American Indians and Alaska Natives (AIs) experience higher rates of mental health concerns, including ..... 135-132). Washington, DC: American Psycho-.
The Use of Psychotropic Medications in the IHS: Considerations for Embedding Medical Psychology within a Cultural Context Jeffrey D. Shahidullah Doctoral Student in School Psychology Michigan State University
American Indians and Alaska Natives (AIs) experience higher rates of mental health concerns, including depression, substance abuse, posttraumatic stress, violence, and suicide, compared to other Americans (Costello, Farmer, Angold, Burns, & Erklani, 1997; Gone & Trimble, 2012). American Indian children, specifically, exhibit more behavioral health problems, suicide rates, and feelings of sadness and hopelessness compared to their peers in the general population (Blum, Harmon, Harris, Bergeisen, & Resnick, 1992). Despite the prevalence of mental health problems within these groups, access to quality mental health services remains poor. Jeffrey Shahidullah
Recently, efforts have been made by the Indian Health Service (IHS) agency of the U.S. Public Health Service (PHS) to provide an increased quality of care and access to service for poor, rural, and medically-underserved AI populations. However, despite financial appropriations to serve about 1.5 million eligible AIs, IHS-funding for mental health treatment is not keeping up with demand (USDHHS, 2001a). To contain costs, managed mental healthcare policies in the PHS favor the prescription of psychotropic medication in lieu of psychotherapeutic services. As a means of meeting the increased prescribing needs, the IHS utilizes pharmacologically-trained psychologists to serve AIs, who typically live in remote settings. Pharmacologically-trained psychologists (i.e., medical psychologists) in the IHS can prescribe psychotropic medications and possess the training to recognize the unique psychosocial influences on adherence and compliance to medical interventions. These skills allow psychologists to understand the unique cultural influences on understandings of mental illness and views on healing and treatment that is vital in working competently with any cultural group, but particularly with AI cultures where common approaches within Western medicine must be provided within the context of the spiritual beliefs and approaches of traditional Indian medicine. It is the belief of many in the field of professional psychology (e.g., Levine & Foster, 2010; McGrath & Moore, 2010) that the The Tablet
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increasing reliance on a “psychobiosocial’ model positions medical psychologists to provide the cultural sensitivity needed to embed medical psychology within a cultural context, as compared with the more medicalcentric model used by physicians. This psychobiosocial lens identifies the patient’s perceptions, personal values, and needs as critical factors for dictating care. Working With American Indian Populations Though recent research has been conducted on the mental health of AIs, vast heterogeneity exists among different tribes and groups in the realms of physical, emotional, intellectual, and spiritual, and social practices, values, and beliefs. When reviewing the research literature for specific tribes and native groups, the evidence-base becomes extremely limited. When reviewing the research literature for AI perceptions of mental illness, views toward psychiatric medications, and views toward seeking help from Western mental health service providers, the vast within-group differences must also be noted. Further, regarding drug treatment efficacy, there is a paucity of data on treatment effects in AIs in general, and virtually none looking at the vast within-group variations of this group. Therefore, extrapolating the research conducted within one particular group to all other group increases the risk for our clinical and therapeutic work with these populations to be unproductive, and even harmful. This paper is not intended to be prescriptive in the delivery of mental health service to one particular tribe or group, but rather, is intended to more globally equip service providers with the awareness to know when cultural differences may be most salient. This awareness may
There is vast heterogeneity among different tribes and extrapolating research findings from one group to the next may be unproductive and even harmful
foster the cultural sensitivity in medical psychologists needed to understand how cultural differences may necessitate differential service provision by making specific cultural adaptations.
American Indian Perceptions of Mental Health and Psychiatric Treatment Many AIs that live in rural or isolated communities have limited access to mental health service. Those that have access to quality mental health care may not always trust or be willing to seek help from government-sponsored sources of care. The U.S. Commission on Civil Rights (2004) recognized that AIs extensive history of disenfranchisement and oppression by the U.S. government has persisted in the form of “deep-rooted intergenerational anger, grief, and mistrust” toward governmental bodies. Limited research has examined the prevalence of AIs seeking mental health treatment and utilization of mental health resources. Robin and colleagues (1997) found in their study that only 32% of AIs with a mental disorder had received mental health services. In a study focused on mental health service utilization rates among AI children, Costello and colleagues (1997) found that only one in seven AI youth with mental disorders receive The Tablet
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professional mental health treatment. Johnson and Cameron (2001) explore the effect of acculturation in AI groups whereby they value their own cultural identity while also valuing the cultural identity of the dominant group. These people are more likely to seek relations with the dominant group and be receptive to a combination of service methods whereby their traditional methods of health care are combined with that of the dominant culture. However, a number of barriers may prevent this type of acculturation from happening as many AIs live with a resentment of past treatments by the dominant group, and so, have grown to either reject the culture of the dominant group or become suspicious of service provided by this group (Johnson & Cameron, 2001). The Surgeon General’s Report (USDHHS, 2001) suggests that these low mental health service utilization rates is likely due to myriad factors, but that directly or indirectly stem from these group’s turbulent history with the U.S. government and White authorities. Though previous research has shown evidence that AIs are more likely to prefer receiving treatment from ethnically similar providers (Haviland, Horswell, O’Connell, & Dynneson, 1983) there is a paucity of more recent evidence on whether AIs are more willing to seek care if the provider is also an AI (USDHHS, 2001). The trouble is that except for traditional healers, there are very few available AI mental health providers available (Menderscheid & Henderson, 1998). Menderscheid and Henderson (1998) found that there were only approximately 100 AI providers for every 100,000 AIs in general, compared with 173 per 100,000 for Caucasians. Regardless of the difficulty in accessing
Many AIs assign meanings to their mental illnesses that significantly differ from the challenges present as a result of AIs differing biologically-based underpinnings assumed views of mental illness compared to Western in many Western etiologies quality mental health service providers, other
views. Many AIs assign meanings to their mental illnesses that are divergent from the common Western etiologies that typically have biologically underpinnings (Kleinman, 1988). The significance attached to various illnesses is moderated by cultural meanings. These cultural meanings dictate whether one is motivated to seek treatment, where they seek treatment (e.g., IHS or traditional healer), and how well they are likely to fare in treatment (Johnson & Cameron, 2001). These factors likely influence treatment adherence and compliance rates of AI patients. Todd-Bazemore and Bull Bear (1996) surveyed mental health service patients on the Pine Ridge Oglala Sioux Reservation in South Dakota and found that the majority of patients were not taking the medications they were prescribed. Further, most of these patients did not even have their prescriptions filled. Treatment adherence outcomes in these populations are likely dependent on whether assessment The Tablet
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and diagnosis decisions are culturally informed. Early and accurate diagnosis of mental illness, such as depression, is critical, especially in AI populations given the linkage to substance abuse. While clinicians working with these patients will often diagnose AIs with depression and mood disorders, it is important to remember that specific DSM-IV-TR diagnoses, such as a depressive disorder, may not correspond directly to mental illness categories used by AIs, and thus requires, as Duran (2006) describes, “the necessity at times to meet patients in their world and work within their root metaphor to provide the best treatment possible” (p. 79). An example of this variation of meaning might be a young AI boy who reports to his mental health care provider that he sees the spirit of his deceased grandfa-
Duran (2006) has emphasized the need to understand the client’s world when providing the best possible treatment
ther and speaks with him often. In AI culture this may be a normal function, but without the cultural context this might be a sign of a thought disorder. This example highlights how early diagnoses of mental disorders are often difficult to make.
Assessment in a cross-cultural setting must rely on obtaining the patient’s perspective of what is occurring as their understanding and expectations of illness may be different from the clinicians’ (Biernoff, 1999). Psychologists must also be mindful that many AI groups have relied on holistic diagnostic methods for centuries and it is critical to not downplay the effectiveness of these traditional methods of assessment (Lim, 2006). While some symptoms may align well with DSM-IV-TR criteria for a clinical disorder (e.g., hearing voices of deceased family members), they may actually be normal in that particular culture. This example highlights the need for medical psychologists to utilize a culturally competent approach to assessment whereby they can understand the language and metaphors used by their clients when discussing either culturally normal or abnormal presentations of illness. Because many of the assessment tools that clinicians may use, such as It is important to recognize that some the standard mental status examination and its diagnos- symptoms considered pathological in tic criteria, are not standardized on this population the DSM-IV-TR may be considered (Biernoff, 1999), it is vital that providers understand ill- “normal” in a particular culture ness through the worldview of the patient. Duran (2006) explains that many AIs describe their various afflictions as “visitors.” Therefore, medical psychologists must initially abandon their traditional nomenclature to first understand the patients’ perception of their illness. Another cultural consideration regarding the diagnosis of a patient is the use of alternative explanatory models of illness that may differentiate depending on the patient’s culture. Though typical Western etiologies of mental illness lie in the biological or neurological basis of behavior and emotions, AI groups may view these within a spiritual realm, such as breaking religious or spiritual taboos. As part of the assessment process, the clinician must consider the degree to which the patient has assimilated the values and traits of the mainstream culture. Unfortunately, the research literature exploring AIs cultural perceptions The Tablet
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of illness and treatment is limited, and do not account for the vast within-group differences between tribal and/or group distinctions. In addition to culture, language may also present a barrier to obtaining quality mental health care for many AIs. Non-English proficient and limited-English–speaking patients receive less health education, poorer doctor-patient interactions, and report lower overall patient satisfaction as a result of the discordant language use between patient and healthcare provider (Ngo-Metzger et al., 2007). While English proficiency is a marker for acculturation, more studies are needed to examine the prevalence within various tribes and their emphasis on traditionalism. Most studies that do exist use the concept of traditionalism to explore various groups’ reliance on and preference for traditional healing practices versus Western biomedical practices (Novins, Beals, Moore, Spicer, & Manson, 2004). Some of the few researchers to explore this were Coe and colleagues (2004), who examined the attitudes and behavior toward traditional versus more modern approaches in a randomly selected sample of 559 Hopi women. The results indicated that women with more traditional views on healing were found to be healthier and have fewer disease risks. Similar results have been found in samples of Lakota men and women (Cheyenne River Sioux Tribe; Han, Hagel, Welty, Ross, Leonardson, & Keckler, 1994). These types of studies can be helpful to clinicians who work with specific AI groups by delineating the nature of the relationship between cultural factors and health-related behavior. However, more research is clearly needed in this area. As previously noted, a critical weakness of the research literature is the lack of specificity of attitudes and views toward the use of Western medical treatments. With the small percentage of AIs compared to the general population, it is difficult to obtain nationally representative studies with sufficient sample inclusion of AIs needed to draw accurate conclusions regarding their specific views toward mental health care and treatment (USHHS, 2001). Based on the current research literature, it is even more difficult to draw accurate conclusions regarding the various views of different AI groups. Another weakness in the research literature which limits medical psychologists’ ability to provide effective and efficient service is the lack of information on symptom presentation for a variety of mental illnesses (e.g., mood disorders) in these populations as illness always occurs within a cultural context (Biernoff, 1999). With greater knowledge of symptom presentation differences between groups, medical psychologists can more accurately assess and diagnose mental illness.
A significant weakness in the treatment literature is the underrepresentation of ethnic minorities in clinical drug trials
An additional weakness in the research literature is the under-representation of ethnic minorities in clinical drug trails (USDHHS, 2001b). As a result, these studies cannot assess treatment efficacy/safety within specific minority groups with known differences (e.g., metabolism, polymorphism). Despite recent pharmaThe Tablet
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ceutical advances in developing revolutionary drugs that treat a range of previously undeterred mental and medical illness, it is regrettable that so much of the research literature has neglected differential psychiatric treatment based on cultural factors. Commonly, the results of randomized drug studies conducted with mostly Caucasian participants are simply extrapolated to minority populations. By indiscriminately assuming that the same drug reaction will occur in groups other than in which it was assessed can be ineffective and dangerous. Embedding Medical Psychology into the Cultural Context: Implications for Practice and Research It is clear that there are potential challenges in delivering quality evidence-based medical interventions to AIs within the IHS. Tilus and colleagues (2011) recognized that “of the 564 federally recognized AI tribes and their descendants eligible for services provided by the IHS, approximately 57% rely on the IHS to provide all of their healthcare services” (p. 97). It is unlikely that research will provide the knowledge to acutely differentiate service provision to these groups in a way that takes into account all of the vast interand intra-group differences. However, understanding salient areas in which tribal and other group differences are likely to manifest and their implications for openness to healthcare is a vital competency for medical psychologists.
Western medicine, including psychotropic medications, must be used on conjunction with traditional medicines within AI cultures IHS policy endorses that Western medicine be used in conjunction with, not in lieu of traditional medicine (Dixon & Roubideaux, 2001, p. 74). Though the Indian cultures have typically become more accepting of Western medicine, some still “reject the ‘white man’s medicine’- viewing it as being in conflict with their cultural and religious beliefs” (DeJong, 2008, p. 117). Most today, however, recognize the benefits of modern medicine while still upholding their traditional beliefs. Todd-Bazemore (1999) emphasizes the importance of creating collaborative relationships with traditional spiritual healers in the care of AI patients. These spiritual healers can act as a liaison between the patient and therapist and be a valuable resource in providing competent care while still being sensitive to traditional practices and beliefs. Of course these traditional practices vary from one group to the next, and so, medical psychologists must approach assessment, diagnosis, and treatment with cultural intentionality. While traditional clinical interviews may not adequately account for unique cultural variables, the use of a multicultural clinical interview (also see the “Outline for Cultural Formulation” in DSM-IV-TR, 2000) may facilitate the cultural intentionality needed to conceptualize assessment, diagnosis, and treatment within the cultural context of the client. The use of traditional practices such as a blessing from a medicine man or spiritual healer may provide the bridge needed to link traditional Indian perspectives on mental health with Western practice. The Tablet
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As is often the case, practice may likely facilitate needed research in the area of providing culturally competent mental health and psychiatric care to AIs. With better understanding of AI conceptions of mental illness, views toward psychiatric medication and factors that foster greater treatment acceptability needed for adherence and compliance, medical psychologists can continue to improve their service provision to these groups. Medical psychologists’ competence in providing both psychopharmacological and psychosocial treatments based upon the best available evidence will continue to position them to fill a healthcare need through their work in the IHS in service to AI populations. References American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental
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