2 inuit mental health status

Inuit Mental Health:!

Current Indicators Allison Crawford, MD, FRCPC

Germaine Arnaktauyok Night and Day

Learning from History: Arctic Hysteria Also known as piblokto/ pibloktoq, was first documented in 1800s by the explorer Robert Peary. It was understood as a “culture-bound” syndrome that affected Inuit women; involving social withdrawal, extreme agitation, and dissociation. This diagnosis was perpetuated in the DSM (psychiatric diagnostic manual) until the revision in 2014.

Piblokto is now thought to be a complex phenomenon influenced by contact/ colonialism/ and a racialized process of “othering”.

Observation is contextual. It is not “objective.” It says as much about the observer as the observed. We need to remember that our categories of diagnosing “illness” can also be harmful.

Social Determinants of Mental Health •

This module follows the one on social and historical context to help make the point that mental illness does not occur in isolation, but rather in the context of family, community and society

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According to the World Health Organization, social determinants of health (SDH) are:! “the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.” http://www.who.int/social_determinants/en/

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SDH are responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries; the result of a failure of public policies

REFLECTION What are the social conditions at play around you that you feel contribute to the overall health of the community that you are in?

Consider: economics; social class; housing; employment opportunities; education; access to healthcare; diet and undernourishment; governemental policies‌ Do you think these conditions relate to your job as a health provider? Why? How?

Take a moment to write brief answers to these questions in your journal

Resilience and Strengths-based Approach “How people feel is not an elusive or abstract concept, but a significant public " health indicator; as significant as rates of smoking, obesity and physical activity”"

United Kingdom Department of Health 2001

Resilience is an individual’s ability to cope with stress and adversity. How well they “bounce back”. Having good mental health is a source of resilience. It is also possible to think of resilient locations as places and communities that promote wellness.

Positive mental health is generally seen as including: ! emotion (affect/feeling), ! cognition (perception, thinking, reasoning) ! social functioning (relations with others and society) ! coherence (sense of meaning and purpose in life).

A strengths-based approach is a path to building resilience. It is not a set of interventions, but a way of responding—a belief that people have competencies and resources, that they are able to learn new skills, and that they can collaborate in addressing their own concerns

REFLECTION Measuring Resilience Click to open the The Warwick-Edinburgh Mental Well-being Scale (WEMWBS)

It can also be found at: http://www.healthscotland.com/documents/1467.aspx

Life Course: Pathways to Mental Health

Community INEQUITIES:! e.g., Economic disadvantage Under-employment Community-level traumas

Family Substance abuse

Individual biology and psychology

Hospitalizations Poor parenting skills

Fetal alcohol effects

Domestic violence

Early outcomes

Attachment disruption Leaves school Poor self-esteem Substance abuse Poor affect regulation Problematic peer skills group

Later outcomes Justice system Mental health disorder Etc‌

Context for current health indicator data The framework of social determinants and health inequities, balanced by resilience, is a foundation for understanding current mental health indicators in Inuit communities.

Mental health disorders can affect all ages, genders and social groups in Canada.

Our expertise in treating mental health problems is one aspect of what we can contribute to the work we do in Nunavut.

Inuit Health Survey (IHS) 2007-8 Adult participants from randomly selected households completed initial parts of the survey on land, in their community. The second part of the survey was done on the Canadian Coast Guard Ship Amundsen, where participants had a clinical appointment.

In 2007, 1,214 Inuit adults in 18 coastal communities in the Baffin and Kivalliq regions of Nunavut were involved.

REFLECTION Given what you learned in the previous module on social and historical context, what might the IHS research project reminded some participants of?

What are potential consequences of that history?

HIS: Community Wellness Participants were asked if, in their opinion, their community was generally peaceful or affected by violence. !

69% answered “peaceful” or “moderately peaceful” place to live!

7% women answered “very violent”!

2% men answered “very violent”

90% said that it was “very-” or “somewhat” important for them to go out on the land, with fishing being the most common activity

HIS: Community Mental Health Indicators Felt depressed in the last month!

9% all or most of the time!

43% some of the time!

Men = women Lifetime thoughts about committing suicide!

48% (14% in last 12 months) Previous suicide attempt!

29% (5% in last 12 months)!

Women (31%) > Men (25%)

HIS: Interpersonal violence and abuse Severe Sexual Abuse in Childhood

Physical Abuse as an Adult

Sexual Assault as an Adult

Women

52%

52%

27%

Men

22%

46%

5%

Total

41%

50%

18%

Suicide Suicide is the second leading cause of death in Nunavut, with young men at the greatest risk of dying by suicide. !

The rate of death by suicide among 15- to 24-year-old Inuit men in Nunavut is 28 times higher than in the rest of Canada

Qaujivallianiq Inuusirijauvalauqtunik !

Learning from lives that have been lived The Nunavut follow-back study was conducted from 2005 – 2010 The study looked at the 120 lives of those who committed suicide in Nunavut from 2003-5 and compared them with a same-age group of peers by interviewing friends and relatives and examining health records In the group of those who committed suicide they found‌.

http://inuusiq.com/wp-content/uploads/2013/06/Report-NFBS-Final-English.pdf

Higher levels of psychiatric illness, especially depression and substance abuse

http://inuusiq.com/wp-content/uploads/2013/06/Report-NFBS-Final-English.pdf

Higher levels of childhood maltreatment

http://inuusiq.com/wp-content/uploads/2013/06/Report-NFBS-Final-English.pdf

Higher levels of personality disorder diagnoses

http://inuusiq.com/wp-content/uploads/2013/06/Report-NFBS-Final-English.pdf

Conclusions from Follow-back Study The rapid increase in suicidal behaviour in recent decades, particularly among young people, is likely the result of social determinants of health, including historical trauma and its impacts (interpersonal violence, substance abuse, parenting and attachment problems, etc) These inequities, disadvantages, and intergenerational traumas likely contribute or predispose youth to developing mental health disorders Mental health disorders, as seen globally, are risk factors for suicide Historical trauma will be explored in a subsequent module.

Community-based perspectives One of the risks in focusing on suicide and mental health disorder is that we can forget about the community context. Healthy communities with a strong sense of cohesion can be a source of strength and resilience.

This may be particularly important in cultures and groups that value collaboration Although there needs to be more research and evidence gathered for community-based prevention and intervention work in Inuit communities, this is an important area to develop!

For a great example of a community-based initiative see the Ilisaqsivik group in Clyde River http://ilisaqsivik.ca!

You can also read about traditional Inuit knowledge approaches: http://www.naho.ca/documents/it/2006_Suicide_Prevention-Elders.pdf

Land-based approaches to mental wellness The IHS demonstrated the importance of land-based cultural activities for Inuit Activities that lead to mental wellness and resilience can be culturally specific Our “western” approach to mental health in offices may be at odds with this natural form of healing.

Healing through the land should be a focus of future research and integrated into best-practices.

There’s things [we] use that [we]’ve used for centuries. Way before my time. Like you just take a walk down to the park, you can see rings there that are ten thousand years old.

You know, it’s a symbol of the strength of the ability to heal [our]selves "

Quoted in Fletcher and Denham, 2008

Nunavut Tunngavik Inc. (NTI): Research in Inuit Communities

In their recent annual report, which focused on the Inuit Health Survey, NTI stressed the importance of Inuit selfdetermination over research Inuit need to be collaborators in all stages of research design, implementation, analysis and dissemination Results need to be communicated to Nunavut communities in a collaborative and timely way.

Not about us, without us‌ http://www.tunngavik.com/files/2014/02/2011-12-12-13-SICS-Annual_Report-Eng.pdf

Formulation: pull all of these factors together in understanding the individual PREDISPOSING Biological and early life events

PRECIPITATING Events that caused current crisis

PERPETUATING Ongoing contributing life factors

PROTECTIVE Sources of resilience and strength

BIOLOGICAL! CONTRIBUTORS

Genetics Inutero events Illnesses Impact of parenting and early events Cognitive disability

Illness Medications/ changes Substance abuse Seasonality Changes in sleep Diet

Illness Medications/ changes Substance abuse Seasonality Changes in sleep Diet

Good health Good genes Exercise Healthy diet Medication compliance

PSYCHOLOGICAL! FACTORS

Attachment disorder Loss/ grief/ trauma Early trauma or abuse

Poor coping skills Poor problem solving!

Helplessness Unresolved grief

Good coping skills!

Secure attachment!

Good self-esteem

SOCIAL AND CULTURAL DETERMINANTS

Community health inequities

Interpersonal conflict Unresolved stressor Lack of resources Lack of social support!

Poor access to healthcare Lack of cultural safety

Strong cultural identity Community and family resilience Faith Employment Support group Access to health care Cultural safety

Social stressor (eg loss of job, housing, problem in support group)

Etc‌.

Bibliography and Resources Mental Health and Resilience – Report by WHO! http://www.euro.who.int/__data/assets/pdf_file/0012/100821/E92227.pdf