Depression and American Indian and Alaska Native Women
Depression is a common and highly treatable disorder affecting more than 17-20 million Americans annually. Untreated and under-treated depression is the leading cause of suicide in the United States. Once identified, depression can almost always be successfully treated. Unfortunately, there is limited information available about the prevalence of mental illness among American Indian and Alaska Native (AIAN) women. The two major studies conducted-The Epidemiologic Catchment Area Study and the National Comorbidity Survey-did not report data on AIANs. Prevalence among AIAN populations is problematic because they may be susceptible to unique factors that may affect their vulnerability to mental illness. Awareness and knowledge is the first step to prevention and successful treatment. This fact sheet can help.
What is depression?
Clinical depression is a serious medical illness that is much more than temporarily feeling sad or blue. It involves disturbances in mood, concentration, sleep, activity level, interests, appetite and social behavior. Although depression is highly treatable, it is frequently a life-long condition in which periods of wellness alternate with recurrences of illness. Suicide is a particular concern with untreated depression.
What are the symptoms of major depression?
The onset of the first episode of major depression may not be obvious if it is gradual or mild. The symptoms of major depression characteristically represent a significant change from how a person functioned before the illness and include:
- persistently sad or irritable mood;
- pronounced changes in sleep, appetite and energy;
- difficulty thinking, concentrating and remembering;
- physical slowing or agitation;
- lack of interest in or pleasure from activities that were once enjoyed;
- feelings of guilt, worthlessness, hopelessness and hopelessness;
- recurrent thoughts of death or suicide; and
- persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders and chronic pain.
Support through traditional culture may protect AIAN women from common mental disorders; AIAN women are more likely to be at a higher risk for mental illness because of adverse factors faced by their ethnic group.
What are the risk factors for American Indian and Alaskan Native women?
Available evidence suggests that mental illnesses impact approximately 20 percent of the total AIAN population. The overall mental health picture for AIANs is not fully documented because previous studies are restricted by small sample sizes, limited funding, racial misclassification and a focus on specific conditions. In the AIAN population, high lifetime risk rates of substance use disorders, anxiety disorders and low socioeconomic conditions combine to give context to the greater risk for the development of depression.
Many minority women experience depression and stress brought on by persistent racism, gender bias, violence, poverty, large family size and social disadvantages. Yet access to culturally relevant therapy is rare, access to mental health services is poor and the quality is poor. According to the 2001 Surgeon General's report, minority women with access to mental health services are less likely than Caucasian women to use them for reasons related to access to income and availability of health insurance, but also personal history and culture.
The report also found women of this group tend to view therapy as a sign of weakness. Among minority women, there is greater tendency to engage in other informal sources of help, such as prayer or support groups where women gather and talk with friends, hoping to gain what others often gain by having individual therapy. The main cause for not seeking outside treatment is because of a lack of trust.
Another reason minority women do not seek formal therapy is because of their respective cultures. There are other ways of regaining a sense of peace and well-being. Native American women and women of Alaskan descent often rely on traditional healers, who may work side by side with formal health providers in tribal mental health programs. AIAN women have access to some mental health care services through the American Indian Health Service on their reservations, though finding culturally competent services can be a challenge.
A final challenge is that there is little research done in this community. Research can be helpful to improve the quality of interventions and may inform cultural competence work as well. NIH and NIMH have begun to fund a few studies directly impacting Native Americans. For a list of these studies go to clinicaltrails.gov and search for the specific medical area or group you are interested in.
How is major depression treated?
Although major depression can be a devastating illness, it is highly treatable. Between 80-90 percent of persons diagnosed with major depression can be effectively treated and return to their usual daily activities and feelings. Many types of treatment are available, and the type chosen depends on the individual and the severity and patterns of his or her illness. There are three well-established types of treatment for depression: medications, psychotherapy and electroconvulsive therapy (ECT). For people who have a seasonal component to their depression, light therapy may be useful. Transcranial magnetic stimulation (TMS) may be helpful for depression that has not responded to one trial of an antidepressant. These treatments may be used alone or in combination. Additionally, peer education and support can promote recovery. Attention to lifestyle, including diet, exercise and smoking cessation, can result in better physical and mental health.
Medication. Research has shown that imbalances in neurotransmitters or chemicals in the brain, like serotonin, dopamine and norepinephrine can be improved with antidepressants. It often takes two-to-four weeks for antidepressants to start having an effect, and 6-12 weeks for antidepressants to take full effect.
Individuals and their families must be cautious during the early stages of medication treatment because normal energy levels and the ability to take action often return before mood improves. At this time-when decisions are easier to make, but depression is still severe-the risk of suicide may temporarily increase. A greater risk of self harm occurs in individuals taking antidepressants who are under 25-in 2004 the FDA put a black box warning on antidepressants noting increased risk of suicidal thoughts and feelings in the first months of treatment.
Psychotherapy. There are several types of psychotherapy that have been shown to be effective for depression including cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT). CBT concentrates on changing the negative attributional bias (seeing every cup as half-empty) associated with major depression. The focus in IPT is on a patient's relationships with peers and family members and the way they see themselves. Research has shown that mild to moderate depression can often be treated successfully with either of these therapies used alone. However, severe depression appears more likely to respond to a combination of psychotherapy and medication.
Traditional interventions like medications and psychotherapy can be done in concert with more traditional AIAN interventions.
Be informed and voice all your questions and concerns about your treatment to your health care provider. By building a strong relationship, you can work together for the most effective treatment for you.
Hope is never lost: Special considerations
Help is a two-way street. There are actions others are pursuing and those you can achieve too.
Published in the 2002 American Journal of Public Health, a Native American women's "stress and coping model" hypothesizes important individual- and community-level variables that may both heighten vulnerability to and protect against mental illness. This model, acts as an important guide for future research, draws attention to external and internalized attitudes and behaviors (i.e., racism, sexism, religious intolerance and homophobia) and the other forms of stratification that continue to affect AIAN families from within and without.
Be an advocate. Power in numbers for more mental health funding and to help establish pathways to specialized, culturally competent mental health services from primary and urgent care settings starts with you. Mental disorder prevention and treatment for AIAN women must take into account co-morbid conditions, specifically anxiety disorders with both substance abuse and major depression. Building and maintaining a strong support network can aid in the recovery and future prevention from clinical depression.
Reviewed by Ken Duckworth, M.D.