wounded spirits, ailing hearts: recent advances in

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


Lay-administered interview including core NVVRS measures and UM-CIDI, both conservatively modified for culturally rele-vant application

Southwest n = 316Northern Plains n = 305


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


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%



Percent Using Any Services (Biomedical or Traditional)Percent Using Any Services (Biomedical or Traditional)

0%

10%

20%

30%

40%

50%



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


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


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


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%.


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.


Our findings were comparable for men, but vastly different for women who reported equivalent trauma exposure to men.


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.


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.


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.


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.


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.


19.2%8.9%19.5%11.7%FemalesFemales MalesMales

Northern PlainsSouthwest

PTSD Prevalence Based on3 Worst Qualifying Traumas


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.


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.


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


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.


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.


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.


In preparation:

PTSD and asthma

PTSD and traumatic brain injury

PTSD and diabetes


Historical trauma, secondary traumatiza-tion, intergenerational grief

Challenges in conceptualizing, operation-alizing, measuring, and analyzing key constructs


Jervis LL, Klein SA, Beals J, Manson SM, et al. Historical consciousness among two American Indian tribes. American Behavioral Scientist, in press.


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


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.


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


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.


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.

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