Mental Health Deserts for American Indians and Alaska Natives

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Q&A

Recent research from GoodRx finds that over 113,000 American Indians and Alaska Natives (AI/AN) live in a county that lacks an adequate amount of mental health providers, with some having fewer than 1 mental health provider available for every 30,000 people.¹ We sat down with Tori Marsh, MPH, Director of GoodRx Research to discuss the new findings.

PT: AI/AN individuals have worse health outcomes than other ethnic and racial groups in the US. What should clinicians do to best serve this population?

Marsh: Now more than ever, it is crucial for clinicians to help achieve health equity by reducing long-standing socioeconomic and cultural barriers in order to provide comprehensive, effective, and culturally competent care to AI/AN individuals. Clinicians can take some of the following steps to best serve the AI/AN community, including:

• Incorporating AI/AN traditions and culture in the program design, settings, and staff development
• Incorporating routine mental health screening into practice
• Increasing the frequency of outpatient visits or communications
• Involving a patient’s support system—whether that is a friend or family members—and sharing resources with all parties involved in a patient’s care plan
• Learning more about and becoming more familiar with AI/AN specific mental health care intervention models
• Advocating for increased AI/AN mental health care within your organization

PT: Can you speak more to the influence of generational trauma?

Marsh: Generational trauma is the transmission of genes, behaviors, and experiences—such as colonialism, genocide, and forced relocation—that cause negative physical, mental, and/or emotional harm and are passed down from one generation to the next.² Those affected by generational trauma can experience long-term illnesses like heart disease, diabetes, substance use disorders, posttraumatic stress disorder (PTSD), and anxiety to name a few.^3-5 For AI/AN, generational and historical trauma is believed to be a root cause of substance use and poor mental health.⁶

The effects of generational trauma continue to impact the AI/AN community today. For example, a 2016 study found that 70% of AI/AN men and 63% of AI/AN women will meet the criteria for at least one mental health condition over the course of their life. This number is significantly lower in non-white Hispanic individuals, where 62% and 53% of men and women, respectively, will meet the criteria.⁷

Generational trauma does not completely go away and is an ongoing recovery process, but techniques like cognitive behavioral therapy and family therapy can help.^8,9 However, if traumatic patterns are not addressed, they will only continue to repeat and compound for future generations.

PT: According to the new research, mental health access in the central US and in Alaska seems to be particularly difficult. Do you think telehealth initiatives could be utilized to help these mental health deserts? How does poor internet access affect this possibility?

Marsh: Increasing access to telehealth is just one of many public health strategies that could help address mental health disparities the AI/AN community faces and provide timely care in rural areas. It could also reduce health care costs and patient burdens like traveling long distances to onsite care facilities, taking time off of work, or child care.¹⁰

But poor internet access could limit any efforts to provide mental health care via telehealth. Broadband internet is typically necessary for video or online telehealth calls, and broadband internet is not always accessible to those living in rural areas. Some mental healthcare providers have even switched to providing their services completely online. Our research determined that the vast majority of counties in which 50% or more of residents were AI/AN struggled with broadband access.¹ In fact, 94% of these counties with high populations of AI/AN residents had broadband access below the national average. Another GoodRx analysis published in JAMA Network Open, in collaboration with Harvard Medical School, complements this finding and found a significant association between health care deserts, lower median household income, and limited internet access.¹¹

PT: AI/AN individuals can receive care for free through the Indian Health Service (IHS); however, the IHS is severely underfunded. Is there anything clinicians can do to support this institution?

Marsh: While the IHS provides needed care in tribal areas, it is indeed an underfunded program. For example, California has America’s largest Native American population, but it has not received millions of dollars of IHS funding that was promised over four decades ago. Additionally, a 2018 study by the US Government Accountability Office found that 25% of IHS positions are not filled.¹²

Although most IHS clinics and hospitals provide services at no cost to tribe members and are located on reservations, 87% of those who identify as AI/AN live outside of tribal areas.¹³ Individuals living outside of tribal areas, therefore, may have to depend on services based on eligibility or rely on programs like Medicaid, Medicare, or private insurance. This means it is not always feasible for all AI/AN individuals to find accessible, affordable, high-quality, or culturally competent mental health care that meets their needs.

Improving care for AI/AN individuals via the IHS will most likely require policy and institutional change as well as increased funding.¹⁴ However, clinicians can help improve AI/AN mental health by becoming more knowledgeable about culturally competent interventions, implementing and increasing mental health screening efforts, and collaborating with key community stakeholders to improve the standard of care.

PT: Do you have any recommendations for connecting AI/AN individuals to mental health resources?

Marsh: Providing culturally competent care is critical in meeting the mental health needs of the AI/AN community as they have a unique perspective of mental health treatment compared to other racial/ethnic communities across America. In addition to the IHS, clinicians can connect AI/AN individuals to other mental health resources like Native Hope, One Sky Center, and the StrongHearts Native Helpline.

PT: Are there any groups or organizations who you believe are adequately addressing this problem? How can others emulate?

Marsh:The Blackfeet tribe in Montana provides solutions, like their crisis line created during the COVID-19 pandemic, that allow tribal members to have open, honest conversations about their mental health and connect them to resources.¹⁵

Other groups and organizations can emulate the work of the Blackfeet tribe by providing customized mental health interventions that are developed by and for communities they intend to serve. It is important for groups or organizations to consider the following when implementing mental health solutions:

• Efforts should be informed by experiences based on race, ethnicity, religion, and other factors pertaining to identity
• Tailored information, programming, and resources
• Diverse representation of mental health care providers and community stakeholders as well as facilitating open and ongoing dialogues about programmatic feedback between both parties

Ms Marsh is Director of GoodRx Research.

References

1. Chase L, Cisneros T. More than 100,000 American Indians and Alaska Natives struggle to get mental health care. GoodRx. November 23, 2022. Accessed January 10, 2023. https://www.goodrx.com/healthcare-access/research/american-indian-alaska-native-mental-health-deserts

2. Inter-generational trauma: 6 ways it affects families. Duke Office for Institutional Equity. Accessed January 10, 2023. https://oie.duke.edu/inter-generational-trauma-6-ways-it-affects-families

3. Vergnaud S, Armitage M. Heart disease: your GoodRx guide. GoodRx. September 13, 2021. Accessed January 10, 2023. https://www.goodrx.com/health-topic/heart

4. Guarnotta E, Pourang A. Substance use disorder: your GoodRx guide. GoodRx. August 16, 2021. Accessed January 10, 2023. https://www.goodrx.com/conditions/substance-use-disorder

5. Palmer C, Gomez IB. Post-traumatic stress disorder (PTSD): your GoodRx guide. GoodRx. July 16, 2021. Accessed January 10, 2023. https://www.goodrx.com/conditions/ptsd

6. Behavioral health services for American Indians and Alaska Natives: for behavioral health service providers, administrators, and supervisors. Substance Abuse and Mental Health Services Administration. Accessed January 10, 2023. https://store.samhsa.gov/sites/default/files/d7/priv/tip_61_aian_full_document_020419_0.pdf

7. Yellow Horse Brave Heart M, Lewis-Fernández R, Beals J, et al. Psychiatric disorders and mental health treatment in American Indians and Alaska Natives: results of the National Epidemiologic Survey on Alcohol and Related Conditions. Soc Psychiatry Psychiatr Epidemiol. 2016; 51(7):1033-1046.

8. Kavanaugh S, Bapat M. All you need to know about cognitive behavioral therapy (CBT). GoodRx. March 1, 2022. Accessed January 10, 2023. https://www.goodrx.com/well-being/healthy-mind/cognitive-behavioral-therapy

9. Rousseau D. Breaking the cycle – intergenerational trauma. April 28, 2019. Accessed January 10, 2023. https://sites.bu.edu/daniellerousseau/2019/04/28/breaking-the-cycle-intergenerational-trauma/

10. Telehealth for the treatment of serious mental illness and substance use disorders. Substance Abuse and Mental Health Services Administration. 2021. Accessed January 10, 2023. https://store.samhsa.gov/sites/default/files/pep21-06-02-001.pdf

11. Loccoh EC, Nguyen A, Kim G, et al. Geospatial analysis of access to health care and internet services in the US. JAMA Netw Open. 2022;5(11):e2243792.

12. Agency faces ongoing challenges filling provider vacancies. Indian Health Service, Government Accountability Office. 2018. Accessed January 10, 2023. https://www.gao.gov/products/gao-18-580

13. American Indians and Alaskan Natives in the United States. United States Census Bureau. Accessed January 10, 2023. https://www2.census.gov/geo/maps/DC2020/AIANWall2020/2020_AIAN_US.pdf

14. Lofthouse J. Improving accountability and performance in the Indian Health Service. Mercatus Center. January 31, 2022. Accessed January 10, 2023. https://www.mercatus.org/research/policy-briefs/improving-accountability-and-performance-indian-health-service 

15. Tribal/urban tour report. Kauffman & Associates Incorporated, Montana Crisis Recovery. 2021. Accessed January 10, 2023. https://dphhs.mt.gov/assets/amdd/montanacrisisrecovery/TribalTourReport.pdf