When a chronically depressed 9-year-old girl at the Pine Ridge Indian Reservation in South Dakota became so sad that she stopped eating, Ethleen Iron Cloud-Two Dogs came up with a treatment plan: not antidepressant drugs, but a spiritual assessment, followed by a healing ceremony at a Lakota purification lodge that represents the womb.
"There is a hole dug in the middle and rocks that are heated," she said. "Because we believe that everything has a spirit, rocks are addressed as grandfather spirits. The water is taken in and poured on the rocks -- the steam that results is the breath of the grandfathers which then purifies and renews us."
Over the next three months, the girl recovered, said Iron Cloud-Two Dogs, who treats emotionally disturbed and suicidal children at a federally funded Native American mental health program called Nagi Kicopi, "Calling the Spirit Back." The healer dismissed those who demand evidence that her techniques work.
"They will say, 'Where's the proof, where's the research base, how can you document this?' -- all the Western aspects of clinical interventions," she said. "We understood from the beginning that we would get those reactions, so our stance is, 'We are Lakota people and these are Lakota children, and we will use the methods that have worked for thousands of years and that's all there is to it.' "
Nagi Kicopi is only one example of a deep divide between mainstream psychiatry's approach to mental disorders and subcultures with very different notions of why people become emotionally disturbed and how they can be cured.
Many Native American patients rebel against the notion that mental illnesses are primarily brain disorders to be treated with drugs, said several experts who work with such patients. Native tribes volunteered for drug studies in the 1950s, '60s and '70s, but they saw very little benefit and are now reluctant to participate in such research, said Spero Manson, a psychiatrist at the University of Colorado.
"Native communities feel they have been used as guinea pigs for research purposes to support the agenda of the biomedical world," he said.
They might be willing to volunteer for research again, he added, but it would have to be for science they believe is relevant and that is respectful of native traditions. Some demand that traditional healing techniques be studied alongside drug-based treatments, but pharmaceutical companies, which conduct most drug studies, are not interested.
William Lawson, chairman of psychiatry at Howard University, said the lack of data is troubling because suicide rates are high in some Native American communities: "You would think there would be studies on depression."
Lawson is one of the scientists who has received grants from the National Institutes of Health to increase the participation of minorities as research subjects in clinical trials.
Other clinicians are devising novel ways to bridge the gap between mainstream and traditional approaches. Iron Cloud-Two Dogs's healing program includes a psychotherapist, she said, but the "Western" therapist takes a back seat to traditional healers.
Anthony Dekker, who directs community health care at the Phoenix Indian Medical Center in Arizona, recalled treating one Native American patient who was psychotic. When she refused to take medication -- she called it "the white man's medicine" -- Dekker asked her to consult a traditional healer.
"The medicine man listened to her and said, 'You live in the white man's world and you have a white man's disease and you need to take the white man's medicine,' " said Dekker, in an interview. The woman agreed to take the drugs.
"If I said, 'Don't go to the medicine man, he has never been to medical school' -- that would alienate 90 percent of my patients," Dekker added.
Reconciling the brain disease model of mental disorders with America's increasingly diverse cultural fabric is more than a matter of gaining patient trust.
A host of small studies has shown that psychiatric drugs do not have the same risks and benefits in every ethnic group: Research showed that Caucasians experience twice the side effects of Hispanics from the antidepressants Prozac and Paxil, said Michael Smith, a psychiatrist at the University of California at Los Angeles. And with an earlier class of antidepressants called tricyclics, Hispanics given half the dose had twice the side effects of Caucasians.
Blacks on some anti-psychotic drugs seem more likely than whites to suffer tardive dyskinesia -- repetitive, involuntary movements. Another study found that Asians who got half the dose of an anti-psychotic drug responded better than Caucasians who received the regular dose.
Some patients have avoidable side effects, Smith said, because "standards were developed in Caucasians and were inappropriately extended to other ethnic groups."
Smith and other advocates for "cultural competence" point out that substantial differences also exist among individuals within each ethnic group. Because of the lack of systematic data about variations in drug effectiveness, Smith advises doctors to tailor drug dosages to individuals:
"Most drug companies don't acknowledge the fact that their medications require individualized dosing, because when you say that, it makes it much more difficult for the average doctor to say one dose fits all."