Addictions and Mental Health Best Practices in Native Populations

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Addictions and Mental Health Best Practices in
Native Populations
R. Dale Walker, MD Patricia Silk Walker,
PhD Douglas Bigelow, PhD
Bentson McFarland, MD August 1, 2006 Fort
Hall, Idaho
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Goals for Today

• What is the problem?
• What do we know about addictions and mental
  health?
• Fragmentation issues
• Indigenous Knowledge Evidence Based Best
  Practice
• What are some solutions?

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10 Leading Causes of Disability in the World
(WHO, 1997)

• Unipolar Depression
• Iron-deficiency Anemia
• Falls
• Alcohol Use
• COPD
• Bipolar disorder
• Congenital anomalies
• Osteoarthritis
• Schizophrenia
• Obsessive-compulsive disorder

• 10.7
• 4.7
• 4.6
• 3.3
• 3.1
• 3.0
• 2.9
• 2.8
• 2.6
• 2.2

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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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Native American Admissions, 1999
Total Female Male Admissions
(Thousands) 43.2 15.0 28.2 Primary Substance
(percent) Alcohol 62.2
55.6 65.7 Marijuana 12.4 11.4
13.0 Opiates 9.0 10.8 8.0 Cocaine
6.4 8.9 5.0 Stimulants 5.4
8.2 4.0 Other 4.7 5.0
4.5 Total 100.0 100.0
100.0

Source 1999 SAMHSA Treatment Episode Data Set
(TEDS).
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Percentage using any illicit drugs in the past
year
Total Female Male Total
11.9 9.8 14.1 Native American 19.8 23.3 15.6 N
on-Hispanic White 11.8 9.9 13.9 Non-Hispanic
Black 13.1 10.2 16.6 Hispanic Central
American 5.7 4.2 7.7 Hispanic Cuban
8.2 5.5 11.4 Hispanic Mexican 12.7 9.2 15.8

Source 1999 SAMHSA Treatment Episode Data Set
(TEDS).
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Percentage reporting dependence on alcohol
Total Female Male Total 3.5 2.1
4.9 Native American 5.6 6.8 4.3 Non-Hispanic
White 3.4 2.2 4.8 Non-Hispanic
Black 3.4 2.0 5.2 Hispanic Central
American 2.8 0.8 5.4 Hispanic
Cuban 0.9 0.5 1.3 Hispanic Mexican 5.6 2.6 8.
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Source 1999 SAMHSA Treatment Episode Data Set
(TEDS).
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Lifetime History
Mental Disorder 22.5 Comorbidity 29 3.1
1.5 1.7 1.1
Alcohol Disorder 13.5 Comorbidity 45
Drug Disorder 6.1 Comorbidity 72
Regier, 1990
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Multiple Diagnoses Increases

• treatment seeking
• use of services
• poor outcome
• suicide risk
• likelihood of no services
• treatment costs

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Lifetime, Annual and 30 Day Prevalence of
Intoxication Among 224 Urban Indian Youth
R. Dale Walker, M.D. 100 completion sample
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Changes in Lifetime Substance Use Among Urban
Indian Youth Over Nine Years
Percentage ever used
R. Dale Walker, M.D.
100 Completion Sample
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Age of Onset of Substance Use Among Urban
American Indian Adolescents, by Substance Used
R. Dale Walker, M.D. (5/2000) Cohorts 4 5
were sampled every third year recall and
sampling bias apply
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Lifetime Substance Disorder Diagnoses Among
Primary Caretakers (N207)
R. Dale Walker, M.D. (7/97)
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Lifetime Psychiatric DiagnosesAmong Primary
Caretakers (N207)
R. Dale Walker, M.D. (7/97)
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Indigenous Knowledge
Definitions

• 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 lifes
  needs.

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Traditional Medicine
Definitions

• The sum total of health knowledge, skills and
  practices based upon theories, beliefs and
  experiences indigenous to different culturesused
  in the maintenance of health.
• WHO 2002

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Evidence-based Practices
Definitions

• Interventions that show consistent scientific
  evidence of improving a persons outcome of
  treatment and/or prevention in controlled
  settings.
• SAMHSA 2003

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Best Practices
Definitions

• 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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World Conference on Science
A partnership begins!

• Recommended that scientific and indigenous
  knowledge be integrated in interdisciplinary
  projects dealing with culture, environment and
  chronic illness.
• 1999

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ID Best Practice
Best Practice
Clinical/Services Research
Mainstream Practice
Traditional Healing
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The Intervention Spectrum for Behavioral
Disorders
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Selective Health Risk Groups
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Universal General Population
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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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Spectrum of Intervention Responses
Thresholds for Action
No Problems
Mild Problems
Severe Problems
Moderate Problems
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Ecological Model
Individual
Peer/Family
Society
Community/ Tribe
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Interpersonal societal
Environmental
Stigma
Community
Tribal attitudes
Parents
Peers
National attitudes
Personality
Attitudes beliefs
Individual
Genetics
Cultural beliefs
Schools
Local legal
Interpersonal
State attitudes
Personal situations
Individual
Portrayal in media
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Prevention

• Primary
• Risk factors
• Protective factors
• Prevent 1st use

• Secondary
• Prevent kids who use from continuing
• Prevent kids who misuse from experiencing use
  related problems or dependency

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Prevention Programs Should . . . .
Reduce Risk Factors

• ineffective parenting
• chaotic home environment
• lack of mutual attachments/nurturing
• inappropriate behavior in the classroom
• failure in school performance
• poor social coping skills
• affiliations with deviant peers
• perceptions of approval of drug-using behaviors
  in the school, peer, and community environments

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Prevention Programs Should . . . .
Enhance Protective Factors

• strong family bonds
• parental monitoring
• parental involvement
• success in school performance
• prosocial institutions (e.g. such as family,
• school, and religious organizations)
• conventional norms about
• drug use

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Prevention Programs Should . . . .
Target all Forms of Drug Use
. . .and be Culturally Sensitive
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Prevention Programs Should . . . .
Include Interactive Skills-Based Training

• Resist drugs
• Strengthen personal commitments against drug use
• Increase social competency
• Reinforce attitudes against drug use

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Prevention Programs Should be. . . .
Family-Focused

• Provides greater impact than parent-only or
  child-only programs
• Include at each stage of development
• Involve effective parenting skills

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Prevention Programs Should . . . .
Involve Communities and Schools

• Media campaigns and policy changes
• Strengthen norms against drug use
• Address specific nature of local drug
  problem

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Implications for Treatment

• Teach adolescents how to cope with difficulties
  and adversity
• Increase their repertoire of coping strategies
• Cognitive therapy is most effective approach

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Treatment Settings - Social Support

• Tribal
• Community
• Family
• Sibs
• Peers
• Individual

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Evidence-Based Practices

• Brief intervention
• Social skills training
• Motivational enhancement
• Community reinforcement
• Behavioral contracting
• Miller et al., (1995) What works A
  methodological analysis of the alcohol treatment
  outcome literature. In R. K. Hester W. R.
  Miller (eds.) Handbook of Alcoholism Treatment
  Approaches Effective Alternatives. (2nd ed., pp
  12 44). Boston Allyn Bacon.

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Scientifically-Based Approaches

• Cognitivebehavioral interventions
• Community reinforcement
• Motivational enhancement therapy
• 12-step facilitation
• Contingency management
• Pharmacological therapies
• Systems treatment
• L. Onken (2002). Personal Communication.
  National Institute on Drug Abuse.
• Principles of Drug Addiction Treatment A
  research-based guide (1999). National Institute
  on Drug Abuse

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Alcohol/Drug Treatment Core Components and
Comprehensive Services
Medical
Mental Health
Financial
Vocational
Housing Transportation
Educational
Child Care
Legal
Family
AIDS / HIV Risks
Etheridge, Hubbard, Anderson, Craddock, Flynn,
1997 (PAB)
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Cultural Approach

• Original Holistic Approach
• Psychopharmacology Approach
• The unconscious has always been there
• Group Therapy
• Network Therapy
• Recreational / Outdoors
• Traditional Interventions
• Indian is...

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What Is Integrative Medicine?
Wellness
Basic Science
CAM literacy
Patient Centered Care
Evidence Based Medicine
Cultural Sensitivity
Power Of the Mind
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Unified Services Plan

• Case management should address
• Mental health
• Education/vocation
• Leisure/social
• Parenting/family
• Housing
• Financial
• Daily living skills
• Physical health

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The Future

• 1. Predictable Funding
• 2. Long Term Planning
• 3. Improve Critical Mass of Health
• Care Systems
• 4. Tribal Coordinated Self
• Governance
• 5. Department of Indian Trust

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Mechanisms for Coordinating Care

• Routine sharing of patient information between
  providers with patient knowledge and consent
• Screening of patients for comorbid mental,
  substance-use, and general medical problems
• Evidence-based coordinationlinkage mechanisms

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Evidence-based coordinationlinkage mechanisms

• formal agreements among mental, substance-use,
  and primary health care providers
• case management of mental, substance-use, and
  primary health care
• co-location of mental, substance-use, and primary
  health care services
• delivery of mental, substance-use, and primary
  health care through clinically integrated
  practices of primary and M/SU care providers.

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Principles of Integrative Medicine

• It is better to prevent disease than to have to
  treat it later.
• Recognition of the interaction between body,
  mind, spirit, and environment.
• A desire to integrate the best of conventional
  and unconventional medicine.
• The belief that bodies respond uniquely, so
  treatment must be customized.
• A belief in the innate healing powers of the
  body.

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Contact us at 503-494-3703 E-mail Dale Walker,
MD onesky_at_ohsu.edu Or visit our
website www.oneskycenter.org