Almost every state is reckoning with a mental health crisis. But for areas with underserved populations and limited resources, like where psychiatric nurse practitioner Whitney Fear grew up in Pine Ridge, South Dakota, and where she currently lives in North Dakota, treating mental health conditions presents an even greater challenge. In primarily rural states like North and South Dakota, a chronic lack of mental health resources — for both Native Americans and non-Natives — continues to set back those in need of care.

Between 2014 and 2016, mental health — including a demand for services, providers and tele-psychiatry — ranked as the second most common need across community health needs assessments conducted throughout North Dakota. This demand for mental healthcare can be linked to an increase in suicides throughout the area. Between 1999 and 2016, suicides rose by 58 percent, increasing more than in any other state. In 2017, suicide was the eighth leading cause of death throughout North Dakota; and by 2019, the state’s age-adjusted suicide rate (18.5) was significantly higher than the national rate (13.9).

Prior to the pandemic, 20.5% of adults in North Dakota suffered a mental illness. Of those who needed mental health treatment but did not receive it, 36.3% said it was due to cost. COVID-19 only further exacerbated underlying mental health struggles in the area. In 2020, 19.2 percent of North Dakota residents had been diagnosed with some form of depression. Among adults surveyed in North Dakota in fall 2021, 33.3 percent reported symptoms of anxiety and/or depression — 1.7 percent higher than the U.S. average.

Unfortunately, North Dakota is limited in its ability to meet its residents’ needs. Some call the state’s community-based services “inadequate or nonexistent,” and jails have been compared to “warehouses” for those with untreated mental health conditions. Western North Dakota, an area that one local news article deems “a mental health care desert,” is particularly desperate. The cities of Dickinson and Williston have no psychiatric inpatient beds.

But for Native Americans living in North Dakota, the mental health crisis is even more dire. In 2020, 26.1 percent of American Indian and Alaska Natives in North Dakota reported that they suffered from some form of depression. Data from the 2019 Fargo Cass Public Health Assessment revealed a suicide rate of 45.1 for Native Americans in North Dakota, compared to the national average of 13.4.

In North Dakota and beyond, societal and historical factors such as colonialism, genocide, oppression and systemic racism have contributed to a collective trauma that leads to higher instances of mental health issues among Native Americans. Research has in fact established a direct link between historical trauma and conditions such as depression, anxiety and substance use disorders. There’s also an indirect link to suicidal ideation. Experts say that this “shared suffering” may be reflected in mental health disparities on a population-level. More than 10 percent of American Indians and Alaska Natives feel sad, hopeless or that “everything is an effort,” all or most of the time. This is compared to 6.6 percent of non-Hispanic whites.

Although they are more likely to experience mental illness, Native Americans are also more likely to face significant barriers to mental health services. Across the country, approximately 43 percent of Indigenous peoples rely on Medicaid or public health coverage. As recent as 2019, 14.9 percent of Indigenous peoples in America had no health insurance at all — more than three times the rate of uninsured white people. They also face cultural barriers. In the United States, psychiatrists, therapists and prescription medications are often used to treat mental health disorders, and experts note that these approach may be in conflict with Native Americans who value a more holistic approach to care. Some of the culturally based interventions used to treat mental health conditions among Indigenous peoples include traditional healers, practices for wellness, ceremonies, prayers and even storytelling. Unfortunately, most healthcare professionals trained in the United States are unaware of Indigenous traditional medicine or how to contextualize it into current clinical care.

In “Who Cares,” Whitney Fear speaks to some of the cultural challenges she witnesses in behavioral health, such as prolonged eye contact. This behavior that practitioners often use to evaluate patients is actually considered impolite in the Lakota culture. Fear also describes one instance where a Native American patient was prescribed antipsychotics for having a spiritual sighting of a creature that’s culturally significant to the Lakota. Each of these anecdotes speaks to the gap between available mental health resources and culturally sensitive care. The Pine Ridge Reservation, where Fear grew up, exhibits how Native American communities can struggle with the availability of mental health resources and the low life expectancy that can result from untreated behavioral and mental health disorders.

But there are steps we can all take to help overcome this gap in care. The first is to become more aware of culturally appropriate resources already available for your patients, who may need your help and support as a leader in your community’s health. For instance, there are nationwide youth enrichment and empowerment programs for Native American children and families. Consider getting involved in ongoing research to help clinicians learn how to provide more effective and culturally appropriate mental and behavioral health care to Native Americans. There’s research currently underway that needs partners for a screening tool in emergency departments to help Native teens at risk of suicide. Reach out to schools of public health that provide specific resources and cultural sensitivity training for communities you’re trying to reach. And don’t forget the importance of diverse representation in healthcare, like Whitney Fear’s role in the Fargo community. There are special resources and scholarships to encourage members of diverse communities to become leaders in their community’s health and wellbeing.

We’ve outlined a few organizations and resources to get you started below. Never forget the difference it can make when one person cares. Especially if that person is a nurse.

Discussion Questions

  1. The mental health disorder statistics are high in North Dakota, and even more so for Native Americans in the area. Are there any groups in your city or state that are more at risk for mental or behavioral health disorders? If so, who? How can you better reach them?
  2. In “Who Cares,” Whitney shares about her Lakota heritage and values, then demonstrates her culturally sensitive approach to care. Do you come from a culture that’s considered “a minority”? If so, how does that influence the way you approach your patients? If not, think of some underserved populations in your area. What can you do to become more culturally aware of care that might better serve those individuals?
  3. In your opinion, why is cultural humility important in nursing? How does it impact overall health outcomes?
  4. Do you know anyone who suffers from mental or behavioral health issues, either personally or professionally? How does that impact their overall health? How does it impact the way other healthcare providers treat them?

For Further Reading

  1. “Prevalence of DSM-IV disorders and attendant help-seeking in 2 American Indian reservation populations.” Arch Gen Psychiatry. 2005.
  2. “Factors Associated with American Indian Mental Health Service Use in Comparison with White Older Adults,” Journal of racial and ethnic health disparities, 5(4). 2018 Sept.
  3. “Tribal Affairs,” Substance Abuse and Mental Health Services Administration. 2022 Mar.
  4. “Mental health workforce taxed during COVID-19 pandemic: Worker shortage hinders access,” The Nation’s Health January 2022, 51 (10) 1-14. 2022 Jan.
  5. “Suicide Risk and Mental Disorders,” International Journal of Environmental Research and Public Health. 2018 Sep.
  6. “The Implications of COVID-19 for Mental Health and Substance Use,” Kaiser Family Foundation. 2021 Feb.
  7. “Poverty and Health Disparities for American Indian and Alaska Native Children: Current Knowledge and Future Prospects,” Reducing the Impact of Poverty on Health and Human Development: Scientific Approaches, Vol. 1136, Issue 1. 2008 Jul.
  8. “Access to Mental Health Services at Indian Health Service and Tribal Facilities,” Department of Health and Human Services Office of Inspector General. 2011 Sep.
  9. “A Quiet Crisis: Federal Funding and Unmet Needs In Indian Country,” S. Commission on Civil Rights. 2003 Jul.
  10. “Fargo Cass Public Health 2019 Community Health Assessment,” Fargo Cass Public Health. 2019.
  11. “Risk and protective factors related to the wellness of american indian and alaska native youth: a systematic review,” Int Public Health J. 2016

Community Resources & Organizations to Make a Difference

  1. Center for Indigenous Health Research and Policy, Oklahoma State University Center for Health Sciences
  2. Johns Hopkins Center for American Indian Health
  3. “Culturally Competent Healthcare,” National Indian Council on Aging
  4. “Engaging American Indian Families: Supporting Mental Health,” Child Welfare Information Gateway.
  5. “Addressing the Health Care Needs of American Indians and Alaska Natives,” American Journal of Public Health. 2011 Oct.
  6. Indians Into Medicine (INMED), University of North Dakota
  7. “Increasing Culturally Responsive Care and Mental Health Equity With Indigenous Community Mental Health Workers,” Psychological Services Vol. 18, 1. 2021 Feb.
  8. “American Indian and Alaska Native Culture Card: A Guide to Build Cultural Awareness,” Substance Abuse and Mental Health Services Administration
  9. “Improving Cultural Competence to Reduce Health Disparities for Priority Populations,” Effective Health Care (EHC) Program, Agency for Healthcare Research and Quality, DHHS. 2014 Jul.
  10. Indigenous | NAMI: National Alliance on Mental Illness