Transcript A National Strategy for Native Youth Mental Health

The American Indian/Alaska Native National Resource Center
for Substance Abuse and Mental Health Services
Building on Success :
A National Strategy for Native Youth
Mental Health Treatment and Prevention
2006 Juvenile Justice National Conference
Washington, DC
January 11, 2006
Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD
Bentson McFarland, MD, PhD, Michelle Singer
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One Sky
Center
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Native Aspirations!
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Overview
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An Environmental Scan
Behavioral Health Care System Issues
Fragmentation and Integration
Discuss Suicide, Comorbidity, Disaster
Indigenous Knowledge + Evidence Based Knowledge
= Best Practice
• Integrated care approaches are best for treatment of
these chronic illnesses
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Six Missions Impossible?
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How do we define problems?
How do we define disaster?
How do we ask for help?
How do we get Federal and State agencies to
work together and with us?
• How do we build our communities?
• How do we restore what is lost?
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Health Problems
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6.
Alcoholism 6X
Tuberculosis 6X
Diabetes 3.5 X
Accidents 3X
Physicians 72/100,000 (US 242)
60% Over 65 live in poverty
(US 27%)
American Indians
• Have same disorders as general
population
• Greater prevalence
• Greater severity
• Much less access to Tx
• Cultural relevance more challenging
• Social context disintegrated
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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
5. State and Local Agencies
6. Federal Agencies: SAMHSA, VAMC
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Disconnect Between
Addictions / Mental Health
• Professionals are undertrained in one of two
domains
• Patients are underdiagnosed
• Patients are undertreated
• Neither integrates well with medical and
social service
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Difficulties of Program
Integration
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Separate funding streams and coverage gaps
Agency turf issues
Different treatment philosophies
Different training philosophies
Lack of resources
Poor cross training
Consumer and family barriers
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Different goals
Resource silos
One size fits all
Activity-driven
How are we functioning?
(Carl Bell, 7/03)
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Culturally
Specific
Best
Practice
Outcome
Driven
Integrating
Resources
We need Synergy and an Integrated
System (Carl Bell, 7/03)
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Suicide: A National Crisis
• In the United States, more than 30,000 people die by
suicide a year.1
• Ninety percent of people who die by suicide have a
diagnosable mental illness and/or substance abuse
disorder.2
• The annual cost of untreated mental illness is $100
billion.3
1 The
President’s New Freedom Commission on Mental Health, 2003.
Center for Health Statistics, 2004.
3 Bazelon Center for Mental Health Law, 1999.
2 National
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Our Community Issue
• For every suicide, at least six people are affected.4
• There are higher rates of suicide among survivors
(e.g., family members and friends of a loved one who
died by suicide).5
• Communities are linked to each other via a national
network.
• Healthy communities are stronger communities.
4 National
5 National
Center for Health Statistics, 1999.
Institute of Mental Health, 2003.
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Suicide Rates by Age, Race, and
Gender 1999-2001
AI Male
Black Male
AI Female
50
40
30
20
Age Groups
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Source: National Center for Health Statistics
85+
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
0
10-14
10
5-9
Rate/100,000 .
60
White Male
SUICIDE: A MULTI-FACTORIAL EVENT
Psychiatric Illness
Co-morbidity
Personality
Disorder/Traits
Neurobiology
Impulsiveness
Substance
Use/Abuse
Hopelessness
Suicide
Severe Medical
Illness
Family History
Access To Weapons
Life Stressors
Psychodynamics/
Psychological Vulnerability
Suicidal
Behavior
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Comorbidity Defined
“Individuals who have at least one mental
disorder as well as an alcohol or drug use
disorder. While these disorders may interact
differently in any one person….at least one
disorder of each type can be diagnosed
independently of the other.”
- Report to Congress of the Prevention and
Treatment of Co-Occurring Substance Abuser
Disorders and Mental Disorders, SAMHSA, 2002
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Lifetime History
Mental Disorder
22.5%
Comorbidity
29%
Alcohol Disorder
13.5%
Comorbidity
45%
Drug Disorder
6.1%
Comorbidity
72%
Regier, 1990
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Multiple Diagnoses Increase
• Treatment seeking
• Use of services
• Likelihood of no services
• Treatment costs
• Poor outcome
• Suicide risk
• Dual diagnosis is an expectation, not an
exception
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Disaster Defined
• FEMA: A natural or man-made event that negatively
affects life, property, livelihood or industry often
resulting in permanent changes to human societies,
ecosystems and environment.
• NHTSA: Any occurrence that causes damage,
ecological destruction, loss of human lives, or
deterioration of health and health services on a scale
sufficient to warrant an extraordinary response from
outside the affected community area.
• NOAA: A crisis event that surpasses the ability of an
individual, community, or society to control or recover
from its consequences.
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The Intervention Spectrum
for Behavioral Disorders
Case
Identification Standard
Treatment
for Known
Indicated—
Disorders
Diagnosed
Youth
Selective—
Health Risk
Groups
Universal—
General Population
Compliance
with Long-Term
Treatment
(Goal:Reduction in
Relapse and Recurrence)
Aftercare
(Including
Rehabilitation)
Source: Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of
Medicine, Washington, DC: National Academy Press, 1994.
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Ecological Model
Society
Community/
Tribe
Peer/Family Individual
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Environmental
Interpersonal
societal
Stigma
Community
Tribal
attitudes
Parents
Peers
Personality
National
attitudes
Genetics Individual Attitudes
beliefs
Cultural
beliefs
Schools
Interpersonal
Local
legal
State
attitudes
Personal situations
Individual
Portrayal in media
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Suicide: Individual Factors
Risk
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Mental illness
Age/Sex
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
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Suicide: Peer/Family Factors
Risk
• History of
interpersonal
violence/abuse/
• Bullying
• Exposure to
suicide
• No-longer married
• Barriers to health
care/mental health
care
Protective
• Family cohesion (youth)
• Sense of social support
• Interconnectedness
• Married/parent
• Access to
comprehensive health
care
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Suicide: Community Factors
Risk
• Isolation/social
withdrawal
• Barriers to health
care and mental
health care
• Stigma
• Exposure to
suicide
• Unemployment
Protective
• Access to healthcare and
mental health care
• Social support, close
relationships, caring
adults, participation and
bond with school
• Respect for help-seeking
behavior
• Skills to recognize and
respond to signs of risk
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Suicide: Societal Factors
Risk
• Western
• Rural/Remote
• Cultural values and
attitudes
• Stigma
• Media influence
• Alcohol misuse and
abuse
• Social disintegration
• Economic instability
Protective
• Urban/Suburban
• Access to health care &
mental health care
• Cultural values affirming
life
• Media influence
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Addictions: Effective
Interventions for Adults
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Cognitive/Behavioral Approaches
Motivational Interventions
Psychopharmacological Interventions
Modified Therapeutic Communities
Assertive Community Treatment
Vocational Services
Dual Recovery/Self-Help Programs
Consumer Involvement
Therapeutic Relationships
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Addictions: Effective
Interventions for Youth
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Family Therapy
Multisystemic Therapy
Case Management
Therapeutic Communities
Community Reinforcement
Circles of Care
Motivational Enhancement
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Definitions:
Indigenous Knowledge
• Is local knowledge unique to a given culture
or society; it has its own theory, philosophy,
scientific and logical validity, which is used as
a basis for decision-making for all of life’s
needs.
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Definitions:
Traditional Medicine
• The sum total of health knowledge, skills and
practices based upon theories, beliefs and
experiences indigenous to different
cultures…used in the maintenance of health.
WHO 2002
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Definitions:
Evidence-based Practices
• Interventions that show consistent scientific
evidence of improving a person’s outcome of
treatment and/or prevention in controlled
settings.
SAMHSA 2003
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Definitions:
Best Practices
• Examples and cases that illustrate the use of
community knowledge and science in
developing cost effective and sustainable
survival strategies to overcome a chronic
illness.
WHO 2002
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ID Best Practice
Best Practice
Clinical/services
Research
Mainstream
Practice
Traditional
Healing
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Circle of Care
Traditional
Healers
Primary Care
A&D
Programs
Best
Practices
Child &
Adolescent
Programs
Boarding
Schools
Colleges &
Universities
Prevention
Programs
Emergency
Rooms
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“Creating both vertical and horizontal
partnerships at and between each level of
government is essential for effective …
prevention efforts; this requires
overcoming traditional agency boundaries
in order to focus on both broader
populations and symptomatic individuals
immediately in need of care.”
Caine, E., Preventing Suicide, Attempted Suicide, and their antecedents Among Men in the
Middle Years of Life. Executive Summary of a Scientific Consensus Conference, 11-12 June
2003, Washington, D.C.
Partnered Collaboration
Grassroots
Groups
Community-Based
Organizations
Research-Education-Treatment
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The good news and the bad
news
While there are no easy
solutions to complex
problems; there are complex
solutions.
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Community Based Prevention
Interventions
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Public awareness and media campaigns
Youth Development Services
Social Interaction Skills Training Approaches
Mentoring Programs
Tutoring Programs
Rites of Passage Programs
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Effective Family Intervention
Strategies: Critical Role of Families
• Parent training
• Family skills training
• Family in-home support
• Family therapy
Different types of family interventions are used
to modify different risk and protective factors.
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Suicide Prevention Resources
• Suicide Prevention Resource Center
http://www.sprc.org/
• Indian Health Service Director’s Initiatives
http://www.ihs.gov/
• Office of Juvenile Justice Model Programs
http://www.dsgonline.com/mpg2.5/mpg_index.htm
• One Sky Center http://www.oneskycenter.org/
• Screening for mental health
http://www.mentalhealthscreening.org/
• Jason Foundation
http://www.jasonfoundation.com/home.html
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Addiction Resources
• SAMHSA Co-occurring Disorders
http://alt.samhsa.gov/Matrix/matrix_cooc.asp
• National Institute of Alcohol Abuse and Alcoholism
http://www.niaaa.nih.gov
• National Institute of Drug Abuse
http://www.nida.nih.gov
• National Institute of Mental Health
http://www.nimh.nih.gov
• Treatment Improvement Protocol (TIP) Series
– (800) 729-6686
• Monitoring the Future Study
http://www.monitoringthefuture.org
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For information, contact us at
503-494-3703
E-mail
Dale Walker, MD
[email protected]
Or visit our website:
www.oneskycenter.org
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