Behavioral Health Among American Indian and Alaska Natives: An Overview 
Released: 2016-09-16T00:00:00

About This Report

This report provides background information and a summary of federal programs related to behavioral health among the American Indian and Alaska Native (AI/AN) population. Both Congress and the Administration have demonstrated an interest in addressing AI/AN behavioral health. Congressional hearings have focused on behavioral health problems such as alcohol use disorders, drug use disorders, and youth suicide in the AI/AN population. Members have introduced legislation containing behavioral health elements as part of larger efforts to improve the health of the AI/AN population. For example, some bills would call for recommendations to improve behavioral health (among other things) or fund demonstration projects addressing behavioral health (among other things). In 2014, the President specifically mentioned behavioral health problems such as substance abuse and suicide in his remarks when he announced the creation of Generation Indigenous (Gen-I), a federal initiative that collaborates with organizations such as the Aspen Institute to assist tribal youth through programs, policies, and leadership opportunities.

This report begins by clarifying the scope of information covered. It then provides background information about AI/AN behavioral health—including the high prevalence of risk factors, the high prevalence of specific behavioral health problems, and limited access to care. The report then summarizes each of the programs that meet criteria for inclusion. It concludes with a brief discussion of how an understanding of the scope and limits of existing programs might inform certain policy decisions.

Behavioral health among the AI/AN population is a broad and potentially amorphous topic. This report limits the scope by setting parameters for (1) the definition of behavioral health used, (2) the definition of the AI/AN population used, (3) the federal agencies included, and (4) the types of programs included.

Behavioral Health Defined

The term "behavioral health" is defined differently in different contexts; however, it is generally used to include both mental health disorders (e.g., depression) and substance use disorders (e.g., alcohol or drug use disorders). This report describes programs that support prevention and treatment of mental health disorders, alcohol or drug use disorders, and suicide or attempted suicide. It does not include programs specifically focused on tobacco use.

American Indian and Alaska Native (AI/AN) Population Defined

The overall AI/AN population—that is, individuals who self-identify as AI or AN—differs from the population who are members of Indian Tribes (ITs), which is generally the population targeted by federal programs (see Table 1 ). The self-identified AI/AN population, according to the U.S. Census Bureau in 2014, was 5.2 million—including 2.6 million people who considered themselves to be only AI or AN and 2.7 million people who considered themselves to be AI/AN in combination with another race.

Both of these numbers are larger than the number of individuals who are members of federally recognized tribes, estimated at 2.0 million by the Bureau of Indian Affairs in 2010. Note that Native Hawaiians are not included in this report because they are not considered to be members of an IT (see Table 1 ) and are generally not eligible for federal programs that target tribal members.

Federal Agencies Included in This Report

Designing and implementing programs to improve AI/AN behavioral health is a challenging task that requires collaboration among federal agencies, tribal governments, other organizations, communities, and individuals. This report, however, focuses on the activities of two agencies within the U.S. Department of Health and Human Services (HHS): the Indian Health Service (IHS) and the Substance Abuse and Mental Health Services Administration (SAMHSA). IHS is the lead federal agency on health care (including behavioral health care) among the AI/AN population. SAMHSA is the lead federal agency on behavioral health care among the general population (including the AI/AN population).

This report does not address other federal agencies that support—but are not focused on—behavioral health care among the AI/AN population. For example, some federal programs focus on improving the well-being of AI/AN children either exclusively or as part of a larger program focus. Improving child well-being could include activities related to behavioral health and could ultimately result in lower rates of behavioral health conditions for the AI/AN population; however, programs that do not focus exclusively on behavioral health care are beyond the scope of this report. Other programs may finance behavioral health services for the AI/AN population. Such programs may finance health services for a population broader than the AI/AN population and pay for health services beyond those intended to treat behavioral health conditions. Although programs offering such financing are an important source of federal support for behavioral health services (see text box), they are beyond the scope of this report.

Indian Health Service (IHS)

The Indian Health Service (IHS) provides health care directly or provides funds for Indian Tribes (ITs) or Tribal Organization (TOs) to operate health care facilities (collectively referred to in this report as IHS-funded facilities). IHS serves approximately 2.2 million individuals who are primarily members of federally recognized tribes. IHS may also serve individuals who are not members of federally recognized tribes (e.g., individuals who are considered to be Indian by the community in which they live). IHS provides services to individuals of all ages through a network of facilities located in 35 states. Specific services vary by facility, but generally focus on primary care, prevention, and treatment of conditions common among American Indians and Alaska Natives, including behavioral health conditions.

Substance Abuse and Mental Health Services Administration (SAMHSA)

SAMHSA supports community-based mental health and substance abuse services through various grant programs and other activities (e.g., technical assistance and data collection). ITs and TOs are eligible to apply directly for certain SAMHSA grants and may benefit indirectly from grants awarded to states or other entities (e.g., if a state uses a portion of block grant funding to support programs serving the AI/AN population). Two of SAMHSA's formula grant programs are unusual in that each awards a portion of funds to a single tribal entity. One such program is the Substance Abuse Prevention and Treatment Block Grant, which distributes funds to states (including the District of Columbia and U.S. territories) and the Red Lake Band of the Chippewa. The other such program is the Protection and Advocacy for Individuals with Mental Illness program, which distributes funds to protection and advocacy systems designated by each state (including the District of Columbia and specified U.S. territories) and the American Indian Consortium.

SAMHSA has formal mechanisms for collaborating with ITs, TOs, and other stakeholders. SAMHSA's Office of Tribal Affairs and Policy is responsible for working on behavioral health issues affecting tribal communities in collaboration with ITs, TOs, other SAMHSA offices and centers, and other federal agencies; its responsibilities also include supporting agency efforts to implement the Tribal Law and Order Act of 2010 (Title II of P.L. 111-211 ), which seeks to reduce alcohol and illicit drug usage (among other things). SAMHSA's Tribal Technical Advisory Committee, comprising 14 members from federally recognized tribes, enables tribal leadership and SAMHSA staff to "exchange information about public health issues, identify urgent mental health and substance abuse needs, and discuss collaborative approaches to addressing these behavioral health issues and needs."

IHS and SAMHSA Programs Included in This Report

This report includes IHS and SAMHSA programs that specifically target behavioral health in the AI/AN population; it does not include every IHS or SAMHSA program that may be used to support behavioral health in the AI/AN population. That is, this report does not compile every program administered by IHS's Division of Behavioral Health and every SAMHSA grant for which ITs or TOs are eligible. For example, IHS offers scholarships and loan repayment to recruit providers (including but not limited to behavioral health providers) to IHS facilities. These workforce programs are not discussed in this report because they do not specifically target behavioral health. Similarly, IHS programs that focus on problems such as domestic violence or sexual assault (which may cause or exacerbate behavioral health problems) are beyond the scope of this report.

Both IHS and SAMHSA participate in interagency (within HHS) and interdepartmental activities related to AI/AN behavioral health (see text box); however, they generally approach AI/AN behavioral health in ways that are not directly comparable. IHS delivers health care (including behavioral health care) directly or under contracts/compacts with ITs or TOs. As such, it has specific health service programs, including facilities focused on behavioral health. SAMHSA does not deliver health care services or operate health care facilities. SAMHSA primarily awards grants to support behavioral health activities of other entities (e.g., states or ITs).

Background on AI/AN Behavioral Health

Research on AI/AN behavioral health demonstrates three key points: The AI/AN population has (1) a high prevalence of risk factors for behavioral health problems, (2) a high prevalence of behavioral health problems, and (3) limited access to care for behavioral health problems.

High Prevalence of Risk Factors Among AI/AN

A wide variety of health outcomes have been found to depend on factors such as education, employment, poverty, and culture, among others—factors collectively known as "social determinants." High rates of behavioral health problems (and other health problems) in the AI/AN population may be attributable to "issues rooted in economic adversity and poor social conditions," such as "inadequate education, disproportionate poverty, discrimination in the delivery of health services, and cultural differences." The AI/AN population has been found to be "poorer, less educated, less employed, less healthy ... than virtually any other demographic group in the United States." For example, as of 2012, fewer AI/AN adults had at least a high school diploma (85%) compared to non-Hispanic whites (92%), and the median income for the AI/AN population ($37,353) was two-thirds that of the non-Hispanic white population ($56,565).

Health disparities, including those in behavioral health that may result from social determinants, are not exclusive to the AI/AN population; rather they may occur in all disadvantaged populations. Social determinants, in turn, may adversely affect all types of health conditions, not just behavioral health conditions. Moreover, behavioral health conditions may exist in individuals without these risk factors.

High Prevalence of Behavioral Health Problems Among AI/AN

The AI/AN population has a higher prevalence of some behavioral health problems than many other racial or ethnic groups. For example, in 2014 the AI/AN population had the highest suicide rates among other racial ethnic groups for both the male population (27.4 per 100,000) and the female population (8.7 per 100,000), as shown in Figure 1 . Similarly, in 2014 the rate of past-year substance use disorders was higher among the AI/AN population (16%) than among other racial and ethnic groups: non-Hispanic white (8%), non-Hispanic black (8.6%), Hispanic (8.5%), Asian (4.5%), and Native Hawaiian or other Pacific Islanders (10%).

Researchers have found that the AI/AN population has particularly high rates of certain behavioral health problems, including alcohol and marijuana use disorders. According to IHS, substance use disorders result in "devastating intergenerational social, economic, physical, mental, and spiritual health disparities" in AI/AN communities, including a rate of alcohol-related deaths (49.6 per 100,000) that is six times greater than the rate for all races (8.0 per 100,000). Posttraumatic stress disorder, childhood conduct disorder, and suicidal behaviors are also present at higher rates than in other races. However, these higher rates are not consistent across all behavioral health problems; for example, researchers found that major depressive disorder is less common among the AI/AN population than among the overall adult U.S. population.

Despite a greater prevalence of some behavioral health disorders among the AI/AN population, collecting and analyzing data poses several challenges. First, when researchers present prevalence rates (or other data) by race or ethnicity, they often do not report data for groups of comparatively small size (such as the AI/AN population) because the samples of such groups are too small to support statistical analysis. Second, studies conducted specifically among the AI/AN population can report data for that population but lack comparisons to other groups. Third, the designation of individuals as AI/AN may not be consistent: some datasets may categorize individuals as AI/AN based on self-identification, whereas others may do so based on tribal membership. Also, an AI/AN designation does not capture variation within that population (e.g., differences between tribes).

Limited Access to Care Among AI/AN

Preventing and treating behavioral health conditions generally requires regular access to health care providers who can screen and, if necessary, treat behavioral health conditions. AI/ANs often have difficulty accessing care because they are more likely to live in rural and remote areas than the U.S. population as a whole. A number of rural areas are designated as mental health shortage areas by the federal government thereby making these areas eligible for programs that seek to reduce provider shortages; this designation includes areas with federally recognized Indian Tribes, which are automatically designated as shortage areas.

The IHS system provides access to care but has difficulty recruiting and retaining providers generally and behavioral health providers specifically. For example, IHS noted that it has approximat ely 1,500 vacant health care provider positions and that it has difficultly recruiting providers because of the remote locations of many of its facilities.

Even when health care facilities are geographically close and health care providers are available, other factors may impede access to care that is acceptable to and appropriate for the AI/AN population. Whereas IHS-funded facilities specialize in the AI/AN population, non-IHS-funded facilities do not and may be less likely to provide culturally competent care. AI/AN patients may be reluctant to visit non-IHS-funded mainstream health care facilities due to cultural differences between the patients and the providers available to treat them. For example, non-IHS health care providers typically speak in terms of "treatment," whereas the AI/AN population might relate to the concept of "healing." If health care providers are not able to provide culturally competent care, AI/AN patients may feel alienated or disrespected, and they may be less compliant with treatment. Another access barrier may be financial. AI/ANs receive free care at IHS-funded facilities when services are provided directly by these facilities. However, non-IHS facilities generally require AI/ANs to pay for services, and some people may not be able to afford such costs because they have low incomes or they lack insurance coverage.

Program Summaries

IHS and SAMHSA have programs aimed at improving AI/AN behavioral health. In some cases, both agencies have programs with the same (or a very similar) specific focus (e.g., suicide prevention). Given the fundamental differences between the two agencies—with IHS primarily delivering health care services and SAMHSA primarily awarding grants—programs with similar names or goals may not be comparable. Programs and grants are listed separately below according to agency.

The programs in this report do not represent a comprehensive list of IHS programs that may treat behavioral health conditions and SAMHSA programs for which ITs and TOs are eligible. That is, AI/ANs may receive behavioral health services as part of IHS programs that are not focused on behavioral health, and ITs or TOs may receive funds from SAMHSA programs that have not been identified as particularly relevant to the AI/AN population. Furthermore, some of the SAMHSA programs included in this report are not limited to ITs, TOs, or the AI/AN population. For these reasons, presenting funding for the included programs would be misleading—underestimating spending in AI/AN behavioral health in some ways and overestimating it in others. This report is not intended to capture federal spending on AI/AN behavioral health and does not include funding for the programs.

IHS Programs

IHS programs are authorized by the Indian Health Care Improvement Act (IHCIA). Title VII of the act specifically authorizes programs related to behavioral health. IHS has structured its behavioral health programs under two main umbrella programs: (1) the Alcohol and Substance Abuse Program, and (2) the IHS Mental Health/Social Services Program. Programs presented below are ordered alphabetically and described under their umbrella program.

The Alcohol and Substance Abuse Program

The Alcohol and Substance Abuse Program (ASAP) is an overarching program that incorporates preventive, educational, and treatment services to address the behavioral health status of AI/ANs. Program services may be delivered in conjunction with primary health services and through telehealth when appropriate. Alcohol and substance abuse program services can be provided by the IHS, ITs, or TOs using funds received through two Indian Self-Determination Education and Assistance Act (ISDEAA) funding mechanisms: contracts and compacts (see definitions in Table 1 ). IHS reports that 80% of alcohol and substance abuse programs are operated by ITs or TOs. In addition, IHS requires that health care providers who work in IHS facilities operated by the federal government and who have the authority to prescribe opioids consult their state's Prescription Drug Monitoring Program (PDMP) databases prior to prescribing and dispensing opioids for more than seven days.

IHS programs within ASAP's scope include Fetal Alcohol Spectrum Disorders (FASD), Integrated Substance Abuse Treatment in Primary Care, Methamphetamine and Suicide Prevention Initiative (MSPI), and Youth Regional Treatment Centers (YRTCs).

Fetal Alcohol Spectrum Disorders

IHS provides funding to the Fetal Alcohol and Drug Unit (FADU) at the University of Washington's Alcohol and Drug Abuse Institute. The FADU provides consultations and referrals for evaluation and diagnosis to AI/ANs with fetal alcohol spectrum disorders (FASD) and their families. FADU offers resources, referrals, workshops, and technical support on FASD issues for service providers in Washington State, and online courses for out-of-state health care providers. FADU data are collected to inform strategies for FASD prevention and treatment.

Integrated Substance Abuse Treatment in Primary Care

The Integrated Substance Abuse Treatment in Primary Care program incorporates substance abuse treatment into primary care and emergency services at IHS-funded facilities. Patients identified as having substance use disorders are provided with medical advice and/or substance abuse consultations, while patients with more severe substance use-related problems are referred to treatment. As part of this program, IHS promotes the Screening, Brief Intervention, and Referral to Treatment (SBIRT) strategy, a community-based screening for health risk behaviors, including substance use. The Center for Medicare and Medicaid Services (CMS) reimburses IHS-funded facilities for SBIRT provided to individuals enrolled in CMS-administered programs.

Methamphetamine and Suicide Prevention Initiative

The Methamphetamine and Suicide Prevention Initiative (MSPI) program is a nationally coordinated grant program that awards substance abuse, suicide prevention, and intervention resources to IHS-funded facilities (i.e., the entity including an IT or a TO that operates the facility). Grantee programs must address at least one of the following four purpose areas: (1) community needs assessment and strategic planning; (2) suicide prevention, intervention, and postvention; (3) methamphetamine prevention, treatment, and aftercare; and (4) Gen-I Initiative support. Programs operate within a five-year period, and 128 MSPI programs were selected for the 2015 through 2020 program cycle. IHS collects data from the grantee programs in conjunction with Tribal and Urban Epidemiology Centers, the National Indian Health Board, and the National Council of Urban Indian Health.

In FY2016, MSPI and Gen-I Initiative supported a new MSPI grantee cycle that made funds available to both new applicants and current MSPI grantees. These grants were awarded to help support the overarching goals of the MSPI and Gen-I Initiative by implementing early intervention strategies and youth development programming that seek to reduce risk factors for substance abuse and suicidal behavior. If awarded a grant, new applicants are required to implement evidence-based approaches to promote development and self-sufficiency among AI/AN youth, promote family engagement, increase access to culturally appropriate substance use and suicide prevention activities for youth, and hire behavioral health staff specializing in child, adolescent, and family services. Current MSPI grantees that receive funding under the FY2016 initiative are required to hire additional behavioral health staff, and may use funds to supplement existing MSPI-related activities.

Youth Regional Treatment Centers

IHS funds 11 Youth Regional Treatment Centers (YRTCs) that provide residential substance abuse and mental health treatment services to AI/AN youth. These services include clinical evaluation; substance abuse education; individual, group, and family psychotherapy; medication management or monitoring; and post-treatment follow-up. These facilities are designed to provide regionalized services in each of IHS's 12 areas, where patients travel to a centralized facility to obtain services. The IHS has 12 areas but has fewer YRTCs because two areas have opted to contract for YRTC services. An additional YRTC facility is under construction in California.

IHS Mental Health/Social Services Program

The IHS Mental Health/Social Services (MH/SS) Program is an overarching program that provides preventive and clinical mental health services that are provided by the IHS or by ITs and TOs. Currently, 50% of mental health programs are operated by ITs or TOs. The most common MH/SS program model is an acute, crisis-oriented outpatient service. After-hour emergency services are typically offered by local non-IHS hospital emergency departments, some of which provide services under contractual agreements with IHS. IHS-funded facilities may also purchase inpatient services from non-IHS hospitals or these services may be provided by state or county mental health hospitals. Access to intermediate level services—such as group homes, transitional living support, and intensive case management—are typically offered through state and local resources, and are not generally reimbursable through IHS mechanisms. IHS programs within MM/SS's scope are Behavioral Health Integration with Primary Care, Telebehavioral Health and Workforce Development, and Zero Suicide Initiative.

Behavioral Health Integration with Primary Care

The Behavioral Health Integration with Primary Care program incorporates behavioral health treatment into primary care. Primary care support enables health care providers to identify and provide interventions for high-risk individuals before their behavior becomes more clinically significant. The program integrates the medical home model, a partnership between the patient, family, and primary provider in cooperation with specialists and support from the community.

Telebehavioral Health and Workforce Development

The IHS Telebehavioral Health Center of Excellence (TBHCE) was developed in partnership with the University of New Mexico Center for Rural and Community Behavioral Health. TBHCE provides televideo clinical services to patients at IHS-funded facilities. Clinical services include addiction medicine, adult psychiatry, and child/adolescent psychiatry as well as family, adult, and child/adolescent therapy. TBHCE provides continuing education courses by webinar to personnel at IHS-funded facilities.

Zero Suicide Initiative

IHS launched a suicide prevention initiative, called the Zero Suicide Initiative, in FY2015. This initiative is based on a model developed by the Education Developmental Center, Inc. (EDC) and the Suicide Prevention Resource Center (SPRC), both of which receive funding from SAMHSA. The Zero Suicide Initiative involves educating health care providers (e.g., how to conduct suicide screening and risk assessment) and supporting evidence-based practices. In FY2016, IHS is funding 10 pilot sites that are implementing this model. IHS has also developed a suicide surveillance reporting tool to document incidents of suicide in a standardized, systematic fashion. The reporting tool gathers data, such as the method and other epidemiological information, related to specific incidents of suicide.

American Indians into Psychology Program

The American Indians into Psychology Program (INPSYCH), a grant program administered by the IHS, is designed to attract AI/ANs into health professions and to ensure the availability of health professionals to serve AI/AN populations. It provides scholarships (tuition, books, fees, stipends) for AI/ANs enrolled in programs offering training in clinical psychology. Most recently in FY2014, three institutions of higher education were selected to receive grant funding over a five-year term: Oklahoma State University, the University of North Dakota, and the University of Montana.

Graduate students accepted into the INPSYCH program must work in an AI/AN community for one year for each year of funding they receive. Graduates may fulfill this commitment at an IHS-funded facility or at a private practice if the practice is situated in a federally designated health professional shortage area and addresses the health care needs of a substantial number of AI/ANs.

SAMHSA Programs

SAMHSA pursues its mission primarily by awarding grants, some of which are open to ITs and TOs. As described below, several grants are specifically aimed at the AI/AN population or highly customized for that population, as identified by SAMHSA. Each of the grants is administered by one of three centers within SAMHSA: the Center for Mental Health Services, the Center for Substance Abuse Prevention, and the Center for Substance Abuse Treatment.

Center for Mental Health Services

Most of the programs identified by SAMHSA as particularly relevant to the AI/AN population are administered by SAMHSA's Center for Mental Health Services and focus on supporting mental health treatment or suicide prevention. Several of the programs are part of larger programs and may be commonly known by more than one name.

Systems of Care

The Systems of Care (SOC) program, also called the Children's Mental Health Initiative, provides funds to ITs and TOs (among other eligible entities) to adopt or expand the SOC approach to improve mental health outcomes for children aged 21 or younger with serious mental health conditions and their families. The SOC approach aims to address children's "physical, intellectual, emotional, cultural, and social needs" by delivering evidence-based, culturally and linguistically appropriate services in the least restrictive environment. In addition, the SOC program supports the development of infrastructure to provide such services.

Circles of Care

The Circles of Care program supports ITs, TOs, Urban Indian programs, and tribal colleges (without competition from other entities) in implementing an SOC model of behavioral health services and supports for children and families. Grantees may use funds for planning, developing infrastructure, and building local capacity. They must adopt culturally appropriate methods; incorporate family, youth, and community resources; and emphasize collaboration across systems. Circles of Care grantees may not use funds to provide direct services.

Garrett Lee Smith (GLS) Youth Suicide Prevention—Campus

The Garrett Lee Smith (GLS) Youth Suicide Prevention—Campus program aims to improve the suicide prevention efforts of institutions of higher learning, including tribal colleges and universities. GLS Campus grants support services to address problems "such as depression, substance abuse, and suicide attempts." Grant-funded activities may include outreach to and services for students experiencing substance abuse and mental health issues who may be at greater risk for suicide and non-fatal attempts.

GLS Youth Suicide Prevention—State/Tribal

The GLS Youth Suicide Prevention—State/Tribal program aims to improve the suicide prevention efforts of states, U.S. territories, ITs, and TOs. Awardees may use funds for the development and implementation of statewide or tribal youth suicide prevention and early intervention strategies in order to reduce suicides and non-fatal attempts. SAMSHA requires grant recipients to collaborate with local youth-serving institutions, such as schools and foster care systems, prevention/health related programs in the recipient's community, and the Suicide Prevention Resource Center.

Native Connections

The Native Connections program, also called Tribal Behavioral Health Grants, supports ITs, TOs, and IT/TO consortia (without competition from other entities) in their efforts to promote mental health and reduce substance abuse and suicidal behavior among AI/AN youth (aged 24 or younger). Grantees are required to assess their current behavioral health resources; identify and address gaps using established strategies; and develop the infrastructure to collect data on suicide attempts, deaths, and substance abuse data in conjunction with SAMHSA's Tribal Training and Technical Assistance Center. Grantees must also collaborate with public and private partners, such as those managing foster care and juvenile justice. Grantees may use funds on follow-up care and support services for young community members who abuse substances or have attempted suicide.

Project LAUNCH

Project LAUNCH (Linking Actions for Unmet Needs in Children's Health) aims to promote the health and well-being of children (aged eight or younger) through the coordination of child-serving agencies and organizations, and the development of policy and funding reforms to improve behavioral health services. The grants are open to states, territories, and ITs. The grants support pilot programs in communities with a demonstrably high need for service, and aim to address the physical, social, emotional, cognitive, and behavioral aspects of children's development.

Center for Substance Abuse Prevention

SAMHSA's Center for Substance Abuse Prevention, which addresses behavioral health through evidence-based prevention approaches, administers the Strategic Prevention Framework- Partnerships for Success grants.

Strategic Prevention Framework-Partnerships for Success

Strategic Prevention Framework-Partnerships for Success (SPF-PFS) State and Tribal Initiative grants address underage drinking (among those aged 12 to 20) and prescription drug misuse and abuse (among those aged 12 to 25). These grants are intended to prevent the onset and reduce progression of substance abuse by incorporating SAMSHA's Strategic Prevention Framework, which emphasizes strategic planning and the implementation of evidenced-based prevention. To be eligible for an SPF-PFS grant, states and ITs must have completed SAMHSA's Strategic Prevention Framework State Incentive Grant (SPF-SIG), which helps grantees build a foundation for providing and sustaining prevention services. SPF-PFS grantees are expected to increase infrastructure and the capacity for providing preventive services at the state, IT, and community levels. ITs may allocate grant funds to target additional substance abuse prevention priorities, such as marijuana or heroin, at their discretion.

Center for Substance Abuse Treatment

SAMHSA's Center for Substance Abuse Treatment, which addresses substance abuse treatment and recovery services for individuals and families, administers the drug court grants (within a larger program for criminal justice activities).

Drug Courts

Treatment drug courts are coordinated efforts between the court, law enforcement, and mental health and social services, among others, to intervene, provide treatment, and reduce recidivism. SAMHSA's Treatment Drug Court grants support substance abuse treatment services in adult drug courts, Tribal Healing to Wellness Courts (i.e., the tribal version of adult drug courts), and (tribal or non-tribal) Juvenile Treatment Drug Courts. Treatment Drug Court grant funds must serve individuals diagnosed with substance use disorder(s) as the primary condition and in need of treatment. Funds are distributed to IT, state, and local governments with direct involvement with the tribal court or drug court. Grantees may use funds to provide services for co-morbid conditions such as mental health disorders. SAMHSA Treatment Drug Court grant expenditures must remain consistent with the drug court model, which requires judicially supervised treatment, mandatory periodic drug testing, and the use of other rehabilitation services.

Issues for Future Consideration

This report is intended to provide background information about behavioral health among the AI/AN population and a summary of the most relevant federal programs. The report is not intended to address policy options for modifying, eliminating, or adding such programs (and future CRS reports may explore these policies in greater detail); however, the information in this report may help policymakers address a range of potential policy issues related to AI/AN behavioral health care.

For example, one challenge that IHS and SAMHSA-supported programs face is the shortage of behavioral health providers, particularly in rural areas, where much of the IHS beneficiary population resides. IHS, SAMHSA, and the Health Resources and Services Administration (which administers the majority of federal health workforce programs) are seeking to address these workforce issues. Policymakers may consider coordinating or modifying existing workforce programs to reduce the effects of workforce shortages on programs that support AI/AN behavioral health prevention and treatment. However, policymakers may face fiscal constraints in doing so, as a number of these programs have more applicants than can be supported with the funding available.

As another example, some research has found that improving access to culturally competent care (e.g., through integration of traditional AI/AN healing practices with mainstream health care) may lead to better health outcomes and better patient satisfaction. Although some existing federal programs aim to increase the number of AI/AN behavioral health care providers (e.g., the American Indians into Psychology Program), such training may take years to complete and may train only a limited number of providers. Policymakers may consider additional approaches to increase the culturally competent workforce, such as programs teaching qualified health care providers from other racial and ethnic groups about elements of AI/AN culture.

Policymakers may consider whether current data are sufficient to determine the need for programs and to evaluate their effectiveness. As noted above, data collection is complicated by several factors: efforts to identify the AI/AN population in research may be confounded by differences between self-identification and tribal membership (or program eligibility);getting a sufficient sample size for analysis of specific behavioral health conditions and comparison with other populations is difficult because the AI/AN population is comparatively small; and mapping the rates of conditions to the AI/AN population served is an ongoing challenge. Policymakers may consider requiring additional data collection or may find that the need for services is so apparent that additional data collection is not necessary.

Finally, many of the behavioral issues that AI/ANs experience may be related to the AI/AN socioeconomic conditions. As such, policymakers may consider the balance among programs that address behavioral health directly, programs that address the socioeconomic conditions of AI/AN (which may affect behavioral health indirectly), and programs that address some combination of the two. Similarly, policymakers may consider whether they would like to see evaluations of the association (if any) between implementation of programs aimed at improving socioeconomic conditions and subsequent changes in the rates of behavioral health conditions.