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University of Colorado Denver

Centers for American Indian and Alaska Native Health
 
 
 

NCAIANMHR

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
NIMH 

Dates of Funding
1995 - 2000

Principle 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  
 

AI-SUPERPFP


1) SPECIFIC AIMS/RESEARCH GOALS:

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.

 

2) RESEARCH DESIGN:

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.  Current efforts focus on manuscript preparation.
Click Here to View the SUPERPFP Training Manual in PDF Format

 

3)  AI-SUPERPFP INSTRUMENTATION

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).

AI-SUPERPFP LAY INTERVIEW 

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 an 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: http://aianp.uchsc.edu/ncaianmhr/dac.htm

 

4) PUBLICATIONS

As publications emanate from this dataset, they will be placed both on our publications web page (http://aianp.uchsc.edu/ncaianmhr/staffpub.htm) and below.

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: http://www.kluweronline.com/issn/0165-005X

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: http://www.ajph.org/content/vol93/issue10/index.shtml

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.

REFERENCES
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)
Click Here to View the SUPERPFP Training Manual in PDF Format

 

SECONDARY ANALYSIS PROJECTS



1) NIAAA Health Disparities (D. Novins, PI)

The use and abuse of alcohol among American Indians (AI) is a major public health concern. To date, the best information derives from adolescent populations. Compared to their non-AI counterparts, AI youth are more likely to use alcohol, more likely to become problem drinkers, more likely to meet diagnostic criteria for alcohol abuse and dependence, more likely to use alcohol in combination with drugs, and more likely to have both an alcohol use disorder and a psychiatric disorder. From service system data and vital statistics, we know that AIs generally are more likely to develop a variety of physical health conditions that are related to alcohol use and to die from alcohol-related causes. Research to date also suggests that rates of the alcohol-related health disparities (ARHDs) vary substantially across AI tribes. Despite the compelling nature of these disparities, surprisingly little is known regarding key aspects of their descriptive epidemiology. Indeed, the specific relationships of alcohol use, abuse, and dependence with comorbid drug, psychiatric, and physical health conditions among AI adults are largely unexplored. Yet findings from studies focused on the US general population suggest that these interrelationships are critical for understanding ARHDs.

The goal of the project is to analyze data from the recently completed American Indian Service Utilization, Psychiatric Epidemiology, and Risk/Protective Factors Project - the first large-scale, population-based study of AIs between the ages of 15 and 54. The specific aims for this project are as follows: 1) to describe disparities in the epidemiology of alcohol use across 2 AI population-based samples of 15-54 year-olds as well as between these 2 AI samples and samples representative of the US general population; 2) to conduct a parallel investigation regarding disparities in the epidemiology of alcohol abuse and dependence in these same samples; 3) to extend this line of inquiry to explore disparities in the epidemiology of drug use, abuse, and dependence comorbid with alcohol use, abuse and dependence; 4) to depict disparities in the epidemiology of non-substance use psychiatric disorders comorbid with alcohol use, abuse, and dependence; and 5) to investigate disparities in the epidemiology of physical health conditions comorbid with alcohol use, abuse, and dependence across these 2 AI tribes and between these tribes and the US general population.

 

2) NIAAA Services (J. Beals, PI)

American Indian (AI) populations are at special risk for alcohol problems. Mortality statistics indicate that the ratios of age-adjusted mortality rates for American Indians and Alaska Natives (AIANs) compared to the US "All Races" were 6.7 for alcoholism and 4.4 for chronic liver disease and cirrhosis. The high prevalence of alcohol problems significantly impacts the health services systems dedicated to AIAN populations. At the same time, investigators and commentators have raised significant concerns about the overall availability, accessibility, and acceptability of alcohol services available to this population. Meanwhile, the service delivery systems for AIANs are undergoing radical changes, with the tribes assuming greater responsibility for the purchasing and delivery of services.

Despite the high prevalence of alcohol problems and concerns about service for such difficulties, almost no empirically derived findings exist regarding the prevalence, patterns, and correlates of service utilization for alcohol use and related problems among AIANs. This proposal responds to Program Announcement (PA-98-037) with a plan for secondary quantitative analyses of the recently completed American Indian Service Utilization, Psychiatric Epidemiology  and Risk Protective Factors Project (AI-SUPERPFP) with a coordinated ethnographic primary data collection to address the following aims. Specific Aim 1: To depict the prevalence and patterns of alcohol-related service utilization within 2 AI populations.  Further, to portray the perceived availability, accessibility, and acceptability of these services. Specific Aim 2: To study the relationship between alcohol problem recognition and indicators of problematic use. Specific Aim 3: To develop models of service utilization for those with alcohol-related problems employing the Stress-Coping Model of Treatment Entry as a theoretical framework. Specific Aim 4: To expand this and other contemporary theoretical frameworks using integrated ethnographic and quantitative methods.

The proposed analyses of this first large-scale, community-based epidemiologic study of AIs will provide insights into the prevalence, patterns, and correlates of service utilization for alcohol use and related problems. Thus, it represents an opportunity to significantly advance our understanding of these issues among AIs. This multidisciplinary effort combines qualitative and quantitative methodologies to test and refine contemporary theoretical frameworks, promising to inform alcohol-related services research in other populations. Finally, the new understandings of service utilization for alcohol problems that promise to emerge from the proposed work will guide the development of newly emerging delivery models for this unique and important population.

 

3) NIDA Health Disparities (J. Beals, PI)

American Indian (AI) youth consistently report higher use of drugs than do most other populations in the United States. Further, AI youth are as likely, if not more so, to experience serious consequences from drug use.  However much remains unknown:  The extant literature is largely restricted to AI youth and, generally, little attention is paid to cultural differences.  A more comprehensive description of the negative consequences of drug use is needed.   Finally, incorporation of availability, access, and acceptability of health services into the understanding of health disparities is warranted.  This proposal responds to RFA DA-01-008 with a plan to make significant progress in depicting and understanding these disparities. Data from the recently completed American Indian Service Utilization, Psychiatric Epidemiology, and Risk/Protective Factors Project (AI-SUPERPFP) provide an opportunity to better understand the drug-related health disparities between 2 of the largest tribal populations. The specific aims are: 1) To develop models of the biopsychosocial factors important to understanding health disparities in drug use and its adverse consequences. 2) To depict the disparities in the use of drugs (including tobacco) between 2 AI populations and, futher, to investigate the degree to which ethnic differences in biopsychosocial factors may account for these disparities. 3) To dipict the disparities in the behavioral, social, medical, and mental health consequences of drug use and to investigate the degree to which differences in biopsychosocial factors and drug use explain these disparities. 4) To describe the disparities in utilization of health services and to investigate the relationships of health services, biopsychosocial factors, drug use, and adverse consequences. 5) To place these findings in a national context with the use of judicious comparisons to the National Comorbidity Survey (NCS) and the National Household Survey of Drug Abuse (NHSDA).

The proposed analyses of AI-SUPERPFP-the first large-scale, community-based alcohol, drug and mental health (ADM) epidemiologic study promises to provide insights into drug-related health disparities in a manner never before possible: first with a thorough investigation of such disparities across 2 of the largest, but culturally distinct, tribal groups; and later with targeted comparisons of these findings with national data from two comparable efforts with national samples. Furthermore, the Division of American Indian and Alaska Native Programs (DAIANP) provides a unique multidisciplinary environment (including staff from psychology, psychiatry, medicine, demography, anthropology, and public health) in which to conduct this work, thus promising to inform disparities research more generally.

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