Partnering with Indigenous Elders in primary care improves mental health outcomes of inner-city Indigenous patients: Prospective cohort study.

OBJECTIVE: To determine whether including Indigenous Elders as part of routine primary care improves depressive symptoms and suicidal ideation in Indigenous patients. DESIGN: Prospective cohort study with quantitative measures at baseline and 1, 3, and 6 months postintervention, along with emergency department (ED) utilization rates before and after the intervention. SETTING: Western Canadian inner-city primary care clinic. PARTICIPANTS: A total of 45 people who were older than age 18, who self-identified as Indigenous, and who had no previous visits with the clinic-based Indigenous Elders program. INTERVENTION: Participants met with an Indigenous Elder as part of individual or group cultural sessions over the 6-month study period. MAIN OUTCOME MEASURES: Changes in depressive symptoms, measured with the PHQ-9 (Patient Health Questionnaire), following Indigenous patients' encounters with Indigenous Elders. Secondary outcomes included changes in suicide risk (measured with the SBQ-R [Suicidal Behaviors Questionnaire-Revised]) and ED use. RESULTS: Characteristics among those who consented to participate were as follows: 71% were female; mean age was 49 years; 31% had attended residential or Indian day school; and 64% had direct experience in the foster care system. At baseline 28 participants had moderate to severe depressive symptoms (PHQ-9 score of ≥ 10). There was a 5-point decrease that was sustained over a 6-month period (P = .001). Fourteen participants had an above-average suicide risk score at baseline (SBQ-R score of ≥ 7), and there was a 2-point decrease in suicide risk that was sustained over a 6-month period (P = .005). For all participants there was a 56% reduction in mental health-related ED visits (80 vs 35) when comparing the 12 months before and after enrolment. CONCLUSION: Encounters with Indigenous Elders, as part of routine primary care, were associated with a clinically and statistically significant reduction in depressive symptoms and suicide risk among Indigenous patients. Emergency department use decreased, which might reduce crisis-oriented mental health care costs. Further expansion and evaluation of the role of Indigenous Elders as part of routine primary care is warranted.

"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.

BACKGROUND: Mental health services in urban settings generally have not been adapted to serve the needs of Indigenous patients. We explored how patients' encounters with Indigenous Elders affected their overall mental health and well-being to identify therapeutic mechanisms underlying improvement. METHODS: We conducted qualitative interviews of participants enrolled in a 6-month prospective mixed-methods evaluation of a program for mental health and well-being that featured the inclusion of Elders in the direct care of Indigenous patients in an inner city primary care clinic. Individual semistructured interviews were conducted to explore patients' experiences and perceptions of their participation in the Elders program. RESULTS: We included 37 participants from at least 20 different First Nations. All but 1 participant described substantial benefits from their encounters with Elders, and none reported being negatively affected. Five overarching themes were identified: experiencing healing after prolonged periods of seeking and desperation; strengthening cultural identity and belonging; developing trust and opening up; coping with losses; and engaging in ceremony and spiritual dimensions of care as a resource for hope. INTERPRETATION: Our evaluation illustrates that the Elders program was perceived by participants to have a broad range of positive impacts on their care and well-being. Although this study was based on experiences at a single urban clinic, these findings support the Truth and Reconciliation Commission of Canada's calls to action regarding the inclusion of Elders as a strategy to improve care of Indigenous patients in Canadian health care systems.