma in the risk, prevention, and treatment of chronic physical health conditions such as diabetes and cardiovascular disease, which occur with alarming frequency among Native people. Supported by the National Institute of Diabetes and Digestive and Kidney Diseases, my colleagues and I examined the association of psychological distress, coping skills, family support, trauma exposure, and spirituality with initial weight and weight loss among participants in the Special Diabetes Program for Indians’ Diabetes Prevention Program, which was implemented at 36 Indian health care programs across the country.6 Psychological distress and negative family support were linked to greater weight at the beginning of the study, while cultural spirituality was correlated with lower weight. Furthermore, over the course of the intervention, psychological distress and negative family support predicted less weight loss, and positive family support predicted greater weight loss. These findings demonstrate the influence of psychosocial factors on weight loss in AI/AN communities and have substantial implications for incorporation of additional intervention components.
These exciting advances, all supported in part by the National Institutes of Health (NIH), illustrate how the emphasis and scope of alcohol, drug, and mental health research among Native people have evolved over the last two decades. They represent the continued marriage of good science with local benefit, consistent with the expectations of NIH and tribal communities.
1Dillard DA, Muller CM, Smith JJ, Hiratsuka VY, Manson SM. The impact of patient and provider factors on depression screening of American Indian and Alaska Native people in primary care. J Prim Care Community Health. 2012; 3:120-124.
2Hiratsuka VY, Smith JJ, Norman SM, Manson SM, Dillard DA. Guideline concordant detection and management of depression among Alaska Native and American Indian people in primary care. Int J Circumpolar Health. 2015; 74: 28315. doi: 10.3402/ijch.v74.28315
3Hiratsuka VY, Moore L, Dillard DA, et al. Development of a screening and brief intervention process for symptoms of psychological trauma among primary care patients of two American Indian and Alaska Native health systems. J Behav Health Serv Res. 2016 doi: 10.1007/s11414-016-9519-6.
4Shore JH, Brooks E, Anderson H, et al. Characteristics of telemental health service use by American Indian veterans. Psychiatr Serv. 2012; 63(2): 179-181.
5Shore JH, Brooks E, Savin D, Manson SM, Libby A. An economic evaluation of telehealth and in-person data collection with rural and frontier populations. Psychiatr Serv. 2007; 58(6): 830-835.
6Dill EJ, Manson SM, Jiang L, et al. Psychosocial predictors of weight loss among American Indian and Alaska Native participants in a diabetes prevention translational project. J Diabetes Res. 2016; 1546939. doi: 10.1155/2016/1546939.