Reviewing suicide in Native American communities: situating risk and protective factors within a transactional-ecological framework

Connected for life: How social connectedness can help prevent suicide in American Indian and Alaska Native communities

Enhancing social support and connectedness can reduce suicide risk, yet few studies have examined this effect in American Indian and Alaska Native (AI/AN) adults. We assessed suicidal ideation and behavior, thwarted belongingness, social support, enculturation, historical trauma, and traumatic life events in 709 AI/AN adults at high risk of suicide from five AI/AN communities. Suicidal ideation was associated with thwarted belongingness and protected against by social support and engaging in AI/AN ceremonies. Among those who made lifetime suicide attempts, traumatic life events, symptoms of depression/anxiety due to historical trauma, and thwarted belongingness were linked to more attempts. More engagement in cultural practices was associated with fewer suicide attempts. Higher levels of social support were associated with more suicide attempts, an observation potentially attributable to the cross-sectional nature of the study. Interventions should focus on protective factors and context-specific interventions emphasizing community history, values, and strengths.

Elder-led cultural identity program as counterspace at a public university: Narratives on sense of community, empowering settings, and empowerment

Higher education institutions present unique settings in which identities and life paths are distinctively shaped. While at their best universities should serve as empowering settings that support their members to grow and develop, to raise awareness of injustice, and to catalyze change, too often systems of higher education in the United States serve to marginalize Indigenous cultures and promote assimilation to White, Euro-American cultures. Counterspaces offer an important response, spaces developed by and for people experiencing oppression that allow for solidarity-building, social support, healing, resource attainment, skill-building, resistance, counter-storytelling, and ideally, empowerment. The Alaska Native (AN) Cultural Identity Project (CIP) is based at an urban U.S.-based university and was rolled out during the COVID-19 pandemic. Developed from the best available scientific and practice literature, local data from AN students, and traditional wisdom from Elders, CIP incorporated storytelling, experiential learning, connection, exploration, and sharing of identity and cultural strengths with the aim of helping AN students understand who they are and who they are becoming. In all, 44 students, 5 Elders, and 3 additional staff participated in the space. In this paper, we sought to understand how CIP was experienced by these unique members who co-created and engaged in this space through 10 focus groups with 36 of the CIP members. We found that the counterspace promoted a sense of community, served as an empowering setting, and set the stage for empowering actions and ripple effects beyond its impact on individuals.

Behavioral health services in Urban American Indian Health Programs: Results from six site visits

This study explores behavioral health services for American Indians and Alaska Natives (AIANs) at six Urban Indian Health Programs (UIHPs). Interviews and focus groups with clinicians and staff inquired about behavioral health treatment available, service needs, client population, and financial and staffing challenges. Resulting site profiles were created based on focused coding and integrative memoing of site visit field notes and respondent transcripts. These six UIHPs evidenced diversity across multiple facets of service delivery even as they were united in their missions to provide accessible and effective behavioral health treatment to urban AIAN clients. Primary challenges to service provision included heterogenous client populations, low insurance coverage, limited provider knowledge, lack of resources, and incorporation of traditional healing. Collaborative research with UIHPs harbors the potential to recognize challenges, identify solutions, and share best practices across this crucial network of health care sites for improving urban AIAN well-being.

Neural processes of inhibitory control in American Indian peoples are associated with reduced mental health problems

American Indians (AI) experience disproportionately high prevalence of suicide and substance use disorders (SUD). However, accounting for risk burden (e.g. historical trauma and discrimination), the likelihood of mental health disorders or SUD is similar or decreased compared with the broader population. Such findings have spurred psychological research examining the protective factors, but no studies have investigated its potential neural mechanisms. Inhibitory control is one of the potential neurobehavioral construct with demonstrated protective effects, but has not been examined in neuroimaging studies with AI populations specifically. We examined the incidence of suicidal thoughts and behaviors (STB) and SUD among AI (n = 76) and propensity matched (sex, age, income, IQ proxy and trauma exposure) non-Hispanic White (NHW) participants (n = 76). Among the AI sample, functional magnetic resonance imaging (fMRI) data recorded during the stop-signal task (SST) was examined in relation to STB and SUDs. AIs relative to NHW subjects displayed lower incidence of STB. AIs with no reported STBs showed greater activity in executive control regions during the SST compared with AI who endorsed STB. AI without SUD demonstrated lower activity relative to those individual reporting SUD. Results are consistent with a growing body of literature demonstrating the high level of risk burden driving disparate prevalence of mental health concerns in AI. Furthermore, differential activation during inhibitory control processing in AI individuals without STB may represent a neural mechanism of protective effects against mental health problems in AI. Future research is needed to elucidate sociocultural factors contributing protection against mental health outcomes in AIs and further delineate neural mechanisms with respect to specific concerns (e.g. SUD vs STB).

Understanding suicide risk for youth who are both Black and Native American: The role of intersectionality and multiple marginalization

INTRODUCTION

Native American and multiracial youth experience elevated risk for suicide ideation (SI) and suicide attempts (SA); however, intersectional identities are often unexamined in suicide research.

METHOD

We examined the prevalence of SI and SA, and the impact of intersectional identities (sex, sexual minority identity, and economic insecurity) on these rates, in 496 biracial Black-Native American, 2,804 Native American, 14,220 Black, 5,569 biracial Native American-White, 4,076 biracial Black-White, and 118,816 White youth who participated in the Minnesota Student Survey.

RESULTS

Black-Native American youth reports of SI and SA resembled other Native American youth and were significantly higher than those reported by Black, White, and Black-White (SA only) youth. While sexual minority youth reported higher rates of SI and SA than heterosexual youth, this difference between sexual minority and heterosexual Black-Native American youth was smaller as compared to their peers.

CONCLUSION

Though they largely resemble their mono/biracial Native American peers, Black-Native American youth show some distinct patterns of SA when accounting for their intersectional identities. Despite presumed similarities in systemic risk factors, Black and Black-Native American youth differ considerably in reported suicidality. The experiences of Black-Native American teens warrant further examination.

Beliefs about causal factors for suicide in rural Alaska Native communities and recommendations for prevention

Rural Indigenous communities in Alaska suffer staggeringly high rates of suicide. In close-knit Alaska Native villages, each suicide leaves a trail of affected family and community members in its wake. This research aimed to understand community perceptions of what causes suicide in rural Alaska Native villages and generate recommendations for prevention strategies. In-depth interviews were conducted with 25 Alaska Native university students who moved from rural villages to an urban area to attend college. All had been profoundly affected by others' suicides and shared their beliefs about causal factors and recommendations for prevention efforts. Perceived causes included resistance to seeking help or discussing personal problems, loss of culture, traumatic experiences, geographical and social isolation, lack of opportunity, substance abuse, and exposure to others' suicides. Participants believed that suicide is preventable and recommended multi-level approaches to address suicide disparities. They provided recommendations for potentially effective and culturally appropriate prevention strategies, including increasing cultural and social connections, educating community members about mental health, and increasing accessibility of counseling services/reducing barriers to mental health services utilization.

Suicide and the opioid overdose crisis among American Indian and Alaska Natives: a storm on two fronts demanding swift action

The opioid crisis in the United States has received national attention and critical resources in the past decade. However, what has been overlooked is the effect the opioid crisis may be having on a three-decade suicide crisis among American Indian and Alaska Native (AIAN) communities that already have too few resources to address behavioral and mental health issues. This paper describes recent epidemiological trends associated with both opioid overdose and suicide at a national level for AIANs and the rest of the United States. We used data reported by the Centers for Disease Control and Prevention to report historical trends of opioid overdose and suicide for AIAN and non-AIAN populations. We found alarming and potentially correlated trends of opioid use and suicidality among AIAN populations. We highlight both current and future research that will be essential to understanding and addressing the unique intersection between opioid and suicide risk and protective factors to inform dual prevention and intervention efforts among AIAN populations with potential relevance to public health response among other at-risk populations.

Suicide Across Buddhism, American Indian-Alaskan Native, and African Traditional Religions, Atheism and Agnosticism: An Updated Systematic Review

Religion can exert a powerful influence on human behavior, including suicide. Research has demonstrated that religiosity can potentially serve as a protective factor against suicidal behavior, but may also, at times, serve as a risk factor. In clinical practice with individuals managing suicidality, a clear understanding of the influence of religion on suicidality is required to effectively assess for risk of suicide. In the 10 years since the article, 'Religion and suicide: Buddhism, American Indian/Alaskan Native (AIAN) and African religions, Atheism, and Agnosticism' (Lizardi and Gearing, J Relig Health 49:377-384, 2010), there has been a significant increase in research advancing our understanding of the nature of this relationship across faiths and beliefs. Consequently, this article provides an expanded and updated review of the research in the 10 years since our original publication examining the relationship between suicide and religion across Buddhism, AIAN, African religions, as well as atheism, agnosticism. The databases PsycINFO, MEDLINE, SocINDEX, and CINAHL databases were searched for published articles on religion and suicide over the last decade, between 2009 and 2019. Epidemiological data on suicidality across these world religions, and attitudes and beliefs toward suicide are presented. Updated recommended practice guidelines for effectively incorporating religiosity into suicide risk assessment and treatment are provided, and areas of future research are identified.

Law Enforcement and Suicide Calls for Service: A Mixed-Methods Study of Suicide Attempts and Deaths

INTRODUCTION

Suicide is a major public health issue, however, little is known about the characteristics/circumstances of suicide events. Data from law enforcement (LE) call reports are an important source of information related to suicide. Hence, this study explores suicide events captured in LE call reports.

METHOD

This mixed-methods study used data from call reports collected in a metropolitan county in 2017 in a Midwestern state wherein LE responded to suicide incidents (N=213). Descriptive and bivariate analyses of quantitative data were used to assess differences between incident type (i.e. attempts vs. deaths). Themes of suicide emerged from the qualitative data.

RESULTS

Findings revealed that suicide decedents tended to be male, older, and had at least one intrapersonal issue as a precipitating factor. The qualitative sections illuminated three themes across suicide attempts: self-harm as an autonomy seeking strategy; challenging claims of suicidality; and promising to not self-harm.

CONCLUSIONS

Suicide incidents that rise to the level of crisis requiring a LE response is understudied in both the suicide and LE literature. Increasing the sophistication of call report documentation procedures would allow for communities to deepen their understanding of how suicide manifests and could create pathways to non-institutionalized care.

Factors Associated with Recovery in Aboriginal People in Canada Who Had Previously Been Suicidal

To explore factors associated with recovery from suicidal ideation among Aboriginal peoples living off reserve in Canada. Recovery is defined as being free of serious suicidal thoughts for the past year. Data for this study came from the 2012 Aboriginal Peoples Survey, a nationally representative sample of Aboriginal peoples in Canada who are living off-reserve. The sample consisted of those who had seriously considered suicide at some point in their life (n = 2,680). Those who had been suicidal in the past year were compared to those who were no longer suicidal using Pearson chi-square and logistic regression analyses. Several factors were associated with recovery among Aboriginal peoples living off-reserve in Canada who had previously been suicidal. Recovery was higher among women, individuals who were older, and those who were food secure, spoke an Aboriginal language, had a high school degree, had a confidant, and had no previous diagnosis of mood disorders or learning disability. Several sociodemographic factors appear to influence recovery from suicidality among Aboriginal peoples. Intervention approaches to promote recovery from suicidal ideation would benefit from targeted outreach, a strength-based, culturally-specific approach using traditional practices, and encouraging involvement of various community members to foster resilience and formation of relationships.

Entrepreneurial, Economic, and Social Well-Being Outcomes from an RCT of a Youth Entrepreneurship Education Intervention among Native American Adolescents

Background: Entrepreneurship education has demonstrated positive impacts in low-resource contexts. However, there is limited evidence of such programs evaluated among Native American (NA) youth in a rural reservation. Methods: A 2:1 randomized controlled trial evaluated the impact of the Arrowhead Business Group (ABG) entrepreneurship education program on entrepreneurship knowledge, economic empowerment, and social well-being among 394 NA youth. An intent to treat analysis using mixed effects regression models examined within and between study group differences from baseline to 24 months. An interaction term measured change in the intervention relative to change in the control. ABG participants were purposively sampled to conduct focus groups and in-depth interviews. Results: Significant intervention vs. control group improvements were sustained at 12 months for entrepreneurship knowledge and economic confidence/security. Significant within-group improvements were sustained for ABG participants at 24 months for connectedness to parents, school, and awareness of connectedness. Qualitative data endorses positive impacts on social well-being among ABG participants. Conclusion: Observed effects on entrepreneurship knowledge, economic empowerment, and connectedness, supplemented by the experiences and changes as described by the youth themselves, demonstrates how a strength-based youth entrepreneurship intervention focused on developing assets and resources may be an innovative approach to dually address health and economic disparities endured in Native American communities.

Suicide, Alcohol Intoxication, and Age Among Whites and American Indians/Alaskan Natives

BACKGROUND

Among American Indians/Alaskan Natives (AI/ANs), suicides are disproportionately high among those younger than 40 years of age. This paper examines suicide and alcohol intoxication (postmortem BAC ≥ 0.08 g/dl) by age among Whites and AI/ANs to better understand the reasons for the high rate of suicide among AI/ANs for those younger than 40.

METHODS

Data come from the restricted 2003 to 2016 National Violent Death Reporting System (NVDRS), with postmortem information on 79,150 White and AI/AN suicide decedents of both genders who had a BAC test in 32 states of the United States.

RESULTS

Among Whites, 39.3% of decedents legally intoxicated are younger than 40 years of age, while among AI/ANs the proportion is 72.9% (p < 0.001). Multivariable logistic regression with data divided by age shows that in the 18 to 39 age group, AI/ANs are about 2 times more likely than Whites to have a postmortem BAC ≥ 0.08. Veteran status compared to nonveteran, and history of alcohol problems prior to suicide were also associated with BAC ≥ 0.08. Suicide methods other than by firearm and a report of the presence of 2 or more suicide precipitating circumstances were protective against BAC ≥ 0.08. Results for the age group 40 years of age and older mirror those for the younger group with 1 exception: Race/ethnicity was not associated with BAC level.

CONCLUSIONS

The proportion of suicide decedents with a BAC ≥ 0.08 is higher among AI/ANs than Whites, especially among those 18 to 39 years of age. However, acute alcohol intoxication does not fully explain differences in suicide age structure between AI/ANs and Whites.

Lived Experiences of Suicide Risk and Resilience among Alaska Native and American Indian People

This study explored the lived experiences of suicidality and help-seeking for suicide prevention among Alaska Native and American Indian (AN/AI) people in a tribal health system. An interpretive phenomenological approach was used to analyze semi-structured, in-depth interviews with 15 individuals (ages 15-56) with self-reported histories of suicide ideation and/or attempt. Several factors were found to be central to acquiring resilience to suicide risk among AN/AI people across a wide age range: meaningful and consistent social connection, awareness about how one's suicide would negatively effect loved ones, and knowledge and utilization of available health services. Findings highlight the mutable nature of suicide risk and resilience, as well as the importance of interpersonal factors in suicidality.

Mental health issues among indigenous communities and the role of traditional medicine

INTRODUCTION

Mental health in indigenous communities is a relevant issue for the World Health Organization (WHO). These communities are supposed to live in a pure, clean and intact environment. Their real condition is far different from the imaginary; they are vulnerable populations living in difficult areas, exposed to pollution, located far from the health services, exposed to several market operations conducted to extract natural resources, facing criminal groups or illegal exploitation of land resources. These factors may have an impact on mental health of indigenous population.

METHODS

We reviewed all papers available on PubMed, EMBASE and The Cochrane Library until December 2018. We focused on those factors affecting the changes from a traditional to a post-modern society and reviewed data available on stress-related issues, mental distress affecting indigenous/aboriginal communities and the role of Traditional Medicine (TM). We reviewed articles from different countries hosting indigenous communities.

RESULTS

The incidence of mental distress and related phenomena (e.g. collective suicide, alcoholism and violence) among indigenous populations is affected by political and socio-economic variables. The mental health of these populations is poorly studied and described even if mental illness indicators are somewhat alarming. TM still seems to have a role in supporting affected people and may reduce deficiencies due to poor access to medical insurance/coverage, psychiatry and psychotherapy. It would be helpful to combine TM and modern medicine in a healthcare model to face indigenous populations' health needs.

CONCLUSION

This review confirms the impact of societal changes, environmental threats and exploitation of natural resources on the mental health of indigenous populations. Global Mental Health needs to deal with the health needs of indigenous populations as well as psychiatry needs to develop new categories to describe psychopathology related to social variance as recently proposed by the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5).

Social Support and Its Effects on Attempted Suicide Among American Indian/Alaska Native Youth in New Mexico

Objective:How social support (SS) affects the odds of suicide attempt among American Indian/Alaska Native (AI/AN) youth in New Mexico and is modified by school location and metropolitan status.Methods:Multiple logistic regression for complex design was used to produce the adjusted odds of suicide attempt by SS using the New Mexico Youth Risk and Resiliency Survey (NM-YRRS) for 2011 (n = 2,730), 2013 (n = 3,171), and 2015 (n = 2,604) while adjusting for age, grade, gender, and maternal education level. Primary outcome: [Formula: see text]one self-reported suicide attempt in the past 12 months. Primary exposure: social support, categorized as low, moderate, and high support. Additional analysis on the 2015 NM-YRRS to understand how SS and the odds of suicide attempt were modified by (a) school location and (b) metropolitan status while adjusting for age, grade, gender, maternal education level, urbanicity, reservation status, unstable housing, forced sexual intercourse, and teen dating violence (n = 1,373).Results:The adjusted odds of suicide attempt among AI/AN students with low support compared to those with high support has declined from 2011 to 2015 (AOR= 5.5, 95% CI 3.3-9.6, in 2011; AOR= 2.2, 95% CI 1.3-3.7, in 2015). Low SS is a significant risk factor for rural/on reservation students. In contrast, low SS was not a risk factor for AI/AN students who attended schools in urban counties.Conclusion:Results address a gap in current research regarding differences in urban/rural AI/AN youth. In addition to SS, this study indicates there are unknown risk factors that drive suicide attempt for AI/AN youth in off reservation/urban schools.

A Culturally-Grounded Biopsychosocial Assessment Utilizing Indigenous Ways of Knowing with the Cowichan Tribes

Extant research foregrounds the need for culturally responsive, evidence-based mental health practices when working with Indigenous communities. This study presents an Indigenous biopsychosocial assessment designed by members of the Cowichan Tribes to evaluate the social, developmental, and mental health histories of Cowichan youth. The assessment takes the form of an in-depth narrative interview whose parameters were developed through a culturally grounded, community-based process. This process supported a focus on relationality, interdependence, and intergenerational transmission of knowledge during the interview. Five participants aged 12-18 years completed interviews, which yielded sufficient data to enable completion of both Indigenous and standard biopsychosocial assessments.

Understanding Indigenous Suicide Through a Theoretical Lens: A Review of General, Culturally-Based, and Indigenous Frameworks

Many American Indian/Alaska Native (AI/AN) communities throughout North America continue to experience the devastating impact of suicide. Theoretical explanations of suicide from a psychological, sociological, cultural, and Indigenous perspective all differ in focus and applicability to AI/AN communities. These diverse theoretical frameworks and models are presented herein to examine the potential applicability, strengths, and limitations in understanding AI/AN suicide. In providing these perspectives, continued discussions and empirical examinations of AI/AN suicide can guide informative, culturally-informed suicide prevention and intervention efforts.

Examining protective and buffering associations between sociocultural factors and adverse childhood experiences among American Indian adults with type 2 diabetes: a quantitative, community-based participatory research approach

OBJECTIVES

The purpose of this study was to determine the frequency of select adverse childhood experiences (ACEs) among a sample of American Indian (AI) adults living with type 2 diabetes (T2D) and the associations between ACEs and self-rated physical and mental health. We also examined associations between sociocultural factors and health, including possible buffering processes.

DESIGN

Survey data for this observational study were collected using computer-assisted survey interviewing techniques between 2013 and 2015.

SETTING

Participants were randomly selected from AI tribal clinic facilities on five reservations in the upper Midwestern USA.

PARTICIPANTS

Inclusion criteria were a diagnosis of T2D, age 18 years or older and self-identified as AI. The sample includes n=192 adults (55.7% female; mean age=46.3 years).

PRIMARY MEASURES

We assessed nine ACEs related to household dysfunction and child maltreatment. Independent variables included social support, diabetes support and two cultural factors: spiritual activities and connectedness. Primary outcomes were self-rated physical and mental health.

RESULTS

An average of 3.05 ACEs were reported by participants and 81.9% (n=149) said they had experienced at least one ACE. Controlling for gender, age and income, ACEs were negatively associated with self-rated physical and mental health (p<0.05). Connectedness and social support were positively and significantly associated with physical and mental health. Involvement in spiritual activities was positively associated with mental health and diabetes-specific support was positively associated with physical health. Social support and diabetes-specific social support moderated associations between ACEs and physical health.

CONCLUSIONS

This research demonstrates inverse associations between ACEs and well-being of adult AI patients with diabetes. The findings further demonstrate the promise of social and cultural integration as a critical component of wellness, a point of relevance for all cultures. Health professionals can use findings from this study to augment their assessment of patients and guide them to health-promoting social support services and resources for cultural involvement.

Developing a culturally appropriate branding for a social and emotional wellbeing intervention in an Aboriginal community

ISSUE ADDRESSED

An initial consultation process to implement a culturally appropriate social and emotional wellbeing campaign in an Aboriginal community indicated that the fundamental principles of the Act-Belong-Commit mental health promotion campaign were acceptable, but that a cultural adaptation of the branding should be sought.

METHODS

A competition was held inviting community members to design a brand logo for the campaign in their community. Local judges selected "winners" in various categories, and six of the submissions were selected for testing in the broader community via street intercept interviews. Respondents were asked which logo they liked best, their perceived meanings of the designs and the perceived appropriateness of the designs for a social and emotional wellbeing campaign.

RESULTS

A convenience sample of N = 26 local Aboriginal people who lived and/or worked in Roebourne completed the questionnaire. There was a clear majority preference for logo "D," which communicated appropriate meanings of pride and strength in standing together, and reflected the underlying strengths and capacities of Aboriginal people which this project seeks to harness and support.

CONCLUSIONS

The approach of using a logo competition to develop the campaign brand was highly successful and enabled further meaningful engagement with the community and other service providers in the town. The success of the competition process resulted from an emphasis on relationship building, listening to the local community and involving the community in decision-making. So what? By conforming to established, but not always adhered to, recommendations for community consultation, successful and more enduring outcomes are likely.

Protective Factors in the Inuit Population of Nunavut: A Comparative Study of People Who Died by Suicide, People Who Attempted Suicide, and People Who Never Attempted Suicide

Epidemiological data shows an alarming prevalence of suicide in Aboriginal populations around the world. In Canada, the highest rates are found in Inuit communities. In this article, we present the findings of a secondary analysis conducted with data previously collected as part of a larger study of psychological autopsies conducted in Nunavut, Canada. The objective of this secondary analysis was to identify protective factors in the Inuit population of Nunavut by comparing people who died by suicide, people from the general population who attempted suicide, and people from the general population who never attempted suicide. This case-control study included 90 participants, with 30 participants in each group who were paired by birth date, sex, and community. Content analysis was first conducted on the clinical vignettes from the initial study in order to codify the presence of protective variables. Then, inferential analyses were conducted to highlight differences between each group in regards to protection. Findings demonstrated that (a) people with no suicide attempt have more protective variables throughout their lifespan than people who died by suicide and those with suicide attempts within the environmental, social, and individual dimensions; (b) people with suicide attempts significantly differ from the two other groups in regards to the use of services; and (c) protective factors that stem from the environmental dimension show the greatest difference between the three groups, being significantly more present in the group with no suicide attempt. Considering these findings, interventions could focus on enhancing environmental stability in Inuit communities as a suicide prevention strategy.

Culturally-Informed Interventions for Substance Abuse Among Indigenous Youth in the United States: A Review

PURPOSE

Given the disproportionately high levels of alcohol and other drug abuse among Indigenous youth in the United States, the purpose of this systematic review was to explicate the current state of empirically-based and culturally-informed substance abuse prevention and intervention programs for Indigenous youth (ages 9-18).

METHOD

The 14 articles that met inclusion criteria for this review were analyzed both in terms of the cultural intervention itself (primary population, intervention, core tenants, focus of intervention, intervention goals, location, intervention location, and program length) and their evaluation approach.

RESULTS

Results indicate variable integration of cultural components with the majority of interventions taking place in schools and treatment facilities, targeting primarily individuals.

DISCUSSION

There is a current gap in research on culturally-informed substance abuse interventions for Indigenous youth, which this review begins to address. Promising areas of future research and interventions include bringing communities and families into treatment and prevention.

A CBPR Approach to Finding Community Strengths and Challenges to Prevent Youth Suicide and Substance Abuse

Purpose: To improve health and reduce health disparities, research partnerships with American Indian and Alaska Native communities should build on existing traditions and strengths. The overall goal of this pilot project was to clarify the needs of tribal community members and determine strengths and resources available to the community. Design: Community-based participatory research was the approach used to obtain community input. Data collection methods included, Photovoice ( n = 16), digital storytelling ( n = 4), and community capacity surveys ( n = 128). Results: Quantitative and qualitative findings supported the need to (1) address youth suicide and substance abuse on the reservation and (2) use preexisting resources available in the community. The results led to the development of a strengths-based intervention incorporating the Gathering of Native American’s curriculum. Conclusion: Integral to the development, implementation, and sustainability of the intervention was the truly reciprocal relationship developed between community and university partners.

Embedding DBT Skills Training Within a Transactional-Ecological Framework to Reduce Suicidality in a Navajo Adolescent Female

American Indian/Alaska Native (AI/AN) youth have higher rates of suicidality than any other ethnic or cultural group in the United States. Dialectical behavior therapy (DBT) is an evidence-based treatment that has been found to reduce suicidality in adolescents, but there is little literature speaking to its efficacy with the AI/AN population. The transactional-ecological model of suicidality helps identify protective factors that can be bolstered at the individual, familial, community, and spiritual levels to reduce suicidality and suicidal contagion in AI/AN youth. The current study examines a case where DBT was culturally adapted and embedded within a transactional-ecological framework to treat a 14-year-old Navajo female with Major Depressive Disorder with psychotic features who presented to a psychiatric inpatient facility following a suicide attempt. The patient’s wish to die was motivated by her belief that her death could lead to positive changes in an extended family system plagued by historical trauma, alcoholism, suicide, and domestic violence. Ongoing assessment was conducted using the Suicide Status Form (SSF), Suicide Probability Scale (SPS), Reasons for Living Scale for Adolescents (RFL-A), and the DBT diary card. Navajo healing traditions were used in conjunction with DBT skills training and enhancement of ecological protective factors. Initial reduction in depression and suicidality was complicated by an increase in homicidal ideation. A comprehensive psychiatric evaluation was completed, and treatment was modified through medication changes, increased mindfulness practice, bolstering support systems, and engagement in a Navajo healing ceremony. Implications for clinicians treating suicidality in Navajo youth are discussed.

Urban American Indian Community Perspectives on Resources and Challenges for Youth Suicide Prevention

American Indian (AI) youth have some of the highest rates of suicide of any group in the United States, and the majority of AI youth live in urban areas away from tribal communities. As such, understanding the resources available for suicide prevention among urban AI youth is critical, as is understanding the challenges involved in accessing such resources. Pre-existing interview data from 15 self-identified AI community members and staff from an Urban Indian Health Organization were examined to understand existing resources for urban AI youth suicide prevention, as well as related challenges. A thematic analysis was undertaken, resulting in three principal themes around suicide prevention: formal resources, informal resources, and community values and beliefs. Formal resources that meet the needs of AI youth were viewed as largely inaccessible or nonexistent, and youth were seen as more likely to seek help from informal sources. Community values of mutual support were thought to reinforce available informal supports. However, challenges arose in terms of the community's knowledge of and views on discussing suicide, as well as the perceived fit between community values and beliefs and formal prevention models.

Suicide: scientific overview and relevance for trauma care providers

The World Health Organization estimates that in the year 2000, approximately one million people died from suicide worldwide. Over the last 45 years, suicide rates have increased by 60%, with a particularly precipitous rise among young people. The underlying psychology of suicide is complex and individual. However, certain themes emerge from studying individuals who have attempted or completed suicides. This paper will provide an overview of suicide and suicidal behaviour as it relates to trauma practitioners, detailing risk factors, biologic and genetic interactions, and opportunities for prevention and treatment.

Creating a Community of Practice to Prevent Suicide Through Multiple Channels: Describing the Theoretical Foundations and Structured Learning of PC CARES

It is critical to develop practical, effective, ecological, and decolonizing approaches to indigenous suicide prevention and health promotion for the North American communities. The youth suicide rates in predominantly indigenous small, rural, and remote Northern communities are unacceptably high. This health disparity, however, is fairly recent, occurring over the last 50 to 100 years as communities experienced forced social, economic, and political change and intergenerational trauma. These conditions increase suicide risk and can reduce people's access to shared protective factors and processes. In this context, it is imperative that suicide prevention includes--at its heart--decolonization, while also utilizing the "best practices" from research to effectively address the issue from multiple levels. This article describes such an approach: Promoting Community Conversations About Research to End Suicide (PC CARES). PC CARES uses popular education strategies to build a "community of practice" among local and regional service providers, friends, and families that fosters personal and collective learning about suicide prevention in order to spur practical action on multiple levels to prevent suicide and promote health. This article will discuss the theoretical underpinnings of the community intervention and describe the form that PC CARES takes to structure ongoing dialogue, learning, solidarity, and multilevel mobilization for suicide prevention.

Advancing suicide prevention research with rural American Indian and Alaska Native populations

As part of the National Action Alliance for Suicide Prevention's American Indian and Alaska Native (AI/AN) Task Force, a multidisciplinary group of AI/AN suicide research experts convened to outline pressing issues related to this subfield of suicidology. Suicide disproportionately affects Indigenous peoples, and remote Indigenous communities can offer vital and unique insights with relevance to other rural and marginalized groups. Outcomes from this meeting include identifying the central challenges impeding progress in this subfield and a description of promising research directions to yield practical results. These proposed directions expand the alliance's prioritized research agenda and offer pathways to advance the field of suicide research in Indigenous communities and beyond.

Reconsidering culturally competent approaches to American Indian healing and well-being

There is an urgent need to eliminate mental health disparities experienced by American Indians and Alaska Natives (AI/ANs). Service providers and researchers often address these disparities by focusing on low rates of participation in Western mental health services. In part, this reflects limited understandings of the sociopolitical and historical context of AI/AN mental health problems. Furthermore, this emphasis fails to recognize the importance of emic understandings of locally resonant coping strategies, healing, and treatment. In this article, we describe (a) a study designed to address these gaps, (b) findings related to the importance of land and place, and (c) a community-university collaboration to translate these findings into meaningful change within one Diné community. Connections to the land were an important cultural strength on which to build efforts to promote mental health. Thus, effective treatment might involve more in-depth understanding of cultural processes through which healing occurs and well-being is maintained.

Characteristics of borderline personality disorder in a community sample: comorbidity, treatment utilization, and general functioning

This study provides estimates of the prevalence and demographic features of borderline personality disorder (BPD) in a community sample as well as BPD comorbidity rates with Axis I and II disorders. In addition, the authors provide data on general functioning and treatment seeking among individuals with BPD. Data from 34,481 participants in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were analyzed. Results suggest that 2.7% of adults in the United States meet diagnostic criteria for BPD, with slightly higher rates of the disorder in females, people in lower income brackets, people younger than 30, and individuals who are separated or divorced. Racial/ethnic differences were evident, with Native Americans (5.0%) and Blacks (3.5%) having significantly higher rates of the disorder, on average, and Asians having significantly lower rates (1.2%). Individuals with a BPD diagnosis were likely to have co-occurring lifetime mood disorders, anxiety disorders, substance use disorders, and other personality disorders. Specifically, 84.8% of individuals with BPD also had a lifetime anxiety disorder, 82.7% had a lifetime mood disorder/episode, and 78.2% were diagnosed with a lifetime substance use disorder. Individuals with BPD showed significant impairment in functioning and were highly likely to seek therapy or receive medication for mental health concerns.

A protective factors model for alcohol abuse and suicide prevention among Alaska Native youth

This study provides an empirical test of a culturally grounded theoretical model for prevention of alcohol abuse and suicide risk with Alaska Native youth, using a promising set of culturally appropriate measures for the study of the process of change and outcome. This model is derived from qualitative work that generated an heuristic model of protective factors from alcohol (Allen et al. in J Prev Interv Commun 32:41-59, 2006; Mohatt et al. in Am J Commun Psychol 33:263-273, 2004a; Harm Reduct 1, 2004b). Participants included 413 rural Alaska Native youth ages 12-18 who assisted in testing a predictive model of Reasons for Life and Reflective Processes about alcohol abuse consequences as co-occurring outcomes. Specific individual, family, peer, and community level protective factor variables predicted these outcomes. Results suggest prominent roles for these predictor variables as intermediate prevention strategy target variables in a theoretical model for a multilevel intervention. The model guides understanding of underlying change processes in an intervention to increase the ultimate outcome variables of Reasons for Life and Reflective Processes regarding the consequences of alcohol abuse.

Ethics and Community Involvement in Syntheses Concerning American Indian, Alaska Native, or Native Hawaiian Health: A Systematic Review

BACKGROUND

The objective of the research was to review reporting of ethical concerns and community involvement in peer-reviewed systematic reviews or meta-analyses concerning American Indian, Alaska Native, or Native Hawaiian (AI/AN/NH) health.

METHODS

Text words and indexed vocabulary terms were used to query PubMed, Embase, Cochrane Library, and the Native Health Database for systematic reviews or meta-analyses concerning AI/AN/NH health published in peer-reviewed journals, followed by a search through reference lists. Each article was abstracted by two independent reviewers; results were discussed until consensus was reached.

RESULTS

We identified 107 papers published from 1986-2012 that were primarily about AI/AN/NH health or presented findings separately for AI/AN/NH communities. Two reported seeking indigenous reviewer feedback; none reported seeking input from tribes and communities. Approximately 7% reported on institutional review board (IRB) approval of included studies, 5% reported on tribal approval, and 4% referenced the sovereignty of AI/AN tribes. Approximately 63% used evidence from more than one AI/AN/NH population study, and 28% discussed potential benefits to communities from the synthesis research.

CONCLUSIONS

Reporting of ethics and community involvement are not prominent. Systematic reviews and meta-analyses making community-level inferences may pose risks to communities. Future systematic reviews and meta-analyses should consider ethical and participatory dimensions of research.

Why an alternative to suicide prevention gatekeeper training is needed for rural Indigenous communities: presenting an empowering community storytelling approach

The need for effective youth suicide prevention is uncontested, and is particularly urgent for Indigenous populations. The Indigenous youth suicide rates in some North American communities can be 18 times greater than for other young people. Despite the clear need, evidence in support of Indigenous youth suicide prevention strategies remain mixed. The most common approach to youth suicide prevention - gatekeeper training - may have limited effects in Indigenous communities. Based on recent work undertaken with Indigenous leaders in rural Alaska, we describe culturally grounded, practical alternatives that may be more effective for Indigenous communities. We highlight the ways in which research informed, grassroots interventions can address cultural, practical and systemic issues that are relevant when addressing risks for suicide on a community level. Built on a transactional-ecological framework that gives consideration to local contexts, culture-centric narratives and the multiple, interacting conditions of suicide, the innovative approach described here emphasizes community and cultural protective factors in Indigenous communities, and extends typical suicide prevention initiatives in ways that have important implications for other ethnically diverse communities.

"The weight on our shoulders is too much, and we are falling": Suicide among Inuit male youth in Nunavut, Canada

Inuit youth suicide is at an epidemic level in the circumpolar north. Rapid culture change has left Inuit in a state of coloniality that destabilized their kin-based social organization, and in spite of advances in self-governance social problems such as suicide continue. Drawing on ethnographic fieldwork I carried out in Nunavut, Canada (2004-2005), including 27 interviews with Inuit between the ages of 17 and 61, I examine male youth in particular in the context of recent colonial change, gender ideologies and behavior, youth autonomy, and the family. Anger is common among Inuit male youth, often directed toward girlfriends and parents, and suicide is embedded in some of these relationships. Many Inuit male youth are struggling with a new cultural model of love and sexuality. Inuit speak about a need for more responsible parenting. Evidence is beginning to show, however, that local, community-based suicide prevention may be working.

The Racial-Cultural Framework

Suicide-related outcomes are a major public health challenge in communities of color in the United States. To address these challenges, this Major Contribution makes theoretical, empirical, and practice-related contributions to scholarship on suicide-related outcomes among people of color. In this article, the authors present a new framework to conceptualize previous suicidology scholarship, address existing literature gaps, and inform counseling psychologists’ future work on suicide-related outcomes in U.S. communities of color. The framework consists of three components and nine principles that highlight the types of constructs, populations, and preventive interventions that should be emphasized in theory, research, and practice addressing suicide-related outcomes in communities of color. The authors explain why suicide-related outcomes in communities of color deserve attention, describe the framework, and discuss implications of the framework for future practice and training. It is hoped that this framework can serve as a resource and impetus for new paradigms of suicidology work in communities of color.

"We're still in a struggle": Diné resilience, survival, historical trauma, and healing

As part of a community/university collaborative effort to promote the mental health and well-being of Diné (Navajo) youth, we explored the relevance of addressing historical trauma and current structural stressors, and of building on individual and community strengths through healing and social transformation at multiple levels. Qualitative analyses of 74 ethnographic interviews with 37 Diné youth, parents, and grandparents suggested that a focus on historical trauma as a conceptual frame for behavioral health inequities, understood within the context of resilience and survival, is appropriate. Our findings also highlight the salience of current stressors such as poverty and violence exposure. We explore the fit of an historical trauma healing framework and present implications for intervention and transformation through revitalization of traditional knowledge, culturally based healing practices, intergenerational education, and social change strategies designed to eliminate social inequities.

Culturally responsive suicide prevention in indigenous communities: unexamined assumptions and new possibilities

Indigenous communities have significantly higher rates of suicide than non-Native communities in North America. Prevention and intervention efforts have failed to redress this disparity. One explanation is that these efforts are culturally incongruent for Native communities. Four prevalent assumptions that underpin professional suicide prevention may conflict with local indigenous understandings about suicide. Our experiences in indigenous communities led us to question assumptions that are routinely endorsed and promoted in suicide prevention programs and interventions. By raising questions about the universal relevance of these assumptions, we hope to stimulate exchange and inquiry into the character of this devastating public health challenge and to aid the development of culturally appropriate interventions in cross-cultural contexts.

American Indian and Alaska Native mental health: diverse perspectives on enduring disparities

As descendants of the indigenous peoples of the United States, American Indians and Alaska Natives (AI/ANs) have experienced a resurgence in population and prospects since the beginning of the twentieth century. Today, tribally affiliated individuals number over two million, distributed across 565 federally recognized tribal communities and countless metropolitan and nonreservation rural areas. Although relatively little evidence is available, the existing data suggest that AI/AN adults and youth suffer a disproportionate burden of mental health problems compared with other Americans. Specifically, clear disparities have emerged for AI/AN substance abuse, posttraumatic stress, violence, and suicide. The rapid expansion of mental health services to AI/AN communities has, however, frequently preceded careful consideration of a variety of questions about critical components of such care, such as the service delivery structure itself, clinical treatment processes, and preventive and rehabilitative program evaluation. As a consequence, the mental health needs of these communities have easily outpaced and overwhelmed the federally funded agency designed to serve these populations, with the Indian Health Service remaining chronically understaffed and underfunded such that elimination of AI/AN mental health disparities is only a distant dream. Although research published during the past decade has substantially improved knowledge about AI/AN mental health problems, far fewer investigations have explored treatment efficacy and outcomes among these culturally diverse peoples. In addition to routine calls for greater clinical and research resources, however, AI/AN community members themselves are increasingly advocating for culturally alternative approaches and opportunities to address their mental health needs on their own terms.

Unikkaartuit: meanings of well-being, unhappiness, health, and community change among Inuit in Nunavut, Canada

Suicide among young Inuit in the Canadian Arctic is at an epidemic level. In order to understand the distress and well-being experienced in Inuit communities, a first step in understanding collective suicide, this qualitative study was designed. Fifty Inuit were interviewed in two Inuit communities in Nunavut, Canada, and questionnaires asking the same questions were given to 66 high school and college students. The areas of life investigated here were happiness and wellbeing, unhappiness, healing, and community and personal change. Three themes emerged as central to well-being: the family, talking/communication, and traditional Inuit cultural values and practices. The absence of these factors were most closely associated with unhappiness. Narratives about community and personal change were primarily about family, intergenerational segregation, an increasing population, more trouble in romantic relationships among youth, drug use, and poverty. Change over time was viewed primarily as negative. Discontinuity of kinship structure and function appears to be the most harmful effect of the internal colonialism imposed by the Canadian government in the 1950s and 1960s. Directions toward community control and action are encouraging, and are highlighted. Inuit community action toward suicide prevention and community wellness is part of a larger movement of Indigenous self-determination.

Do schools differ in suicide risk? The influence of school and neighbourhood on attempted suicide, suicidal ideation and self-harm among secondary school pupils

BACKGROUND

Rates of suicide and poor mental health are high in environments (neighbourhoods and institutions) where individuals have only weak social ties, feel socially disconnected and experience anomie - a mismatch between individual and community norms and values. Young people spend much of their time within the school environment, but the influence of school context (school connectedness, ethos and contextual factors such as school size or denomination) on suicide-risk is understudied. Our aim is to explore if school context is associated with rates of attempted suicide and suicide-risk at age 15 and self-harm at age 19, adjusting for confounders.

METHODS

A longitudinal school-based survey of 1698 young people surveyed when aged 11, (primary school), 15 (secondary school) and in early adulthood (age 19). Participants provided data about attempted suicide and suicide-risk at age 15 and deliberate self-harm at 19. In addition, data were collected about mental health at age 11, social background (gender, religion, etc.), and at age 15, perception of local area (e.g. neighbourhood cohesion, safety/civility and facilities), school connectedness (school engagement, involvement, etc.) and school context (size, denomination, etc.). A dummy variable was created indicating a religious 'mismatch', where pupils held a different faith from their school denomination. Data were analysed using multilevel logistic regression.

RESULTS

After adjustment for confounders, pupils attempted suicide, suicide-risk and self-harm were all more likely among pupils with low school engagement (15-18% increase in odds for each SD change in engagement). While holding Catholic religious beliefs was protective, attending a Catholic school was a risk factor for suicidal behaviours. This pattern was explained by religious 'mismatch': pupils of a different religion from their school were approximately 2-4 times more likely to attempt suicide, be a suicide-risk or self-harm.

CONCLUSIONS

With several caveats, we found support for the importance of school context for suicidality and self-harm. School policies promoting school connectedness are uncontroversial. Devising a policy to reduce risks to pupils holding a different faith from that of their school may be more problematic.

Critiquing fetal alcohol syndrome health communication campaigns targeted to American Indians

It is widely recognized American Indians and Alaska Natives have suffered from far worse health status than that of other Americans. Health communication campaigns directed to American Indians and Alaska Natives and their outcomes must be grounded in an understanding of the historical and ongoing marginalization and cultural dislocation of these groups. The authors draw upon the specific case of health communication campaigns to reduce cases of fetal alcohol syndrome among American Indians and Alaska Natives. Counteracting stereotyping of American Indians and alcohol consumption by mainstream American popular culture and mediated discourses, coverage of fetal alcohol syndrome in the media is assessed. The study analyzes 429 American Indian news articles from 1990 to 2010. Mainstream American and American Indian media should cover health concerns such as fetal alcohol syndrome more extensively. Researchers, health communication campaign developers, health policy makers, and mainstream media must be knowledgeable about American Indian and Alaskan Native identity, cultures, and history, and diversity across Nations. Last, and most important, health communication strategists and health policy makers must welcome American Indians and Alaska Natives to take leadership roles in communicating culture- and Nation-specific health campaign strategies to eliminate health disparities.

Getting into trouble: perspectives on stress and suicide prevention among Pacific Northwest Indian youth

Suicide rates among Indian youth in the United States are two to three times the national average. Although researchers have identified related risk and protective factors, they have limited understanding of the perspectives of youth at risk. In this descriptive, ethnographic study in a Pacific Northwest tribe, the goal was to gain an understanding of the life experiences of the youth. Focus groups and observations were conducted with 30 Indian youth aged between 14 and 19 years in a Pacific Northwest tribe. Youth were asked to talk about their stressors, sense of family/community support, and hopes for the future. Youth reported major stress and noted that friends and family were both a support and also a source of stress. They hoped for strengthening of cultural values, economic development, and opportunities to give their talents to the tribe. These findings provide further insight about suicide risk among Indian youth and advance the understanding of suicide prevention in a transcultural setting.

Religion and suicide: Buddhism, Native American and African religions, Atheism, and Agnosticism

Research has repeatedly demonstrated that religiosity can potentially serve as a protective factor against suicidal behavior. A clear understanding of the influence of religion on suicidality is required to more fully assess for the risk of suicide. The databases PsycINFO and MEDLINE were used to search peer-reviewed journals prior to 2008 focusing on religion and suicide. Articles focusing on suicidality across Buddhism, Native American and African religions, as well as on the relationship among Atheism, Agnosticism, and suicide were utilized for this review. Practice recommendations are offered for conducting accurate assessment of religiosity as it relates to suicidality in these populations. Given the influence of religious beliefs on suicide, it is important to examine each major religious group for its unique conceptualization and position on suicide to accurately identify a client's suicide risk.

Circle of strength: a case description of culturally integrated suicide prevention

This article presents a case description of an American Indian female at high risk for suicide in effort to document the potential effectiveness of a college student suicide prevention program designed for Northern Plains American Indian students. The program is integrative and culturally grounded within the Medicine Wheel, stressing continuity of care through programming and ongoing communication across support systems. The composite case description presented illustrates the secondary prevention aspects of the model, and how utilizing the model within the framework of continuous care was helpful for a suicidal person and produced a successful outcome over the course of 6 months.

`So I Can Be Like a Whiteman': The Cultural Psychology of Space and Place in American Indian Mental Health

Careful analysis of a single ethnographic interview demonstrates that profound cultural divergences in Western professional and American Indian therapeutic traditions may well emanate from easily overlooked sources of ethnopsychological orientation and intelligibility, namely distinctive cultural psychologies of space and place. Interview responses from a middle-aged Native American Traditionalist on the Fort Belknap Indian reservation revealed that robust `mental health' was seen to result from participation in indigenous ritual spaces enacted or performed in designated sacred places on or near the reservation. In contrast, this respondent observed that consultation by community members with `White psychiatrists' in the local Indian Health Service clinic was an open invitation to `brainwash me forever so I can be like a Whiteman'. For those American Indians who share the respondent's cultural standpoint, reservation-based mental health clinics, despite their intentional designation as therapeutic spaces, may be seen to function as sites of colonial incursion and Native resistance in cultural—and especially ethnopsychological—terms. This article explores the implications of this distinctive cultural psychology of space and place with regard to the interdisciplinary investigation of therapeutic landscapes and the promise of `culturally competent' mental health services.