Tribal Behavioral Health: Growing Healthy Communities and Healthy People Charles H. Smith, PhD Regional Administrator – Region VIII Substance Abuse and Mental Health Administration Pathways to Respecting American Indian Civil Rights Conference August 8, 2012

2 Behavioral Health: A National Priority SAMHSA’s Mission: Reduce the impact of substance abuse and mental illness on America’s communities Behavioral health is essential to health Treatment is effective Prevention works People recover 2

3 SAMHSA’s Principles PEOPLE Stay focused on the goal PARTNERSHIP Cannot do it alone PERFORMANCE Make a measurable difference

4 SAMHSA’s New Regional Presence Represent SAMHSA leadership in the Regions Provide SAMHSA with regional feedback Establish working relationships with: – Regional representatives of OpDivs (HRSA, ACF, CMS, AoA) and internal staff divisions – State authorities for mental health and substance abuse, providers, advocates, and groups, state and local health departments. Coordinate support for State implementation of health reform. Coordinate, as needed, implementation of SAMHSA Strategic Initiatives and resources across SAMHSA to address emerging needs Consultation and technical assistance within the regions.

5 Public Health Social Problem Insufficient Response Attention to Symptoms Individual Blame National Dialogue Health Needs of People & Communities Behavioral Health: Public Health Or Social Problem? 5

6 Tribal Behavioral Health: Scope of the Problem Congress: Substance abuse “most severe health and social problem” for Indian tribes  Costs of consequences  Risk factor for other problems  Cause of death and disability

7 Tribal Communities and Behavioral Health Challenges  21.6 % of American Indians or Alaska Natives (AI/AN) experienced mental illness in the past year (vs % overall pop)  The rate of past month binge alcohol use was ↑ among AI/AN adults than the national average (30.6 vs. 24.5%)  The rate of past month illicit drug use was ↑ among AI/AN adults than the national average (11.2 vs. 7.9%)  Only 1 in 8 (12.6%) of AI/AN adults (24,000 people) in need of alcohol or illicit drug use treatment in the past year received treatment at a specialty treatment facility  American Indians are overrepresented in incarceration and arrests rates; in one Minnesota county, American Indians account for 50% of the arrests, but only 11.5% of the county population is American Indian.

8 Health Disparities: A Snapshot Indian Country Rates Nationally* 72 % higher suicide rate 92 % higher homicide rate 149 % higher unintentional injury rate (includes motor vehicle crashes) 195 % higher diabetes rate 500 % higher tuberculosis rate 519 % higher alcoholism rate *Retrieved from

9 Health Disparities: A Snapshot Urban Indian Rates Nationally* 38% higher accident mortality 54% higher diabetes mortality 126% higher chronic liver disease mortality 178% higher alcohol-related mortality Urban Indian youth are nearly 5 times more likely to attempt suicide requiring hospitalization than all other urban youth combined 9 *Urban Indian Health Institute (2004) The Health Status of Urban American Indian and Alaska Natives; (2010) Visibility Through Data: Health information for Urban American Indian and Alaska Native Communities, retrieved from

10 Suicide Among American Indian and Alaskan Natives Suicide among AI/NA populations Higher risk: young and middle-aged AI/AN Ages 15 – 24: Rates of per 100,000 Ages 40 – 59: Rates of per 100,000 Suicide is the second leading cause of death for AI/AN youth in the age group, 2.5x the national rate for this age group Suicidal thoughts and plans among AI/AN adults age 18 and older 54,000 (5.0%) had serious thoughts of suicide in the past year vs. 3.7% overall population 26,000 (2.4%) made a suicide plan vs. 1.0% of overall population Suicide attempts among AI/AN adults age 18 and older 16,000 (1.4%) made a suicide attempt vs. 0.05% of overall population 10

11 Current, Binge, and Heavy Alcohol Use among Persons Aged 12 & Older, by Race/Ethnicity: NSDUH – Summary of National Findings

12 Substance Dependence or Abuse in the Past Year by Race/Ethnicity: 2010

13 Indian Country at a Glance Challenges in AI/AN Communities: Higher adolescent death rates Higher youth suicide rates Higher past month binge alcohol use Higher past month illicit drug use Higher sexual assault rates against females Higher homicide rates against women Higher rates of intimate partner violence Higher rates of historical trauma AND……... 13

14 Indian Country at a Glance AND ……… Lower mental / substance use disorder treatment rates in non-IHS/specialty treatment settings 14

15 SAMHSA Programs Serving AI/AN Communities 17 Strategic Prevention Framework Tribal Incentive Grants 54 Drug Free Communities Support grants 29 Garrett Lee Smith Tribal Youth Suicide Prevention grants 65 Native communities served by Native Aspirations (bullying, violence, and suicide prevention) 7 Circles of Care Infrastructure grants for Children’s Mental Health Systems 1 Project LAUNCH grantee Native American Center for Excellence (provides technical assistance to native communities)

16 SAMHSA Block Grants Currently, 2/3 of SAMHSA’s budget goes to State Block Grants. – Mental Health Services Block Grant – Substance Abuse Prevention & Treatment Block Grant 2011 & 2012 Uniform Block Grant – States must show evidence they consulted with the Federally recognized Tribes within borders – Current analysis of Section G –Tribal Consultation

17 Behavioral Health – Tribal Prevention Grant (BH-TPG) A proposed non-competitive, multi-year grant included in SAMHSA’s FY 2013 budget request. $40 million from ACA Prevention Fund “Basic” award for every Federally recognized Tribe that submits a plan to prevent substance abuse and suicide. On-going Tribal Consultations on distribution formula and program design.

18 Health Care Reform More people will have insurance coverage ↑ Demand for qualified and well-trained BH professionals Medicaid (and States) will play a bigger role in M/SUDs Focus on primary care & coordination w/ specialty care Major emphasis on home & community-based services; less reliance on institutional and residential care Priority on prevention of diseases & promoting wellness Focus on quality rather than quantity of care 18

19 Tribal Law and Order Act (TLOA) TLOA was signed into law on July 29, It reauthorized and amends the Indian Alcohol and Substance Abuse Prevention and Treatment Act (IASA) of TLOA Section 241: SAMHSA Shall… Lead interagency coordination of efforts, resources and services. Seek Tribal Leader input (consultation) Develop a Memorandum of Agreement with Justice, Interior and HHS. 19

20 Tribal Law and Order Act of 2010  Signed into law July 29, 2010  Reauthorizes and amends: Indian Alcohol and Substance Abuse Prevention and Treatment Act (IASA) of

21 Tribal Law and Order Act of 2010 Key Features: Three (plus) federal Departments – U.S. Dept of Health and Human Services – U.S. Dept of the Interior – U.S. Dept of Justice – Plus… U.S.D.A., Dept of Ed, DOL, ONDCP Establish objectives/goals Encourage development of “Tribal Action Plans” (TAPs) Respect for Tribal sovereignty No additional $$ 21

22 Tribal Law and Order Act of 2010 Key Features: Three main goals (1) Determine scope of the problems faced by Tribes (2) Identify relevant resources and programs of each partner agency (3) Coordinate existing agency programs with those established under the Act 22

23 Tribal Law and Order Act of 2010 Key Features: Encourage development of “TAPs” Tribal Action Plan  coordinate resources and programs to combat substance abuse in the tribe Federal cooperation  at the tribe’s request, federal partner agencies help develop a TAP Implementation  federal area representatives enter into agreement with tribe to implement TAP 23

24 Tribal Law and Order Act of 2010 Key Features: Respect for Tribal sovereignty  Unique historical, legal, moral responsibility  Tribal sovereignty to determine what’s best for their people Together, these are the basis of:  Government-to-government relationship 24

25 TLOA also requires SAMHSA to… Create and staff a SAMHSA Office of Indian Alcohol and Substance Abuse (OIASA): Secure operating framework for a Tribal Action Plan (TAP). Establish Inventory/Resource Workgroup. Establish Newsletter Workgroup. Establish an Education Services Workgroup. Launch OIASA website:

26 OIASA Quarterly Newsletter  Publish quarterly  Include reviews of exemplary AI/AN programs  Provide contact and follow-up information about the programs 26

27 Raising Awareness about Behavioral Health in Tribal Communities

28 National Network to Eliminate Disparities in Behavioral Health (NNED)

29 Multicultural Public Awareness Campaign Raising Awareness about Mental Health Problems in Tribal Communities 29

30 Thank You Charles H. Smith, PhD Regional Administrator – Region VIII (CO, MT, ND, SD, UT, WY) Substance Abuse and Mental Health Services Administration (303)