First Nations women’s mental health: results from an Ontario survey
The mental health of Canada’s Aboriginal women has received little scholarly attention. This paper describes the mental health of First Nations women living on reserve in Ontario and compares these findings with results from the National Population Health Survey (NPHS). Reserve communities were randomly selected within urban, rural, remote and special access regions. Depression was measured by the Composite International Diagnostic Interview. Alcohol use and health services utilization questions were identical to those used in the NPHS. Compared with NPHS women, First Nations women reported significantly higher rates of depression (18% vs 9%) but significantly lower rates of alcohol use (55% vs 74% reported drinking in the last year), although significantly greater proportions reported having 5+ drinks on one occasion (43% vs 24%). Given the burden of suffering associated with depression and the twofold risk found here, it is important to examine risk and protective factors specific to First Nations women. The findings of a higher proportion of abstainers, but also a higher proportion of consumers of 5+ drinks among First Nations women relative to NPHS women indicate the need for a more careful investigation, based on community rather than clinical data, of patterns of alcohol use.
KeywordsFirst Nations Women Mental health Depression
Women’s mental health issues have become a greater focus among researchers and health care professionals (Blumenthal 1996) and some efforts to examine women’s mental health in the context of ethnic diversity have been made. In 1996, for example, the Annals of the New York Academy of Sciences volume on Women and Mental Health included separate papers on the mental health of Hispanic, African-American and Asian-American women (Gil 1996; Chisholm 1996; Shum 1996). However, Native American women were not included.
Even more recently, an article by Duran and colleagues (2004) referred to the paucity of information that exists about the extent of mental illness among American Indian and Alaska Native (AIAN) women. In an attempt to examine the prevalence and correlates of psychiatric disorders among AIAN women presenting to primary care, these authors screened a sample of patients presenting to Indian Health Service clinics over a five-month period in Albuquerque, New Mexico (n = 489). Among a subsample (n = 234; 59% of those selected) who underwent the Composite International Diagnostic Interview (CIDI), 20.9% suffered from mood disorder in the past year, of which 81% was depression. There were also high rates of other psychiatric conditions, including alcohol abuse disorders and anxiety disorders. The authors noted that the past-year rates for mood disorder in their sample were 50% higher than those found among women in the National Comorbidity Survey (NCS; Kessler et al. 1994).
Although these findings support the general perception that American Indian adults experience depression at higher rates than their counterparts in the non-Native population (Whitbeck et al. 2002), the results are conflicting. The American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP), conducted to allow comparisons with the NCS, found that the prevalence estimates for lifetime and 12-month depression were lower in the American Indian samples compared with the NCS sample (Beals et al. 2005a, b). The American Indian samples involved two tribes: one from the Southwest and another from the Northern Plains. These results point to the diversity of Native American cultures and the problems in assuming that results of one region apply to another (Whitbeck et al. 2002). It is essential that information about US Native Americans, including women, not be assumed to apply to Aboriginal women in Canada.
The mental health of Canada’s Aboriginal women has received even less scholarly attention than their American counterparts. A search of Medline, Healthstar and Cinahl revealed a paucity of Canadian studies regarding the mental health of Aboriginal women. Although depression is one of the most prevalent mental health disorders in North American women generally, depression among First Nations women has received little attention (Kessler et al. 1994; Offord et al. 1996). A review of the epidemiology of Aboriginal women’s mental health in Canada provided data only on suicide: women living on First Nation reserves had twice the rate of Canadian women nationally (Waldram et al. 1995). Health Canada estimated that the suicide rate among First Nations women is four times higher than Canadian women in general (First Nations and Inuit Branch 2001). The Final Report of the Aboriginal Women’s Synthesis Project (Dion Stout et al. 2001) referred to the effects of colonization, community stress and exploitation on the health of Aboriginal women, and emphasized the need to recognize the many burdens faced by them, including violence, poverty, unemployment, among others. The Royal Commission on Aboriginal People’s report on suicide (1995) indicated that “reactive depression and unresolved grief may be widespread problems.” Nonetheless, studies such as the National Population Health Survey (NPHS) (Statistics Canada 1995), and the Mental Health Supplement to the Ontario Health Survey (OHSUP) (Boyle et al. 1996) did not include First Nations people living on reserve in their sampling frame.
Why is the epidemiology of depression so important to examine within First Nations women? Depression affects twice as many women as men in the general population (Kessler et al. 1994; Offord et al. 1996). As highlighted by Manson, one of the leading American researchers in Aboriginal health, “From a public health perspective, depressive disorders are of particular interest for intervention: they are common and have serious consequences, such as loss of social contacts, decreased work productivity, and the risk of suicide” (Manson 2000). Effective therapies are available for the treatment of depression; however, few have been evaluated specifically with First Nations people (Miranda et al. 2005).
The Ontario First Nations Regional Health Survey (OFNRHS), a province-wide survey which examined the health status of First Nations people living on reserve, provides a unique opportunity to examine the mental health of First Nations women. This paper presents findings about the prevalence of major depressive disorder and associated features in First Nations women living on reserve in Ontario, and compares the findings to those for Ontario women in the National Population Health Survey (NPHS). Since remote residence may play a role in mental health, health behaviours and service use (Middleton et al. 2003), we also describe differences within the OFNRHS sample by geographic stratum.
Of the 120 First Nation communities in Ontario with “on-reserve” population (Indian and Northern Affairs Canada 1996), 30 were systematically selected after stratification by location: urban (eight selected to participate), rural (12 selected), special access, i.e., no year-round road access (nine selected) and remote (one selected). A second stage of sampling occurred within communities: individuals were stratified by gender and age (newborn to 11, 12 to 17, and 18 and over) and systematically selected; for example, for a community with a population of 95 females over age 18, we selected every fourth female. In-home interviews were conducted by trained Aboriginal interviewers in March through October 1997. A detailed description of the survey methodology appears elsewhere (MacMillan et al. 2007).
The sampling unit for the NPHS (1994–95) was the household, in a two stage stratified design (Statistics Canada 1995). However, the data presented here derive from the health portion of the interview; only one member of the household responded to this section. Women aged 18 and over from Ontario (NPHS-O) were selected as the comparison group.
The OFNRHS measures reported here are identical to those in the NPHS. Depression in the last 12 months was measured by the University of Michigan version Composite International Diagnostic Interview (UM-CIDI) which included modifications to the original CIDI (World Health Organization 1990) to improve its usefulness in general population surveys (Kessler et al. 1994; Offord et al. 1996). The CIDI used DSM-III-R and ICD-10 criteria. Field trials showed good inter-rater reliability, test–retest reliability and validity for the majority of psychiatric diagnoses with the exception of psychosis (World Health Organization 1990; Wittchen 1994; Offord et al. 1996).
Distress, chronicity and impairment were a subset of other CIDI variables. The distress scale contained six items regarding feelings such as nervousness and hopelessness; the score range was 0 to 24, with higher scores indicating more distress. Chronicity was measured by three items regarding the frequency and intensity of distressed feelings. Scores could range from 1 to 8; higher scores indicated better health. All respondents were asked the distress and chronicity items. The impairment item (“How much do these experiences usually interfere with your life or activities: a lot, some, a little or not at all?”) was asked only of those who reported some distress.
Questions regarding alcohol use (frequency of drinking in the past 12 months, number of drinks on one occasion) and use of health services (seeing a health professional for mental or emotional problems) were identical to those in the NPHS.
Data from both surveys were weighted. The OFNRHS survey weights adjusted for community non-response, individual non-response and out-of-scope units in the selected sample of individuals, and community population counts. In the NPHS, weighting procedures were applied to adjust for sampling design and non-response (Statistics Canada 1995). (Further information about use of weighting in the OFNRHS survey is available from the authors on request.)
All analyses were carried out on weighted data using SUDAAN for Windows (Release 7.5.3) which makes statistical adjustments for survey design effects (Levy and Lemeshow 1999). Differences between the samples were tested by calculating t, where the standard error of the difference of estimates equals the square root of the sum of the squared standard errors. Because of the number of tests, alpha was set at .0017; using a conservative estimate of degrees of freedom (df = 100), the critical t value was 3.23. Significant differences noted in the tables are based on this value.
Twenty-three communities agreed to participate; three special access communities, two rural and one urban community refused to take part in the survey, and one special access community selected did not have an on-reserve population so was therefore ineligible. Reasons for non-participation included involvement in other research commitments, lack of interest in research, or mistrust of the research process. Within communities who agreed to participate, the response rate for women was 90.9% (769/846). Non-respondent women were not statistically different from respondents in geographical region and age.
Characteristics of women, by sample
OFNRHS women n769 (unweighted) % (standard error)
NPHS-O women n2,662 (unweighted) % (standard error)
Age group 18–44a
Married or common-law
Some high school or lessa
Working for pay or profit
Perceived health as excellent/very good/gooda
Household size 1–3 personsa
Mental health indicators
Mental health indicators, by sample
OFNRHS women n769 (unweighted) % (standard error)
NPHS-O women n2,662 (unweighted) % (standard error)
Talked to health professional about emotional or mental healtha
Felt like dying/taking your life
How much distress interfered with life: a little, some or a lota
Had an alcoholic drink in last 12 monthsa
Drank once a week or less in last 12 months (includes non-drinkers)a
Had 5+ drinks on one occasion in last 12months (includes non-drinkers)a
Mean (standard error)
Mean (standard error)
Number of times talked to health professional in last 12 months (of those who talked to HP)
Distress score (0–24)a
Chronicity score (1–8)
Significantly fewer First Nations women reported having had a drink in the last 12 months than their NPHS counterparts. A much higher proportion indicated having one drink a week or less in the last year, compared with NPHS-O women. However, more First Nations women than NPHS-O women reported having five or more drinks on one occasion (see Table 2).
Analysis of OFNRHS data by geographic stratum (urban, rural, remote/special access) showed no differences in rates of depression or in chronicity scores; however, a significantly higher proportion of women living in remote/special access communities reported that they felt like dying or taking their lives in the last 12 months (24%, se = 4.5) than those in urban (11%, se = 2.9) or rural (12%, se = 2.3) communities. Distress scores were significantly higher in remote/special access communities (mean = 7.0, se = .41) than in urban (mean = 4.9, se = .63). Further, significantly more rural (71%, se = 2.2) and remote/special access (77%, se = 5.0) respondents compared with urban respondents (61%, se = 3.5) reported that distress interfered with their activities. Although there was no significant difference by remoteness in the proportion of women who spoke to a mental health professional in the last year, there was a significant difference in the number of times women saw that professional. Women in urban communities averaged 6.1 (se = .84) visits and those in rural areas averaged 6.8 (se = 1.05); these means were significantly higher than women in remote/special access areas, who averaged 3.0 (se = 0.45) visits.
No significant differences among urban, rural and remote/special access respondents were found in the rates of drinking at all in the last 12 months, in the frequency of drinking or in having five or more drinks on one occasion.
The findings from the OFNRHS about the mental health of First Nations women living on reserve in Ontario provide important and unique information about the prevalence of depression and associated features. Furthermore, the data are from a community survey rather than a clinical sample. As emphasized by Kirmayer and colleagues in a review on the mental health of Aboriginal peoples, most estimates of the prevalence of psychiatric illness are based on service utilization records (Kirmayer et al. 2000). Service utilization is an inadequate proxy measure of the extent of mental health problems in a community. The same authors also note that “lack of specific diagnostic measures” in the First Nations and Inuit Regional Health Surveys generally “makes it impossible to estimate the rate of psychiatric disorders” in Canada’s Aboriginal people (Kirmayer et al. 2000). The OFNRHS used a measure of depression that is well-validated and has been used across North America with a wide range of ethnic groups. Because the measure has been used in population-based surveys, a number of Aboriginal people living off reserve would have participated in validation studies. To our knowledge however, prior to the OFNRHS, no study specific to Aboriginal peoples had been conducted using the UM-CIDI to measure depression. Results of the AL-SUPERPFP, which involved a sample of two American tribes (Beals et al. 2005a, b) were based on use of an adaptation of the UM-CIDI; this survey was carried out in the late 1990’s and so the results were not available to us at the time of the OFNRHS. Of note, they reported that some of their participants found the depression questions difficult (Beal et al. 2005b); this was not the case for the pilot study or the OFNRHS survey. We did not have the opportunity due to time and cost constraints to validate the UM-CIDI against clinician diagnoses prior to conducting the OFNRHS.
One of the most important findings of the OFNRHS is the high rate of depression among First Nations women—twofold that of the NPHS-O sample. While emotional problems are often described as common among First Nations people, the OFNRHS provides some of the first community-based information about the prevalence of depression among First Nations women. Depression is associated with major disability and suffering; in addition, there is a strong link between depression and suicidal behaviour (American Psychiatric Association 2003). Although no comparison data are available from the NPHS-O sample, almost 15% of women acknowledged that they felt like dying, and/or taking their own life in the past year. Understanding the factors that lead to increased depression among First Nations women is essential in developing approaches to reduce both mood disorders and suicide.
The OFNRHS Technical Advisory Committee (TAC) and Research Team considered patterns of alcohol use as an important concept to include; however, gathering information about specific alcohol abuse/dependence disorders was not deemed a priority. Excessive alcohol use is frequently listed as one of the most common problems in Aboriginal communities (Statistics Canada 1993; Postl et al. 1994), yet the OFNRHS data suggest that the majority of First Nations women living on reserve are consuming alcohol infrequently. However, there is a substantial proportion (43%) of women who have had five or more alcoholic drinks on one occasion in the past year. This type of data can be useful in designing future questions that help to identify those women most at risk for alcohol abuse.
The data about contact with a health professional in the last 12 months was somewhat encouraging, since research to date suggests that access to health professionals is a major problem in many First Nations communities. A much greater proportion of First Nations women indicated contact with a mental health professional compared to the Ontario subsample of the NPHS women; this may be due in part to greater proportions of First Nations women experiencing emotional health problems. However, women in remote/special access areas saw a mental health professional significantly fewer times than women in urban and rural areas.
Differences between the First Nations and NPHS-O samples on mental health indicators were not likely due to the youth of the First Nations sample. Among First Nations women, no significant differences by age were found for rates of depression, feeling like dying, distress interfering with life, or for distress or chronicity scores. A significantly greater proportion of younger women than older had talked to a professional regarding mental health, although among those who did see a professional, the number of times seen was not different by age. However, younger First Nations women were significantly more likely than older women to have had an alcoholic drink in the past 12 months, drank more than once a week and had 5+ drinks on at least one occasion. Despite this, rates of alcohol use were for the most part lower than those in the NPHS-O sample.
There are some important limitations to the OFNRHS. The survey did not include questions about major psychiatric illnesses comorbid with depression, including other mood disorders, anxiety, eating, posttraumatic or psychotic disorders. As noted above, questions that would provide prevalence rates of substance abuse disorders were not included. The aim of the OFNRHS was not to collect data on an exhaustive list of health conditions. Decisions about the concepts to be measured were based on those physical, social, emotional and spiritual aspects of health that were considered by the TAC to be of greatest relevance to the Ontario First Nations people living on reserve. The survey included many aspects of health, and it was important to avoid respondent burden by restricting the interview to less than two hours. We hope that the OFNRHS will provide the foundation for further surveys to examine additional aspects of the health of First Nations people who have previously been excluded from large-scale surveys such as the NPHS or the OHSUP.
A second limitation of the OFNRHS is that data about some of the confounding variables for depression were determined too culturally sensitive to collect. For example, no questions asked about current or childhood income level. A number of studies have shown that social adversity is associated with depression in women (Bifulco et al. 1998). Yet it was considered of paramount importance to respect the sensitivities identified by the First Nations representatives in determining the priorities for measuring different constructs within the OFNRHS. Information from studies of American Indian adults suggests that a broad range of factors may increase the risk for depression among Native Americans, including discrimination, culture conflict, poverty and inadequate parenting (Whitbeck et al. 2002). Findings from the work of Duran and colleagues (2004) suggest that socioeconomic deprivation as measured by high debt was associated with lifetime history of mood disorders. In addition to negative life events and alcohol consumption, Whitbeck and colleagues found that perceived discrimination was highly correlated with depressive symptoms among American Indian men and women.
Indeed there is a long history of ethnocentric research in Aboriginal communities where the preferences of researchers are placed above the needs of Native communities (Davis and Reid 1999). A major strength of the OFNRHS findings about First Nations women’s mental health is that the choice of these issues for study was determined by the TAC in collaboration with the Research Team. A second strength is the survey’s high response rate; we attribute this to the guidance of the TAC, which was composed of representatives of First Nations organizations across Ontario, and to the skills of the First Nations interviewers.
While it is tempting to make recommendations on the basis of these findings, the OFNRHS is just the first step in identifying some aspects of the mental health status of First Nations women. The OFNRHS considered only First Nations women living on reserve; it is also essential to consider the health status of Native people living off reserve. Future research priorities as well as plans for policy based on this information need to be determined by First Nations people themselves (MacMillan et al. 1996). While these data are not necessarily generalizable to other First Nations women in Canada, these Ontario data highlight the need to consider the mental health needs of Aboriginal women in Canada a priority.
The Technical Advisory Committee and the Research Team would like to acknowledge the commitment and support of all the First Nations communities who participated in the Ontario First Nations Regional Health Survey. This study was supported with funding from the Tobacco Demand Reduction Strategy, Health Canada. Dr. MacMillan was supported by a William T. Grant Faculty Scholar Award, and by the Wyeth Canadian Institutes of Health Research Clinical Research Chair in Women’s Mental Health. Dr. Offord was supported by a Career Scientist Award from Health Canada.
Members of the Technical Advisory Committee (subsequently known as the Health Coordination Unit):
Tracey Antone, Chiefs of Ontario Health Coordinator
Phyllis Williams, Health Director, Union of Ontario Indians
Cathryn George, Health Director, Association of Iroquois and Allied Indians
Deanna Jones-Keeshig, Health Coordinator, Independent First Nations
Richard Green, Health Director, Grand Council Treaty #3
Alvin Fiddler, Health Policy Analyst, Nishnawbe-Aski Nation
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