Relatively little research has examined directly the mental health status and treatment needs of the indigenous peoples of the world. This is both unsurprising and remarkable. Unsurprising in that the needs and rights of indigenous peoples have been historically of little concern to those larger and more powerful nations that moved across the globe in pursuit of wealth; remarkable in that during that same period of colonialism there has been no lack of knowledge of the brutalities to which indigenous peoples have been and continue to be subjected.
In 1552, Bartolome de las Casas, a Spanish friar, published The Devastation of the Indies, an account of the atrocities committed by the Spanish, whom he described as behaving like ravening beasts, wolves, tigers, or lions that have been starved many days, in their conquest of the New World. Las Casas estimated that some 15 million indigenous people were slaughtered in the Americas during the half century following Columbus' arrival in the New World.
While the mass killings of indigenous peoples have been reduced in scale over the last 500 years, they have never stopped. Indigenous peoples in El Salvador and Guatemala have been the targets of political violence. Amnesty International has called for inquiries into killings of tribal peoples in the Chittagong Hill Tracts of Bangladesh, human rights violations against indigenous peoples in Myanmar, political killings of tribal members in the Cordillera region of the Philippines, and the torture, rape, and death of tribal peoples while in legal custody in India.
Given the trauma and dislocations that indigenous peoples have experienced, and to which they continue to be subjected, we can assume that they suffer from high rates of various neuropsychiatric and behavioral problems, yet relatively few data exist concerning the mental health status and treatment needs of indigenous peoples. What we do know points to great unmet needs. Throughout the Western Hemisphere, indigenous peoples suffer from high rates of alcoholism and suicide. The same can be said of the peoples of Oceania and northern Russia, as well as the aboriginal groups of Taiwan. Furthermore, we can safely conjecture the dislocation, epidemics, depopulation, and subjugation have put indigenous peoples everywhere at high risk of depression and anxiety.
The Worlds of Indigenous Peoples
It is estimated there are 5000 to 6000 distinct groups of indigenous peoples living in more than 70 countries. Their numbers total about 250 million persons, or four to five percent of the world's population. This population is far from homogeneous. While it may be true that indigenous peoples share a close attachment to their land, commonly lack statehood, are subject to economic and political marginalization, and are the objects of cultural and ethnic discrimination, they exhibit wide diversity in lifestyles, cultures, social organization, histories, and political realities.
The most important factor in the history of indigenous peoples has been the European economic expansion and development that began a little more than 500 hundred years ago and continues to the present day. The initial phase of European colonialism in the 16th, 17th, and 18th centuries, which saw the discovery and exploitation of the New World, the beginning of the exportation of slaves from Africa to Europe and America, the establishment of colonies and trade routes in Asia, and the colonization of Oceania, was the first step towards bringing the entire world into a single economic system. The effects were disastrous for indigenous peoples: smallpox, diphtheria, influenza, measles, and other epidemics killed millions across the world, and European expansion brought with it an economic system that sought lands and markets to exploit, resulting in enormous pressures on indigenous peoples to protect their lands and ways of life against overwhelming and merciless forces. Indigenous peoples continue to be seen as standing in the way of development because they do not want to relinquish their lands for exploitation, and while they are no longer subjected to the brutal methods of slaughter and dislocation that were employed in the past, they are still subject to forces used with the intent to remove them from the land and destroy their way of life. Everywhere, the cultures of indigenous peoples have been repressed, challenged, or overwhelmed by larger populations and more powerful states.
Depopulation
The Mehinaku Indians live in the Upper Xingu basin of the Amazon rain forest in Brazil. When first contacted in 1877, about 3000 lived in the area. Less than 100 years later, when Gregor did his field work, their population had fallen to approximately 700, partly as a result of measles and influenza epidemics. The effects of this demographic change were significant: two original villages consolidated into one while also absorbing refugees from other groups that had disbanded or died off. Mehinaku culture also changed in the process. With depopulation and its associated loss of collective memory, many rituals and games disappeared. The disastrous effects of contact with the outside world have made the Mehinaku insecure about their future.
Violence
The legacy of violence against indigenous peoples is appalling. One need look no further than the slaughter of the aboriginal peoples of the Western Hemisphere. But while mass killings are no longer the rule for contact between states and indigenous peoples, they do occur. During the 1994 war in Rwanda, as many as 30 percent of the Tutsi died or were killed in massacres, and another 30 percent were forced to flee the country. During the Guatemalan civil war, reports of atrocities committed against Maya were documented almost daily, and by 1983, the survival of many of the smaller Mayan groups was in doubt. During a period of 30 years, an estimated 75,000 Guatemalan Indians disappeared or were killed. More than 300,000 have sought refuge in other countries such as Mexico, Belize, Honduras, and the United States.
Dislocation
Whenever they have come into contact with more powerful nations, indigenous peoples have been pushed aside and forced to give up their traditional territories. The Navajos and Hopis of the Southwest United States were relocated so that mineral resources could be developed in northern Arizona; Australian Aborigines have been driven off their lands by cattle ranchers; in Thailand, many of the hill tribes were relocated because the government believed that the tribes' traditional methods of slash and bum agriculture were destroying the forests; and in Brazil, China, India, Malaysia, and the Philippines, hydroelectric projects have displaced millions of peoples. Finally, dislocation occurs when, for sheer economic survival, indigenous peoples are forced to migrate to urban areas.
Poverty
Not surprisingly, indigenous peoples are among the poorest of the poor. A World Bank report concluded that poverty among Latin America's indigenous peoples is pervasive and severe: their living conditions are abysmal, they receive less education, they work more and cam less, and their overall health is poorer than non-indigenous populations. The Scheduled Tribes of India lag economically far behind the rest of the country. Unemployment rates among the Maori of New Zealand are three times as high as those of non-Maoris. The Lese and Efe of the Democratic Republic of Congo are impoverished as a result of exploitation by government authorities. Finally, a survey of patients -- 90 percent of whom were Inuit -- seen in a psychiatric service clinic on Baffin Island found that less than one-third had been employed in a previous year.
The Context of Mental Health: Sociocultural Environments and Mental Health
It is critical to note that an essential feature of a people's sociocultural environment is meaning. Each culture provides pathways by which individuals may satisfy their needs for positive affect, prestige, and meaning. Small-scale, hunter-gatherer societies provide several such pathways: excellence in hunting, storytelling, or as a healer. More complex societies offer a greater array of pathways. Whatever its size, complexity or environment, a central task of any culture is to provide its members with a sense of meaning and purpose in the world. What happens, then, when a people's way of life is destroyed through disease, genocide, loss of territory, and repression of language and culture, when pathways to meaning are no longer available? As an overview of the literature on mental health problems of indigenous peoples makes clear, it leads to both psychopathology and mortality.
The interrelationship between sociocultural environments and mental health must be held firmly in mind when discussing the mental health of indigenous peoples. Mental health must be considered as being deeply enmeshed with economic and political concerns such as poverty, hunger and malnutrition, social change, and violence and dislocation. Social pathologies such as substance abuse and violence, health problems such as heart disease and depression, and social conditions such as poverty are interrelated to such an extent that it is impossible to differentiate precisely one problem from another.
Problems of Diagnosis and Treatment
Epidemiological data on psychiatric disorders and behavioral problems among indigenous peoples are rare. Even when data do exist, methodological issues raise questions of their accuracy. Indeed, all cross-cultural psychiatry faces problems of diagnostic validity.
A recent review of the literature on the interrelationships between culture and depression concluded that a better understanding of the phenomenology of depression must not only encompass symptoms but take into consideration the social contexts and cultural forces that shape one's everyday world, that give meaning to interpersonal relationships and life events. Furthermore, it is widely believed that the manifestation of depression in non-Western populations tends to take the form of somatic symptoms rather than psychological ones, the implication being that diagnostic categories are, to a great extent, culturally constructed and their symptom profiles are not universal.
Although depression is the most frequently diagnosed problem among American Indians who present at mental health treatment facilities, it is easily misdiagnosed, and its relationships to other conditions such as alcoholism, antisocial behavior, physical illness, and grief, are not well understood. A better understanding of the character of depression among American Indians must precede accurate estimates about its prevalence and the testing of hypotheses about its etiology and the development of effective guidelines for its treatment in these populations. Among the Hopi Indians in the American Southwest, Manson and colleagues found that few (seven percent) of the subjects knew of any Hopi word or phrase that was the equivalent of the term depression. Moreover, 22 percent of the clinical sample with major depression reported dysphoric mood for one but not two weeks, indicating that duration of this symptom may vary significantly from one cultural setting to another. Fully one-half of the clinical sample (compared to one-quarter in the general population) was suffering from both chronic and major depression, a pattern that may explain why the clinical course of depression among American Indians is so pernicious and debilitating. Finally, the coexistence of alcoholism and depression among American Indian men deserves closer examination, in view of the fact that this research found that major depression was secondary to an alcoholic condition in every male subject.
The Mental Health of Indigenous Peoples
Despite data limitations, it seems safe to conclude that the stressors to which the indigenous peoples of the world have been and continue to be exposed result in relatively high rates of mental disorders and behavioral problems such as depression and anxiety, suicide and substance abuse.
Depression, substance abuse, and suicide represent the areas of greatest need with regard to the mental health of indigenous peoples. These problems cannot be separated from the social, cultural, and historic contexts in which they occur. A strictly biomedical approach to depression is insufficient when the individuals seeking treatment are constantly facing life conditions that engender stress. This is not to imply that treatment for depression through the use of psychopharmacology and psychotherapy is not potentially efficacious. But it does mean that any mental health program for indigenous peoples must offer a community psychiatry perspective broad enough to address both the needs of individuals and the local worlds in which they live. Mental health professionals must place their practice within the wider frameworks of social justice and better living environments.
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