American Indian and Alaska Native ProgramsAmerican Indian and Alaska Native ProgramsUniversity of Colorado Health Sciences CenterUniversity of Colorado Health Sciences Center
October 3, 2006October 3, 2006
Wounded Spirits, Ailing Hearts: Recent Wounded Spirits, Ailing Hearts: Recent Advances in Understanding Trauma and Its Advances in Understanding Trauma and Its
Consequences among American Indians Consequences among American Indians
Spero M. Manson, Ph.D.Spero M. Manson, Ph.D.Professor and HeadProfessor and Head
Posttraumatic Stress Posttraumatic Stress Disorder: DefinitionDisorder: Definition
Posttraumatic stress disorder (PTSD) is an anxiety disorder that a person may develop after experiencing or witnessing an extreme, overwhelming traumatic event during which s/he felt intense fear, helplessness, or horror.
Posttraumatic Stress Posttraumatic Stress Disorder: TraumaDisorder: Trauma
A trauma is an intensely stressful event during which a person suffers serious harm or the threat of serious harm or death or witnesses an event during which another person (or persons) is killed, seriously injured, or threatened.
Posttraumatic Stress Posttraumatic Stress Disorder: Trauma TypesDisorder: Trauma Types
Abuse: mental, physical, sexual, verbal (i.e., sexual and/or violent content)
Catastrophe: harmful and fatal accidents, natural disasters, terrorism
Violent attack: animal attack, assault, battery, domestic violence, rape
War, battle, and combat: death, explosion, gunfire
Posttraumatic Stress Posttraumatic Stress Disorder: PrevalenceDisorder: Prevalence
The literature reveals that traumatic events –the etiological stressor central to the diagnosis of PTSD -- are not random, vary in frequency across population subgroups, and are related to the conditional risk for this disorder.
Posttraumatic Stress Posttraumatic Stress Disorder: PrevalenceDisorder: Prevalence
Given the stressful social, physical environ-ments in which many American Indians live, and the high levels of trauma to which they are consequently exposed, PTSD is likely to be especially prevalent in this special population.
American Indian Vietnam American Indian Vietnam Veterans ProjectVeterans Project
Congressionally mandated replication of the National Vietnam Veterans Readjustment Study (Kulka et al, 1989)
Department of Veterans Affairs-sponsored, cross-sectional study of 621 American Indian Vietnam theater military veterans
American Indian Vietnam American Indian Vietnam Veterans Project: AimsVeterans Project: Aims
Ascertain prevalence of psychiatric dis-orders, readjustment problems, and risk as well as protective factors
Compare prevalence of psychiatric disorders to White, Black, Hispanic, Native Hawaiian, and Japanese counterparts
Describe nature and extent of service use
American Indian Vietnam American Indian Vietnam Veterans Project: DesignVeterans Project: Design
Two reservation-based, tribal communities: Southwest and Northern Plains
Representative samples of tribally enrolled, male, Vietnam theater military veterans, residing within or near (50 miles) of reservation boundaries
American Indian Vietnam American Indian Vietnam Veterans Project: DesignVeterans Project: Design
Lay-administered interview including core NVVRS measures and UM-CIDI, both conservatively modified for culturally rele-vant application
Southwest n = 316Northern Plains n = 305
American Indian Vietnam American Indian Vietnam Veterans Project: DesignVeterans Project: Design
Clinician-administered reinterview (SCID) of select subsample, inclusion based on MPTSD score
Southwest n = 118Northern Plains n = 100
Relevant PublicationsRelevant Publications
Beals J, Holmes T, Ashcraft M, FairbankJ, Friedman M, Jones M, Schlenger W, Shore J, Manson SM. A comparison of the prevalence of post-traumatic stress disorder across five racially and ethnically distinct samples of Vietnam theater veterans. Journal of Traumatic Stress, 2002; 15(2): 89-97.
American Indian Vietnam American Indian Vietnam Veterans ProjectVeterans Project
Representative samples of tribally enrolled, male, Vietnam theater military veterans, residing within or near (50 miles) of reservation boundaries
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
Southwest Northern Plains Hispanic Black White
LifetimeCurrent
Prevalenceof PTSD
American Indian Vietnam American Indian Vietnam Veterans Project: ResultsVeterans Project: Results
Point prevalence of PTSD (22.1-25.3%) greater than that of White Vietnam combat veterans (10%)
Lifetime prevalence of PTSD (45-57%) greater than that of all other combat veterans
Combat exposure most powerful predictor of PTSD
Relevant PublicationsRelevant Publications
Gurley D, Novins DK, Jones MC, Beals J, Shore JH, Manson SM. Comparative use of biomedical services and traditional healing options by American Indian veterans. Psychiatric Services, 2001; 52(1): 68-74.
Percent of Veterans Using Any Biomedical FacilitiesPercent of Veterans Using Any Biomedical Facilities
0%
10%
20%
30%
40%
50%
Help with ADM Problem Help with Physical Problem
Northern Plains Southwest
Percent of Veterans Using Traditional Healing OptionsPercent of Veterans Using Traditional Healing Options
0%
10%
20%
30%
40%
50%
Help with ADM Problem Help with Physical Problem
Northern Plains Southwest
Percent Using Any Services (Biomedical or Traditional)Percent Using Any Services (Biomedical or Traditional)
0%
10%
20%
30%
40%
50%
Help with ADM Problem Help with Physical Problem
Northern Plains Southwest
AIAI--SUPERPFPSUPERPFP
5 year, $7.2 million NIMH-sponsored study
Large community-based investigation of the epidemiology of major mental illness employing DSM-IIIR and DSM-IV criteria
Multi-method approach to estimating service utilization patterns and rates
AIAI--SUPERPFP: AimsSUPERPFP: Aims
To obtain prevalence rates of the major DSM disorders among 2 large tribes in U.S.
To examine the interrelationships among predisposing factors, stress, mediators and psychiatric morbidity
AIAI--SUPERPFP: AimsSUPERPFP: Aims
To obtain utilization rates for mental health services
To investigate hypotheses regarding the relationships among background charac-teristics, social network factors, and mental health service use
AIAI--SUPERPFP: DesignSUPERPFP: Design
Enrolled members of a Northern Plains and a Southwest tribe who were 15-54 years old, lived on or within 20 miles of their reservations
Stratified random sampling of tribal rolls by age (4 categories) and gender (2 categories)
Data collected between 1997 and 1999
AIAI--SUPERPFP: DesignSUPERPFP: Design
Found living on or near reservation39.5% Southwest46.5% Northern Plains
Located, deemed eligible and interviewed73.7% Southwest, n= 1,44676.8% Northern Plains, n= 1,640
AIAI--SUPERPFP: DesignSUPERPFP: Design
3-stage designCAI by layperson, employing UM-CIDI, extensive characterization of risk and protective factors as well as multi-method measurement of service useClinical reinterview (SCID) of 10% of sample, selected for meeting MDD, PTSD, and/or Alcohol DependenceEthnographic follow-up of key index cases to examine context of service use through life history and narrative analyses
Relevant PublicationsRelevant Publications
Manson SM, Beals J, Klein S, Croy C, et al. The social epidemiology of trauma in two American Indian reservation populations. American Journal of Public Health, 2005; 95(5): 851-859.
AIAI--SUPERPFP: ResultsSUPERPFP: Results
Lifetime exposure to at least one traumatic event ranged from 62.4% to 69.8%.
AIAI--SUPERPFP: ResultsSUPERPFP: Results
The NCS estimated the lifetime prevalence of exposure to any trauma for US men and women at 60.7% and 51.2%, respectively.
Australian National Mental Health Survey using methods akin to the NCS, reported remarkably similar lifetime rates: 64.6% for men and 49.5% for women.
AIAI--SUPERPFP: ResultsSUPERPFP: Results
Our findings were comparable for men, but vastly different for women who reported equivalent trauma exposure to men.
AIAI--SUPERPFP: ResultsSUPERPFP: Results
Inter-tribal differences also emerged, notably with respect to life-threatening accidents and natural disasters among NP males in contrast to SW tribal members.
Both AI populations witnessed traumatic events, experienced traumas to loved ones, and were victims of physical attacks more often then the US as a whole.
Relevant PublicationsRelevant Publications
Beals J, Manson SM, Whitesell NR, Spicer P, Novins DK, Mitchell CM, et al. Prevalence of DSM-IV disorders and attendant help-seeking in two American Indian reservation populations. Archives of General Psychiatry, 2005; 62: 99-108.
Relevant PublicationsRelevant Publications
Manson SM, Beals J, Klein S, Croy C, et al. The prevalence of Post-traumatic Stress Disorder in two American Indian reservation populations. Archives of General Psychiatry, in press.
AIAI--SUPERPFP: ResultsSUPERPFP: Results
Calculated on the basis of the single worst qualifying trauma, women (14%) were significantly more likely than men (7.1%) to be diagnosed with lifetime DSM-IV PTSD.
The Detroit Area Survey, based on the worst qualifying trauma, estimated the lifetime prevalence of DSM-IV PTSD at 9.5% for men and 17.7% for women.
AIAI--SUPERPFPSUPERPFP
The NCS -- which likewise employed the single worst trauma, but did not use the DSM-IV A criterion -- revealed a similar two-fold difference in DSM-III-R PTSD between males (5%) and females (10.4%).
This series of findings is in keeping with the earlier Epidemiological Catchment Area Survey which first documented the greater vulnerability of women (1.3%) than men (0.5%) to PTSD.
AIAI--SUPERPFP: ResultsSUPERPFP: Results
Previous studies demonstrate unequi-vocally that the risk of PTSD increases significantly in terms of increased exposure to traumatic events.
This association was robust here: reporting two or three traumatic events among the worst increased the lifetime prevalence of PTSD by two- and nearly three-fold, respectively.
AIAI--SUPERPFP: ResultsSUPERPFP: Results
19.2%8.9%19.5%11.7%FemalesFemales MalesMales
Northern PlainsSouthwest
PTSD Prevalence Based on3 Worst Qualifying Traumas
Relevant PublicationsRelevant Publications
Libby AM, Orton HD, Novins DK, Beals J, Manson SM, et al. Childhood physical and sexual abuse and subsequent depressive and anxiety disorders for American Indians. Psychological Medicine, 2005; 34:1-12.
Relevant PublicationsRelevant Publications
Libby AM, Orton HD, Novins DK, Spicer P, Buchwald D, Manson SM, et al. Childhood abuse and lifetime alcohol and drug disorders for American Indians. Journal of Studies on Alcohol, 2004; 65(1): 74-83.
Relevant PublicationsRelevant Publications
Libby AM, Orton HD, Novins DK, Beals J, Manson SM, et al. Childhood abuse and later parenting outcomes in two American Indian tribes. Child Abuse & Neglect, in press.
New Lines of InquiryNew Lines of Inquiry
Alterations in central and autonomic nervous system function and hormonal dysregulation are associated with trauma, which, in turn, increase risk for CVD.
It may be that high rates of trauma exposure contribute to the increasing prevalence of CVD among American Indian men and women: their leading cause of death.
General Mind-Body Mechanism Neurocardiac Model of Stress,
Depression, and Cardiovascular Function
Amygdala
Hippocampus
Locus Coeruleus
Pituitary
Hypothalamus
Cerebral Cortex
Adrenal
CRF
ACTHNE
extinction to fearthrough amygdalainhibition
Processing of stress
Fear response
cortisol
output tocardiovascularSystem, HR, BPEffects on HRV, Endothelium, etc
Anterior Cingulate/ PrefrontalCortex
StressStress
PET and Cyclotron
Highly sensitive, non-invasive method to detect myocardial dysfunctionMeasures flow reserve and ventricular functionUses superconducting magnet to measure concentrations of positron emitting radioisotopes in the body
Relevant PublicationsRelevant Publications
Sawchuk CN, Roy-Byrne P, Goldberg J, Manson SM, Buchwald D. The relation-ship between post-traumatic stress disorder and cardiovascular disease in an American Indian tribe. Psychological Medicine, 2005; 35: 1785-1794.
New Lines of InquiryNew Lines of Inquiry
Similarly, trauma is closely linked to pain; a relationship verified in our own work among Native people.
Pain affects help-seeking behavior, adherence to treatment recommenda-tions, and speed of surgical recovery, all often compromised in American Indians.
Relevant PublicationsRelevant Publications
Buchwald D, Goldberg J, Noonan C, Beals J, Manson SM, et al. Relationship between Posttraumatic Stress Disorder and pain in American Indians. Pain Medicine, 2005; 6(1): 72-9.
Relevant PublicationsRelevant Publications
In preparation:
PTSD and asthma
PTSD and traumatic brain injury
PTSD and diabetes
New Lines of InquiryNew Lines of Inquiry
Historical trauma, secondary traumatiza-tion, intergenerational grief
Challenges in conceptualizing, operation-alizing, measuring, and analyzing key constructs
Relevant PublicationsRelevant Publications
Jervis LL, Klein SA, Beals J, Manson SM, et al. Historical consciousness among two American Indian tribes. American Behavioral Scientist, in press.
New Lines of InquiryNew Lines of Inquiry
Real-time, interactive videoconferencing offers effective means – clinically and fiscally -- of bridging treatment gaps in geography and cultural.
Home-based telecommunication technolo-gies, promise more continuous, responsive care.
Center for Native American Center for Native American TeleHealthTeleHealth and and TeleEducationTeleEducation
CNATT organizes and focuses techno-logical resources for Native health to offer education, clinical care, research opportunities and training.
CNATT monitors the impact of these telecommunication services.
CNATT offers important models for using telehealth to improve services for under-served populations.
COMPONENTSCOMPONENTS
Clinical Programs (Telehealth)
Web-Based Services (www.uchsc.edu/ai)
Research
Technological Assistance (NTOTAP)
Seattle Indian Seattle Indian Health BoardHealth Board
Sioux San, Sioux San, Rapid CityRapid City
Rosebud Rosebud VeteransVeterans’’CenterCenter
SinteSinte GleskaGleskaUniversity, University, MissionMission
Providence Health Care
Anchorage, AK
University of University of Colorado Health Colorado Health Sciences CenterSciences Center
Veterans Administration Medical Center
AIANP Active Partnerships in Telehealth and AIANP Active Partnerships in Telehealth and TeleEducationTeleEducation
ChildrenChildren’’s s HospitalHospital
Riverton VA Riverton VA Outreach Outreach ClinicClinic
Pine Ridge Pine Ridge SchoolSchool
Crow IHSCrow IHS
Northern Northern Cheyenne IHSCheyenne IHS
Clinical ServicesClinical Services
PTSD assessment and treatment for Northern Plains American Indian veterans
Child/adolescent consultation to Sioux San IHS Hospital, Rapid City
Geriatric medicine and psychiatry consultation-liaison to Alaska Native nursing home
American Indian Veterans American Indian Veterans PTSD Clinics PTSD Clinics
Program NeedProgram Need
Approximately 60% rate of PTSD among Lakota military combat veterans, 3 times that of their White counterparts
Local stigma and poor confidentiality
Inadequate clinical expertise among IHS personnel
Program NeedProgram Need
VA facilities 180-300 miles distant and lack transportation
Distrust federal government
PTSD ServicesPTSD Services
Weekly clinics offering initial assessment, medication management, individual and group psychotherapy
4 active; 3 more to be implemented July 2006
Community liaison (TeleHealth Outreach Workers)
Different models and partnerships
Clinic StructureClinic Structure
Weekly 6 hour clinics
2 hour intake
2-3 hours for medication management and follow-up
1-one hour weekly therapy group
PTSD Clinic ModelsPTSD Clinic Models
IHS servicesTraditional Healers
Tribal Vet Center
Unique Programs
2 TOWS
2 Tribes
IHS (2 end-sites)
Crow/ Northern Cheyenne
2 TOWS1 TOWEnd-Site support
2 Tribes1 Tribe# of Tribes
End-site/ Partners
VA outreach clinic
Multiple system
Wind RiverRosebud
PTSD Service ProfilePTSD Service Profile
5.66.3Average Contacts per week
1060623437Total Number of Patient Contacts
766452314Total Number of Sessions
2.82.33.3Group Attendance
21816454# of Groups
527282245# of Follow-ups
763838# of Intakes
19212468Total Clinics Held
April 02 – April 05Oct 03 –April 05Dates
TotalRosebudWind River
Relevant PublicationsRelevant Publications
Shore JH, Manson SM. The American Indian Veteran and Post-traumatic Stress Disorder: A telehealth assessment and formulation. Culture, Medicine and Psychiatry, 2004; 28: 231-243.
Relevant PublicationsRelevant Publications
Shore JH, Manson SM. Telepsychiatriccare of American Indian veterans with post traumatic stress disorder: Bridging gaps in geography, organizations, and culture. Journal of Telemedicine and Telecare, 2004; 10(2): S64-S69
Relevant PublicationsRelevant Publications
Shore JH, Manson SM. Rural tele-psychiatry: A developmental model. Psychiatric Services, 2005; 56(8): 976-980.
Shore JH, Savin D, Novins DK, Manson SM. Cultural aspects of Telepsychiatry: Spanning distance and culture. Journal of Telemedicine and Telecare, in press.
Relevant PublicationsRelevant Publications
Savin D, Garry M, Novins DK. Telepsychiatry for treating rural American Indian youth. Journal of the American Academy of Child and Adolescent Psychiatry, 2006; 45(4): 484-488.