**2. Mental health disparities for Native Americans: U.S., California and rural trends**

**General issues**. The SGR of 2001 offered general definitions of mental health, mental illness, and mental health problems. It described mental health as important for personal well-being, family and interpersonal relationships, and successful contributions to community or society. These elements are jeopardized by mental health problems and mental illnesses. While these elements of mental health may be identifiable, mental health itself is not easy to define more precisely because any definition is rooted in value judgments that may vary across individuals and cultures. The Report outlines risks and protective factors (e.g., community or social factors are schools, availability of health and social services, and social cohesion).

The SGR of 2001, found that racial and ethnic minorities bear a greater burden from unmet mental health needs, ranking second only to cardiovascular disease in their impact on disability (Murray and Lopez 1996; Manson, 1996a). The foremost barriers include the cost of care, societal stigma, and the fragmented organization of services. Additional barriers include clinicians' lack of awareness of cultural issues, bias, or inability to speak the client's language, and the client's fear and mistrust of treatment. More broadly, disparities also stem from minorities' struggles with racism and discrimination, which affect their mental health and contribute to their lower economic, social, and political status.

**U.S. Native Americans**. Most Native Americans live in Western States, including California, Arizona, New Mexico, South Dakota, Alaska, and Montana, with 42% residing in rural areas, compared to 23% of whites (Rural Policy Research Institute, 1999). The number of Native Americans who live on reservations and trust lands has decreased substantially in the past few decades. Some events affecting Native American families parallel trends of other popu‐ lations. Native American families maintained by a single female increased by 27% between 1980 and 1990, compared to the national figure of 17%. In addition, the removal of Native Americans from their lands, as well as other policies summarized above, has resulted in the high rates of poverty that characterize this ethnic minority group.

or that there is an extended waiting period before services will be available (e.g., the Oglala Sioux has one of the best rehabilitation centers, but it does not have sufficient funding to staff

The five primary contributors to disparities in health status and outcomes for Native Ameri‐

**2.** Poor access to health insurance, including Medicaid, Medicare, and private insurance.

The Indian Health Service (IHS) has been given primary responsibility to decrease disparities, as the primary source of biomedical services in many reservation communities, but is dra‐ matically underfunded (Manson 2000), particularly with respect to mental health services (Nelson et al 1992). The IHS but Native Americans continue to experience significant rates of diabetes, mental health disorders, cardiovascular disease, and injuries. Native Americans are 770% more likely to die from alcoholism, 650% more likely to die from tuberculosis, 420% more likely to die from diabetes, and 280% more likely to die from accidents (Indian Health Care

**2. Mental health disparities for Native Americans: U.S., California and**

**General issues**. The SGR of 2001 offered general definitions of mental health, mental illness, and mental health problems. It described mental health as important for personal well-being, family and interpersonal relationships, and successful contributions to community or society. These elements are jeopardized by mental health problems and mental illnesses. While these elements of mental health may be identifiable, mental health itself is not easy to define more precisely because any definition is rooted in value judgments that may vary across individuals and cultures. The Report outlines risks and protective factors (e.g., community or social factors

The SGR of 2001, found that racial and ethnic minorities bear a greater burden from unmet mental health needs, ranking second only to cardiovascular disease in their impact on disability (Murray and Lopez 1996; Manson, 1996a). The foremost barriers include the cost of care, societal stigma, and the fragmented organization of services. Additional barriers include clinicians' lack of awareness of cultural issues, bias, or inability to speak the client's language, and the client's fear and mistrust of treatment. More broadly, disparities also stem from minorities' struggles with racism and discrimination, which affect their mental health and

are schools, availability of health and social services, and social cohesion).

contribute to their lower economic, social, and political status.

the facility properly).

**3.** Insufficient federal funding.

**4.** Quality of care issues.

**rural trends**

**1.** Limited access to appropriate health facilities.

**5.** Disproportionate poverty and poor education.

Improvement Act Amendments of 2003).

cans are:

76 Telemedicine

The Native American Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP) was designed to compare findings with the results of the baseline National Comorbidity Survey (NCS). It determined the lifetime prevalence of common mental disorders to be 35.7% for Southwest women to near 50% for men (Beals et al 2005a; Beals et al 2005b). Alcohol abuse and dependence were the most common disorders for men, with posttraumatic stress disorder most prevalent for women, with cultural and perhaps regional variations (Spicer et al 2003). A current study of lifetime and current physical and sexual abuse among Native American women found: 1) a significant relationship between childhood abuse, substance abuse/dependence, and adult re-victimization; and 2) a significant relationship between cumulative lifetime abuse events, substance abuse/dependence, and depression (Bohn 2003). Older Native Americans report that over 30% of older Native American adults visiting one urban IHS outpatient medical facility reported significant depressive symptoms; this rate is higher than most published estimates of the prevalence of depression among older whites with chronic illnesses (9%- 31%) (Manson 1992).

Two studies have assessed children and adolescents. The Great Smoky Mountain Study assessed psychiatric disorders among 431 youth ages 9 to 13 (Costello et al 1997). Overall, Native American children were found to have fairly similar rates of disorder (17%) in com‐ parison to white children from surrounding counties (19%) (SGR 2001). The second study reported a follow-up of a school-based psychiatric epidemiological study involving Northern Plains youth, 13 to 17 years of age (Beals et al 1997). Altogether, more than 15% of the students qualified for a single diagnosis; 13% met criteria for multiple diagnoses. In terms of the broad diagnostic categories, 6% of the sample met criteria for an anxiety disorder, 5% for a mood disorder (either major depressive disorder or dysthymia), 14% for one or more of the disruptive behavior disorders, and 18% for substance abuse disorders.

**California Native Americans**. There are over 100 federally recognized tribes in California with 69,238 active health service users, defined as a visit in the last year (U.S. Census Bureau 2000). Native Americans constitute approximately 1% of the California population, 1.9% when the definition includes Native American/Alaskan Native in combination with other race, and are considered among the nation's most vulnerable populations due to high rates of psychiatric, medical, and substance use disorders (U.S. Census Bureau 2000). One study with a 20-year follow-up found the lifetime prevalence of mental disorders to be 70% (U.S. Department HHS, SAMSHA 2004).

Population dispersion of tribal groups in California makes it unlikely that a hospital-based service program will develop or support the members, meaning many rural and even some urban clinics depend on specialists outside the IHS. High costs associated with distance, time, and a shortage of primary care physicians in rural areas put Native Americans at high risk for suicide, trauma, and diabetes. Native Americans often do not obtain treatment due to barriers to care, differences in help-seeking behaviors, and higher dropout rate for mental health outpatient services than Caucasians (Weinick et al 2000).

assistance (Geller and Muus 2002; Geller 1999). However, rural areas inherently have provider

Mental Health Services for California Native Americans — Usual Service Options and a Description…

http://dx.doi.org/10.5772/56569

79

Health providers use a number of psychiatric, health service and disease management models to reach primary care patients, predominantly in suburban and urban locales (Katon et al 1995; Pincus 1987; Strathdee 1987). The traditional referral or replacement model uses the psychiatrist as the principal provider of mental health services. The consultation care model includes the PCP as the principal provider of mental health services, after a psychiatric consultation. The collaborative care model involves mental health services jointly provided by the PCP and psychiatrist, including frequent communication between providers. Variations on these models also include use of mental health extenders and a stepped care to judiciously use scarce psychiatric resources (Katon et al 1997). Quality improvement programs also improve treatment rates and outcomes for depressed patients with comorbid medical illness

These models have been evaluated both in the United States and Great Britain. In Great Britain, the majority of psychiatrists function in the traditional referral model (Strathdee 1987). The majority of PCPs, though, favored the collaborative care model, as having the psychiatrist located in the primary care clinic setting versus an offsite mental health clinic greatly improved the consultation process (Katon et al 1995; Bailey et al 1994). Such research shows that those PCPs patients are more likely to receive adequate doses of antidepressants and recover from depression (Simon et al 2000). But in rural areas, there is a dearth of specialists (Off Tech Assessment 1990), resulting in travel for patients or providers. In addition, some rural sites have unique needs and issues (e.g., high rates of substance disorders and few treatment options at an Native American reservation; enmeshed small communities, wherein patients want an

Telemedicine, defined as the use of technology to deliver health care (usually through videoconferencing), is one strategy to improve the accessibility of mental health care, partic‐ ularly to areas underserved by physicians (Preston et al 1992; Hilty et al 2004a; Hilty et al 2013a). Telecommunications technology has been used to link specialists at academic health centers with health care professionals in rural areas for the management of patients (Hilty et al 1999). Videoconferencing, telephone and computer-based (e.g., e-mail) connect specialists with PCPs for patient care (Nesbitt et al 2000; Levine and Gorman 1999; Dick et al 1999; Hilty

Medical home, home health and other mobile technology methods are in development and need to be better studied, although costs are dramatically decreasing. The patient-centered medical home (PCMH) is a concept founded on the presence of inadequate treatment in primary care and/or an inability to access needed services (Rosenthal 2008). PCMH allows telepsychiatric input at home, still under the general purview of the primary care provider, and it has been shown to improve patient care and health (Hollingsworth et al 2011). Deskmounted video systems offer great convenience for therapy to cancer patients to avoid travel, but the cost used to be prohibitive for most consumers (Cluvey et al 2005). Internet-based video

shortages, particularly with regard to consultation-liaison psychiatrists.

in primary care (Koike et al 2002) and are cost-effective, too (Wells et al 2001).

objective person from the outside).

**3.2. Telemedicine history**

et al 2004b).

#### **2.1. Substance, rural health and Native Americans**

A few studies have been completed regarding substance issues in Native Americans. A previously mentioned study that examined the relationship of substance abuse and psychiatric disorders among family members (Robin et al 1997) also considered their use of mental health services. Of those with a mental disorder, only 32% had received mental health or substance abuse services. The AI-SUPERPFP showed that Native American men were more likely than those in NCS to seek help for substance use problems from specialty providers; Native American women were less likely to talk to nonspecialty providers about emotional problems (Beals et al 2005b). Help-seeking from traditional healers was common in both Native Amer‐ ican populations and was especially common in the Southwest.

There are many serious manifestations of untreated mental illness in Native Americans, particularly in rural areas. The prevalence rate of suicide for Native Americans is 1.5 times the national rate, particularly higher rates for males aged 15-24 and women aged 25-44 (U.S. HHS 2004; National Women's Health Information Center 2006). More Native Americans live in rural areas compared to Caucasians (42% to 23%) (U.S. HHS 2004). These areas have a shortage of mental health services and inadequate treatment (e.g., 70% of patients have an inadequate antidepressant dose for depression) (Unutzer et al 2002), and rural depressed patients have three times more hospitalizations and higher suicide rates than suburban patients (Rost et al 1999; Rost et al 1998). On the whole, rural communities are experiencing an acute shortage of adult, adolescent, and child psychiatric providers and those skilled in culturally appropriate care (Am Acad Child Adol Psychiatry 2004; Martinez 1993).
