How the US Mental Health System Makes Natives Sick and Suicidal
At a youth wellness conference at Yakama Nation I helped organize in 2001, an elder of the Kah-Milt-Pah honored us with her presence. For the first two days, she sat next to her daughter in the front row, one palm resting on a handmade cane, watching and listening as keynote speakers stepped up. I remember she became particularly focused when a youth invited to the stage to share his life challenges broke down mid-sentence.
At 4:30 p.m., near the end of the last day, she struggled to rise and then stood next to her chair. Members of the discussion panel fell silent while she was helped to the stage by her daughter. She then turned around to face the 700 or so mostly Native attendees and began speaking in her native dialect about the sacredness of children. A microphone was hurriedly brought over as her daughter stood beside her, carefully translating her words into English.
This translating was time-consuming, and as an organizer, I knew the event center closed at 5 p.m. Soon, a custodian approached me and whispered, “We need to shut down.”
We stood together for a moment listening to and watching her, dressed in her dark calico dress, a kerchief holding back her grey braids, leaning over her cane.
“Fine,” I said, “you tell her.”
He smiled and shook his head. She finished at about 7:30 p.m., and I don’t believe anyone left, not even that custodian.
Later on, I found out that she understood and spoke English well; she just chose not to speak it. Her insistence on using her native language told everyone present how she felt about the colonizing language of English, imposed in her lifetime by coercion and force. It may have become the common tongue of Indian Country, but she would not feel obliged to use it. Only her Native words could speak to the heart about “what has happened” to the children.
The intrusion of a new language upon a people can build bridges, tear them down, or serve an oppressive agenda. It can do all three at once. In the last 40 years, certain English words and phrases have become more acceptable to indigenous scholars, thought leaders, and elders for describing shared Native experiences. They include genocide, cultural destruction, colonization, forced assimilation, loss of language, boarding school, termination, historical trauma and more general terms, such as racism, poverty, life expectancy, and educational barriers. There are many more.
One might expect such words to be common within the mental health system in Indian Country. Yet the major funder and provider of Native mental health, the Indian Health Service (IHS), doesn’t seem to speak this language.
For example, the agency’s behavioral health manual mentions psychiatrist and psychiatric 23 times, therapy 18 times, pharmacotherapy, medication, drugs, and prescription 16 times, and the word treatment, a whopping 89 times. But it only uses the word violence once, and you won’t find a single mention of genocide, cultural destruction, colonization, historical trauma, etc.—nor even racism, poverty, life expectancy or educational barriers.
This federal agency doesn’t acknowledge the reality of oppression within the lives of Native people. Instead, it uses another powerful word, depression. For about a decade, IHS has set as one of its goals the detection of Native depression. This has been done by seeking to widen use of the Patient Health Questionnaire-9 (PHQ-9), which asks patients to describe to what degree they feel discouraged, downhearted, tired, low appetite, unable to sleep, slow-moving, easily distracted or as though life is no longer worth living.
The PHQ-9 was developed in the 1990s for drug behemoth Pfizer Corporation by prominent psychiatrist and contract researcher Robert Spitzer and several others. Although it owns the copyright, Pfizer offers the PHQ-9 for free use by primary health care providers. Why so generous? Perhaps because Pfizer is a top manufacturer of psychiatric medications, including its flagship antidepressant Zoloft® which earned the company as much as $2.9 billion annually before it went generic in 2006. Even with the discovery that the drug can increase the risk of birth defects, 41 million prescriptions for Zoloft® were filled in 2013.
The Pfizer PHQ-9’s lead developer, Dr. Spitzer, was the “task force leader” for the Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM III-R) when I started graduate training as a clinical psychologist in 1986. The DSM III-R created 110 new psychiatric labels, a number that had climbed by another 100 more by the time I started working at an IHS clinic in 2000.
Around that time, Pfizer, like many other big pharmaceutical corporations, was pouring millions of dollars into lavish marketing seminars disguised as “continuing education” on the uses of psychiatric medication for physicians and nurses with no mental health training.
I recall being asked if I was going to one of these seminars, held at the fanciest restaurant in a city north of the Yakama Nation Reservation. Although a government employee is technically not allowed to accept gifts of more than $20, this lavish (and free) meal seemed a grey area. After all, it was “educational.” I didn’t happen to drink alcohol, so I wasn’t interested. After this event, several primary care colleagues began touting their new expertise in mental health, and I was regularly advised that psychiatric medications were (obviously) the new “treatment of choice.”
Since those days, affixing the depression label to Native experience has become big business. IHS depends a great deal upon this activity—follow-up “medication management” encounters allow the agency to pull considerable extra revenue from Medicaid. One part of the federal government supplements funding for the other. That’s one reason it might be in the best interest of IHS to diagnose and treat depression, rather than acknowledge the emotional and behavioral difficulties resulting from chronic, intergenerational oppression.
The most recent U.S. Public Health Service practice guidelines, which IHS primary care providers are required to use, states that “depression is a medical illness,” and in a nod to Big Pharma suppliers like Pfizer, serotonin-correcting medications (SSRIs) like Zoloft® “are frequently recommended as first-line antidepressant treatment options.” This means IHS considers Native patients with a positive PHQ-9 screen to be mentally ill with depression. And in just the last four years, the Indian Health Service has spent over $1.1 billion to treat Mentally Ill Indians. In quiet ways, IHS admits to being obsessed on this point. For instance, in its National Behavioral Health Strategic Plan 2011-2015, IHS states an objective to “recognize the heavy influence of biomedical models” (it’s not certain what happens after recognition), but in its very next objective, notes a desire to “assist the Indian Health System to make needed prescribed psychotropic medications available to persons served.”
There are many things wrong with this model. For instance, the biomedical theory IHS is still promoting is obsolete. After more than 50 years of research, there’s no valid Western science to back up this theory of depression (or any other psychiatric disorder besides dementia and intoxication). There’s no chemical imbalance to correct. Even psychiatrist Ronald Pies, editor-in-chief emeritus of Psychiatric Times, admitted “the ‘chemical imbalance’ notion was always a kind of urban legend.”
Researchers, writers, and mental health professionals have sought to get word out about the deceptiveness of this false science for decades. In 2011, Marcia Angell, former editor of the New England Medical Journal, summarized the work of three such voices for the New York Review of Books. Angell reviewed The Emperor’s New Drugs by Harvard psychologist Irving Kirsch in which he concludes that there is no significant difference between the drugs and sugar pills for reducing depression. Angell also reviewed award-winning investigative journalist Robert Whitaker’s book, Anatomy of an Epidemic, in which he describes the pharmaceutical industry’s funding of “key opinion leaders” for promoting its medications and its profound influence on increasing the number of DSM “disorders” eligible for medicating. Dr. Angell closes with a review of Daniel Carlat’s Unhinged: The Trouble With Psychiatry. After Carlat thoroughly “follows the money” in pharmaceutical funding of psychiatry, he admits to nearly doubling his hourly income by seeing his patients for “psychopharmacology” instead of therapy.
IHS continues to apply the PHQ-9 in its stated belief that “early identification of depression will contribute to reducing incidence” of suicide, violence, etc. while allowing “providers to plan interventions and treatment to improve the mental health and well being of American Indians and Alaska Natives.”
Antidepressants do not reduce suicide. Much money has been spent on studies trying to support such an idea that either fail or are easily exposed for poor science and shoddy designs that result in retractions and back-pedaling. A 2010 study of sales of antidepressants in Norway, Finland, Sweden and Denmark from 1975 to 2006 found no relationship between suicide rates and the great popularity of psychiatric drugs.
In an astonishing twist, researchers working with the World Health Organization (WHO) concluded that building more mental health services is a major factor in increasing the suicide rate. This finding may feel implausible, but it’s been repeated several times across large studies. WHO first studied suicide in relation to mental health systems in 100 countries in 2004, and then did so again in 2010, concluding that:
“[S]uicide rates… were increased in countries with mental health legislation, there was a significant positive correlation between suicide rates, and the percentage of the total health budget spent on mental health; and… suicide rates… were higher in countries with greater provision of mental health services, including the number of psychiatric beds, psychiatrists and psychiatric nurses, and the availability of training in mental health for primary care professionals.”
In fact, authors of the 2010 study stated rather specifically that the suicide rate climbed alongside the increased “availability of training in mental health for primary care professionals.” This describes the very strategy IHS has been using to try to reduce suicide.
Mental health folks didn’t care for such findings and wanted to try again. A 2013 follow-up study by Anto Rajkumar and colleagues using similar WHO data gathered from 191 countries found, “Countries with better psychiatric services experience higher suicide rates.” It might be beside the point to mention that research repeatedly demonstrates physicians commit suicide at twice the rate of other people. After all, they have more legal access to drugs.
Despite what’s known about their significant limitations and scientific groundlessness, antidepressants are still valued by some people for creating “emotional numbness,” according to psychiatric researcher David Healy. Research undertaken at the University of Washington in 2004 suggested people will quit using antidepressants because of feeling numb while others continue for the same reason.
The side effect of antidepressants, however, in decreasing sexual energy (libido) is much stronger than this numbing effect—sexual disinterest or difficulty becoming aroused or achieving orgasm occurs in as many as 60 percent of consumers. Such a side effect can in itself increase anxiety, depressed mood and hopelessness. In this way, IHS has become complicit in reducing sexual interest while having a potentially negative impact on intimate relationships within the communities it serves. The agency has been spreading lies about faulty brains with “chemical imbalances” for years now and recasting reactions to oppressive social conditions and life challenges as a pathological illness to be numbed or sedated.
Dr. David Healy is better known for his research showing that antidepressant medication increases suicide and violence in certain people. When I mentioned his early work to IHS primary care colleagues, I met great skepticism. But Healy’s work has withstood the test of time, including repeated scrutiny by major scientific authorities worldwide, even by a reluctant FDA that dragged its heels before mandating a “black box warning” about suicide and violence potential. Over the years, I’ve thought about Dr. Healy’s work when incidents of mass violence have occurred at Red Lake, Tule River and Marysville.
A formal report on IHS internal “Suicide Surveillance” data issued by Great Lakes Inter-Tribal Epidemiology Center states the suicide rate for all U.S. adults currently hovers at 10 for every 100,000 people, while for the Native patients IHS tracked, the rate was 17 per 100,000. This rate varied widely across the regions IHS serves—in California it was 5.5, while in Alaska, 38.5. It’s important to note that IHS has experienced chronic difficulties in getting its providers to comply with entering all the suicides they encounter in their practices for this project. Yet there are crucial lessons to learn from what has been tallied.
Suicides for all U.S. youth in the age range of 15 to 24 nearly tripled from 1958 to 1982, but since 1999, this rate has remained stable at between 10 and 11 per 100,000. The IHS Suicide Surveillance data reveals the rate for Native youth to be climbing . Over 52 percent of suicides described in the Great Lakes report were by young Native people aged 10 to 24. Between 2005 and 2010, the average suicide rate for Native 14 to 24 year olds greatly exceeded even the overall Native rate. According to the Center for Disease Control, the Native youth and young adult suicide rate hit an all-time high in 2014 at 31 per 100,000. That’s triple the U.S. youth rate.
It’s not surprising that alcohol was involved in 82 percent of reported suicide attempts. It’s a shocker, however, that medication overdose was the primary method people used. Fifty-nine percent of Native people attempting suicide favored overdosing on meds—well beyond use of firearms, hanging, intentional car wrecks, or other means.
Nearly one in four of these suicidal medication overdoses used psychiatric medications. The majority of these medications originated through the Indian Health Service itself and included amphetamine and stimulants, tricyclic and other antidepressants, sedatives, benzodiazepines, and barbiturates. The Suicide Surveillance report doesn’t specify what “other prescription medications” make up an additional 22 percent of medication overdoses and may have also originated at IHS.
Despite what IHS may say, there’s no evidence to suggest that psychiatric medication reduces either suicide or what it prefers to call depression. However, there’s solid evidence the agency’s expansion of its biomedical model and the drugs it promotes may be increasing the Native youth suicide rate—these drugs are being favored as a means of taking one’s life.
What’s truly remarkable is that this is not the first time the mental health movement in Indian Country has helped to destroy Native people. Today’s making of a Mentally Ill Indian to “treat” is just a variation on an old idea, a fitting example of George Santayana’s overused adage: “Those who cannot remember the past are condemned to repeat it.” The Native mental health system has been a tool of cultural genocide for over 175 years—seven generations. Long before there was this Mentally Ill Indian to treat, this movement was busy creating and perpetuating the Crazy Indian, the Dumb Indian, and the Drunken Indian.
We need to expose what has been made invisible and forgotten. We need to revisit the displaced and poverty-stricken ancestors subjected to Indian Lunacy Determinations and sent away from their homes and families. We need to learn more about the Hiawatha Asylum for Insane Indians, where people were kept shackled until the cuffs of their chains meshed with their skin.
We need to open the skeleton’s closet through which mental health first entered the boarding schools, determined stilted curricula for generations of children, and used its methods to sterilize those it deemed inferior. We must make peace with the fabled Firewater Myth, a false tale of heightened susceptibility to alcoholism and substances that even Native people sometimes tell themselves.
There are forgotten heroes to know, ancestors of those currently trapped by the Native mental health system—a Lakota diagnosed with “horse-stealing mania,” a Cherokee laying claim to the land of Sweden, and a Mohawk, the first Indian psychologist, stepping up to challenge the white man’s labeling of his community’s children as feebleminded.
English will necessarily be the shared language of inquiry, but let’s use it to be accurate about these seven generations of harm.
Because it’s oppression, plain and simple.
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