**Mental Health Services for California Native Americans — Usual Service Options and a Description of Telepsychiatric Consultation to Select Sites**

Donald M. Hilty, Peter M. Yellowlees, Nicole Tarui, Steven R. Viramontes, Margo D. Kerrigan, David L. Sprenger and Jay Shore

Additional information is available at the end of the chapter

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

**1. Introduction**

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74 Telemedicine

### **1.1. Culture and health disparities for Native Americans**

The culture of the patient refers to a set of beliefs, norms, and values (Surgeon General Report (SGR) 2001). This affects symptoms, presentation, meaning, understanding, family issues, coping styles, treatment seeking, trust, stigma, and overall health status. A clinic and its clinicians also have a culture that affects communication and care. Native Americans continue to suffer disproportionately from a variety of illnesses and diseases, despite the funds for health care services, resulting in higher death rates (age 71, nearly 5 years below average) than the rest of the U.S. population (Office General Council 2004). Some of these disparities are directly related to, or significantly affected by individual behavior and lifestyle choices (Office General Council 2004).

The Office of the General Counsel and IHS outlined the causes of the disparities for Native Americans. Racial discrimination, which introduces unique emotional variables, has been noted (NIH 2001), and the Institute of Medicine established that whites are more likely to receive more thorough, diagnostic work and better treatment and care than people of color, even when controlling for income, education, and insurance (Vernellia Randall Institute of Racism 2002). Current research indicates that there are five, non-mutually exclusive, primary five primary contributors to disparities in health status and outcomes for Native Americans. For example, a person may arrive at a health facility only to find a lack of necessary services

© 2013 Hilty et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 Hilty et al.; licensee InTech. This is a paper distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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 facility properly).

**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

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

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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).

behavior disorders, and 18% for substance abuse disorders.

SAMSHA 2004).

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

**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,

high rates of poverty that characterize this ethnic minority group.

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


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 Improvement Act Amendments of 2003).
