Behavioral HealthTitle: Mental and Behavioral Health Issues in the U.S. Arctic
Summary of Activity
In recent years there has been significant improvement in the general health of the Northern resident populations, but significant health disparities remain, especially between native populations and populations on the whole. These health disparities, in part, account for a shorter life expectancy and increased mortality related to suicide and injuries in Arctic residents, compared to residents in more temperate climates. Although Alaskans face many of the same behavioral and mental health issues faced by communities in other states, the severity of many of the problems is often greater and there are special challenges posed by the remoteness of many communities. Some of the health problems of greatest concern include, but are not limited to, abusive alcohol use, high prevalence levels of Fetal Alcohol Spectrum Disorder, high incidence of diabetes, high blood pressure, elevated suicide prevalence, and high rates of unintentional injuries. As described in the Arctic Monitoring and Assessment Programme’s 2002 assessment human health in the Arctic, the younger age structure of the Alaskan population makes the State’s communities particularly vulnerable; however, it also provides an opportunity for establishing treatment programs that emphasize resiliency and preventive measures for behavioral and mental health promotion. Many agencies and organizations have recognized the need to invest in further research and improve current services. There is also increased attention to the issue of appropriate training of health care providers. Coordination of these efforts will provide a maximal benefit to the effected communities.
The indigenous populations and other residents of the high northern latitudes face a variety of mental and behavioral health and heath-related social issues. Although many of these issues parallel those faced by residents of other rural areas, and are similar to those faced by other Native American populations in the lower 48 states, the problems in Alaska are compounded by the challenging physical environment (including extreme cold and photoperiod changes) and limited availability of and access to health services in the region, and aggravated by the rapid social changes in the past few decades.
The Arctic Research and Policy Act, passed in 1984 (PL 98-373) and amended in 1990 (PL 101-609) was enacted to establish national policy, goals, and priorities for Arctic research. The act established the Arctic Research Commission and an Interagency Arctic Research Policy Committee (IARPC). The Commission publishes a report on goals and objectives every two years to help guide the activity of the IARPC and its member federal agencies. In its 2003 report, the commission outlined several research program recommendations. In addition to studies of the Arctic Region, Bering Sea Region, and research on resource evaluation and civil infrastructure, the commission called for studies on the health of Arctic residents.
The Commission’s recommendation for a program of research on Arctic health is divided into two parts: environmental health impacts (e.g., the effects of heavy metals) and major causes of morbidity and mortality. Although the environmental health effects of contaminants is a salient and important issue, the commission recognized that “infectious diseases, chronic diseases such as diabetes, cancer, heart attack and stroke as well as behavioral problems such as alcoholism, drug use and suicide are the most frequent causes of ill health and death in Arctic populations.” (US Arctic Research Commission, 2003, pg 14). The commission recommended that the IARPC begin planning an interagency program to coordinate and emphasize research on health concerns in the Arctic, with the National Institutes of Health as the focal point for the effort.
The eight nations with territory and populations in the Arctic are Canada, Denmark, Finland, Iceland, Norway, the Russian Federation, Sweden and the United States of America. In the United States, the health of our northern residents in Alaska depends on many factors. Essential infrastructures, such as housing, water, waste, energy, and transportation systems, are far more difficult to design and provide than in temperate regions, bringing a variety of health implications. Providing adequate health care is equally challenging.
The issue of mental health care for northern residents has been called a “neglected disparity.” Mental and behavioral health indicators reveal rates of obesity, smoking, alcohol use, and suicide in Alaska that are above national average (Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 2003). It has been estimated that over 60 percent of patients hospitalized at the state’s psychiatric institute have coexisting substance use symptoms (Brems et al., 2002).
Rates of suicide in Alaska are also among the highest in the nation (Centers for Disease Control and Prevention, National Center for Health Statistics, 2003). The state ranked 7th in death rates by suicide in 2001, at 15.9 deaths per 100,000 people. (The most deaths by suicide were in New Mexico with 20.2 per hundred thousand.) Within the state of Alaska, rates of suicide by Alaska Natives were much higher that rates for non-Native Alaskans. In the years 1997-1999 there were approximately 38 suicides per 100,000 for Alaska Natives compared to 21 per 100,000 for non Natives (Alaska Suicide Prevention Council, 2001).
It is estimated that 10 percent of Alaska’s children and youth have severe emotional disturbances and 6.2 percent of the adult population under age 55 have severe mental illness (Alaska Department of Health and Social Services, 2001). Access to care is limited by financing shortages of both the mental health systems and its clients, and by shortages in mental health personnel. Lack of services lead many to have contact with the criminal and legal systems. The Department of Corrections is the largest provider of mental health care in the state (Alaska Department of Health and Social Services, 2001). While Alaskans have a higher incidence of mental and behavioral health disorders, a 2000 study by the Substance abuse and Mental Health Services Administration places Alaska as the state with the third highest unmet need for substance abuse treatment (University of Alaska, 2004).
The international literature shows similar problems for northern residents more broadly. Investigations have been conducted on a variety of populations in other Arctic regions including Canada, Finland, Norway, and Russia and some studies indicate high rates of depression, anxiety, and alcohol abuse (Haggarty et al., 2000) and seasonal shifts in mood for adults (Haggag et al., 1990; Haggarty et al., 2002; Nayha, Vaisanen, and Hassi, 1994) as well as children (Sourander et al., 1999).
Although a great number of Northern Residents are at risk and experience mental and behavioral health complications there is also a portion of inhabitants who are resilient to these risk factors. It is unclear what make some individuals resilient to the same factors that put so many others at risk. With few exceptions, there is no current, compelling framework that guides development of a primary prevention approach for mental illness or addictive disorders. That is, it is not known what broad societal strategies should be pursued, whether related to housing, socioeconomic status, environmental and toxic influences, or crime and violence, to fundamentally lower incidence and prevalence of these disorders. In the behavioral and social sciences, and basic neuroscience fields, research has explored resilience to stress and regeneration, from tissue production of needed enzymes, to recovery of damaged heart tissue, to improved work function or education potential through the treatment of depression, to examining how individuals and families develop strengths across time. This line of research links concerns about illness, broadly defined, to new approaches that derive from a fundamental concern with advancing human development and quality of life. However, further research is needed to identify a more complete set of factors promoting resilience and recovery in individuals who live in the Northern communities.
The health research agenda for Northern residents is much broader than can be accommodated by a single funding agency. In Alaska, multiple Federal, State and Local agencies and in some cases in collaboration with international agencies, such as the Canadian Ministry of Health, are involved in promoting, preventing and treating mental and behavioral health disorders. Each one of these agencies helps comprise the critical piece of the infrastructure that supports and maintains the health of Alaskans’. For example, within the Federal government there at least five agencies active in this task, including the Indian Health Service, Centers for Disease Control, National Institutes of Health, National Science Foundation, and the Health Resources and Services Administration. In addition there are well over 20 non-federal agencies involved in behavioral health research or services in Alaska. Therefore, it was concluded in the 2004 University of Alaska; Health Research in Alaska report that in order to respond to the behavioral health needs and maximize the current and future programs in Alaska, “will require a coordinated effort amount the various agencies and organization currently providing services, conducting research or provide administrated services and funding organization and the state legislature.”
This study would examine the science base, gaps in knowledge, and strategies for the prevention and treatment of mental and behavioral health problems faced by populations in Arctic regions, with a focus on Alaska. Specifically, the committee would:
- Summarize the scope and nature of mental and behavioral health problems among residents of Arctic regions, with special emphasis on Alaska and Alaska Natives.
- Assess the infrastructure for research into the mental and behavioral health issues in Alaska to determine if current mechanisms and resources are appropriate to facilitate progress in the field. This should include analysis of which federal agencies are funding research programs and the mechanisms used.
- Describe factors that contribute to promoting resilience and recovery in Northern residents and provide recommendations for strategies that will increase resilience in the affected populations and reduce health disparities.
- Describe and assess the infrastructure for prevention and treatment of mental and behavioral health in Alaska; including federal, state and community based programs. This should include examination of collaborative efforts and discussion of ways to improve coordination between the multiple public and private agencies involved in promoting improved mental and behavioral health.
- Identify steps that could be taken in the short- , medium-, and long-term to improve the mental and behavioral health of northern US residents, including research needed to understand the impact of Arctic climates and rapid social change on mental and behavioral health, improvements in community infrastructure directly related to health, changes in prevention and treatment programs, and mechanisms to improve training for mental and behavioral health care services.
The IOM and NRC proposes to assemble a study committee of 12 to 14 experts knowledgeable in the fields of mental and behavioral health, suicidology, community based health, Alaska Native culture, sociology, academic / medical administration, health promotion and prevention, epidemiology and biostatistics, and health policy. Committee nominations will be solicited from the Academies membership, relevant organizations and associations, federal agencies, and other experts and stakeholders. The committee will meet over an 18-month period in order to assess the scope and nature of mental and behavioral health problems among residents of Alaska and Arctic regions, and make recommendations improve the mental and behavioral health of northern US residents through research, education and training, and practice.
The committee will hold five meetings throughout the course of the study. The first full committee meeting will be organizational and will include the required bias and conflict of interest discussion. Each of the next two meetings will be held in conjunction with a workshop; each workshop will be dedicated to data gathering and identification of current knowledge and information gaps. The specific topics for addressing in the workshops will be determined at the first meeting of the committee. The final two meetings will be devoted to formulating the recommendations, writing, and reviewing the report.
As part of the study process, the committee will: a) critically review published literature, b) convene public workshops at which leading mental and behavioral health professionals and scientists will summarize current knowledge and identify critical questions, and c) interview leaders of community, state and federal programs regarding infrastructure needs required for improved research, education and training, and practice. The committee also will commission international leaders in Arctic mental and behavioral health to supply in-depth analyses on specific aspects of the study charge. The committee will produce a report that will be published, publicly released, and widely disseminated to stakeholders (e.g., Congress, NIH, research advocacy organizations, professional and scientific organizations).
- Alaska Department of Health and Social Services (2001). Healthy Alaskans 2010, Volume 1: Targets and Strategies for Improved Health. Accessed 1/6/2004 at http://health.hss.state.ak.us/dph/targets/ha2010/volume_1.htm
- Alaska Suicide Prevention Council. (2001). Alaska Statistics: Alaska Suicide Rates by Race. Accessed 1/6/2004 at http://health.hss.state.ak.us/suicideprevention/AlaskaStatistics/AKSRbyrace.htm.
- Allen, J., Levintova, M. & Mohatt, G.V. (2011). Suicide and alcohol related disorders in the U.S. Arctic: boosting research to address a primary determinant of circumpolar health disparities. International Journal of Circumpolar Health, 70, 473-487.
- Arctic Monitoring and Assessment Programme. (2003). AMAP Assessment 2002: Human Health in the Arctic Olso, Norway. xiv + 137 pp.
- Brems C, Johnson ME, Wells RS, Burns R, Kletti N. (2002). Rates and sequelae of the coexistence of substance use and other psychiatric disorders. International Journal of Circumpolar Health, 61(3), 224-44.
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion (2003). Trends Data. Behavioral Risk Factor Surveillance System. Accessed 1/5/2004 at http://apps.nccd.cdc.gov/brfss/Trends/TrendData.asp?state=US&qkey=10110&state_c=AK&grouping=1.
- Centers for Disease Control and Prevention, National Center for Health Statistics (2003). Deaths, Age-adjusted Death Rates, and Comparisons by State for Selected Leading Causes of Death. Centers for Disease Control and Prevention. National Center for Health Statistics. Accessed 1/6/2004 at http://www.cdc.gov/nchs/releases/03facts/morbititytables.htm.
- Haggag A, Eklund B, Linaker O, Goetestam KG. (1990). Seasonal mood variation: An epidemiological study in northern Norway. Acta Psychiatrica Scandinavica, 81(2), 141-145.
- Haggarty JM, Cernovsky A, Husni M, Minor K, Kermeen P, Merskey H. (2002). Seasonal affective disorder in an Arctic community. Acta Psychiatrica Scandinavica, 105(5), 378-384.
- Haggarty J, Cernovsky Z, Kermeen P, Mersky H. (2000). Psychiatric Disorders in an Arctic community. Canadian Journal of Psychiatry, 45(4), 357-362.
- Levintova, M., W.I. Zapol and E. Engmann, 2010. Behavioral and Mental Health Research in the Arctic: Strategy Setting Meeting. Oulu: Circumpolar Health Supplements, (5).
- Nayha S, Vaisanen E, Hassi J. (1994). Season and mental illness in an Arctic area of northern Finland. Acta Psychiatrica Scandinavica, Supplementum, 377, 46-49.
- Sourander A, Koskelainen M, Helenius H. (1999). Mood, latitude, and seasonality among adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 38(10), 1271-1276.
- United States Arctic Research Commission (2003). Report on Goals and Objects for Arctic Research. Accessed 12/26/03 at http://www.arctic.gov/files/GOALS_03.pdf.
- University of Alaska. (2004). Health Research in Alaska: A Report in Response to SJR 44. Accessed 8/27/04 at http://www.alaska.edu/health/downloads/HealthPlanforAlaska.pdf
Warren Zapol MD
US Arctic Research Commission
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Arlington, Virginia 22203
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