For many years, I’ve been curious about the full extent of the Indian Health Service’s psychiatric drug habit.
In my last blog post, I noted promising signs of agency self-reflection at the Indian Health Service (IHS) within a recent behavioral health strategic plan statement recognizing “the heavy influence of biomedical models” and the need to talk about that dominant ideology in “various IHS health conferences and meetings.”1
I view this statement as ‘IHS-speak,’ by which the agency admits that it has a major psychiatric drug habit. I’ve worked alongside people trying to resolve drug and alcohol issues for about 27 years, and am encouraged by this development because often the first step to recovery from addiction is admitting that one has ‘a problem.’
If I was sitting down with the agency and trying to help, I’d likely ask questions like “Well, how much money do you spend on your habit? How often are you using? What are your ‘drugs of choice’?” If I’m to try to assist, I usually try to discover the interdependencies and relationships that represent obstacles to reducing and eventually quitting one’s habit.
In the case of the IHS, those interdependencies are extraordinarily complex. I suspect that the U.S. federal government is the largest single distributor for psychiatric medication in the world. The bigger picture therein can help us to understand the potential extent of Indian Health Service’s drug habit.
The top 3 suppliers to the U.S. Department of Health & Human Services are Merck, Pfizer, and Glaxo-Smith-Kline ‘who’ (pretending they are persons) thereby gross about $3.2 billion in combined sales annually2. This places these corporations alongside numerous other pharmaceutical manufacturers in the top 100 of U.S. federal government suppliers, i.e. ‘prime vendors.’
Public health care practices tend to be conservative in embracing prevailing trends in what is provided to patients. Like the cultural surround in U.S. society, prescribing psychiatric medication as a ‘first-line’ response represents a ‘practice standard’ for mental health intervention in numerous federal agencies. By ‘practice standard,’ I mean that program policies often dictate that if a health care provider doesn’t offer psychiatric medication as a first response to a mental health issue, he or she is will be viewed as behaving negligently.
Consider, for example, the case of diabetes, an epidemic scourge among many U.S. American Indian and Alaska Native communities. This is a devastating, debilitating, and even fatal disease with some clearly genetic pre-dispositional underpinnings that become substantially exacerbated by poor nutrition. Now witness the gradual substitution over many years of a diet high in starch, sugars, and saturated fats through U.S. Department of Agriculture federal commodity foods programs supplying poverty-stricken native families. One might think the federal government was trying to murder people.
In fact, astute long-term IHSer, diabetes clinical consultant, and former Eastern Band Cherokee medical director Ann Bullock, MD (Chippewa) has been driving this ‘poison diet’ thesis at least since I first saw her speak at the 2001 ‘Healing Our Wounded Spirits’ Conference in Grand Ronde, Oregon. The support she and others have received from IHS reflect an important desire to change an oppressive illness that has been made much worse across several generations by acts of federal ‘benevolence.’ Some progress has been made — end-stage renal disease has showed some important declines — yet the rates of diabetes among Native American youth still shot up 110% between 1990 and 20093.
It’s undeniable that a diabetes diagnosis is upsetting and depressing. Therefore, in keeping with the so-called dominant cultural motif, a ‘best practice’ in Indian Health Service diabetes care is ‘depression screening’ which can be “done by many kinds of health professionals” using “a screening tool that is simple to administer and assess, such as the PHQ-9 (Patient Health Questionnaire Mood Scale) screening tool, which assesses Diagnostic and Statistical Manual of Mental Disorders (DSM) depression criteria.”4
Ah, so getting a diabetes diagnosis at the IHS can also entail getting a psychiatric diagnosis. And the recommended ‘first line’ response? Antidepressant medication, of course. Additional approaches? Here’s the list:
Physical activity, support groups, including twelve-step programs as applicable, group and individual therapies, cognitive behavior therapy, interpersonal therapy, solution-focused techniques EMDR, psychoeducation, which involves teaching people about their problem, how to treat it, and how to recognize signs of relapse so that they can get treatment before their problem worsens or occurs again. Family psychoeducation includes teaching coping strategies and problem-solving skills to families, friends, and caregivers to help them more effectively deal with the patient, coping skills and problem-solving training, various activity-type therapies (e.g., movement therapy, art therapy, equine-assisted psychotherapy), relaxation, meditation and mindfulness, guided imagery, and breathing techniques light therapy, which is especially helpful for seasonal affective disorder encourage patients to talk to spiritual counselors and/or to participate in ceremonies as is appropriate to their belief system.4
Of course, one wonders why at least some of these wouldn’t be tried first. The reason has to do with public health care ‘culture’: the initial recommendation of antidepressants in IHS diabetes-related depression ‘best practices’ reflects a revisionist cultural idea. Despite the celebrated work of Dr. Bullock and others, diabetes can never be officially or otherwise viewed by the Indian Health Service as a problem traceable to the disruptions in dietary habits forced upon native people by intergenerational oppression. Instead, it’s an individual problem of chemical imbalances.
Just how dominant is the cultural view that brings these drugs through public health care models toward native people? There’s a lot of money and influence involved. Consider overall U.S. sales for selected psychiatric medications between July, 2013 and June, 2014:
- Abilify (aripiprazole) from Japan’s Otsuka Pharmaceuticals and prescribed for schizophrenia, bipolar disorder, or depression was the #1 drug in gross sales ($7.2 billion) and the #10 drug in monthly scripts (8.7 million average prescriptions filled).
- Cymbalta (duloxetine), an SSRI from Eli Lilly prescribed for depression, was #17 in sales ($2.8 billion) and #8 in monthly prescriptions (10 million).
- Vyvanse (lisdexamfetamine) from Shire Pharmaceuticals for those with the ADHD label was #28 in sales and #9 in monthly prescriptions (10 million).6
Strattera for ADHD and depression was #93 in sales ($659 million) and had monthly prescriptions averaging 2.3 million. Adderall ($177 million), which was once a proprietary formula combining dextro- and levoamphetamine, is now a generic medication made by a number of pharmaceutical companies. Combine its sales with other psychostimulants like methylphenidate (Ritalin) and dextroamphetamine and the total approaches $1 billion in the same time period.7 There are many other psychiatric drugs to consider — Seroquel, Lunesta, Viibryd, Latuda — as well as a variety of drugs crossing between pain management and psychiatry.
My guesstimate for total U.S. sales revenue from combined brand name and generic psychiatric medications in the same period of July, 2013 to June, 2014 is around $36 billion, and I think that’s conservative — right in line with U.S. Public Health ideology.
But my burning question remains: how much psychiatric medication does Indian Health Service use and what’s the cost of this agency’s habit?
There’s no easy way to get a clear answer, but let’s try a few thinking exercises. According to the Pharmaceutical Research and Manufacturers Association of America,8 public health programs account for about one-third of outpatient prescription sales each year.
I can’t find a better way to estimate what percentage of psychiatric medication sales are paid for by tax dollars — so that’d be around $12 billion annually.
Medicaid and CHIP (8.4% of public program outpatient scripts), Department of Defense (2.4%), and Veteran’s Affairs (1%) are major supply streams through which the Indian Health Service fills prescriptions for its Native American patients. If you think that’s filled with entangling interdependencies, that’s only the beginning.
The IHS pharmaceutical formulary is supplied through the National Supply Service Center, which describes itself as using the following routes to purchase medications:
“Government Federal Supply Schedule contracts, VA contracts, DOD contracts, GSA contracts, Prime Vendor contracts, Area contracts and Blanket Purchase Agreements.”9
I can’t find a resource that directly bears upon what psychiatric medications are thereby ordered specifically for the Indian Health Service and tribal-run clinics.
But if roughly 12% of the annual outpatient psychiatric meds pertain just to Medicaid, DOD, and the VA, all of which help with the purchase of psychiatric medications for the Indian Health Service, we end up with roughly $1.2 billion in sales.
Now let’s look at Medicaid itself for a moment. About 1 in 5 of the 5.2 million enrolled American Indians and Alaska Natives are enrolled therein— about half of the 2.2 million patients seen by the Indian Health Service. That’s 1.6 percent of the total of 62 million enrolled in Medicaid. Recall that Medicaid-based sales are about 8.4 percent of one-third (public program) of our guesstimated outpatient psychiatric prescription sales of $36 billion.
Assuming the Native American Medicaid patent population has a similar consumption pattern to the rest of the Medicaid population for psychiatric medication (hmm, I wonder), what is the approximate amount of psychiatric medication sales through Medicaid at the Indian Health Service and tribal-run health programs?
This is a story problem. I should make you do the work.
Okay, it’s nearly $1 billion per year. Now representing the Native American Medicaid recipients at 1.6 percent of $1 billion spent on psychiatric medication totals to $16 million annually.
Well, darn it, I thought this was supposed to be a critical analysis. That doesn’t seem like so much, does it?
Wait—you forgot to factor back in all those missing ‘other’ funding streams of “Government Federal Supply Schedule contracts, VA contracts, DOD contracts, GSA contracts, Prime Vendor contracts, Area contracts and Blanket Purchase Agreements.”
Umm, how much is that? I don’t know. Well, how many prescriptions would it be, say on a monthly basis? The data is unavailable. Maybe FOIA would help.
But let’s consider that 16% of Medicaid’s total drug costs go to psychotropics for children and the costs for those is 57% more than the typical prescription.
But wait—each of those prescriptions merits a regular Medicaid encounter with a health care provider, right? And did I mention how much revenue each encounter makes for an Indian Health or tribal-run clinic?
Yes, I did. And that’s a major interdependency.
I discussed this issue in a prior blog but I’ll tell you again in case you don’t want to look back.
A single Medicaid encounter is worth $294 where I live in Washington state. Now, if the average Medicaid prescription costs $50 (what I consider a reasonable guess given that the average children’s psychotropic through the same program costs $65) and I divide that into $16 million, I get 320,000 prescriptions being written annually. That’s just initial encounters.
Now multiply 320,000 times $294 and that’s $94 million in annual revenue to the Indian Health Service through Medicaid prescription encounters for psychiatric medication. Well, yes, I admit the actual encounter could be and likely often is pertaining to other health issues. Diabetes, for example.
My point is that it’s not how much is spent on psychiatric medication at the Indian Health Service that gets in the way of curing the “heavy influence of biomedical models” issue, but how much money is made.
I propose that something between $50 million and $200 million in revenue comes into Indian Health Service and tribal-run clinics annually in relation to the prescribing of psychiatric medication.
I hope I’m wrong and I’d like to have my reasoning refuted. I’d like to be shown that it’s a lot less than I think.
But if this strategy statement means anything at all, it’s the responsibility of the Indian Health Service to derive more accurate figures regarding their ‘biomedical models’ and how much psychiatric medication it foists upon native people labeled as pathological by its methodologies. That would be an important next-step in organizational self-reflection toward addiction recovery. That would represent one means of demonstrating that this federal agency is not directly involved in sedating emotional and behavioral reactivity to oppressive events with which it has been complicit.
The Indian Health Service will never move closer toward some sort of allied community approach to helping any Native American with intergenerational behavioral issues traceable to oppression when this kind of money is currently supporting its major psychiatric drug habit.
The Indian Health Service is suffering from an addiction and has recently become willing to talk about it. That’s excellent news. However, it’s about as far as the agency has been able to take it so far and exactly what their behavioral health strategy plan said in the first place.10
Perhaps there’s some sort of family intervention in order . . .
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1 Indian Health Service, Behavioral Health Strategic Plan, 2011-2015
2 Federal Procurement Report, 2013
3 Diabetes Among American Indians and Alaska Natives, Facts at a Glance
4 Diabetes Care Manual, Indian Health Service
7 U.S. Pharmaceutical Sales, Q4-2013,
8 Chart-Pack: Biopharmaceuticals in Medicare, Medicaid, and Department of Veterans Affairs, Pharmaceutical Research & Manufacturers Association
9 Indian Health Service, National Supply Service Center
10 See first citation
Indian Health and Medicaid, Medicaid.gov
Children Using Psychotropics Account for 16% of Medicaid Drug Costs, Express Scripts