Microsoft Word - MS 10820 Cover page.docx The International Indigenous Policy Journal Volume 12 | Issue 2 May 2021 Mental Health Interventions for First Nations, Inuit, and Métis Peoples in Canada: A Systematic Review Simon Graham Office of the Chief Medical Officer, First Nations Health Authority, Canada, grahams1@unimelb.edu.au Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Australia Krista Stelkia Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada, krista_stelkia@sfu.ca Cornelia Wieman Office of the Chief Medical Officer, First Nations Health Authority, West Vancouver, British Columbia, Canada, Nel.Wieman@fnha.ca Evan Adams Chief Medical Officer First Nations Health Authority, West Vancouver, British Columbia, Canada, Evan.Adams@canada.ca Recommended Citation Graham, S., Stelkia, K., Wieman, C., & Adams, E. (2021). Mental health interventions for First Nations, Inuit, and Métis peoples in Canada: A systematic review. The International Indigenous Policy Journal, 12(2). https://doi.org/10.18584/iipj.2021.12.2. 10820 Mental Health Interventions for First Nations, Inuit, and Métis Peoples in Canada: A Systematic Review Abstract Higher rates of anxiety, depression, and attempted suicide are reported among First Nations, Inuit, and Métis people compared with non-Indigenous people in Canada. This systematic review summarises the key components of mental health interventions among Indigenous Peoples in Canada. We searched MEDLINE, PubMed, PsycINFO, and Web of Science between January 1,1970, and August 30, 2019. Studies needed to be an intervention addressing suicide, depression, or anxiety. There were 14 studies included in the analysis: 8 quantitative, 2 qualitative, and 4 mixed methods. By geographical location, 5 were urban, 5 non-urban, and 4 included multiple areas. Beneficial interventions included ceremony, being on the land, engaging in traditional food gathering, culturally grounded indoor and outdoor activities, and the sharing of Indigenous Knowledge by Elders. Keywords Indigenous, Aboriginal, First Nations, Métis, Inuit, anxiety, depression, suicide, Elders, culture as treatment Acknowledgments All of the authors are Indigenous people. Simon Graham’s salary was supported by the Australian Government Department of Education and Training through an Endeavour Research Leadership fellowship and an Australian National Health & Medical Research Council fellowship. Disclaimer The content of this article is solely the responsibility of the authors and does not reflect the views of the First Nations Health Authority, the Australian Department of Education and Training, or the University of Melbourne. Creative Commons License This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License. 1 Graham et al.: Indigenous Mental Health Interventions Published by Scholarship@Western, 2021 Mental Health Interventions for First Nations, Inuit, and Métis Peoples in Canada: A Systematic Review Mental health is a major health priority for First Nations, Inuit, and Métis peoples in Canada, collectively called Indigenous Peoples (Alianait Inuit-Specific Mental Wellness Task Group, 2007; Anderson, 2015; First Nations Health Authority, 2019; Wieman, 2006). Indigenous Peoples in Canada are estimated to comprise 4.9% of the total population (Statistics Canada, 2017). Indigenous people have a strong connection to community and land and have a holistic view of health that includes the physical, emotional, and spiritual well-being of a person and their community. Although the health and well-being of Indigenous people in Canada has improved significantly, Indigenous people continue to have higher rates of poor mental health, suicide, infant mortality, diabetes, obesity, food insecurity, and lower life expectancy (Gionet & Roshanafshar, 2016; Public Health Agency of Canada, 2018; Ring & Brown, 2003). The Government of Canada has released strategies to reduce these disparities and acknowledged that culture may play a role in improving well-being, including mental health. From 2019 to 2020, the Government of Canada invested $425 million to address mental health and well-being among First Nations and Inuit populations through culturally grounded prevention services, supports, and treatment programming (Indigenous Services Canada, 2019). Considering the increased demand and investment in Indigenous-specific mental health interventions and programming, it is imperative to understand what components of mental health interventions are effective at improving mental health and well-being of Indigenous Peoples. Therefore, this review aims to summarize mental health interventions that were specifically designed by or for Indigenous Peoples in Canada. Literature Review First Nations, Inuit, and Métis Peoples in Canada In Canada, there are three distinct Indigenous groups: First Nations, Inuit, and Métis (Government of Canada, 1982). While recognized as comprising the Indigenous population in Canada, each nation is culturally distinct with unique histories, cultural practices, and beliefs (Assembly of First Nations, 2020; Métis Nation, 2020; Tungasuvvingat Inuit, 2020). First Nations have for millennia lived across the land that is now Canada and are the only Indigenous group in Canada subject to the Indian Act (Government of Canada, 2020). First Nation people who are formally recognized under the Indian Act are designated as a “Status Indian” and are subject to its race-based legislation and eligible to access services provided by the federal government (Government of Canada, 2020). However, while 697,510 people (49.8% of the total Indigenous population) are Status First Nations, approximately 214,000 (15.3%) are “non-Status” First Nations: People who self-identify as First Nations but are not formally recognized by the Government of Canada under the Indian Act (Government of Canada, 2011). Inuit are the Indigenous inhabitants of Northern Canada, but they are not formally recognized as “Indians” under Canadian law (Tungasuvvingat Inuit, 2020). The intermarriage of European men and First Nation women during the 17th century led the founding of a distinct group called the Métis (Métis Nation, 2020; Smylie, 2009). As each Indigenous Nation in Canada is unique, it is important to consider each group’s diverse experiences when examining programs and services to better meet the needs of each Indigenous population. 2 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10820 Indigenous Peoples have poorer mental health outcomes, including anxiety, depression, and suicide, compared to non-Indigenous peoples in Canada (Kumar & Tjepkema, 2019; Statistics Canada, 2017). While Indigenous Peoples overall experience poorer mental health outcomes, there are differences in mental health outcomes among First Nations, Inuit, and Métis peoples (Statistics Canada, 2020). For example, compared to non-Indigenous people in Canada, suicide rates were 3 times higher among First Nations, 9 times higher among Inuit, and 2 times higher among Métis people (Statistics Canada, 2020). Suicide rates were highest among 15- to 24-year-old Inuit males and females and First Nations males (Kumar & Tjepkema, 2019). Geographical location also seems to play a role, with First Nation people living on reserve having twice the suicide rate of those living off reserve (Kumar & Tjepkema, 2019). On reserve, approximately 1 in 4 First Nations youth and 1 in 5 First Nations adults report psychological distress that have been linked to moderate to severe mental health disorders (First Nations Information Governance Centre, 2018). To address mental health disparities that exist within Indigenous populations, effective components of mental health interventions for Indigenous Peoples need to be identified. Given the historical and intergenerational trauma brought on by settler colonialism, mental health interventions designed and led by Indigenous people and communities in Canada hold greater promise at improving overall mental health and well-being compared to Western-based approaches (Aguiar & Halseth, 2015; Bartram & Chodos, 2013). As culture and identity are central to one’s mental health and well-being, interventions which focus on “culture as treatment” may reduce trauma and advance overall mental health and well- being (Gone, 2013). There has been an increased demand for decolonizing mental health programming to focus on culturally specific interventions that are holistic, grounded in Indigenous Knowledges and ways of being, trauma-informed, and center around culture (Ansloos et al., 2019; Thunderbird Partnership Foundation, 2011). The Impact of Colonization on the Mental Health of Indigenous Peoples in Canada The ongoing impacts of colonization continue to have detrimental effects on the mental, emotional, physical, and spiritual health and well-being of Indigenous Peoples (Allan & Smylie, 2015; Gracey & King, 2009). The impact of Canada’s colonial history plays a central role in understanding the disproportionate rates of mental health outcomes within Indigenous communities (Wilk et al., 2017). The Truth and Reconciliation Commission of Canada (2015a) declared, “For over a century, the central goals of Canada’s Aboriginal policy were to eliminate Aboriginal governments; ignore Aboriginal rights; terminate the Treaties; and, through a process of assimilation, cause Aboriginal peoples to cease to exist” (p. 3). The harmful impacts of colonial policies continue to have long-term and intergenerational effects on health (McKenzie et al., 2014; Truth and Reconciliation Commission of Canada, 2015b). Survivors of the Canadian residential school system have poorer physical, mental, and emotional health, including higher rates of depression, mental distress, substance misuse, stress, and suicidal behaviours (First Nations Information Governance Centre, 2018; Hackett et al., 2016; Wilk et al., 2017). A study in British Columbia examined the mental health profiles of 127 Survivors of the residential school system and found that only two were not diagnosed with a mental disorder (Corrado & Cohen, 2003). The most prevalent disorders included post-traumatic stress disorder, substance abuse disorder, and depression (Corrado & Cohen, 2003). Residential school Survivors have reported isolation from family; verbal, emotional, and physical abuse; loss of cultural identity; and harsh discipline as the most common factors that contributed to their negative health and well-being (First Nations Information Governance 3 Graham et al.: Indigenous Mental Health Interventions Published by Scholarship@Western, 2021 Centre, 2018; Truth and Reconciliation Commission of Canada, 2015b). The harm and trauma perpetrated on Survivors has also been found to have intergenerational mental health impacts on their children and grandchildren, such as an increased risk of depression and higher rates of suicidal thoughts or attempts (Bombay et al., 2011; Elias et al., 2012). Therefore, the harmful impacts of these colonial policies and practices continue to play a role in undermining Indigenous mental health and well-being today (King et al., 2009; Nelson & Wilson, 2017). Mental Health Interventions Among First Nations, Inuit, and Métis Peoples in Canada There is a critical need to address the mental health and well-being of Indigenous Peoples in Canada. Mental health continues to be identified as a key priority area by First Nations, Inuit, and Métis organizations and communities across Canada (Alianait Inuit-Specific Mental Wellness Task Group, 2007; First Nations Health Authority, 2019; Métis Nation, 2018). The need to address the growing mental health disparities in Indigenous Peoples compared with non-Indigenous peoples in Canada was emphasized in the findings of the Truth and Reconciliation Commission of Canada. The Truth and Reconciliation Commission of Canada Call to Action #19 called upon the federal government to “close the gap in health outcomes between Aboriginal and non-Aboriginal communities,” including mental health, suicide, and addiction (Truth and Reconciliation Commission of Canada, 2015c, pp. 2-3). This was further highlighted by the National Inquiry into Missing and Murdered Indigenous Women and Girls (2019), which focused on increasing funding and support for holistic services and programming in areas including trauma, addictions treatment, and mental health services. This review will summarise Indigenous interventions that have improved the mental health of First Nations, Inuit, and Métis peoples in Canada. Methods This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement (Moher et al., 2009). Rationale The rationale for this study was to highlight the work Indigenous communities were doing to improve the mental health of their communities through designing local culturally based interventions that could provide additional benefits for Indigenous people in Canada. Primary and Secondary Outcomes The primary outcome was: • To summarize the interventions that improved mental health (anxiety, depression, and suicide or attempted suicide) outcomes among Indigenous Peoples in Canada. The secondary outcome was: • To identify what components within these interventions improved the mental health of Indigenous Peoples in Canada. 4 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10820 Eligibility Criteria Study Design We included qualitative, quantitative, and mixed method studies that evaluated an intervention and was published in the peer review literature. Grey literature, letters, books, reviews, editorials, conference abstracts, and theses and dissertations were excluded. Inclusion and exclusion criteria. Studies were included if they reported anxiety, depression, or suicidal thoughts or attempts among Indigenous people in Canada and included an intervention. We included studies that focused on Status First Nations, non-Status First Nations, Inuit, and/or Métis peoples. Only publications in English were included. We excluded studies of Indigenous people outside of Canada, studies of non-Indigenous people, or studies that reported results by combining Indigenous and non- Indigenous people, unless Indigenous people from Canada made up more than 50% of the sample. Studies were excluded if they were reviews, guidelines, or commentaries, or were not in English (Figure 1). If only the abstract or presentation was available, we contacted the corresponding author of the study to assess the published paper or presentation. The reference lists of included studies were examined for additional studies. Search strategy On August 26, 2019, the first and second authors discussed which electronic databases would be used. They also developed the Medical Subject Headings (MeSH) and truncation of the MeSH words. On August 27, 2019, the first author searched the electronic database PubMed and then adapted the search terms for MEDLINE, Web of Science, and PsycINFO. The time period for the search was from January 1, 1960, to August 25, 2019. The below MeSH words were used, and Appendix A provides a breakdown of the MeSH words, truncation, and combinations used in each electronic database. 1. Mental health OR mental wellness OR addiction OR anxiety OR depression OR suicide OR resilience OR trauma; AND 2. Intervention OR community-based OR client centered OR patient centered OR wrap around; AND 3. Aboriginal OR Indigenous OR First Nations OR Inuit OR Métis OR Native; AND 4. Canada The studies that met the inclusion criteria were imported into EndNote. The first author then reviewed the full text against the inclusion criteria and the second author reviewed these studies for inclusion. The first and second authors met and discussed the studies until a consensus was reached. 5 Graham et al.: Indigenous Mental Health Interventions Published by Scholarship@Western, 2021 Figure 1. Flow Diagram of Included Studies Duplicates removed (n = 5) Studies included (n = 14) Studies screened (N = 995) Studies screened (n = 290) Studies removed based on abstract (n = 700) Reasons: 1. Not in Canada (n = 10) 2. Not mental health related (n = 231) 3. Not Indigenous (n = 89) 4. Not an intervention (n = 370) Id en tif ic at io n Sc re en in g El ig ib ili ty In cl ud ed Electronic library databases: 1. MEDLINE (n = 127) 2. PubMed (n = 316) 3. Web of Science (n = 414) 4. PsycINFO (n = 138) Total (N = 995) Studies screened (n = 990) Studies removed based on review of full paper Reason: 1. Not an intervention (n = 276) 6 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10820 Data Extraction Data from each study were extracted by the first author and placed in a Microsoft Excel 2016 table to ensure consistency of the extraction and that all data were entered in the same format. For each study, information was extracted on author, year the study was published, year(s) the study was conducted, the location of the study, the Indigenous group (First Nations, Inuit, and/or Métis), population group (youth, adults, women), sex, age, sample size, study design, incentives provided, the goal of the study, assessment tools used to measure the participants’ mental health status (Appendix C), information about the intervention, and the outcomes or benefits of the intervention. If a study did not report the specific Indigenous group (First Nations, Inuit, or Métis) or provide enough information, the authors used the label “Indigenous.” While we acknowledge and respect the cultural differences between First Nations, Inuit, and Métis peoples, we wanted to include all three Indigenous groups due to the small numbers of studies published within each identity group, to learn the strengths of interventions used by each group, to improve the breadth and depth of understanding, and to highlight any unique approaches used by one group that could be adapted by another. Young people were defined as being 18 years or younger and adults as 19 years or older. A mental health intervention was defined as a process or activity introduced that aimed to reduce anxiety, depression, or suicidal thoughts or attempts. This study did not search grey literature. We used already published studies and as a result did not require ethical approval. Results Included Studies Overall, 14 studies were included (Table 1). Eight were quantitative (DeWit et al., 2017; Fox et al., 1984; Hardt, 2012; Miller et al., 2011; Ritchie et al., 2014; Thomas et al., 2013; Tu et al., 2019; Varcoe et al., 2017), two were qualitative (Cooper & Driedger, 2019; Hadjipavlou et al., 2018), and four were mixed method studies (Crooks et al., 2017; Gross et al., 2016; Harder et al., 2015; Varcoe et al., 2019). In total, 11 were cross-sectional studies that compared before versus after an intervention (Crooks et al., 2017; DeWit et al., 2017; Fox et al., 1984; Gross et al., 2016; Harder et al., 2015; Hardt, 2012; Miller et al., 2011; Ritchie et al., 2014; Thomas et al., 2013; Varcoe et al., 2017, 2019), one was a prospective cohort study (Tu et al., 2019), four conducted one-on-one interviews (Crooks et al., 2017; Hadjipavlou et al., 2018; Harder et al., 2015; Varcoe et al., 2019), one conducted focus groups (Gross et al., 2016), and one used snowball sampling methods to recruit the participants (Hadjipavlou et al., 2018). 7 Graham et al.: Indigenous Mental Health Interventions Published by Scholarship@Western, 2021 Table 1. Summary of Mental Health Intervention Studies Among First Nations, Inuit, and Métis Peoples in Canada Author, year published When the study occurred Location Indigenous groupa Population group Sample size Study design, methods Incentives provided Study goals / aims / objectives Cooper, 2019 September 2015- March 2016 Winnipeg, Manitoba First Nations, Métis Adult women and young girls (8-12 years old) 60 Qualitative: Weekly workshops for 7 weeks 877 photographs, 3 hours of video recordings, 19 hours of audio recordings, 60 hours of notes Not reported What does it mean to be happy, healthy and safe? What is needed to actualise these goals? Crooks, 2017 2011, 2012, 2013 Southwestern, Ontario First Nations, Métis, Inuit Young people (Grades 7 & 8) 105 Mixed methods: Semi- structured interviews Surveys each year $10 gift card What are the effects of a culturally relevant school-based mentoring program for Indigenous youth? DeWit, 2017 Not reported All provinces First Nations, Métis, Inuit Young people (6-17 years old) 125 Quantitative: 2 cross- sectional surveys (before vs. after) $5 gift card 2 movie passes The mentoring relationship experiences of Aboriginal youth The impact of being mentored on behavioural, psychological, and social functioning 8 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10820 Table 1. Summary of Mental Health Intervention Studies Among First Nations, Inuit, and Métis Peoples in Canada (continued) Author, year published When the study occurred Location Indigenous groupa Population, ages Sample size Study design, methods Incentives provided Goals / aims / objectives Fox, 1984 1971-1974 vs. 1976-1980 Manitoulin Island, Ontario First Nations Young people 200 Quantitative: Data from the Coroner’s office Reports from the Ontario Provincial Police Clinical contacts of the Native Health Team and psychiatric facility None given To decrease the suicide rate among First Nations youth Gross, 2016 August 2014- May 2015 Vancouver, Prince George, Smithers, & Moricetown, British Columbia First Nations Vulnerable Indigenous men 95 Mixed methods: Two cross- sectional surveys (before vs. after) Focus-groups Cooking and cleaning services To build brotherhood between members To promote men’s health through education, dialogue, health screening To build pride and fulfilment in their lives Hadjipavlou, 2018 December 2015- March 2016 Vancouver, British Columbia First Nations, Métis, Inuit Patients (25-61 years old) with mental health & substance abuse history 37 Qualitative: Semi-structured interviews at 1, 3, & 6 months None given To examine the impact of Indigenous Elders program on the mental health of Indigenous patients 9 Graham et al.: Indigenous Mental Health Interventions Published by Scholarship@Western, 2021 Table 1. Summary of Mental Health Intervention Studies Among First Nations, Inuit, and Métis Peoples in Canada (continued) Author, year published When the study occurred Location Indigenous groupa Population, ages Sample size Study design, methods Incentives provided Goals / aims / objectives Harder, 2015 2007 Northern British Columbia First Nations Individuals aged 13-25 years 130 Mixed methods: Two cross- sectional surveys (before vs. after) One-on-one interviews Not reported To determine if youth participation would reduce levels of depression, hopelessness, and suicide Hardt, 2012 Not reported Victoria, British Columbia First Nations, Inuit, Métis Adults (25-60 years) 40 Quantitative: Two cross- sectional (before vs. after) None given To determine if alpha brainwave neurofeedback training can have positive psychological results Miller, 2011 Not reported Western Canada Indigenous School students in Grades 2-7 192 Quantitative: Three cross- sectional surveys Not reported To enrich culturally the Friends for Life Program To prevent and reduce anxiety symptoms by offering the enriched program in public schools Ritchie, 2014 Not reported Northern Ontario First Nations Individuals aged 12-18 years 73 Quantitative: Two cross- sectional surveys (before vs. after) Not reported To evaluate the impact of an outdoor adventure leadership experience over 2 years on the resilience of adolescents on reserve 10 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10820 Table 1. Summary of Mental Health Intervention Studies Among First Nations, Inuit, and Métis Peoples in Canada (continued) Author, year published When the study occurred Location Indigenous groupa Population Sample size Study design Incentives provided Goals / aims / objectives Thomas, 2013 June 2011 Rural areas of British Columbia First Nations Adults 12 Quantitative: Two cross- sectional surveys (before vs. after) Not reported To assess the impact of ayahuasca- assisted group therapy on mental and behavioural health Tu, 2019 2014- 2016 Western Canada First Nations Adults attending a primary health care clinic 45 Quantitative: Prospective cohort None given To determine whether including Indigenous Elders into routine primary care improved depressive symptoms and suicidal ideation Varcoe, 2017 Not reported Urban area of Canada First Nations Adult women 21 Quantitative: Two cross- sectional time- periods Not reported To determine whether a health promotion intervention for Indigenous women who have experienced intimate partner violence (Intervention for Health Enhancement after leaving) improves women’s mental and physical health Varcoe, 2019 Not reported Urban area in Western Canada First Nations Adult women 89 Mixed methods: Quantitative: pre vs. post vs. six- months after the intervention Qualitative: one- on-one interviews $25 for each interview Childcare Can an intimate partner violence health promotion intervention (Intervention for Health Enhancement after leaving) improve women’s mental and physical health? Note. a Indigenous group: the Indigenous group name reported by each study is used; however, if the study did not report an Indigenous group, it was labelled as Indigenous. 11 Graham et al.: Indigenous Mental Health Interventions Published by Scholarship@Western, 2021 Mental Health Assessment Tools Used by the Different Studies A total of 29 different tools were used by the studies to measure the mental health status of participants (Table 2 and Appendix C). There were a range of tools used to measure anxiety (e.g., Revised Social Anxiety Scale for Children), depression (e.g., Beck Depression Inventory-II) and suicidal thoughts (e.g., Beck Scale for Suicidal Ideation). There were assessment tools that were broader in scope, such as the 11-item Cultural Connectedness Scale, the McGill Quality of Life Survey, and Sullivan’s Quality of Life Scale. None of the studies used the same assessment tool to measure anxiety or depression or attempted suicide and, as a result, we were not able to group the assessment tools or compare scores of anxiety or depression in one study to another study. Summary of Interventions Used Each study used a range of similar components that have been summarised into three categories: culturally grounded indoor and outdoor activities; Elder or peer-to-peer mentorship; and group activities with other Indigenous people and an Elder (Appendix B). Culturally Grounded Indoor and Outdoor Activities Culturally grounded indoor and outdoor activities included retreats, camps, ceremonies, and Indigenous language study. As highlighted by the outcomes in Table 2, cultural activities that had a strong Indigenous component seemed to provide some benefits in reducing anxiety, depression, or suicidal thoughts. One study conducted culture camps that included traditional food gathering techniques, language, survival techniques, and clan affiliation (Harder et al., 2015). These camps produced positive quantitative outcomes, including a decrease in average depression scores from 10 before compared to 7 after, a decrease in average hopelessness scores from 4 to 3.1, and increases in language skills, connectedness of culture, and connection to community Elders. Qualitative results also support the benefits of an intervention that involves engaging in culturally grounded activities together, with one participant saying, “After the camp I felt very good, like I learned more about what culture is and who I actually am” (Harder et al., 2015, p. 27). Another participant said, “I used to be ashamed of being Native and now I’m not…so yeah, it made me happy for who I am and where I come from” (Harder et al., 2015, p. 27). Elder or Peer-to-Peer Mentorship Some studies paired an Indigenous Elder with a young person. For example, a study by Crooks et al. (2017) compared one group of young people who were mentored by an Indigenous Elder compared to another group who were not. Over a two-year period, the group who were mentored had better mental health scores (on average 61.6 compared to 52.0 for those without a mentor). This study also examined the impact mentorship had on cultural identity; two years of mentoring resulted in an increased cultural identity score of 36.7 in the mentored group compared to 33.2 for those without a mentor (Crooks et al., 2017). Qualitative results support this with one young participant saying, “We can talk about more open things and they are our cultural background too so it seems like we can open up to them more than we can to our teachers” (Crooks et al., 2017, p. 98). 12 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10820 Table 2. Mental Health Interventions Used by Studies and Outcomes Among First Nations, Métis, and Inuit Peoples in Canada Author, year published Study goals / aims / objectives Tools used to measure mental health status Intervention / activities Quantitative outcomes Qualitative outcomes Cooper, 2019 To what does it mean to be happy, healthy and safe? What is needed to actualise these goals? None used Self-reported mental health status Métis specific arts-based workshops Non-competitive games, walks, crafts, shared meals Jewellery making, sports, drawing, Discussion circles, storytelling, scavenger hunts, Medicine Wheel Qualitative only After 7 weeks, “the women began to characterise themselves as strong, capable caregivers who guide their girls as they made decisions.” Crooks, 2017 What are the effects of a culturally relevant school- based mentoring program for Indigenous youth? 14-item Mental Health Continuum—Short Form (MHC) 11-item Cultural Connectedness Scale using a 4-point Likert scale Youth received mentoring for 1 year vs. 2 years Average mental health scores: 2 years of mentoring = 61.6 vs. 1 year of no mentoring = 52.0 Average positive cultural identity scores: 2 years of mentoring = 36.7 vs. 1 year of no mentoring = 33.2 “We can open up to them more than we can to our teacher.” “It feels like they understand what I am trying to say.” “When you don’t feel comfortable it’s okay . . . you can tell them.” DeWit, 2017 The mentoring relationship experiences of Aboriginal youth The impact of being mentored on behavioural, psychological, and social functioning Strengths and Difficulties Questionnaire (SDQ) Revised Social Anxiety Scale for Children (SASC-R) Big Brother, Big Sister program Mentoring of Aboriginal youth 2-4 hours per week with mentor for 1 year Mentored youth had significantly less emotional problems 18-months after meeting their mentor Mentored youth had significantly fewer symptoms of social anxiety and distress in new situations with unfamiliar peers Quantitative only 13 Graham et al.: Indigenous Mental Health Interventions Published by Scholarship@Western, 2021 Table 2. Mental Health Interventions Used by Studies and Outcomes Among First Nations, Métis, and Inuit Peoples in Canada (continued) Author, year published Study goals / aims / objectives Tools used to measure mental health status Intervention / activities Quantitative outcomes Qualitative outcomes Fox, 1984 To decrease the suicide rate among youth Confirmed death from Coroner’s office Confirmed patient record at the psychiatric facility Suicide response team: 2 Indigenous mental health workers A travelling mental health clinic Rainbow Lodge Recovery Centre Suicide rate decreased from 27.7 to 23.4 per 100,000 Quantitative only Gross, 2016 To build brotherhood between members To promote men’s health through education, dialogue, health screening clinics To build pride and fulfilment in their lives None used Survey asked about improvements in their quality of life, mental, emotional, physical, and spiritual health Weekly men’s group Shared meal Health programs with doctors and nurses Linking First Nation Elders with vulnerable men 90% of the men’s scores improved in quality of life, and mental, emotional, physical, and spiritual health Higher attendance increased feelings of connectedness Increased feelings of trust, trusting others with their health, and connectedness to culture Hadjipavlou, 2018 To examine the impact of Indigenous Elders program on the mental health of Indigenous patients None reported Regular meetings with an Indigenous Elder Elders provided a safe “place for healing,” they could “laugh” with, receive “gentle guidance,” and they were “respected” compared to previous health care experiences Qualitative only Decreased depression Decreased suicidal thoughts 14 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10820 Table 2. Mental Health Interventions Used by Studies and Outcomes Among First Nations, Métis, and Inuit Peoples in Canada (continued) Author, year published Study goals / aims / objectives Tools used to measure mental health status Intervention / activities Quantitative outcomes Qualitative outcomes Harder, 2015 To determine if youth participation would reduce levels of depression, hopelessness, and suicide Beck Depression Inventory-II Beck Scale for Suicide Ideation Beck Hopelessness Scale Culture camps Traditional food gathering techniques Language, survival techniques Clan affiliation, Bah’Iats system Change in average score: Depression score before 10.0 vs. 7.4 after Suicide score before 2.3 vs. 1.2 after Hopelessness score before 4.0 vs 3.1 after 90% reported an increase in their opinion of themselves 87% reported an increase in their Carrier language skills 96% reported an increase in traditional culture 92% reported an increase in their connection to community Elders “I used to ashamed of being Native and now I’m not.” “After the camp I felt very good, like I learned more about what culture is and who I actually am.” “Friends are complimenting me on stuff, and it’s making me feel better about myself.” “If I hadn’t done any camps, I would probably have ended up going down the wrong path.” Hardt, 2012 To determine if alpha brainwave neurofeedback training can have positive psychological results Multiple Affect Adjective Check list Clyde Mood Scale Profile of Mood States For 7 days, each participant spent 10 hours at the training centre doing activities plus neurofeedback training Improvements when comparing before and after Quantitative only 15 Graham et al.: Indigenous Mental Health Interventions Published by Scholarship@Western, 2021 Table 2. Mental Health Interventions Used by Studies and Outcomes Among First Nations, Métis, and Inuit Peoples in Canada (continued) Author, year published Study goals / aims / objectives Tools used to measure mental health status Intervention / activities Quantitative outcomes Qualitative outcomes Miller, 2011 To culturally enrich the Friends for Life Program To prevent and reduce anxiety symptoms by offering the enriched program in public schools 39-item self-reported Multidimensional Anxiety Scale for Children (MASC) Friends for Life program classroom-based intervention Individual and group activities that teach children to identify anxiety signals, physical bodily symptoms, worried thoughts, and maladaptive behaviours Mean anxiety score reduced from 45.4 at Time 1 to 43.3 at Time 2 to 41.1 at Time 3 Quantitative only Ritchie, 2014 To evaluate the impact of an outdoor adventure leadership experience over 2 years on the resilience of adolescents on reserve Health and Well-Being Questionnaire Outward Bound Process Model Mental Component Score (MCS) Scale of Positive and Negative Emotion— Balance (SPANE) Self-Esteem Scale (SES) Outdoor adventure leadership experience Wilderness canoe expedition Medicine Wheel Outward Bound Process Model Small group activities 8 experiences with 3 each summer Increase in resilience scores (73.6 to 77.0) Increase in mental component scores (1.2 to 3.5) Positive change from the beginning to the end for mental health, balance of emotion, and satisfaction with life Quantitative only 16 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10820 Table 2. Mental Health Interventions Used by Studies and Outcomes Among First Nations, Métis, and Inuit Peoples in Canada (continued) Author, year published Study goals / aims / objectives Tools used to measure mental health status Intervention / activities Quantitative outcomes Qualitative outcomes Thomas, 2013 To assess the impact of ayahuasca-assisted group therapy may have on mental health and behavioural health The Difficulty in Emotion Regulation Scale The Philadelphia Mindfulness Scale The Empowerment Scale The Hope Scale The McGill Quality of Life Survey The 4-Week Substance Abuse Scale Ayahuasca ceremonies Retreats focussed on addressing issues of addiction Improvements in mindfulness, empowerment, hopefulness, quality of life-meaning, and quality of life-outlook Interviews indicated that the retreats had a positive influence on their lives (average score of 7.9 out of 10) “I wish I was introduced to this retreat 20 years ago as it would have saved me a lot of time and trouble.” Quantitative only Tu, 2019 To determine whether including Indigenous Elders in routine primary care improved depressive symptoms and suicidal ideation Patient Health Questionnaire Suicidal Behaviors Questionnaire Indigenous Elders meeting with individuals experiencing depression and suicidal thoughts in a primary health care clinic A 5-point decrease in depressive symptoms A 2-point decrease in suicidal risk sustained over 6 months 56% decrease in mental health- related emergency department visits Quantitative only 17 Graham et al.: Indigenous Mental Health Interventions Published by Scholarship@Western, 2021 Table 2. Mental Health Interventions Used by Studies and Outcomes Among First Nations, Métis, and Inuit Peoples in Canada (continued) Author, year published Study goals / aims / objectives Tools used to measure mental health status Intervention / activities Quantitative outcomes Qualitative outcomes Varcoe, 2017 To develop and pilot test the Reclaiming Our Spirits health promotion intervention, which provides services to Indigenous women who have experienced intimate partner violence Sullivan’s Quality of Life Scale • PTSD Checklist Civilian Version • Centre for Epidemiologic Studies Depression Scale The intervention for Health Enhancement After Leaving (iHEAL) Health promotion after leaving an abusive partner 14 face-to-face meetings with a nurse over 6- months Average reduction in depressive symptoms (from 10 to 8) Average reduction in trauma symptoms (from 8 to 6) Increase in control of their lives Quantitative only Varcoe, 2019 Can an intimate partner violence health promotion intervention (Intervention for Health Enhancement After Leaving) improve women’s mental and physical health? • Sullivan’s Quality of Life Scale • PTSD Checklist Civilian Version • Centre for Epidemiologic Studies Depression Scale (CESD-R) Weekly workshops led by an Indigenous Elder iHEAL program (10-18 sessions over 6 months) Average decrease in depressive symptoms (28 to 22) Average decrease in trauma score (49 to 43) Average increase in quality-of-life score (38 to 42) “I feel I’m more open now with like doctors, nurses.” “I feel l have more confidence.” “I feel like I am better able to start friendships now. That’s always been a problem.” 18 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10820 Group Activities with Other Indigenous People and an Elder Group activities with other Indigenous people and an Elder included non-competitive games, sharing a meal, discussion circles, and the Medicine Wheel. One study provided Indigenous Elders as mentors, and this had positive results with participants saying, “It feels like they understand what I am trying to say” (Crooks et al., 2017, p. 98), and “When you don’t feel comfortable it’s okay . . . you can tell them [Elders]” (Crooks et al., 2017, p. 99). Mentorship with Indigenous Elders seemed to provide a safe space to talk, be heard, and feel like someone was listening. By having an Elder to connect with, participants seemed to not feel alone, and they valued the added cultural connection. This connection with Elders, other Indigenous people, and their shared culture seemed to interrupt the participants’ negative mental health state and made them feel included and wanted. Further Information Within Each Study Only 1 of the 14 studies did not recruit participants and instead used a large dataset for the analysis (Fox et al., 1984). Overall, four studies provided incentives to participants (Crooks et al., 2017; DeWit et al., 2017; Gross et al., 2016; Varcoe et al., 2019), which included one or a combination of the following: cash (Varcoe et al., 2019), movie passes (DeWit et al., 2017), gift cards (Crooks et al., 2017; DeWit et al., 2017), cleaning services (Gross et al., 2016), and childcare (Varcoe et al., 2019). Providing incentives may have influenced participants’ decision to participate. One study aimed to recruit people who identified as Métis so they could build a specific intervention for Métis peoples and avoid pan- Indigenous results in their study (Cooper & Driedger, 2019). However, the community wanted this study to expand the inclusion criteria to include Métis and First Nations peoples because some young people in the study highlighted that they had one parent who identified as Métis and the other parent who identified as First Nations (Cooper & Driedger, 2019). Discussion Despite the urgent need to address mental health and well-being in Indigenous communities, we only found 14 studies that assessed an intervention for Indigenous Peoples in Canada. Our findings support the concept of culture as treatment, with the three main interventions centered around culturally grounded indoor and outdoor activities, Elder and peer mentorship, or participating in collective activities with other Indigenous peers and an Elder. Although these are not new concepts for Indigenous Peoples, our study highlights that these interventions can play a role in reducing anxiety, depression, and suicidal thoughts. Although the authors acknowledge that Western approaches can help to reduce poor mental health outcomes, our review highlights that adding culture as treatment has additional benefits to reduce poor mental health outcomes especially with Indigenous Peoples in Canada. Out of the 14 studies, 8 included First Nations peoples and 5 included a mix of First Nations, Inuit, and Métis people (Fox et al., 1984; Gross et al., 2016; Harder et al., 2015; Ritchie et al., 2014; Thomas et al., 2013; Tu et al., 2019; Varcoe et al., 2017, 2019). Studies found it challenging to recruit Inuit and Métis participants, so they often recruited First Nations people to reach their sample size targets or at the request of the community. This suggests that groundwork is needed early in the project to connect with communities in order to understand the community’s needs and expectations, and to set up an effective recruitment approach with the community’s involvement. Despite the large disparities that exist within Inuit and Métis communities, the findings demonstrate there is a lack of mental health interventions 19 Graham et al.: Indigenous Mental Health Interventions Published by Scholarship@Western, 2021 developed by and for Inuit and Métis peoples. Considering the demand for mental health interventions that respect and honour Indigenous Ways of Knowing, it is integral that mental health interventions do the groundwork to establish relationships with communities that they hope to work with to deliver an intervention, whether it be First Nations or Inuit or Métis or a combination thereof. The findings from this review suggest that mental health interventions that include culturally grounded indoor and outdoor activities, Elder and peer mentorship, or participating in collective activities with other Indigenous peers and an Elder can provide mental health benefits among Indigenous Peoples in Canada. These activities include ceremony, being on the land, the Medicine Wheel, engaging in traditional food gathering, and being connected with an Elder for conversation and guidance; Elders sharing Indigenous Knowledge throughout the participants’ treatment was also found to be beneficial in improving mental health among the studies reviewed. These findings align with other reviews that have found that culturally adapted mental health interventions resulted in a significant improvement in at least one symptom of mental illness (Leske et al., 2016). The specific activities and interventions are listed in Appendix B. Most of these interventions did not reject Western approaches to mental health but instead highlighted the benefits of also having an Indigenous-grounded approach. Perhaps combining both approaches could have increased benefits to improve mental health outcomes. A promising finding of this study was that 6 out of the 14 studies were for young people (Cooper & Driedger, 2019; Crooks et al., 2017; DeWit et al., 2017; Fox et al., 1984; Harder et al., 2015; Miller et al., 2011). This is a positive result as recent household surveys of Indigenous people highlighted that young Indigenous people are at significantly higher risk of suicide compared to non-Indigenous young people (First Nations Information Governance Centre, 2018; Kumar & Tjepkema, 2019). This report also highlighted that other factors could play a role in the elevated risk of suicide, including living on reserve, having lower household income, living in poverty, having lower levels of education, and being divorced, separated, or widowed (Kumar & Tjepkema, 2019). Mentoring young people with Indigenous Elders and adapting the cultural activities to be more youth-focussed could be beneficial. Our study also found that there is a limited number of gender-specific mental health interventions. Overall, two interventions recruited women (Varcoe et al., 2017, 2019), one recruited adult women and young girls (Cooper & Driedger, 2019), and one recruited men (Gross et al., 2016). Given the unique needs of addressing mental distress and trauma for each gender, there might be a need to create more gender-specific mental health interventions. One of the qualitative studies included in this review, included traditional hunting trips with men, which had some benefits as the men hunted and learned together, and these activities allowed a more open dialogue to occur when talking about their struggles (Gross et al., 2016). Lessons for Future Research and Recommendations Future research on effective Indigenous design and led mental health interventions are required. As increases in community-led and driven mental health initiatives occur across Canada, future reviews should examine grey literature to capture interventions and initiatives taking place in communities. This may increase the number of interventions, which can be reviewed to provide a richer analysis of mental health interventions that improve the mental health and well-being among Indigenous Peoples in 20 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10820 Canada. Given that many community-based initiatives often lack funding or interest in publishing in Western-based academic journals, the grey literature may provide a promising space to learn more about culture-based interventions. It is recommended that future studies on Indigenous mental health interventions be as specific as possible when discussing their study population. Future research should focus on examining the needs of subpopulations within Indigenous communities, including urban or off- reserve populations, young people, women and girls, men, and Inuit and Métis communities. This will result in more context-specific findings that will contribute towards a greater understanding of components of mental health interventions. It is also clear that more groundwork is needed in building relationships with communities before researchers build their recruitment strategies and interventions. Implications for Indigenous Peoples in Other Countries The interventions mentioned in this review could be useful for Indigenous people in other countries. In Australia, Aboriginal and Torres Strait Islander people were found to have incidence rates for anxiety and any mental disorder that are 3 times and 4 times higher, respectively, than the non-Indigenous population (Nasir et al., 2018). In 2020, a randomized controlled trial of a mental health intervention in four Aboriginal communities produced promising results that could inform future guidelines and treatment and care programs (Toombs et al., 2020). In New Zealand, M!ori peoples also experience higher rates of poor mental health compared to non-M!ori people in New Zealand (Baxter et al., 2006). A recent study in New Zealand highlighted that having a strong M!ori cultural identity was associated with positive benefits for M!ori youth in terms of improved well-being scores and fewer depressive symptoms (Williams et al., 2018). Designing Indigenous-led and implemented interventions and programs also support the principles of the United Nations Declaration on the Rights of Indigenous Peoples (United Nations, 2007). Our results from Canada could provide some useful information about the benefits of community-designed interventions that could be used by Indigenous people in other countries. Policy Implications Our review provides some policy implications for mental health practice. Our study shows that existing mental health policy and practice could incorporate an Indigenous lens to achieve better mental health outcomes. If the Indigenous-based approaches summarised in our study were combined with existing Western-based mental health approaches, perhaps this could have further benefits. Our review provides the Canadian government’s Advancing the Mental Health Strategy for Canada: A Framework for Action (2017-2022) with information about specific Indigenous programs that have provided benefits (Mental Health Commission of Canada, 2016). It suggests that these Indigenous approaches, which fit under the broad term of culture as treatment can have benefits and should receive funding and policy support to strengthen the evidence base of possible interventions to improve the mental health of Indigenous and non-Indigenous people in Canada. Limitations There are some limitations to be considered when interpreting the results. Overall, 11 of the 14 studies were cross-sectional before and after study designs, limiting the ability to measure the impact of the interventions. Out of the 14 studies, 8 included First Nations peoples and 5 included a mix of First Nations, Inuit, and Métis peoples (Fox et al., 1984; Gross et al., 2016; Harder et al., 2015; Ritchie et al., 21 Graham et al.: Indigenous Mental Health Interventions Published by Scholarship@Western, 2021 2014; Thomas et al., 2013; Tu et al., 2019; Varcoe et al., 2017, 2019). Therefore, studies were not able to provide results specific to Métis or Inuit peoples. Overall, five studies had a sample size less than 100 (Crooks et al., 2017; DeWit et al., 2017; Fox et al., 1984; Harder et al., 2015; Miller et al., 2011), reducing the statistical power of these studies to show a decrease in the three main outcomes (anxiety, depression, and suicidal thoughts and attempts). In total, 8 of the 14 studies were conducted in Western Canada, particularly British Columbia (Gross et al., 2016; Hadjipavlou et al., 2018; Harder et al., 2015; Hardt, 2012; Miller et al., 2011; Thomas et al., 2013; Tu et al., 2019; Varcoe et al., 2019), so our results may not be generalisable to Indigenous people living in other areas of Canada. Among the 10 studies that reported the geographical location where the study was conducted, 6 were conducted in remote areas (Crooks et al., 2017; Fox et al., 1984; Harder et al., 2015; Miller et al., 2011; Ritchie et al., 2014; Thomas et al., 2013). This suggests that our results may not be relatable to Indigenous people living in urban areas. This is unfortunate, as Statistics Canada has reported that the Indigenous population in Canada has slowly become more urbanised over the past two decades due to employment and economic reasons, with an estimated 52% of Indigenous people living in urban areas (Statistics Canada, 2011). Also, we did not include grey literature in our review, which may have resulted in the exclusion of local online project reports or government programs. Conclusion This review identified three key components that improved the mental health outcomes of First Nations, Inuit, and Métis peoples. These were culturally grounded indoor and outdoor activities, Elder and peer mentorship, and participating in collective activities with other Indigenous peers and an Elder. While culture as treatment remains a promising component to address mental health for Indigenous Peoples, there is a great need for mental health interventions designed specifically and distinctly for First Nations, Inuit, and Métis peoples. The list of different culturally based activities in Appendix B could help future interventions to advance the development and delivery of mental health interventions for First Nations, Inuit, and Métis peoples in Canada. Our study has policy implications particularly for the Canadian government’s Advancing the Mental Health Strategy for Canada: A Framework for Action (2017-2022). Our summary of Indigenous interventions provides examples of how existing mental health programs could incorporate Indigenous ways of addressing poor mental health. Our results could have some useful information for Indigenous people in other countries in designing culturally based programs that reduce poor mental health in supporting national strategies and the United Nations Declaration on the Rights of Indigenous People. 22 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10820 References Aguiar, W., & Halseth, R. (2015). Aboriginal Peoples and historical trauma: The processes of intergenerational transmission. National Collaborating Centre for Aboriginal Health. http://www.nccah-ccnsa.ca/Publications/Lists/Publications/Attachments/142/2015-04-28- AguiarHalseth-RPT-IntergenTraumaHistory-EN-Web.pdf Alianait Inuit-Specific Mental Wellness Task Group. (2007). Alianait Inuit Mental Wellness Action Plan. https://www.itk.ca/wp-content/uploads/2009/12/Alianait-Inuit-Mental-Wellness- Action-Plan-2009.pdf Allan, B., & Smylie, J. (2015). First Peoples, second class treatment: The role of racism in the health and well-being of Indigenous Peoples in Canada. https://www.wellesleyinstitute.com/wp- content/uploads/2015/02/Summary-First-Peoples-Second-Class-Treatment-Final.pdf Anderson, T. (2015). The social determinants of higher mental distress among Inuit. https://assembly.nu.ca/library/Edocs/2015/001921-e.pdf Ansloos, J., Stewart, S., Fellner, K., Goodwill, A., Graham, H., McCormick, R., Harder, H., & Jeffrey, M. (2019). Indigenous Peoples and professional training in psychology in Canada. Graduate Education, Research, and Professional Training in Psychology, 60(4), 265-280. https://doi.org/10.1037/cap0000189 Assembly of First Nations. (2020). Assembly of First Nations. https://www.afn.ca/Home/ Bartram, M., & Chodos, H. (2013). Changing directions, changing lives: The mental health strategy for Canada. Canadian Journal of Community Mental Health, 32(4). https://doi.org/10.7870/ cjcmh-2013-001 Baxter, J., Kingi, T. K., Tapsell, R., Durie, M., & McGee, M. A. (2006). Prevalence of mental disorders among M!ori in Te Rau Hinengaro: The New Zealand Mental Health Survey. Australian and New Zealand Journal of Psychiatry, 40(10), 914-923. https://doi.org/10.1080/j.1440- 1614.2006.01911.x Bombay, A., Matheson, K., & Anisman, H. (2011). The impact of stressors on second generation Indian residential school Survivors. Transcultural Psychiatry, 48(4), 367-391. https://doi.org/ 10.1177/1363461511410240 Cooper, E., & Driedger, S. M. (2019). ‘If you fall down, you get back up’: Creating a space for testimony and witnessing by urban Indigenous women and girls. The International Indigenous Policy Journal, 10(1), 1-22. https://doi.org/10.18584/iipj.2019.10.1.1 Corrado, R. R., & Cohen, I. M. (2003). Mental health profiles for a sample of British Columbia’s Aboriginal Survivors of the Canadian residential school system. http://www.ahf.ca/downloads/ mental-health.pdf 23 Graham et al.: Indigenous Mental Health Interventions Published by Scholarship@Western, 2021 Crooks, C. V, Exner-Cortens, D., Burm, S., Lapointe, A., & Chiodo, D. (2017). Two years of relationship-focused mentoring for First Nations, Métis, and Inuit adolescents: Promoting positive mental health. The Journal of Primary Prevention, 38(1-2), 87-104. https://doi.org/10.1007/s10935-016-0457-0 DeWit, D. J., Wells, S., Elton-Marshall, T., & George, J. (2017). Mentoring relationships and the mental health of Aboriginal youth in Canada. The Journal of Primary Prevention, 38(1-2), 49-66. https://doi.org/10.1007/s10935-016-0441-8 Elias, B., Mignone, J., Hall, M., Hong, S. P., Hart, L., & Sareen, J. (2012). Trauma and suicide behaviour histories among a Canadian Indigenous population: An empirical exploration of the potential role of Canada’s residential school system. Social Science and Medicine, 74(10), 1560-1569. https://doi.org/10.1016/j.socscimed.2012.01.026 First Nations Health Authority. (2019). Mental health and substance use. https://www.healthlinkbc.ca/ mental-health-substance-use/resources/fnha-mhsu First Nations Information Governance Centre. (2018). National report of the First Nations Regional Health Survey Phase 3: Volume one. https://fnigc.ca/sites/default/files/docs/ fnigc_rhs_phase_3_national_report_vol_1_en_final_web.pdf First Nations Information Governance Centre. (2018). National report of the First Nations Regional Health Survey Phase 3: Volume two. https://fnigc.ca/wp-content/uploads/2020/09/ 713c8fd606a8eeb021debc927332938d_FNIGC-RHS-Phase-III-Report1-FINAL-VERSION- Dec.2018.pdf Fox, J., Manitowabi, D., & Ward, J. A. (1984). An Indian community with a high suicide rate—5 years after. Canadian Journal of Psychiatry, 29(5), 425-427. https://doi.org/10.1177/ 070674378402900512 Gionet, L., & Roshanafshar, S. (2016). Select health indicators of First Nations people living off reserve, Métis and Inuit (Catalogue no. 82-624-X). Statistics Canada. https://www150.statcan.gc.ca/ n1/pub/82-624-x/2013001/article/11763-eng.htm Gone, J. P. (2013). Redressing First Nations historical trauma: Theorizing mechanisms for Indigenous culture as mental health treatment. Transcultural Psychiatry, 50(5). https://doi.org/10.1177/ 1363461513487669 Government of Canada. (1982). Constitution Act, Section 35. Indigenous Peoples of Canada. https://indigenousfoundations.arts.ubc.ca/constitution_act_1982_section_35/#:~:text=Secti on%2035%20of%20the%20Constitution%20Act%20states%3A,and%20M%C3%A9tis%20peo ples%20of%20Canada Government of Canada. (2011). Aboriginal demographics from the 2011 National Household Survey. http://publications.gc.ca/collections/collection_2013/aadnc-aandc/R5-16-2013-eng.pdf 24 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10820 Government of Canada. (2020). What is Indian Status? https://www.sac-isc.gc.ca/Eng/ 1100100032463/1572459644986 Gracey, M., & King, M. (2009). Indigenous health Part 1: Determinants and disease patterns. The Lancet, 374(9683), 65-75. https://doi.org/10.1016/S0140-6736(09)60914-4 Gross, P. A., Efimoff, I., Patrick, L., Josewski, V., Hau, K., Lambert, S., & Smye, V. (2016). The DUDES Club: A brotherhood for men’s health. Canadian Family Physician, 62(6), E311-E318. Hackett, C., Feeny, D., & Tompa, E. (2016). Canada’s residential school system: Measuring the intergenerational impact of familial attendance on health and mental health outcomes. Journal of Epidemiology and Community Health, 70(11), 1096–1105. https://doi.org/10.1136/jech- 2016-207380 Hadjipavlou, G., Varcoe, C., Tu, D., Dehoney, J., Price, R., & Browne, A. J. (2018). ‘All my relations’: Experiences and perceptions of Indigenous patients connecting with Indigenous Elders in an inner city primary care partnership for mental health and well-being. Canadian Medical Association Journal, 190(20), E608–E615. https://doi.org/10.1503/cmaj.171390 Harder, H. G., Holyk, T., Russell, V. L., & Klassen-Ross, T. (2015). Nges Siy (I love you): A community-based youth suicide intervention in Northern British Columbia. International Journal of Indigenous Health, 10(2), 21-32. https://doi.org/10.18357/ijih.102201514309 Hardt, J. V. (2012). Alpha brain-wave neurofeedback training reduces psychopathology in a cohort of male and female Canadian Aboriginals. Advances in Mind-Body Medicine, 26(2), 8-12. Indigenous Services Canada. (2019). Youth empowerment and healing and wellness investment for First Nations communities. https://www.newswire.ca/news-releases/youth-empowerment- and-healing-and-wellness-investment-for-first-nations-communities-843055793.html King, M., Smith, A., & Gracey, M. (2009). Indigenous health Part 2: The underlying causes of the health gap. The Lancet, 374(9683), 76-85. https://doi.org/10.1016/S0140-6736(09)60827-8 Kumar, M. B., & Tjepkema, M. (2019). Suicide among First Nations people, Métis and Inuit (2011-2016): Findings from the 2011 Canadian Census Health and Environment Cohort (CanCHEC). Statistics Canada. https://www150.statcan.gc.ca/n1/pub/99-011-x/99-011- x2019001-eng.htm Leske, S., Harris, M. G., Charlson, F. J., Ferrari, A. J., Baxter, A. J., Logan, J. M., Toombs, M., & Whiteford, H. (2016). Systematic review of interventions for Indigenous adults with mental and substance use disorders in Australia, Canada, New Zealand and the United States. The Australian and New Zealand Journal of Psychiatry, 50(11), 1040–1054. https://doi.org/ 10.1177/0004867416662150 25 Graham et al.: Indigenous Mental Health Interventions Published by Scholarship@Western, 2021 McKenzie, K., Tuck, A., & Ekanayake, S. (2014). Suicide in diverse populations: Implications for Canada’s suicide strategies. In Routledge International Handbook of Clinical Suicide Research (pp. 103-113). https://www.routledgehandbooks.com/doi/10.4324/9780203795583.ch9 Mental Health Commission of Canada. (2016). Advancing the mental health strategy for Canada: A framework for action (2017-2022). https://www.mentalhealthcommission.ca/sites/default/ files/2016-08/advancing_the_mental_health_strategy_for_canada_a_framework_for_ action.pdf Métis Nation. (2018, September 6). Métis Nation presses health and wellness, family and child care priorities at policy sessions in Ottawa. https://nationtalk.ca/story/metis-nation-presses-health- and-wellness-family-and-child-care-priorities-at-policy-sessions-in-ottawa Métis Nation. (2020). Métis Nation. https://www2.metisnation.ca/ Miller, L. D., Laye-Gindhu, A., Bennett, J. L., Liu, Y., Gold, S., March, J. S., Olson, B. F., & Waechtler, V. E. (2011). An effectiveness study of a culturally enriched school-based CBT anxiety prevention program. Journal of Clinical Child and Adolescent Psychology, 40(4), 618- 629. https://doi.org/10.1080/15374416.2011.581619 Moher, D., Liberati, A., Tetzlaff, J., Altman, D.G., & the PRISMA Group. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med, 6(7). https://doi.org/doi: 10.1371/journal.pmed.1000097 Nasir, B. F., Toombs, M. R., Kondalsamy-Chennakesavan, S., Kisely, S., Gill, N. S., Black, E., Hayman, N., Ranmuthugala, G., Beccaria, G., Ostini, R., & Nicholson, G. C. (2018). Common mental disorders among Indigenous people living in regional, remote and metropolitan Australia: A cross-sectional study. BMJ Open, 8(6). https://doi.org/10.1136/bmjopen-2017-020196 National Inquiry into Missing and Murdered Indigenous Women and Girls. (2019). Reclaiming power and place: The final report of the National Inquiry into Missing and Murdered Indigenous Women and Girls. https://www.mmiwg-ffada.ca/final-report/ Nelson, S. E., & Wilson, K. (2017). The mental health of Indigenous Peoples in Canada: A critical review of research. Social Science and Medicine, 176, 93-112. https://doi.org/10.1016/ j.socscimed.2017.01.021 Public Health Agency Canada. (2018). Key health inequalities in Canada: A national portrait. Government of Canada. https://www.canada.ca/en/public-health/services/publications/ science-research-data/key-health-inequalities-canada-national-portrait-executive-summary.html Ring, I., & Brown, N. (2003). The health status of Indigenous Peoples and others: The gap is narrowing in the United States, Canada, and New Zealand, but a lot more is needed. BMJ, 327(7412), 404- 405. https://doi.org/10.1136/bmj.327.7412.404 26 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10820 Ritchie, S. D., Wabano, M.-J., Russell, K., Enosse, L., & Young, N. L. (2014). Promoting resilience and wellbeing through an outdoor intervention designed for Aboriginal adolescents. Rural and Remote Health, 14, 2523. Smylie, J. (2009). The health of Aboriginal Peoples. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives (2nd ed., pp. 280-304). Canadian Scholars’ Press Inc. Statistics Canada. (2011). National Household Survey: Aboriginal demographics, educational attainment and labour market outcomes. https://www.sac-isc.gc.ca/eng/ 1376329205785/1604610645621 Statistics Canada. (2017). Aboriginal Peoples in Canada: Key results from the 2016 Census. https://www150.statcan.gc.ca/n1/daily-quotidien/171025/dq171025a-eng.pdf Statistics Canada. (2020). Health indicators, by Aboriginal identity, age-standardized rates, four-year period estimates. https://doi.org/10.25318/1310045801-eng Thomas, G., Lucas, P., Capler, N. R., Tupper, K. W., & Martin, G. (2013). Ayahuasca-assisted therapy for addiction: Results from a preliminary observational study in Canada. Current Drug Abuse Reviews, 6(1), 30-42. https://doi.org/10.2174/15733998113099990003 Thunderbird Partnership Foundation. (2011). Honouring our strengths: Growth and evolution to new horizons. https://thunderbirdpf.org/honouring-our-strengths-full-version-2/ Toombs, M., Nasir, B., Kisely, S., Kondalsamy-Chennakesavan, S., Hides, L., Gill, N., Beccaria, G., Brennan-Olsen, S., Butten, K., & Nicholson, G. (2020). Australian Indigenous model of mental healthcare based on transdiagnostic cognitive–behavioural therapy co-designed with the Indigenous community: Protocol for a randomised controlled trial. BJPsych Open, 6(3), e33. https://doi.org/10.1192/bjo.2020.16 Truth and Reconciliation Commission of Canada. (2015a). Canada’s residential schools: The history, Part I origins to 1939 (Vol. 1). Government of Canada. http://www.trc.ca/assets/pdf/ Volume_1_History_Part_1_English_Web.pdf Truth and Reconciliation Commission of Canada. (2015b). Honouring the truth, reconciling for the future: Summary of the final report of the Truth and Reconciliation Commission of Canada. http://publications.gc.ca/collections/collection_2015/trc/IR4-7-2015-eng.pdf Truth and Reconciliation Commission of Canada. (2015c). Truth and Reconciliation Commission of Canada: Calls to Action. http://www.trc.ca/assets/pdf/Calls_to_Action_English2.pdf Tu, D., Hadjipavlou, G., Dehoney, J., Price, E. R., Dusdal, C., Browne, A. J., & Varcoe, C. (2019). Partnering with Indigenous Elders in primary care improves mental health outcomes of inner- city Indigenous patients: Prospective cohort study. Canadian Family Physician, 65(4), 274-281. Tungasuvvingat Inuit. (2020). Tungasuvvingat Inuit. https://tiontario.ca/ 27 Graham et al.: Indigenous Mental Health Interventions Published by Scholarship@Western, 2021 United Nations. (2007). United Nations Declaration on the Rights of Indigenous Peoples. https://www.un.org/development/desa/indigenouspeoples/wp-content/uploads/sites/19/ 2018/11/UNDRIP_E_web.pdf Varcoe, C., Browne, A. J., Ford-Gilboe, M., Dion Stout, M., McKenzie, H., Price, R., Bungay, V., Smye, V., Inyallie, J., Day, L., Khan, K., Heino, A., & Merritt-Gray, M. (2017). Reclaiming our spirits: Development and pilot testing of a health promotion intervention for Indigenous women who have experienced intimate partner violence. Research in Nursing & Health, 40(3), 237-254. https://doi.org/10.1002/nur.21795 Varcoe, C., Ford-Gilboe, M., Browne, A. J., Perrin, N., Bungay, V., McKenzie, H., Smye, V., Price Elder, R., Inyallie, J., Khan, K., & Dion Stout, M. (2019). The efficacy of a health promotion intervention for Indigenous women: Reclaiming our spirits. Journal of Interpersonal Violence. https://doi.org//10.1177/0886260518820818 Wieman, C. (2006). Improving the mental health status of Canada’s Aboriginal youth. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 15(4), 157-158. Wilk, P., Maltby, A., & Cooke, M. (2017). Residential schools and the effects on Indigenous health and well-being in Canada—A scoping review. Public Health Reviews, 38(1). https://doi.org/ 10.1186/s40985-017-0055-6 Williams, A. D., Clark, T. C., & Lewycka, S. (2018). The associations between cultural identity and mental health outcomes for Indigenous M!ori youth in New Zealand. Frontiers in Public Health, 6(319). https://doi.org/10.3389/fpubh.2018.00319 28 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10820 Appendices Appendix A. Search Strategy Database Search strategy PubMed 1. (((((((((((((((Mental health) OR mental-health) OR mental wellness) OR mental-wellness) OR addict*) OR anciet*) OR depression) OR suicid*) OR resilien*) OR wrap-around) OR client-centered) OR patient-centered) OR trauma*[MeSH Terms]))) AND 2. ((((intervention) OR community-based) OR community based) OR patient- centered) OR patient centered) OR wrap-around) OR program[MeSH Terms])))) AND 3. ((((((((Aborigin*) OR First Nation*) OR Native) OR Indians) OR Métis) OR Inuit) AND 4. Canad*[MeSH Terms])) 5. 1 AND 2 6. 3 AND 4 7. 5 AND 6 MEDLINE 1. ((((((((Aborigin*.mp) OR First Nation*.mp) OR Native.mp) OR Métis.mp) OR Inuit.mp) OR Indigenous.mp) [MeSH Terms]))) AND 2. Canad*.mp[MeSH Terms])) 3. (((((((((((((((Mental health.mp) OR mental-health.mp) OR mental wellness.mp) OR mental-wellness.mp) OR addict*.mp) OR anciet*.mp) OR depress*.mp) OR suicid*.mp) OR resilien*.mp) OR wrap-around.mp) OR client- centered.mp) OR patient-centered.mp) OR trauma*.mp[MeSH Terms]))) AND 4. ((((intervention.mp) OR community-based.mp) OR community based.mp) OR client-centered.mp) OR client centered.mp) OR patient-centered.mp) OR patient centered.mp) OR program.mp[MeSH Terms])))) 5. 1 AND 2 6. 3 AND 4 7. 5 AND 6 29 Graham et al.: Indigenous Mental Health Interventions Published by Scholarship@Western, 2021 Appendix A. Search Strategy (continued) Web of Science 1. ts=(Aborigin*) OR ts=(First Nation*) OR ts=(Native) OR ts=(Métis) OR ts=(Inuit) OR ts=(Indigenous) Indexes=SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, BKCI-S, BKCI-SSH, ESCI, CCR-EXPANDED, IC Timespan=All years 2. TS=(mental-health) OR TS=(mental health) OR TS=(mental-wellness) OR TS=(mental wellness) OR TS=(addict*) OR TS=(anxi*) OR TS=(depress*) OR TS=(suicid*) OR TS=(resilien*) OR TS=(trauma) OR TS=(resilien*) OR TS=(trauma) Indexes=SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, BKCI-S, BKCI-SSH, ESCI, CCR-EXPANDED, IC Timespan=All years 3. ts=(intervent*) OR ts=(community-based) OR ts=(community based) OR ts=(client-centered) OR ts=(client centered) OR ts=(patient-centered) OR ts=(patient centered) OR ts=(wrap-around) OR ts=(wrap around) Indexes=SCI- EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, BKCI-S, BKCI-SSH, ESCI, CCR-EXPANDED, IC Timespan=All years 4. ts=(Canad*) Indexes=SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, BKCI-S, BKCI-SSH, ESCI, CCR-EXPANDED, IC Timespan=All years 5. #4 AND #1 6. #3 AND #2 7. #6 AND #5 PsycINFO 1. Aborigin$.tw OR First Nation$.tw OR Native.tw OR Métis.tw OR Inuit.tw OR Indigenous.tw 2. Canad$.tw 3. mental-health.tw OR mental health.tw OR mental-wellness.tw OR mental wellness.tw OR addict$.tw OR anxi$.tw OR depress$.tw OR suicid$.tw OR resilien$.tw OR trauma.tw OR resilien$.tw OR trauma.tw 4. Intervent$.tw OR community-based.tw OR community based.tw OR client- centered.tw OR client centered.tw OR patient-centered.tw OR patient centered.tw OR wrap-around.tw OR wrap around.tw 5. 1 and 2 6. 3 and 4 7. 5 and 6 30 The International Indigenous Policy Journal, Vol. 12, Iss. 2 DOI:10.18584/iipj.2021.12.2.10820 Appendix B. List of Activities Used to Improve Indigenous People’s Mental Health 1. Non-competitive games, walks, crafts, shared meals 2. Jewellery making, sports, drawing 3. Discussion circles, storytelling, scavenger hunts, Medicine Wheel 4. Youth received mentoring for 1 year vs. 2 years 5. Big Brother, Big Sister program 6. Mentoring of Aboriginal youth 7. 2-4 hours per week with mentor for 1 year 8. Suicide response team: 2 Indigenous mental health workers, and travelling mental health clinic 9. Rainbow Lodge Recovery Centre 10. Weekly men’s group 11. Shared meal 12. Health programs with doctors and nurses 13. Linking First Nation Elders with vulnerable men 14. Regular meetings with an Indigenous Elder 15. Elders provided a safe “place for healing,” they could “laugh,” and receive “gentle guidance,” and they were “respected” compared to previous health care experiences 16. Culture camps 17. Traditional food gathering techniques 18. Language, survival techniques 19. Clan affiliation, Bah’Iats system 20. Friends for Life program classroom-based intervention 21. Individual and group activities that teach children to identify anxiety signals, physical bodily symptoms, worried thoughts and maladaptive behaviours 22. Outdoor adventure leadership experience 23. Wilderness canoe expedition 24. Medicine Wheel 25. Outward Bound Process Model 26. Small group activities 27. 8 experiences with 3 each summer 28. Ayahuasca ceremonies 29. Retreats focussed on addressing issues of addiction 30. Indigenous Elders meeting with individuals with depression and suicidal thoughts in a primary health care clinic 31. Weekly workshops led by an Indigenous Elder 32. iHEAL program (10-18 sessions over 6 months) 31 Graham et al.: Indigenous Mental Health Interventions Published by Scholarship@Western, 2021 Appendix C. Tools Used to Measure Participants Mental Health Status 1. 11-item Cultural Connectedness Scale (CCS) 2. 14-item Mental Health Continuum—Short Form (MHC-SF) 3. 6-point Likert scale (1 = Never, 6 = Everyday) 4. Strengths and Difficulties Questionnaire (SDQ) 5. Revised Social Anxiety Scale for Children (SASC-R) 6. Confirmed patient record at the psychiatric facility 7. Beck Depression Inventory-II 8. Beck Scale for Suicide Ideation 9. Beck Hopelessness Scale 10. Multiple Affect Adjective Check list 11. Clyde Mood Scale 12. Profile of Mood States 13. 39-item self-reported Multidimensional Anxiety Scale for Children (MASC) 14. Health and Well-Being Questionnaire 15. Outward Bound Process Model 16. Mental Component Score (MCS) 17. Scale of Positive and Negative Emotion—Balance (SPANE) 18. Self-Esteem Scale (SES) 19. The Difficulty in Emotion Regulation Scale 20. The Philadelphia Mindfulness Scale 21. The Empowerment Scale 22. The Hope Scale 23. The McGill Quality of Life Survey 24. The 4 Week Substance Abuse Scale 25. Patient Health Questionnaire 26. Suicidal Behaviours Questionnaire 27. Sullivan’s Quality of Life Scale 28. PTSD Checklist Civilian Version 29. Centre for Epidemiologic Studies Depression Scale MS 10820 Cover page.pdf MS 10820 Graham Mental health interventions RCE.pdf