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The objective of this article is to document patterns and trends of in-hospital mental health service use by First Nations (FN) living in rural and remote communities in the province of Manitoba. Our sample included all Manitoba residents eligible under the Manitoba Health Services Insurance Plan living on FN reserves and those living in rural and remote communities from 1986 to 2014. Using administrative claims data, we developed multi-level models that describe hospitalization for mental health conditions shown responsive to prima