Colonization, historical oppression, and Western treatment models play a major role in mental health outcomes for Indigenous peoples of the United States.

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Illustration by Alyssa Kiefer

Lifelong and generational adverse life experiences can increase your chances of developing depression and other symptoms of emotional distress.

This is the case for millions of Indigenous people in the United States, who face a high lifetime probability of experiencing mental health symptoms. These challenges often increase due to difficulty getting the support they need, when they need it.

Marginalization, stigma, discriminatory public policies, and racial trauma are a few of the factors greatly affecting health outcomes in this community.

Cultural perspectives of depression and other mental health concerns also affect these outcomes. Accordingly, when health professionals lack awareness of these perspectives and Indigenous culture and traditions, treatment may have little benefit.

Wondering what ‘Indigenous’ means?

We use the term “Indigenous” to describe the people who lived in the United States before settlers arrived, though Indigenous can refer to the original inhabitants of any land.

Yet, we also recognize the ways this term falls short.

Like “Native American,” Indigenous is an umbrella term that collectively describes the 574 Indigenous nations in the United States (including Alaska). These nations have different languages, histories, cultural traditions, medicinal knowledge, and wellness practices — factors that can all play a part in the understanding and treatment of mental health challenges.

Not everyone refers to themselves as Indigenous or Indigenous American. Some prefer Native Americans, while others use the term American Indians. If you aren’t sure how to refer to someone, it’s always wise to ask.

Generally, the more specific you can be, the better, so using the name of someone’s nation is often best.

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When trying to reach a diagnosis, mental health professionals may look for key signs and symptoms of depression. All the same, not everyone has the same symptoms or with the same intensity.

In fact, not everyone who experiences certain thoughts or behaviors may consider them a sign of depression.

In an attempt to provide a diagnosis, mental health professionals working from a Western treatment model may ask you about persistent feelings of sadness, for example.

Yet, Indigenous Americans may be more likely to say they feel hopeless, or that their regular activities require too much effort. They may not describe this as sadness.

In 2016 research examining the prevalence of depression and anxiety symptoms in Indigenous Americans, anger was identified as a common symptom. This also varied according to gender.

In Indigenous men, researchers said depression could also involve:

These symptoms may also vary according to age and the cause of depression.

For example, among Indigenous youth, social discrimination and rejection can affect identity and feelings of self-worth. The sense of being hated by others can fuel self-hatred, diminished self-esteem, and thoughts of suicide.

Suicide in Indigenous communities

The suicide rate in Indigenous communities is devastatingly high, especially among adolescents.

Statistics from 2018 report a suicide rate among American Indian and Alaska Native populations of 22.1 per 100,000. The overall rate of suicide in the United States is 14.2 per 100,000.

The contrast becomes even starker when you take into account that these populations only make up about 1.3% of the total U.S. population.

These statistics also support the consistent finding that suicide rates are highest for Indigenous adolescents and young adults. Evidence suggests male Indigenous youth have a higher rate of suicide than any other population, while female Indigenous youth have the highest rate of suicide attempts.

Depression isn’t the only cause of suicide but it could contribute to suicidal thoughts.

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Peripartum (also called postpartum) depression is another major concern for Indigenous families.

Discrimination, along with historical and present-day trauma, can easily increase someone’s chance of developing this condition. So can socioeconomic inequalities such as living in poverty and having limited access to healthcare.

Untreated postpartum depression can have serious consequences for both parents and children. New parents might fear revealing their symptoms will lead to the loss of their child. Instead, they might turn inward, coping through self-harm or emotional distancing.

Western care models offer only one perspective on wellness. Many white therapists consider this treatment model the only accurate approach — but that certainly isn’t the case.

When dominant healthcare perspectives apply the same limiting treatment norms to all, they ignore valid paths to healing. This further marginalizes people of other cultures by denying their traditions and history.

Plus, what healthcare professionals identify as depression may not always be depression for Indigenous people.

Many Indigenous languages don’t have specific terms for depression or mental illness. This doesn’t suggest these languages are too “simplistic” to capture the nuances of Western mental health diagnoses. It may mean Indigenous nations understand mental and emotional distress differently.

For example, depression or anxiety might be considered somatic expressions of physical illness, or a response to disharmony or a lack of balance.

“Indigenous philosophy views an individual as a physical, emotional, thoughtful, and spiritual being,” explains Carol Ladd, a licensed independent clinical social worker in White Bear Lake, Minnesota.

“These aspects are integrated and balanced to make the ‘whole’ of the individual,” Ladd says. “When balanced with love, nurturing, security, and opportunity, there is health and wellness. When out of balance, through deficiency, there is ill health.”

Kylee Jones, an associate clinical social worker at Indigenous Circle of Wellness in Los Angeles, California, says that avoidance and resistance often arise as signs of intergenerational trauma — trauma handed down through generations and shared among members of a culture.

“In many cases, our ancestors had to assimilate for survival, meaning our parents and elders may have punished us for saying or doing certain things that would otherwise be normal or praised,” Jones says.

Mental health professionals who don’t consider the impact of intergenerational trauma may assume this avoidance or disconnect suggests depression, when in fact it relates to symptoms of trauma.

Although depression can be a sign of trauma, it may be important to recognize it as such, and not as the main concern.

Culturally specific concerns can also involve symptoms that resemble depression to healthcare professionals without cultural awareness. For example:

  • Ghost sickness, experienced by Southwest and Southern Plains nations, can involve weakness, appetite loss, hallucinations, and withdrawal, along with nightmares, anxiety, and fear.
  • Wacinko, a condition recognized in the Oglala Sioux nation, can involve anger, withdrawal, a depressed mood, and slowed-down movements or thoughts. It’s often misdiagnosed as depression or schizophrenia and can sometimes lead to suicide.
  • Tawatl ye sni, noted in the Dakota Sioux nation, can involve feelings of loss and deprivation, distracted or wandering thoughts, thoughts of death, suicide, and ghosts.
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Since the first European settlers arrived to claim Indigenous land for themselves, Indigenous communities have faced:

  • stigma, racism, and discrimination
  • cultural erasure and oppression
  • forced relocation
  • kidnapped children
  • forced sterilization
  • abuse at orphanages and schools
  • slavery
  • genocide

The deep wounds left by historical trauma still linger. Of course, stigma, racism, and land dispossession aren’t just concerns of the past. They continue to drive present-day injustices that can raise depression risk and complicate care.

An illustration of disparity

Perhaps you’ve read recent news reports on the hundreds of unmarked graves found near Indigenous boarding schools in Canada.

Indigenous children taken from their families and forced to attend these schools were neglected, abused, and stripped of their language and culture. Thousands went missing while the schools remained in operation — a trauma that was mostly ignored outside Indigenous communities.

The discovery of the grave sites provides Indigenous communities with an unneeded reminder of this horrifying injustice. It also raises an important consideration for those who aren’t Indigenous.

How might news and media outlets report on unmarked graves containing bodies of white children? How might white religious leaders like the Pope, who has yet to apologize for the role the Catholic Church played in these boarding schools, respond?

Haven’t come across these reports? That only serves to emphasize how the damages done to Indigenous Americans still largely go unrecognized.

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Many Indigenous people remain on small reservations or land allotments with few options for relocation and limited resources — including food, water, employment opportunities, and healthcare.

Both isolation and poverty can make it difficult to seek support, especially when these issues intersect with:

  • no access to reliable transportation
  • difficulty communicating with professionals
  • mistrust of government healthcare and other services

Consider the COVID-19 pandemic. Certainly, it disrupted life for most people in the United States.

In many Indigenous communities, it served as yet another barrier to medical care, as well as essential social support. As a result, already underserved and vulnerable communities were left further isolated and devastated without access to care.

Jones notes that intergenerational trauma often shows up in the context of seeking support.

“There’s hesitation in attending routine checkups and seeking medical advice, even basic treatment, in times of need. Because of added stigma, this hesitation is higher when it comes to mental healthcare, complicating seeking and receiving treatment,” she says.

Most mental health researchers and care professionals have an incomplete or inaccurate understanding of Indigenous cultures and their connection to health. This lack of knowledge makes it tough to measure actual rates of depression.

Screening tools that align with Western care models may:

  • miss key symptoms
  • misdiagnose symptoms of other concerns, including post-traumatic stress disorder (PTSD)
  • overlook cultural norms around discussing emotional distress
  • treat culturally significant emotions and experiences as expressions of depression
  • create falsely high rates of depression in Indigenous communities

Treatment, accordingly, may also fall short.

Therapists who want to support Indigenous clients must include their culture to recognize and assist the whole person, Jones explains.

“Removing or rejecting the cultural influence of our client in [the] wellness space can lead to misguidance of information, mistreatment, and even mistrust in the therapeutic relationship,” Jones says.

For many Indigenous nations and communities, acculturation was necessary for survival.

But forced assimilation to white social norms and ideals carries a heavy consequence: the loss of identity, cultural traditions, and spiritual connection. These effects can increase the chances of depression and suicide and carry forward into new generations.

Cultural reconnection may help provide a sense of balance and meaning, protecting against thoughts of suicide and other mental and emotional distress.

Still, while culture may play an important role in healing, the true key to change lies elsewhere: in white attitudes toward Indigenous peoples.

Experts have identified discrimination as a major factor in depression, suicide risk, and other mental health outcomes for Indigenous adults and adolescents.

For youth, in particular, peer discrimination and a sense of not belonging at school often lead to higher rates of depression and substance use.

In a 2017 study examining the ways self-perception and culture might affect the chance of depression and suicide among Indigenous youth, researchers found that:

  • participants reported high self-esteem and ethnic pride
  • stronger cultural identity and involvement did not lower depression and suicide rates
  • participants reporting greater cultural involvement also reported more discrimination

The researchers suggest that an awareness of discrimination can raise suicide attempts and depression symptoms, even among youth who feel connected to their heritage and cultural values.

Both Jones and Ladd emphasize the importance of culture and the four quadrants of health in healing trauma.

“When we break down the part culture — language, environment, core values, feelings, and spiritual connections — plays in our perception and understanding of the world around us, we can better grasp the role it plays in our healing,” Jones says.

Ladd, who provides therapy at Alliance for Healing and is an enrolled member of the Menominee Tribe of Wisconsin, also explains it’s important to include all aspects of a person in healing, which means physical, emotional, mental, and spiritual healing.

“When the trauma symptoms have been resolved, the negative taken away, we must replace them with positives,” Ladd says.

In her role as an Elder, Ladd provides teachings and stories.

“These teachings are good medicine for living in this world,” she says. “They help reframe thoughts with heart and mind connected, to see the self and others with compassion and love.”

Traditional Indigenous healing approaches can vary by nation, but often include:

  • healing ceremonies
  • prayer and spiritual counsel
  • craft work
  • participation in traditional activities
  • community activities

Also essential for those seeking support? The opportunity to connect with therapists who understand their heritage, cultural traditions, and family ties.

This means non-Indigenous therapists must challenge their own biases in order to:

  • decolonize mental healthcare
  • recognize the role of Indigenous traditions and spirituality in healing
  • offer therapy informed by cultural knowledge

The disparities in income, education, and housing that limit opportunities for Indigenous Americans must also be addressed — their land returned, their culture and values recognized.

Members of Indigenous communities must have equitable opportunities to pursue healing. They must also have the opportunity to choose careers in healing and medicine and offer that healing to others.

The atrocities Indigenous nations faced at the hands of white settlers aren’t simply tragedies of the past. Lingering discrimination and socioeconomic inequities compound historical trauma, affecting health and wellness in ways that Western care models fail to address.

“The best advice I can give a non-Native mental health professional is to be humble and honest,” Ladd concludes.

Non-Indigenous therapists who truly want to support Indigenous communities and individuals in healing depression and trauma must:

  • openly acknowledge racism and bias
  • work toward anti-racism and allyship
  • prioritize Indigenous approaches to healing

These actions enable progress from mere awareness toward much-needed deeper understanding.