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American Indian Services Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project

Project Title
American Indian Services Utilization, Psychiatric Epidemiology, Risk and Protective Factors Projects (AI-SUPERPFP)

Funding Source

Dates of Funding
1995 - 2000

Principal Investigators
Spero Manson, Ph.D., Jan Beals, Ph.D. 

Center Staff Involved
Jan Beals, Ph.D.; Cecelia Big Crow; Dedra Buchwald, M. D.; Buck Chambers; Michelle Christensen, Ph.D.; Denise Dillard, Ph.D.; Karen Dubray; Paula Espinoza, Ph.D.; Candace Fleming, Ph.D.; Ann Wilson Frederick; Joe Gone; Diana Gurley, Ph.D.; Lori Jervis, Ph.D.; Shirlene Jim; Carol Kaufman, Ph.D.; Ellen Keane; Suzell Klein; Denise Lee; Spero Manson, Ph.D.; Monica McNulty; Denise Middlebrook, Ph.D.; Christina Mitchell, Ph.D.; Laurie Moore; Tilda Nez; Ilena Norton, Ph.D.; Douglas Novins, M. D.; Theresa O'Nell, Ph.D.; Heather (Orton) Anderson; Carlette Randall; Angela Sam; James Shore, M. D.; Sylvia Simpson; Paul Spicer, Ph.D.; and Lorette Yazzie  



1.To obtain prevalence rates of the major DSM disorders among the Southwest and Northern Plains, including culture-specific syndromes;

2. To obtain utilization rates for mental health services including those provided by the Indian Health Service, other biomedical service providers, and by traditional medicine men and healers;

3. To examine interrelationships among predisposing factors, stress, mediators and psychiatric morbidity;

4. To compare the results of Specific Aims 1-3 with similar data obtained in other studies; and

5. To obtain ethnographic data necessary to culturally contextualize the results of the previous aims.



The AI-SUPERPFP was an NIMH-sponsored, large-scale, multi-stage, cross-sectional study of the prevalence of DSM-IIIR/–IV disorders and help-seeking behavior among 2 of the larger tribes in the US. Patterned after the NCS, this effort randomly sampled 3,084 individuals 15-54 years of age from tribal rolls.   During the 1st stage, tribal members trained in reseach methods interviewed these participants about their sociodemographic background, personal and social resources, traumatic experiences, attitudes toward mental illness, symptoms, alcohol, drug and mental disorders, and service utilization, both biomedical and cultural options. Considerable effort was expended to inform the content validity of existing measures as well as to operationalize culturally specific mediators such as spirituality and intergenerational trauma. Moreover, three distinct approaches to assessing service utilization (e.g., disorder-, symptom-, and sector-based) were incorporated into the protocol. During the 2nd stage, a clinician administered the SCID to participants meeting criteria for MDD, PTSD, or Alcohol Dependence as well as a sample of those without these diagnoses. Based on findings from the lay interview and SCID, a team of clinicians and ethnographers selected individuals to participate in the 3rd stage through life history and critical incident interviews, to characterize the context of the illness experience. Data collection was completed in 2000. 


The primary objective of the American Indian Services Utilization and Psychiatric Epidemiology Risk and Protective Factors Project (AI-SUPERPFP) was to estimate the prevalence of psychiatric disorders (lifetime and current) and service utilization among two American Indian reservation populations that were aged 15-54 at the time the sampling frame was created. 

There were 3 successive data collection components: the lay interview (N=3,084), the clinical reinterview (N=335), and the ethnographic interviews (N=90).


The full interview protocol (this PDF file is 1,766KB) is available:
Click Here to View the SUPERPFP Interview in PDF Format

We are providing this as a service to researchers and community members who are interested in the specific questions asked in this project. The data collection was computer-assisted: thus, the attached instrument is not highly formatted. Additionally, readers are cautioned that because of our commitment to community confidentiality, all references to specific tribes and culture-specific ceremonies and traditional healing ceremonies have been masked. Finally, users are reminded that some of the instruments used in AI-SUPERPFP are of a proprietary nature (the SF-36 is the best example of this) and should not be used without permission of the original authors.

The AI-SUPERPFP lay interview was a comprehensive interview that included not only assessments of psychiatric disorder but also an extensive health services section. Other health status assessments were included (e.g., chronic health problems, functional status (SF-36),1, 2 preventive health care, use of tobacco). Risk factors included life events, recent events, chronic strains, and traumas. Protective factors assessed included ethnic identity,3 social support, coping,4 mastery,5 and self-esteem.6 In addition to the diagnostic assessments, scalar measures of distress were included both established measures7 and local idioms of distress.

The psychiatric diagnoses are based on either DSM-III-R8 or DSM-IV.9 The diagnostic interview used to generate these diagnoses is the modified version of the Composite International Diagnostic Interview (WHO-CIDI; Version 1)10 used in the National Comorbidity Study (NCS).11  The AI-SUPERPFP instrument preceded the release of the WHO CIDI 2.1 designed to assess DSM-IV. However, we independently added the items necessary to assess DSM-IV.

This instrument was thoroughly reviewed for cultural appropriateness for these American Indian communities in a previous study of Vietnam veterans—the American Indian Vietnam Veterans Project (AIVVP).12 In order to ensure comparability to NCS, few changes were made to the item wording. Although not included in these analyses, culturally relevant items were added to the text to measure local idioms of distress. 

The following diagnoses were assessed using the WHO-CIDI: panic disorder, generalized anxiety disorder, major depressive episode, dysthymic disorder, alcohol abuse, alcohol dependence, drug abuse, drug dependence. Respondent burden was a concern, so several NCS-CIDI disorders were excluded: social phobia, agoraphobia, simple phobia, mania, and nonaffective psychosis. Although phobias have a high prevalence, their service impact is relatively minimal. Mania and nonaffective psychoses were excluded because of low specificity reported by other researchers for these diagnoses11, 13, 14 as well as serious concerns about the cultural validity of certain items in these modules.

We expected trauma—and especially cumulative trauma—and the consequences of such events to be important in these populations. Thus, the NCS post-traumatic stress disorder (PTSD) module was not used because it allowed assessments of Criteria B, C, and D for only one worst event. Instead the AIVVP-PTSD module was used. Following the format of the WHO-CIDI, this module allowed for the assessment of PTSD for up to three traumatic events and had shown reasonable concordance with clinical measures in that previous effort.

Lifetime and 12-month diagnoses for both DSM III-R and DSM-IV were calculated for each disorder. The DSM-III-R diagnoses followed the logic of the NCS algorithms while the DSM-IV diagnoses were based on the WHO-CIDI 2.1 algorithms. 

If interested in using these data please view our Data Access Committee page at:​   ​



LeMaster, P.L., Beals, J., Novins, D.K., Manson, S.M., & the AI-SUPERPFP Team. (2004). The prevalence of suicidal behaviors among Northern Plains American Indians. Suicide and Life-Threatening Behavior, 34(3), 242-254.

Beals, J., Manson, S. M., Mitchell, C. M., Spicer, P., & the AI SUPERPFP Team. (2003). Cultural Specificity and Comparison in Psychiatric Epidemiology: Walking the Tightrope in American Indian Research. Culture, Medicine and Psychiatry, 27, 259-289.  Available at:

Beals, J.,Spicer, P., Mitchell, C. M., Novins, D. K., Manson, S. M., & the AI-SUPERPFP Team. (2003). Racial Disparities in Alcohol Use: Comparison of 2 American Indian Reservation Populations with National Data. American Journal of Public Health, 93(10), 1683-1685.  Available at:

Garroutte, E. M., Goldberg, J., Beals, J., Herrell, R., Manson, S. M., & the AI-SUPERPFP Team. (2003).  Spirituality and attempted suicide among American Indians.  Social Science and Medicine, 56, 1571-1579.
Jervis, L. L., Spicer, P., & Manson, S. M. (2003). Boredom, "trouble," and the realities of postcolonial reservation life. Ethos: Journal of the Society for Psychological Anthropology, 31(1), 38-58.

Mitchell, C. M., Beals, J., Novins, D. K., Spicer, P.,  & The AI-SUPERPFP Team.  (2003).  Drug use among two American Indian populations: Prevalence of lifetime use and DSM-IV substance use disorders.  Drug and Alcohol Dependence, 69, 29-41.

Spicer, P., Beals, J., Croy, C. D., Mitchell, C. M., Novins, D. K., Moore, L., Manson, S. M., & The AI-SUPERPFP Team. (2003). The prevalence of DSM-III-R alcohol dependence in two American Indian populations.. Alcoholism: Clinical and Experimental Research, 27(11), 1785-1797. Available here.

1. Ware JE. SF-36 Health Survey: Manual and Interpretation Guide. Boston, MA: The Health Institute, New England Medical Center; 1993.

2. Ware JE. SF-36 Physical and Mental Health Summary Scales: A User's Manual. Boston, MA: The Health Institute, New England Medical Center; 1994.

3. Oetting ER. Orthogonal cultural identification: Theroretical links between cultural identification and substance use. In: De La Rosa MR, Adrados JLR, editors. Drug abuse among minority youth: Advances in research and methodology. Rockville, MD: National Institute on Drug Abuse; 1993. p. 32-56.

4. Ayers TS. A dispositional and situational assessment of children's coping: Testing alternative theoretical models [Tempe, AZ: Arizona State University; 1991.

5. Wheaton B. Personal resources and mental health: Can there be too much of a good thing?  Research in Community & Mental Health 1985;5:139-84.

6. Rosenberg M. Society and the adolescent self-image. Princeton, N.J.: Princeton University Press; 1965.

7. Liang J. Dimensions of the life satisfaction index A: A structural formulation. Journal of Gerontology 1984;5:613-22.

8. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Third edition, revised (DSM-III-R). Washington, DC: American Psychiatric Association; 1987.

9. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fourth edition (DSM-IV). Washington, DC: American Psychiatric Association; 1994.

10. World Health Organization. Composite International Diagnostic Interview (CIDI), Version 1.0. Geneva, Switzerland: Work Health Organization; 1990.

11. Kessler RC, McGonagle KA, Zhao S, Nelson C, B., Hughes M, Eshlemann S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry 1994;51:8-19.

12. Beals J, Manson SM, Shore JH, Friedman M, Ashcraft M, Fairbank J, & Schlenger W.  The prevalence of posttraumatic stress disorder among American Indain Vietnam Veterans: Disparities and Context.  Journal of Traumatic Stress, 15(2), 89-97.

13. Anthony JC, Folstein M, Romanski AJ, Von Korff MR, Nestadt GR, Chahal R, et al. Comparison of the lay Diagnostic Interview Schedule and a standardized psychiatric diagnosis. Archives of General Psychiatry 1985;42:667-75.

14. Helzer JE, Robins LN, McEvoy LT, Spitznagel EL, Stolztman RK, Farmer A, et al. A comparison of clinical and Diagnostic Interview Schedule diagnoses. Archives of General Psychiatry 1985;42:657-66.

Click Here to View the SUPERPFP Interview in PDF Format
(this PDF file is 1,766KB)


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