Integrative Care Models in Native Communities: Addressing Behavioral Health Disparities

1. Native Suicide: Emerging Community Based Integrative Care Models One Sky Center R Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer NARA”s 1st Annual Spirit of Giving Conference Portland, Oregon Sept 3, 2010

2. NARA is 40! HAPPY BIRTHDAY!

3. Native Communities Advisory Council / Steering Committee Education Opportunity, Research Mentorship One Sky Center Training, Consultation, Technical Assistance Excellence Tribal Leadership

4. Goals for Today • Review An Environmental Scan for Natives • Discuss Fragmentation and Integration • Present Some Behavioral Health Care Issues • Define Social Determinants of Health • Summarize Critical Issues for Native Peoples

5. Who are indigenous peoples? “Indigenous peoples remain on the margins of society: they are poorer, less educated, die at a younger age, are much more likely to commit suicide, and are generally in worse health than the rest of the population." (Source: The Indigenous World 2006, International Working Group on Indigenous Affairs (IWGIA) WHO

6. INDIGENOUS PEOPLE WORLD MAP - 370 million indigenous peoples living in more than 70 countries

11. Native Healthcare Resource Disparities

12. Agencies Involved in B.H. Delivery 1. Indian Health Service (IHS) A. Mental Health B. Primary Health C. Alcoholism / Substance Abuse 2. Bureau of Indian Affairs (BIA) A. Education B. Vocational C. Social Services D. Police 3. Tribal Health 4. Urban Indian Health • State and Local Agencies • Federal Agencies: SAMHSA, VAMC, Justice

13. Different goals Resource silos One size fits all Activity-driven How are we functioning? (Carl Bell and Dale Walker 7/03)

14. Best Practice Culturally Specific Outcome Driven Integrating Resources We need Synergy and an Integrated System (Carl Bell and Dale Walker 7/03)

15. Behavioral Health Care Issues

16. Native Health Issues • Alcoholism 6X • Tuberculosis 6X • Diabetes 3.5 X • Accidents 3X • Poverty 3x • Depression 3x • Suicide 2x • Violence? • Same disorders as general population • Greater prevalence • Greater severity • Much less access to Tx • Cultural relevance more challenging • Social context disintegrated

17. Adult Serious Mental Illness By Race/Ethnicity: 2001 SAMHSA Office of Applied Studies, 2001

18. Frequent Mental Distress by Race/Ethnicity and Year Percent American Indian/ Alaskan Native** African-American** Hispanic White** Asian, Pacific Islander** ** Non-Hispanic Year * Zahran HS, et al. Self-Reported Frequent Mental Distress Among Adults — United States, 1993–2001. Centers for Disease Prevention and Control, MMWR 2004;53(41):963-966.

19. Suicide: A Multi-factorial Event Psychiatric Illness& Stigma Edu., Econ., Rec. Cultural Distress Impulsiveness Substance Use/Abuse Hopelessness Family Disruption/ Domestic Violence Individual Family History Negative Boarding School Psychodynamics/ Psychological Vulnerability Historical Trauma Suicidal Behavior

20. Key Adolescent Risk Factors Aggressive/Impulsive Substance Abuse Depression Trauma

21. 0 Suicide Among ages 15-17, 2001 Death rate per 100,000 2010 Target Females Males Total American Indian White Black Hispanic Asian Source: National Vital Statistics System - Mortality, NCHS, CDC.

22. Suicide: A Native Crisis Source: National Center for Health Statistics 2001

24. North Dakota Teen Suicide Rates (2000-2004 rate per 100,000 teens 13-19 years old)

25. Blog # 1 • I started smoking at the age of eight.Provoking my life of sin to a life of hate, drinking was what made it worse.Thinking of myself while my family hurt.Coming home at late nights with a liquored up shirt, so now I bring it home for my future isn't set in stone.

26. Blog #2 • Jealousy,Frustration,Emptiness,Loneliness,Not dependable at all times,Laziness, Pain • There Is A Boy Named xxxx. He Always Tries To Fight Me.

27. Blog # 3 • My Dad Is Dead. • I Struggle With Wanting to Drink or to take Control of My life And Do Whatever I want even if It Hurts Me Emotionally.I will Struggle When I Have Kids One Day, How They Will turn out.

28. Blog #4 • There are so many deaths because of stuffLike diabetes, heart diseases, and notTaking good care of your self.And all The drugs and Alcohol…

29. Models of Care

30. Treatment Brief Intervention Universal/Selective Prevention Spectrum of Intervention Responses Thresholds for Action No Problems Mild Problems Severe Problems Moderate Problems

31. The Intervention Spectrum for Behavioral Disorders Treatment C a s e I d e n t i f i c a t i o n S t a n d a r d T r e a t m e n t f o r K n o w n Indicated— Diagnosed Youth D i s o r d e r s Prevention Maintenance C o m p l i a n c e Selective— Health Risk Groups w i t h L o n g - T e r m T r e a t m e n t ( G o a l : R e d u c t i o n i n R e l a p s e a n d R e c u r r e n c e ) A f t e r c a r e Universal— General Population ( I n c l u d i n g R e h a b i l i t a t i o n ) Source: Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of Medicine, Washington, DC: National Academy Press, 1994.

32. Domains Influencing Behavioral Health: A Native Ecological Model Risk Protection Individual Peers/Family Community/Tribe Society/Cultural

33. Risk and Protective Factors: Individual • Risk • Mental illness • Age/gender • Substance abuse • Loss • Previous suicide attempt • Personality traits • Incarceration • Failure/academic problems • Protective • Cultural/religious beliefs • Coping/problem solving skills • Ongoing health and mental health care • Resiliency, self esteem, direction, mission, determination, perseverance, optimism, empathy • Intellectual competence, reasons for living

34. WARNING: IS PATH WARM? • I Ideation (ideas/plans about suicide) • S Substance Abuse • P Purposelessness • A Anxiety/Agitation • T Trapped • H Hopelessness • W Withdrawal • A Anger • R Recklessness • M Mood Changes American Association of Suicidology, 2006 Expert Consensus Statement, www.suicidology.org

35. Suicide is Usually Impulsive in Youth • 25% of 153 survivors of near lethal suicide attempts acted within 5 minutes of the impulse to do so • 71% acted within one hour • Factors associated with the medical severity of suicide attempts in youths and young adults, Swahn MH, Potter LB, 2001

36. Protective Factors Help • Important personal resources Strong sense of self-worth & self- esteem Good cognitive skills Sense of personal control Self-management skills • Important social resources Cultural/religious beliefs Coping/problem solving skills Ongoing health and mental health care Strong interpersonal bonds Social support, sense of belonging

37. Individual Intervention • Identify risk and protective factors counseling skill building improve coping support groups • Increase community awareness • Access to hotlines other help resources

38. Effective Interventions for Adults • Cognitive/Behavioral Approaches • Motivational Interventions • Psychopharmacological Interventions • Modified Therapeutic Communities • Assertive Community Treatment • Vocational Services • Dual Recovery/Self-Help Programs • Consumer Involvement • Therapeutic Relationships

39. Culture-Based Interventions • Story telling • Sweat Lodge • Talking circle • Vision quest • Wiping of tears • Drumming • Smudging • Traditional Healers • Herbal remedies • Traditional activities

40. What are some promising strategies?

41. Social Determinates of Health: Whitehall Studies • Within a hierarchical society, there is a social gradient for morbidity and mortality. (Poverty, sanitation, nutrition, and shelter are controlled.) • Higher status folks live longer and healthier. Health Care Improvement Needs More Than Money: • Opportunity, Empowerment, Security, Control, and Dignity…. www.thelancet.com Dec 9, 2006. Marmot AmartyaSen 1998 Nicholas Stern 2004

42. Socio- -economic Socio-cultural Science & technology . Health biological ageing ICT behavioral GENDER environmental HEALTH & SOCIAL JUSTICE Human rights health

43. The Social Determinants of Health • The conditions in which people are born, grow, live, work and age. • Shaped by the distribution of money, power and resources at global, national and local levels. • Are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries. WHO Commission on Social Determinants of Health | August 28 2008

44. Conceptual Framework of Health Determinants

45. Critical Elements for Native Peoples • Self determination • Ecology and environment • Economic prosperity, fairness and equity • Leadership and capacity strengthening • Racism / dominance / imperialism • Healing, services, systems, structures • Cultural sustainability, protection, stewardship • Land • Human rights

46. An Ideal Intervention • Broadly based: Includes individual, family, community, tribe, and society • Comprehensive: Prevention: Universal, Selective, Indicated Treatment Maintenance • Addresses opportunity, empowerment, security, dignity

47. Partnered Collaboration State/Federal Community-Based Organizations Grassroots Groups Research-Education-Treatment

48. Six Key PrinciplesEvidence-based predictors of change • Leadership • Mobilization Community driven • Public health approach • Strength based • Culturally informed • Proactive

49. Areas for Action Health Equity in all Policies Good Governance Fair Financing Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Responsibility Gender Equity Political empowerment – inclusion and voice

50. Again, From the One Sky Center Staff, Happy Birthday NARA Contact us at 503-494-3703 E-mail Dale Walker, MD onesky@ohsu.edu Or visit our website: www.oneskycenter.org