American Indians/Alaska Natives & Mental Health: Some Facts

This post about mental health issues related to American Indians and Alaskan Natives was precipitated by the 20/20 special called Hidden America: Children of the Plains which was hosted by Diane Sawyer (see here). During the program, Sawyer explored the multitude of issues that children of the Oglala Lakota  Sioux tribal nation living on the Pine Ridge Reservation in South Dakota face including extreme poverty and alcoholism. According to some estimates, unemployment on the Pine Ridge Reservation ranges from 83-85% and can be higher during the winter months when it is difficult to travel. As a result, the median income on the Reservation is $2,600 to $3,500 per year and approximately 97% of the population lives below federal poverty lines. The nearest town that could potentially offer employment for those with the ability to travel is Rapid City, South Dakota, which is 120 miles away from the Reservation. Likely due to the lack of opportunity, many on the Pine Ridge Reservation either turn to alcohol or become severely depressed and/or suicidal. On this Reservation alone, alcoholism affects 8 out of 10 families; the death rate from alcohol-related problems is 300% higher than the remaining population. Rampant medical problems among the population including high rates of diabetes, heart disease, and cancer in addition to substance abuse and poor nutrition have resulted in a life expectancy of 48 years for men and 52 years for women (compared to 77.5 years for the US population as a whole).

Because of the serious social and economic difficulties they face, Native American populations like the Oglala Lakota Sioux are more susceptible to mental illnesses. Here are some facts regarding mental health and Native American communities gathered from the National Alliance on Mental Illness (NAMI). 

• Approximately 26% of American Indians/Alaska Natives live in poverty compared to 13% of the general population and 10% of Caucasian Americans.
• The American Indian and Alaska Native populations report higher rates of frequent distress than the general population.
• Alcohol abuse is a problem for a substantial portion of the American Indian adult population, but widely varies among different tribes.
• A study of Alaska Natives in a community health center found that substance abuse was the reason that 85% of men and 65% of women seek mental health treatment. 
• Native Alaskan males have had one of the highest documented suicide rates in the world. Suicide rates are particularly high among Native American males ages 15 - 24 who account for 64% of all suicides by American Indian/Alaska Native individuals.
• The words "depressed" and "anxious" are absent from some American Indian and Native Alaskan languages. Culturally different expressions of illness ("ghost sickness" or "heartbreak syndrome") do not easily correspond to Western psychiatric diagnosis criteria.
• In a Northern Plains study, 61% of children had experienced a traumatic event.
• Compared to the general population, American Indians and Alaska Natives tend to under-utilize mental health services, have a higher therapy dropout rates and are less likely to respond to treatment. This may derive from the fact that individuals tend to have negative opinions of non-Indian health providers and that traditional healing is used by a majority of Native Americans.
• Mental health services are available for the American Indian/Alaska Native communities, such as the services provided by the Indian Health Service (IHS), but they are in need of improvement. Currently only 7% of IHS' s budget is allocated for mental or behavioral health and substance abuse treatment services combined.

Citations:

Gone, J.P. (2004). Mental health services for Native Americans in the 21st century United States. American Psychological Association, Vol. 35, No.1, 10-18.

National Alliance on Mental Health: American Indian and Alaska Native Communities Mental Health Fact Sheet       http://www.nami.org/ContentManagement/ContentDisplay.cfm?ContentFileID=79888

Schwartz, S.M (2006). The arrogance of ignorance: hidden away, out of sight, out of mind. Regarding life, conditions and hope on the Oglala Lakota (Sioux) Reservation of SD. http://www.nativevillage.org/Messages%20from%20the%20People/the%20arrogance%20of%20ignorance.htm

Children's Mental Health: Some Statistics

•  Mental health problems affect 1 in 5 young people at any given moment (U.S. Department of Health & Human Services).

• An estimated 66% of all young people with mental health problems are not getting the help they need (U.S. Department of Health & Human Services).

• Estimates put the number of children with mental disorders between 7.7 million and 12.8 million (U.S. Department of Health & Human Services).

• Approximately, 1% of adolescent girls develop anorexia nervosa. One in ten cases leads to death due to starvation, cardiac arrest or suicide (National Institute of Mental Health).

• Studies suggest that children or adolescents are more likely to have an anxiety disorder if their parents have anxiety disorders (U.S. Department of Health & Human Services). 

• ADHD is the most common psychiatric condition affecting children. Estimates in childhood prevalence rates range from 5 - 10% (Clinical Pediatrics).

• Recent studies show that, at any given time, 1 in 33 children may have clinical depression. The rate of depression among adolescents may be as high as 1 in 8 (U.S. Department of Health & Human Services).

• Almost one-third of 6 to 12 year old children diagnosed with major depression will develop bipolar disorder within a few years (Journal of the American Academy of Child and Adolescent Psychiatry). 

• Of the 100,000 teenagers in juvenile detention, estimates indicate that 60% have behavioral, mental or emotional disorders (Department of Justice).

• Suicide is the third leading cause of death for 15 - 24 year olds and the sixth leading cause of death for 5 - 15 years olds (American Academy of Child and Adolescent Psychiatry). 

• In 1999, more teenagers and young people died as a result of suicide than cancer, heart disease, HIV/AIDS, birth defects, stroke and chronic lung disease combined (U.S. Centers for Disease Control and Prevention).

• Between 500,000 and 1 million young people attempt suicide each year (American Association of Suicidology).

Taken from: Mental Health America

Suicide Linked with Birth Season?

An interesting 2006 study by Emad Salib and Mario Cortina-Borja examined the potential link between suicide and season of birth. Previous studies have revealed seasonal birth trends for such diseases as lymphoblastic leukemia, early onset non-Hodgkin's lymphoma, breast cancer and Crohn's disease among others. In terms of mental illness, one study found that more patients with Alzheimer's and schizophrenia were born in December and January whereas affective disorders, alcoholism, autism, and dyslexia are more frequently reported in those born in spring or summer months (Salib & Cortino-Borja, 2006). For this reason and because few studies have looked at suicide and birth season, Salib and Cortino-Borja sought to examine the possible link between the two phenomenon. Some studies have identified July as a particular month linked with suicide while other studies say winter has ties to an increased risk for suicide (Salib & Cortino-Borja, 2006).

Sample

In this study, the researcher used routinely collected suicide data over a 22-year period in England and Wales. This particular research exceeded previous attempts to examine the same question as its sample size was substantially greater with 27,000 suicides included from over 11 million births. 

Hypothesis

Salib and Cortino-Borja (2006) hypothesized that the risk of suicide would vary according to month of birth and that the association would remain even after controlling for the effects of the total number of births per month in the population. They also predicted that there would be a difference in birth month when specifically looking at suicide by gender and method (violent vs. non-violent). An example of a violent method of suicide would be a gunshot wound while non-violent suicide could be an overdose.

Results/Conclusion

According to the result of this study, there is a 17% increase of suicide for people born in the spring and early summer compared to those born in autumn; this number is greater for women than for men. When split by gender, men born in late spring were at increased risk of suicide while the same was true for women born in midsummer. For suicides by men, the monthly birth rate peaks were in spring for violent methods and summer for non-violent methods. For women, the peaks were in late spring for both methods (Salib & Cortino-Borja, 2006). The researchers' hypotheses regarding the link between seasonality and suicide were confirmed.

The authors concluded that this line of research is important as the etiology of suicide is multifaceted; all aspects of this phenomenon should therefore be studied in order to conceptualize the life trajectory of someone likely to commit suicide better. Seasonality as it relates to suicide has been explained by weather conditions and their effect on the central nervous system. Despite these findings, one cannot say for certain that birth month is related to suicidal tendencies (or alcoholism or autism)., because the issue is so complex . This study in particular was limited as it did not consider co-morbid psychiatric illnesses,  religion, race/ethnicity, and socioeconomic status. The subset of people for which the link between seasonality and suicide holds true may be even smaller that what Salib and Cortino-Borja (2006) found. Still, it is interesting to note the varying formulations used to explain a very tragic occurrence.

Citation:

Salib, E. & Cortino-Borja, M. (2006). Effect of month of birth on the risk of suicide. British Journal of Psychiatry, 188, 416-422.

Failing in Mental Health Access

According to the National Association for the Mentally Ill (NAMI; www.nami.org), the United States' mental health care system is abysmal, currently receiving a D grade. Mental health care refers to both inpatient and outpatient psychiatric services as well as partial or day programs. For the Grading the States report (2009), the grading of the U.S. and individual states was based on four key categories: Health Promotion and Measurement, Financing and Core Treatment/Recovery Services, Consumer and Family Empowerment, and Community Integration/Social Inclusion. Below is an description of each category:

• Health Promotion and Measurement: Number of programs delivering evidence based practice, emergency room wait times and quantity of psychiatric beds by setting
• Financing Core Treatment/Recovery Services: Includes whether Medicaid reimburses providers for all or part of evidence based treatment
• Consumer & Family Empowerment: Consumer/family access to information from the state, family/peer education & support, promotion of consumer-run programs
• Community Integration/Social Inclusion: Includes activities that require collaboration among state mental health agencies and other state agencies and systems

Unfortunately as the need for mental health services is increasing nationwide, especially in light of the economic downturn, state budget cuts are actually decreasing access to necessary psychological care. This has no doubt resulted in the poor quality of the U.S. mental health system. Individually, some states are doing better than others; Massachusetts, Maine, Connecticut, New York, Maryland and Oklahoma each received a B grade. Connecticut was the only one of these states to receive an A grade in any category; the state received top marks in the area of Consumer and Family Empowerment. The category that even the top states struggled with was Community Integration and Social Inclusion, a category in which 5 of the 6 states received a C grade. 

On the other end of the spectrum, the states that received failing (F) grades were South Dakota, Wyoming, West Virginia, Kentucky, Arkansas and Mississippi. In terms of individual categories, Mississippi was the only of these states to receive a grade higher than a D which was received in the Consumer and Family Empowerment category (with a C grade). Florida and Texas, two of the most populated states, received D grades overall. Recommendations for states with poor mental health systems included expanding crisis stabilization, services for veterans and the homeless, creating dual diagnosis programs, and establishing alternatives to inpatient hospitalization that do not include jail.

From this report one can surmise that large segments of the population either do not have access to or are not receiving adequate mental health care. This is especially problematic as the World Health Organization reports that major depressive illness will be the leading cause for disability for women and children by the year 2020 (www.nami.org). Additionally, NAMI reports that without treatment, the consequences of mental illness for both the individual and society include unnecessary disability, unemployment, substance abuse, homelessness, inappropriate incarceration, suicide and wasted lives. It is estimated that untreated mental illness also costs the United States $100 billion annually.  The impact of mental illness on children in particular has important implications for education reform in terms of its effect on academic achievement and future educational attainment. While some states are attempting to make improvements to mental health access, more needs to be done nationally to ensure that those with mental illness can receive any and all required services.

For more information regarding the Grading the States (2009) report, please see www.nami.org

For Many, Mental Health Needs Left Unmet

A recent phone call from a counselor who stated that the parents of her student would not get their suicidal child help due to financial constraints reminded me that for many in the U.S. mental health services are still not easily accessible because of the associated costs. This is especially disheartening given that the need for such services is increasing, not decreasing. Here are some the latest statistics from the American Foundation for Suicide Prevention (www.afsp.org):

• An estimated 19 million Americans suffer from depression
• Approximately 2 million people suffer from bipolar disorder
• About 3 million people suffer from schizophrenia
• More than 34,000 Americans die by suicide every year; suicide is the country's 11th leading cause of death
• Every 15 minutes someone commits suicide
• More than 90% of people who commit suicide have a diagnosable psychiatric illness at the time of their death (most often depression)

As has been discussed previously, there are may barriers to care, one of the most significant likely being the cost. The AFSP reports that depressive illnesses cost approximately $30 - 44 billion each year.  Schizophrenia costs the nation about $48 billion annually. It is likely in part because the high costs of mental health care, that only 1 in 3 depressed people seeks help.

Still, there are many other factors that one needs to consider in regard to this issue. Children often do not have a choice in whether or not to seek mental health services. Providers require parental consent in order to counsel children, so unless the child is clearly a danger to himself or others there's little that can be done to intervene if the parents or guardians refuse psychiatric treatment. Additionally, there are many cultures in which seeking therapy or medication is even more stigmatized than what we already tend to see in American society. It has been noted that African Americans tend to seek mental health services less than their Caucasian counterparts. Certain psychiatric illnesses, such as eating disorders, have, at times, been associated with white people by some minority group members adding another layer of stigma to the disease. Any combination of factors (problematic parents, stigma, financial constraints) unfortunately results in people who need help not seeking it. So for many both within the United States and abroad, specific and, for the most part, treatable mental illnesses are not being addressed to the detriment of the afflicted person and his/her family.

The Business of Mental Health II: Insurance as a Barrier to Care

In the previous post about mental health services, there was discussion about the provider's role in discussing billing procedures. In not being upfront about the financial aspect of the patient's care, mental health providers and/or their administrative staff can create an unintentional barrier to care.  First, a level of mistrust may develop because the provider omitted pertinent information that would allow the patient or parents to make an informed decision about whether the provider was a good fit for their needs and resources. More importantly, the actual billed cost may be too much of a burden for the family to carry long term; treatment may be stopped as a result despite its benefits. Similarly, the U.S. population's general lack of focus on mental health as a facet of overall health due to the stigma associated with it could potentially add to the decision to end care. 

The likely most important aspect of the business side of mental health involves insurance companies. Mental health providers absolutely need to be upfront about any costs associated with care. The seeking of psychological help, however, may first be precipitated by a discussion of insurance coverage and personal finances. Even if a provider is 100% honest about his or her costs, a lack of mental health coverage can be a huge barrier to getting much needed care. Co-pays for mental health services can also be too much for families to afford, especially given the current economic climate. Blue Cross, for example, may require as much as a $25 co-pay per visit. Imagine if you or your child needed to be seen once a week? Twelve hundred dollars annually can break the bank for many families. Additionally, insurance companies sometimes put financial limits on the mental health services that the subscriber can receive per year. This is especially true if a patient needs to be admitted to an inpatient psychiatric facility. Insurance companies decide how long they will pay for a patient to remain in a facility and, in some cases, will refuse to authorize inpatient days beyond a certain point. The specific reason is that insurances may deem additional inpatient days "not medically necessary" despite what the inpatient psychiatric team believes. Thus some may leave (or be discharged by their parents) from treatment too early for their specific needs in order to avoid the astronomical costs of inpatient psychiatric care. All of this results in patients who have been under-treated due to financial concerns, not an unwillingness to seek help.

Discussions of health care reform need to consider the subcategory of mental health coverage and what can be done in order to facilitate treatment for those who need it the most. This nation is only as (mentally) healthy as its sickest person. 

The Business of Mental Health

There are two sides of the health care industry - the service side and the business side. Service, in this sense, refers to the actual delivery of medical attention. More specifically, it refers to a patient's dealings with not only the health care providers but also the administrative staff (particularly when booking appointments and checking in). The second side of the health care industry is the business side. Providers and patients probably prefer not to think of health care as a business, but it is; in order to provide adequate service to their patients, the clinic, doctor's office, or hospital needs to earn money through insurance claims and self-pay statements. While health care is (supposed to be) a non-profit industry, there still needs to be a certain amount in financial returns so that the facility can continue to provide its services to its patients. 

Mental health care can be an especially difficult service to refer to as a "business." Patients are already dealing with mental illness of varying degrees; when you introduce the potential bills related to their mental health services, this can become both an added stressor as well as a potential barrier to care. Still, mental health providers, like all health care professionals, need to generate an income in order to continue counseling patients. Thus the question of how to introduce the topic of billing can be difficult for providers. To what extent do you tell patients, that you will be charging them what some may consider an unjustified amount of money for a service?

This topic can be a little easier when a patient is coming in for an outpatient mental health appointment. The patient (or the patient's parent) made the appointment knowing that there will be a charge (including co-pays, deductibles, etc.) Where things get slightly more complicated is when a patient is seen on a hospital's medical floor for a psychiatric consultation. In this case, the patient was admitted for a medical reason, but was seen by a mental health provider during his or her stay. In this case, how much responsibility is on the mental health provider to warn the patient or his/her parents, that the service is both separate from the medical services and billable? Does the psychiatrist or psychologist provide this information knowing the patient or parent may then refuse what may be a necessary consultation? On the front end, the patient would not receive a service that could potentially improve his/her quality of life. Additionally, the provider's or providers' number of consultations annually could decrease dramatically.  Without this caveat, however, patients or parents may become angry if they receive a bill related to a service for which they were not specifically admitted even if there were benefits to the service. Even when a patient is admitted to an inpatient psychiatric unit, the costs associated with the admission may not be fully understood leading to similar issues. All of the issues described may be part of the problem that many have with health care in general - the costs can astronomical leading to extreme financial hardship. 

While mental health care is indeed a service, is the failure of administrators and providers to underscore the 'business' side of an industry already stigmatized in American society doing a further disservice to the patients they serve?