Inuit Mental Health:

Current IndicatorsAllison Crawford, MD, FRCPC

Germaine Arnaktauyok Night and Day

Learning from History: Arctic Hysteria

Also known as piblokto/ pibloktoq, so-called arctic hysteria 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.

Inuit women through the eyes of early anthropologists

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

• 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/

• 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

Leaves schoolSubstance abuseProblematic peer group

Justice systemMental health disorder

Etc…

Life course

Clyde Hertzman identifies 3 health effects that influence illness from a life course perspective:

Latent effects are biological or developmental early life experiences that influence health later in life (e.g. exposure to alcohol in utero; or family genetics)

Pathway effects are experiences that set individuals onto trajectories that influence health, well-being, and competence over the life course. (e.g., poor access to nutrition leads to academic difficulties that limit employment opportunities)

Cumulative effects are the accumulation of advantage or disadvantage over time that manifests itself in poor health. These involve the combination of latent and pathways effects. http://www.peelearlyyears.com/pdf/The%20Case%20for%20an%20Early%20Childhood%20Development%20Strategy,%20Canada.pdf

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.

http://www.inuithealthsurvey.ca

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?

IHS: 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 live7% 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

IHS: Community Mental Health Indicators

Felt depressed in the last month9% all or most of the time43% some of the timeMen = women

Lifetime thoughts about committing suicide48% (14% in last 12 months)

Previous suicide attempt29% (5% in last 12 months)Women (31%) > Men (25%)

IHS: 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 self-determination 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

Jamasie Teevee, Young Hunters, 1979

Formulation: pull all of these factors together in understanding the individual

PREDISPOSINGBiological and early life events

PRECIPITATINGEvents that caused current crisis

PERPETUATINGOngoing contributing life factors

PROTECTIVESources of resilience and strength

BIOLOGICALCONTRIBUTORS

GeneticsInutero eventsIllnessesImpact of parenting and early eventsCognitive disability

IllnessMedications/ changesSubstance abuseSeasonality Changes in sleepDiet

IllnessMedications/ changesSubstance abuseSeasonality Changes in sleepDiet

Good healthGood genesExerciseHealthy dietMedication compliance

PSYCHOLOGICALFACTORS

Attachment disorderEarly trauma or abuse

Loss/ grief/ trauma Poor coping skillsPoor problem solvingHelplessnessUnresolved grief

Good coping skillsSecure attachmentGood self-esteem

SOCIAL AND CULTURAL DETERMINANTS

Community health inequities

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

Interpersonal conflictUnresolved stressorLack of resources Lack of social supportPoor access to healthcareLack of cultural safety

Strong cultural identityCommunity and family resilienceFaithEmploymentSupport groupAccess to health careCultural safety

Etc….

Formulation

Formulation is a synthesis or putting together of all of the information gathered in a clinical assessment, including what the client says, your observations of the client, and collateral information or historical information that you obtain from other sources.

It allows you to consider all of the factors that contribute to how and why the person is seeking assessment.

These factors include multiple dimensions (biological, psychological and social) across time.

This synthesis becomes a hypothesis about the person that can guide intervention, and can also be modified or re-synthesized over time.

Bibliography and Resources

American Psychiatric Association – Cultural Formulation Interviewhttp://www.psychiatry.org/File%20Library/Practice/DSM/DSM-5/CulturalFormulationInterview.pdf

Clyde Hertzman (2010) The Case for an Early Child Development Strategy http://www.peelearlyyears.com/pdf/The%20Case%20for%20an%20Early%20Childhood%20Development%20Strategy,%20Canada.pdf

Inuit Health Survey http://www.inuithealthsurvey.ca

Qaujivallianiq Inuusirijauvalauqtunik (Learning from lives that have been lived)http://inuusiq.com/wp-content/uploads/2013/06/Report-NFBS-Final-English.pdf

Mental Health and Resilience – Report by WHOhttp://www.euro.who.int/__data/assets/pdf_file/0012/100821/E92227.pdf

Social Determinants of health: The Canadian Facts http://www.thecanadianfacts.org/The_Canadian_Facts.pdf

The Warwick-Edinburgh Mental Well-being Scale (WEMWBS)http://www.healthscotland.com/documents/1467.aspx