Suicide mortality among American Indians and Alaska Natives, 1999-2009

Enhancing sleep health in urban American Indian/Alaska Native adolescents: Implications for culturally tailored interventions

BACKGROUND

Urban American Indian/Alaska Native (AI/AN) adolescents are vulnerable to sleep and other health-related disparities due to numerous social drivers, including historical trauma and relocation to urban areas. This study aims to identify strategies to increase protective factors and culturally tailor sleep health interventions for this population.

METHODS

Using community-based participatory research, the NAYSHAW study conducted in-depth interviews with urban AI/AN adolescents aged 12-19 years to understand critical components needed for developing a culturally sensitive sleep health intervention. Data from two qualitative subsamples (N = 46) and parent surveys (N = 110) were analyzed, focusing on factors that affect sleep health behaviors, including parental involvement, technology, and traditional practices.

RESULTS

Key findings include the detrimental impact of electronics use at night and protective effects of traditional practices on sleep. Parental involvement in sleep routines varied by adolescent's age. Adolescents desired sleep health education in interactive formats, whereas parents preferred workshops and digital applications for sleep health strategies. Findings suggest that interventions need to address electronics use and should also be culturally tailored to address the unique experiences of urban AI/AN adolescents.

CONCLUSIONS

Results underscore the importance of utilizing community-based strategies to develop culturally tailored sleep interventions for underserved populations, specifically urban AI/AN adolescents. Integrating traditional practices with evidence-based sleep health strategies can provide a holistic approach to improving sleep and overall well-being. Parental education and involvement will be critical to the success of such interventions.

Evaluating Two Educational Interventions for Enhancing COVID-19 Knowledge and Attitudes in a Sample American Indian/Alaska Native Population

BACKGROUND

The COVID-19 pandemic has exacerbated existing healthcare disparities among American Indian/Alaska Native (AI/AN) populations rooted in historical traumas and systemic marginalization.

METHODS

This study conducted at a single Indian Health Service (IHS) clinic in central Michigan evaluates two educational interventions for enhancing COVID-19 knowledge and attitudes in a sample AI/AN population. Utilizing a pre/post-intervention prospective study design, participants received either a video or infographic educational intervention, followed by a survey assessing their COVID-19 knowledge and attitudes.

RESULTS

The results indicate significant improvements in knowledge and attitudes post-intervention, with both modalities proving effective. However, specific factors such as gender, political affiliation, and place of residence influenced COVID-19 attitudes and knowledge, emphasizing the importance of tailored interventions.

CONCLUSIONS

Despite limitations, this study highlights the critical role of educational interventions in addressing vaccine hesitancy and promoting health equity within AI/AN communities. Moving forward, comprehensive strategies involving increased Indian Health Service funding, culturally relevant interventions, and policy advocacy are crucial in mitigating healthcare disparities and promoting health equity within AI/AN communities.

Voices of Identity: Exploring Identity Development and Transformation among Urban American Indian/Alaska Native Emerging Adults

Emerging adulthood shapes personal, professional, and overall well-being through identity exploration. This study addresses a gap in the minority identity literature by investigating how urban AI/AN emerging adults think about their identity and discussing challenges and protective factors associated with exploring their identity holistically. This mixed-methods study created a sampling framework based on discrimination experiences, cultural identity, social network support, mental health, and problematic substance use. We recruited 20 urban AI/AN emerging adults for interviews. We sought to gain deeper insights into their experiences and discussions surrounding identity formation and exploration. We provide descriptives for demographic characteristics and conducted a thematic analysis of the qualitative data from the interviews. Four themes emerged: a) being an urban AI/AN emerging adult means recognizing that one's identity is multifaceted; b) a multifaceted identity comes with tension of living in multiple worlds; c) the trajectory of one's identity grows over time to a deeper desire to connect with Native American culture; and d) understanding one's Native American background affects one's professional trajectory. Findings underscore the importance of developing programs to support well-being and identity development through cultural connection for urban AI/AN emerging adults.

Misracialization of Indigenous people in population health and mortality studies: a scoping review to establish promising practices

Indigenous people are often misracialized as other racial or ethnic identities in population health research. This misclassification leads to underestimation of Indigenous-specific mortality and health metrics, and subsequently, inadequate resource allocation. In recognition of this problem, investigators around the world have devised analytic methods to address racial misclassification of Indigenous people. We carried out a scoping review based on searches in PubMed, Web of Science, and the Native Health Database for empirical studies published after 2000 that include Indigenous-specific estimates of health or mortality and that take analytic steps to rectify racial misclassification of Indigenous people. We then considered the weaknesses and strengths of implemented analytic approaches, with a focus on methods used in the US context. To do this, we extracted information from 97 articles and compared the analytic approaches used. The most common approach to address Indigenous misclassification is to use data linkage; other methods include geographic restriction to areas where misclassification is less common, exclusion of some subgroups, imputation, aggregation, and electronic health record abstraction. We identified 4 primary limitations of these approaches: (1) combining data sources that use inconsistent processes and/or sources of race and ethnicity information; (2) conflating race, ethnicity, and nationality; (3) applying insufficient algorithms to bridge, impute, or link race and ethnicity information; and (4) assuming the hyperlocality of Indigenous people. Although there is no perfect solution to the issue of Indigenous misclassification in population-based studies, a review of this literature provided information on promising practices to consider.

Indigenous suicide rates in the United States, Australia and New Zealand between 2006 and 2019

OBJECTIVE

Indigenous suicide prevention is an important focus for national health policies. Indigenous suicide rates in formerly colonial English-speaking countries such as the United States, Australia and New Zealand are considerably higher than the general population, particularly in young males. Given the similarities in their sociocultural history, a time series analysis was conducted to assess recent sex and age trends of suicide in the Indigenous and general populations in the United States, Australia and New Zealand.

METHODS

Using the number of deaths by intentional self-harm and estimated resident population, suicide incidence rates were calculated for the years 2006-2019 and stratified by Indigenous status, year, time period, sex and age group (above 15 years). Incidence rates were plotted. Using the Poisson regression model, calculated suicide incidence rate ratios were used to make comparisons for sex and age.

RESULTS

Across all countries studied, Indigenous suicide rates have increased over time, with Indigenous males having higher suicide rates than Indigenous females. However, the increase in Indigenous female suicides was greater than that for Indigenous males in Australia and New Zealand. Indigenous males aged 15-44 years have the highest suicide rates across all countries.

CONCLUSION

Indigenous suicide rates have remained consistently high in the United States, Australia and New Zealand, with Indigenous males aged 15-44 years showing the highest rate. However, suicide rates for Indigenous females in Australia and New Zealand are increasing more rapidly than males. Given this, it is critical that further research is dedicated to understanding and addressing the issues driving this problem, particularly in youth.

Culturally grounded strategies for suicide and alcohol risk prevention delivered by rural Alaska Native communities: A dynamic wait-listed design evaluation of the Qungasvik intervention

We examined the effectiveness of the Qungasvik (Tools for Life) intervention in enhancing protective factors as a universal suicide and alcohol prevention strategy for young people ages 12-18 living in highly affected rural Alaska Native communities. Four communities were assigned to immediate intervention or to a dynamic wait list. Outcomes were analyzed for 239 young people at four time points over two years of community intervention. Outcomes assessed two ultimate variable protective factors buffering suicide and alcohol risk, and three intermediate variable protective factors at the individual, family, and community level. Dose dependent intervention effects were associated with growth in ultimate but not intermediate variables. This evaluation of the Qungasvik intervention provides support for the effectiveness of its Indigenous strategies for suicide and alcohol misuse prevention in this rural Alaska Native setting. Though findings did not provide support for a theory of change where growth in ultimate variables is occasioned through effects on intermediate variables, research designs focused on young people who enter intervention at lower levels of preexisting protection hold promise for better understanding of intervention change processes. The Qungasvik intervention is responsive to an acute public health need for effective rural Alaska Native suicide and alcohol risk prevention strategies.

Youth Suicide During the First Year of the COVID-19 Pandemic

OBJECTIVE

To identify potential differential changes in youth suicide deaths associated with the coronavirus disease (COVID-19) pandemic to better inform suicide prevention strategies.

METHODS

This cross-sectional study analyzed national suicide data for US youth aged 5 to 24 years from 2015 to 2020. Annual and monthly numbers of suicides were extracted overall and by sex, age, race and ethnicity, and method. Expected suicides were modeled from the trend in monthly deaths before COVID-19 (January 1, 2015-February 29, 2020), by using interrupted time-series analyses with quasi-Poisson regression. Rate ratios (RR) and corresponding 95% confidence intervals (CI) were used to compare expected and observed suicides during the first 10 months of COVID-19 (March 1, 2020-December 31, 2020).

RESULTS

Among 5568 identified youth suicides during the 2020 pandemic, 4408 (79.2%) were male, 1009 (18.1%) Hispanic, 170 (3.3%) non-Hispanic American Indian/Alaska Native, 262 (4.7%) Asian/Pacific Islander, 801 (14.4%) Black, and 3321 (59.6%) white. There was a significant increase in overall observed versus expected youth suicides during the COVID-19 pandemic (RR = 1.04, 95% CI = 1.01-1.07), equivalent to an estimated 212 excess deaths. Demographic subgroups including males (RR = 1.05, 95% CI = 1.02-1.08), youth aged 5 to 12 years (RR = 1.20, 95% CI = 1.03-1.41) and 18 to 24 years (RR =1.05, 95% CI = 1.02-1.08), non-Hispanic AI/AN youth (RR = 1.20, 95% CI = 1.03-1.39), Black youth (RR = 1.20, 95% CI = 1.12-1.29), and youth who died by firearms (RR = 1.14, 95% CI = 1.10-1.19) experienced significantly more suicides than expected.

CONCLUSIONS

Suicide deaths among US youth increased during COVID-19, with substantial variation by sex, age, race and ethnicity, and suicide method. Suicide prevention strategies must be tailored to better address disparities in youth suicide risk.

Planning for implementation and sustainability of a community-based suicide surveillance system in a Native American community

BACKGROUND

Native American youth, primarily living on reservations, suffer the highest burden of suicide of any racial group in the USA. Implementation and sustainability of culturally grounded, evidence-based interventions are needed to address suicide in Native American populations. For nearly 40 years, Montana has ranked at or near the top nationwide for suicide. Fort Peck Tribal leadership declared a state of emergency in 2010 after six suicides and 20 attempts that occurred over a 5-month period.

METHODS

We used a community-based participatory research approach for adapting the Celebrating Life (CL) program with a specific focus on long-term sustainability, which has demonstrated efficacy in addressing suicide with the White Mountain Apache. The aims were to (1) adapt the CL program intake forms through roundtable discussions, (2) conduct asset and resource mapping to identify community and cultural resources to leverage for the CL program within the Fort Peck context, and (3) develop a sustainability plan for CL in Fort Peck through qualitative approaches informed by the Program Sustainability Assessment Tool.

RESULTS

Roundtable discussions resulted in adapted intake forms that capture variables relevant to the Fort Peck context. Asset mapping identified 13 community assets and 10 cultural resources to incorporate within the CL implementation process. Focus group discussions yielded four key themes that were incorporated into a plan for sustainability: (1) strategic partnerships, (2) long-term funding, (3) communication planning, and (4) workforce planning and engagement.

CONCLUSIONS

This paper outlines an avenue for using culturally adapted tools to design an implementation system driven by community and cultural assets within tribal communities and for integrating program planning for sustainability early in the implementation process.

Culturally Adapting Caring Contacts for Suicide Prevention in Four Alaska Native and American Indian Communities

AIM

Despite substantial tribal, state, and federal effort, American Indian and Alaska Native (AI/AN) suicide rates have changed little in the last 30 years, prompting attention to new and innovative approaches to this persistent health disparity. Suicide prevention interventions with demonstrated success in other populations may be useful in AI/AN communities. Caring Contacts is a suicide prevention intervention that has been adapted and shown to reduce suicide ideation, attempts, and deaths in other populations.

CONCLUSION

Overall, AI/AN study participants in four diverse AI/AN communities endorsed the use of Caring Contacts for suicide prevention in their communities. Intervention adaptations for use in these communities centered primarily on message frequency and timing as well as expanding access to Caring Contacts. The results of this study may be applicable to other populations that experience suicide-related health disparities.

METHODS

We used a community-based participatory research approach to gather qualitative data from community members, healthcare providers, and leaders in four AI/AN communities. These data were analyzed thematically and used to adapt Caring Contacts for use in a subsequent clinical trial with AI/AN people at high risk for suicide.

RESULTS

A total of 189 community members and other health system stakeholders in four tribal communities participated in focus groups and interviews. Caring Contacts was perceived in all communities to be acceptable. Feedback for intervention adaptations focused on the themes of trial eligibility criteria; instruments; message frequency, timing, and content; and cultural considerations.

Disparities in Access to Radiation Therapy by Race and Ethnicity in the United States With Focus on American Indian/Alaska Native People

OBJECTIVES

Striking disparities in access to radiation therapy (RT) exist, especially among racial and ethnic-minority patients. We analyzed census block group data to evaluate differences in travel distance to RT as a function of race and ethnicity, socioeconomic status, and rurality.

METHODS

The Directory of Radiotherapy Centers provided the addresses of facilities containing linear accelerators for RT. We classified block groups as majority (≥ 50%) American Indian/Alaska Native (AI/AN), black, white, Asian, no single racial majority, or Hispanic regardless of race. We used the Area Deprivation Index to classify deprivation and Rural-Urban Commuting Area codes to classify rurality. Generalized linear mixed models tested associations between these factors and distance to nearest RT facility.

RESULTS

Median distance to nearest RT facility was 72 miles in AI/AN-majority block groups, but 4 to 7 miles in block groups with non-AI/AN majorities. Multivariable models estimated that travel distances in AI/AN-majority block groups were 39 to 41 miles longer than in areas with non-AI/AN majorities. Travel distance was 1.3 miles longer in the more deprived areas versus less deprived areas and 16 to 32 miles longer in micropolitan, small town, and rural areas versus metropolitan areas.

CONCLUSIONS

Cancer patients in block groups with AI/AN-majority populations, nonmetropolitan location, and low socioeconomic status experience substantial travel disparities in access to RT. Future research with more granular community- and individual-level data should explore the many other known barriers to access to cancer care and their relationship to the barriers posed by distance to RT care.

Supporting the Health and Well-Being of Indigenous Communities: A Position Paper From the American College of Physicians

Indigenous peoples in the United States experience many health disparities and barriers to accessing health care services. In addition, Indigenous communities experience poor social drivers of health, including disproportionately high rates of food insecurity, violence, and poverty, among others. These challenges are unsurprising, given historical societal discrimination toward Indigenous peoples and government policies of violence, forced relocation with loss of ancestral home, and erasure of cultures and traditions. Indigenous peoples have displayed resilience that has sustained their communities through these hardships. Through treaties between the federal government and Indigenous nations, the federal government has assumed a trust responsibility to provide for the health and well-being of Indigenous populations through the direct provision of health care services and financial support of tribally operated health systems. However, despite serving a population that has endured substantial historical trauma and subsequent health issues, federal programs serving Indigenous peoples receive inadequate federal funding and substantially fewer resources compared with other federal health care programs. Access to care is further challenged by geographic isolation and health care workforce vacancies. Given the history of Indigenous peoples in the United States and their treatment by the federal government and society, the American College of Physicians (ACP) asserts the federal government must faithfully execute its trust responsibility through increased funding and resources directed toward Indigenous communities and the undertaking of concerted policy efforts to support the health and well-being of Indigenous people. ACP believes that these efforts must be community-driven, Indigenous-led, and culturally appropriate and accepted, and center values of respect and self-determination.

Mental Illness in Adults With HIV and HCV Infection: Indian Health Service, 2001-2020

INTRODUCTION

Mental health disorders (MHDs) and substance use disorders (SUDs) in people living with HIV, hepatitis C virus (HCV) infection, and HIV/HCV coinfection are common and result in significant morbidity. However, there are no national prevalence estimates of these comorbidities in American Indian and Alaska Native (AI/AN) adults with HIV, HCV infection, or HIV/HCV coinfection. This study estimates the prevalence of MHD and SUD diagnoses in AI/AN adults diagnosed with HIV, HCV infection, or HIV/HCV coinfection within the Indian Health Service (IHS).

METHODS

In 2021, a cross-sectional study using data from the National Patient Information Reporting System was completed to identify MHD or SUD diagnoses in AI/AN adults with HIV, HCV infection, or HIV/HCV coinfection within the IHS during fiscal years 2001‒2020. Logistic regression was used to compare the odds of MHD or SUD diagnoses, adjusting for age and sex.

RESULTS

Of AI/AN adults diagnosed with HIV, hepatitis C virus infection, or HIV/HCV coinfection, the period prevalence of MHD or SUD diagnoses ranged from 57.2% to 81.1%. Adjusting for age and sex, individuals with HCV infection had higher odds of receiving a MHD diagnosis (AOR=1.57; 95% CI=1.47, 1.68) or SUD diagnosis (AOR=3.40; 95% CI=3.18, 3.65) than those with HIV, and individuals with HIV/HCV coinfection had higher odds of receiving a MHD diagnosis (AOR=1.60; 95% CI=1.35, 1.89) or SUD diagnosis (AOR=2.81; 95% CI=2.32, 3.41) than those with HIV.

CONCLUSIONS

MHD and SUD diagnoses were common in AI/AN adults diagnosed with HIV, HCV infection, or HIV/HCV coinfection, highlighting the need for culturally appropriate screening and treatment programs sensitive to the diverse strengths of AI/AN populations and structural challenges they endure.

Cultural efficacy as a novel component of understanding linkages between culture and mental health in Indigenous communities

We used a novel measure of cultural efficacy to examine empirical pathways between enculturation, efficacy, and two wellbeing outcomes. Cultural factors are not consistently linked to better wellbeing in the academic literature despite widespread understanding of these processes in Indigenous communities. Healing pathways is a community-based participatory study with eight reservations/reserves in the upper Midwest and Canada. This study uses data collected in 2017-2018 (n = 453, 58.1% women, mean age = 26.3 years) and structural equation modeling to test the relationships between enculturation, cultural efficacy, and mental health. The direct effect of enculturation on anxiety was positive. The indirect effect of enculturation via cultural efficacy was negatively associated with anxiety and positively associated with positive mental health. Cultural efficacy is an important linking variable through which the protective effects of culture manifest. The complex nature of culture must be met with innovative measures and deep understanding of Indigenous peoples to fully capture the protective role of culture.

Achieving health equity in US suicides: a narrative review and commentary

Suicide rates in the United States (US) reached a peak in 2018 and declined in 2019 and 2020, with substantial and often growing disparities by age, sex, race/ethnicity, geography, veteran status, sexual minority status, socioeconomic status, and method employed (means disparity). In this narrative review and commentary, we highlight these many disparities in US suicide deaths, then examine the possible causes and potential solutions, with the overarching goal of reducing suicide death disparities to achieve health equity.The data implicate untreated, undertreated, or unidentified depression or other mental illness, and access to firearms, as two modifiable risk factors for suicide across all groups. The data also reveal firearm suicides increasing sharply and linearly with increasing county rurality, while suicide rates by falls (e.g., from tall structures) decrease linearly by increasing rurality, and suicide rates by other means remain fairly constant regardless of relative county urbanization. In addition, for all geographies, gun suicides are significantly higher in males than females, and highest in ages 51-85 + years old for both sexes. Of all US suicides from 1999-2019, 55% of male suicides and 29% of female suicides were by gun in metropolitan (metro) areas, versus 65% (Male) and 42% (Female) suicides by gun in non-metro areas. Guns accounted for 89% of suicides in non-metro males aged 71-85 + years old. Guns (i.e., employment of more lethal means) are also thought to be a major reason why males have, on average, 2-4 times higher suicide rates than women, despite having only 1/4-1/2 as many suicide attempts as women. Overall the literature and data strongly implicate firearm access as a risk factor for suicide across all populations, and even more so for male, rural, and older populations.To achieve the most significant results in suicide prevention across all groups, we need 1) more emphasis on policies and universal programs to reduce suicidal behaviors, and 2) enhanced population-based strategies for ameliorating the two most prominent modifiable targets for suicide prevention: depression and firearms.

Suicide rates amongst individuals from ethnic minority backgrounds: A systematic review and meta-analysis

BACKGROUND

Existing evidence suggests that some individuals from ethnic minority backgrounds are at increased risk of suicide compared to their majority ethnic counterparts, whereas others are at decreased risk. We aimed to estimate the absolute and relative risk of suicide in individuals from ethnic minority backgrounds globally.

METHODS

Databases (Medline, Embase, and PsycInfo) were searched for epidemiological studies between 01/01/2000 and 3/07/2020, which provided data on absolute and relative rates of suicide amongst ethnic minority groups. Studies reporting on clinical or specific populations were excluded. Pairs of reviewers independently screened titles, abstracts, and full texts. We used random effects meta-analysis to estimate overall, sex, location, migrant status, and ancestral origin, stratified pooled estimates for absolute and rate ratios. PROSPERO registration: CRD42020197940.

FINDINGS

A total of 128 studies were included with 6,026,103 suicide deaths in individuals from an ethnic minority background across 31 countries. Using data from 42 moderate-high quality studies, we estimated a pooled suicide rate of 12·1 per 100,000 (95% CIs 8·4-17·6) in people from ethnic minority backgrounds with a broad range of estimates (1·2-139·7 per 100,000). There was weak statistical evidence from 51 moderate-high quality studies that individuals from ethnic minority groups were more likely to die by suicide (RR 1·3 95% CIs 0·9-1·7) with again a broad range amongst studies (RR 0·2-18·5). In our sub-group analysis we only found evidence of elevated risk for indigenous populations (RR: 2·8 95% CIs 1·9-4·0; pooled rate: 23·2 per 100,000 95% CIs 14·7-36·6). There was very substantial heterogeneity (I²  > 98%) between studies for all pooled estimates.

INTERPRETATION

The homogeneous grouping of individuals from ethnic minority backgrounds is inappropriate. To support suicide prevention in marginalised groups, further exploration of important contextual differences in risk is required. It is possible that some ethnic minority groups (for example those from indigenous backgrounds) have higher rates of suicide than majority populations.

FUNDING

No specific funding was provided to conduct this research. DK is funded by Wellcome Trust and Elizabeth Blackwell Institute Bristol. Matthew Spittal is a recipient of an Australian Research Council Future Fellowship (project number FT180100075) funded by the Australian Government. Rebecca Musgrove is funded by the NIHR Greater Manchester Patient Safety Translational Research Centre (PSTRC-2016-003).

Suicide Ideation and Depression Quality of Life Ratings in a Reservation-Based Community of Native American Youths and Young Adults

Suicide among adolescents is a significant public health concern in the U.S., especially within American Indian and Alaska Native (AIAN) communities. Lack of quality of life (QoL) estimates for both suicide ideation and depression specific to the AIAN population hinders the ability to compare interventions in cost-effectiveness analysis. We surveyed 200 AI youth and young adults from the Fort Apache Indian Reservation to estimate utility weights for experiencing suicide ideation and depression. Our results indicate that, on a scale of 0-100, with higher scores indicating better health, the general community rates both suicide ideation and depression at 15.8 and 25.1, respectively. These weights are statistically significantly different and lower than for other cultures. Culturally specific QoL values will allow the comparison and identification of the most effective and feasible interventions to reduce the suicide burden among tribal communities.

Association of County-Level Poverty and Inequities With Firearm-Related Mortality in US Youth

Importance

Youth firearm-related deaths are a public health crisis in the US. The association between county-level poverty and the risk of firearm-related deaths among youth is unknown, however.

Objective

To examine the association between county-level poverty concentration and firearm-related mortality rates in US youth.

Design, Setting, and Participants

This cross-sectional study analyzed US firearm fatalities in children and young adults aged 5 to 24 years that occurred between January 1, 2007, and December 31, 2016. Data were obtained from the Centers for Disease Control and Prevention's Compressed Mortality File, and annual intercensal county population data were obtained from the US Census Bureau. Data analyses were conducted between November 1, 2019, and June 30, 2020.

Exposures

County-level poverty was categorized into 5 groups: 0% to 4.9%, 5% to 9.9%, 10% to 14.9%, 15% to 19.9%, and ≥20% of the population living below the federal poverty level.

Main Outcomes and Measures

The main outcomes were firearm-related deaths in total and by specific intent (homicide, suicide, and unintentional) per 100 000 youths over the entire study period. Multivariable negative binomial regression models were used to analyze the association between firearm-related mortality rates and county poverty concentration, controlling for demographic variables, urbanicity, and statewide firearm prevalence. Adjusted incidence rate ratios (IRRs) were calculated, and statewide firearm prevalence was estimated. The population-attributable fraction (PAF) and years of potential life lost for each intent were calculated.

Results

A total of 67 905 firearm-related deaths among youth (predominantly composed of 60 164 male individuals [88.6%]) from 2007 to 2016 were analyzed. Of these deaths, 42 512 were homicides (62.6%), 23 034 were suicides (33.9%), and 1627 were unintentional (2.4%). Firearm-related mortality risk increased in a stepwise manner with increasing county poverty concentration. Compared with counties with the lowest poverty concentration, counties with the highest poverty concentration had an increased rate of total firearm-related deaths (adjusted IRR, 2.29; 95% CI, 1.96-2.67), homicides (adjusted IRR, 3.55; 95% CI, 2.80-4.51), suicides (adjusted IRR, 1.45; 95% CI, 1.20-1.75), and unintentional deaths (adjusted IRR, 9.32; 95% CI, 2.32-37.4). The PAF was 0.51 (95% CI, 0.43-0.57) for all firearm-related deaths, 0.66 (95% CI, 0.57-0.73) for homicides, 0.30 (95% CI, 0.17-0.42) for suicides, and 0.86 (95% CI, 0.46-0.97) for unintentional deaths. This calculation translated to 34 292 firearm-related deaths that would not have occurred if all counties had the same risk as counties with the lowest poverty concentration. A total of 3 833 105 years of potential life lost was observed.

Conclusions and Relevance

This study found an association between firearm-related mortality rates among youth and county-level poverty concentration. With more than half of firearm-related deaths and two-thirds of firearm-related homicides potentially associated with living in an area with a high concentration of poverty, a multidimensional strategy to reduce poverty and firearm-related deaths is urgently needed.

Spiritual connectedness through prayer as a mediator of the relationship between Indigenous language use and positive mental health

OBJECTIVE

The objective of this study is to understand how Indigenous language and spirituality revitalization efforts may affect mental health within Indigenous communities. Although Indigenous communities experience disproportionate rates of mental health problems, research supporting language and spirituality's role in improving mental health is under-researched and poorly understood.

METHOD

Data for this study are from a Community-based Participatory Research Project involving five Anishinaabe tribes in Minnesota and Wisconsin. Participants were sampled from clinic records of adults with a diagnosis of type 2 diabetes, living on or near the reservation, and self-identifying as American Indian (mean age = 46.3; n = 191).

RESULT

Structural equation modeling illustrates that language use in the home is associated with positive mental health through spiritual connectedness.

CONCLUSION

Results support tribal community expressions of the positive effects of cultural involvement for Indigenous wellbeing, and improve what is known about the interconnectedness of language and spirituality. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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.

Prevalence of Moderate and Acute Suicidal Ideation among a National Sample of Tribal College and University Students 2014-2015

OBJECTIVES

To examine the relationship between suicide risk and hazardous drinking, depression, and anxiety, adjusting for demographics, among tribal college students across the United States. Methods. We invited tribal college students enrolled in 22 tribal colleges from fall 2014 and 2015 to participate in the Creating Campus Change study, a cross-sectional online/paper survey assessing alcohol use patterns and mental health outcomes. 3,239 students participated in the survey, yielding a response rate of 31.3%. We assessed alcohol use, depression, and general anxiety, along with demographic characteristics. We used the Mini-International Neuropsychiatric Interview to assess suicide risk. Results. 8.5% indicated moderate or high suicide risk. In the final adjusted model, moderate/high depression was significantly associated with moderate/high suicide risk (OR = 6.64; 3.91-11.28, p < 0.001), as was moderate/high general anxiety (OR = 2.80; 1.58-4.97, p < 0.001), and moderate/high hazardous drinking (OR = 2.09; 1.19-3.66, p < 0.001). Conclusions. Students attending tribal colleges who report moderate/high levels of depression, anxiety, or hazardous drinking have a greater risk of suicidality. Identifying factors buffering the risk of suicidality could support policy changes necessary to address this critical public health issue.

Risk and Protective Factors Associated with Moderate and Acute Suicidal Ideation among a National Sample of Tribal College and University Students 2015-2016

OBJECTIVES

We examined the relationship between suicide risk and disability status, as well as risk and protective factors, adjusting for demographic characteristics, among students attending 22 Tribal Colleges and Universities (TCU; 20 rural and 2 urban) across the United States in fall 2015 and 2016.

METHODS

Tribal college students (N = 3,239) participated in a cross-sectional online or paper survey assessing alcohol use patterns and mental health outcomes, yielding a response rate of 31.3%.

RESULTS

Of the students surveyed, 8.8% indicated moderate or high suicide risk. Hearing impairment was significantly associated with moderate/high suicide risk (OR = 2.11; 1.24-3.61, P = .006), as was vision impairment (OR = 3.03; 1.92-4.77, P < .001), having a physical/mental/or emotional condition (OR = 2.12; 1.75-2.57, P < .001), experiencing critical appraisal (OR = 1.30; 1.24-1.36, P < .001), and experiencing critical isolation (OR = 1.83; 1.66-2.01, P < .001). Scoring high on resilience (OR = 0.93; 0.92-0.95, P < .001), reporting higher emotional social support (OR = 0.75; 0.70-0.79, P < .001), and reporting higher levels of instrumental social support (OR = 0.69, 0.62-0.76, P < .001) were significantly associated with lower suicide risk.

CONCLUSIONS

Students attending tribal colleges who experience hearing impairment, sight impairment, or a physical/emotional/mental condition have a greater risk of suicidality. Students experiencing critical appraisal and critical isolation may benefit from behavioral health interventions to reframe these experiences and develop resiliency skills. Developing avenues of emotional and instrumental social support within TCU settings offers key protective factors to buffer the risk of suicidality. Examining additional ways to build resiliency may also offer protection from suicide risk in this population.

Socio-demographic, psychosocial and environmental factors associated with suicidal behaviour in Indigenous Sami and Greenlandic Inuit adolescents; the WBYG and NAAHS studies

Background. For young Indigenous people, suicide is one of the leading causes of death, and high rates in Arctic areas indicate serious health- and societal concerns. More knowledge is needed, as suicidal behaviour predictslater death by suicide.Objectives. The objective was to study associations between suicidal thoughts and suicide attempts and socio-demographic, psychosocial, and environmental factors in Sami and Greenlandic adolescents, within and between groups and gender.Methods. Working samples included 442 Sami and 399 Greenlandic Inuit (15-16-year-olds), in "The Norwegian Arctic Adolescent Health Study" (NAAHS) and "Well-being among Youth in Greenland" (WBYG). Multivariable logistic regression explored associations between suicidal behaviour and family , ethnic language , school, friendship, and suicide in close relations.Results. Across Indigenous groups, suicidal behaviour was associated with the female gender, relationships with parents, suicide of friends, and rural living. Sami adolescents in stepparent families reported more suicidal behaviour. Inuit adolescents living outside the family and with poor school performance reported more suicidal thoughts. Inuit adolescents spending less time with friends reported more attempts. Gender differences occurred in both groups.Conclusion. To Sami and Greenlandic Inuit, family and peer relations are important factors of suicidal behaviour. Prevention programmes should be sensitive to gender and bereavement.

Caring for American Indian and Alaska Native Children and Adolescents

American Indian and Alaska Native (AI/AN) populations have substantial health inequities, and most of their disease entities begin in childhood. In addition, AI/AN children and adolescents have excessive disease rates compared with the general pediatric population. Because of this, providers of pediatric care are in a unique position not only to attenuate disease incidence during childhood but also to improve the health status of this special population as a whole. This policy statement examines the inequitable disease burden observed in AI/AN youth, with a focus on toxic stress, mental health, and issues related to suicide and substance use disorder, risk of and exposure to injury and violence in childhood, obesity and obesity-related cardiovascular risk factors and disease, foster care, and the intersection of lesbian, gay, bisexual, transgender, queer, and Two-Spirit and AI/AN youth. Opportunities for advocacy in policy making also are presented.

Producing insecurity: Healthcare access, health insurance, and wellbeing among American Indian elders

Although health care is a treaty-guaranteed right for members of federally recognized tribes, decades of research describe persistent disparities in health and access to health services for American Indians. Despite gains in insurance enrollment after the passage of the 2010 Affordable Care Act, underfunding of the Indian Health Service and national debate over the new health law contributes to insecurity, especially among the majority of American Indians aged 55 and older who rely on public insurance. We consider the production of insecurity surrounding health care for American Indian elders, analyzing its pragmatic and affective consequences. Between June 2016 and March 2017, we conducted 96 quantitative surveys and in-depth qualitive interviews with American Indian elders aged 55 and older in two states in the U.S. Southwest. Interviews were recorded, professionally transcribed, and analyzed iteratively using open and focused coding. We found that elders consistently shared discourses of doubt, fear, and uncertainty that centered on: 1) interactions with healthcare providers and facilities, especially the IHS; 2) calculations regarding health insurance and the potential costs of healthcare services; and 3) dynamics at the national level around health policy, particularly for American Indians. We argue that persistent perceptions of healthcare insecurity present a major barrier to wellbeing that remains unaddressed by existing health policy interventions for this population, which focus predominately on individual-level knowledge and behavior.

Delta Event-Related Oscillations Are Related to a History of Extreme Binge Drinking in Adolescence and Lifetime Suicide Risk

Alcohol exposure typically begins in adolescence, and heavy binge drinking is associated with health risk behaviors. Event-related oscillations (EROs) may represent sensitive biomarkers or endophenotypes for early alcohol exposure as well as other risk behaviors such as suicidal thoughts and actions. In this study, young adults (age 18-30 years) of American Indian (AI) (n = 479) and Mexican American (MA) (n = 705) ancestry were clinically assessed, and EROs were generated to happy, sad and neutral faces. Extreme adolescent binge drinking (10+ drinks) was common (20%) in this population of AI/MA and associated with a significantly increased risk of a lifetime history of suicidal acts (SA, suicide attempts, deaths) but not suicidal thoughts (ST, ideation, plans). ST were reported among MA participants, whereas SA were more common among AI young adults. Extreme adolescent binge drinking was also associated with errors in detection of sad and neutral faces, increases in delta ERO energy, and decreases in phase locking (PL), particularly in parietal areas. A lifetime history of ST was associated with increases in delta ERO energy and PL, whereas SA were associated with decreases in both. These studies suggest that ERO measures may represent important potential biomarkers of adolescent extreme binge drinking and risk for suicidal behaviors.

Racial Misclassification in Mortality Records Among American Indians/Alaska Natives in Oklahoma From 1991 to 2015

OBJECTIVE

The primary purpose of this study was to compare age-adjusted mortality rates before and after linkage with Indian Health Service records, adjusting for racial misclassification. We focused on differences in racial misclassification by gender, age, geographic differences, substate planning districts, and cause of death. Our secondary purpose was to evaluate time trends in misclassification from 1991 to 2015.

DESIGN

Retrospective, descriptive study.

SETTING

Oklahoma.

PARTICIPANTS

Persons contained in the Oklahoma State Health Department Vital Records.

MAIN OUTCOME MEASURES

To evaluate the age-adjusted mortality ratio pre- and post-Indian Health Service record linkage (misclassification rate ratio) and to evaluate the overall trend of racial misclassification on mortality records measured through annual percent change (APC) and average annual percent change (AAPC).

RESULTS

We identified 2 stable trends of racial misclassification upon death for American Indians/Alaska Natives (AI/ANs) from 1991 to 2001 (APC: -0.2%; 95% confidence interval: -1.4% to 1.0%) and from 2001 to 2005 (APC: -6.9%; 95% confidence interval: -13.7% to 0.4%). However, the trend identified from 2005 to 2015 decreased significantly (APC: -1.4%; 95% confidence interval: -2.5% to -0.2%). For the last 5 years available (2011-2015), the racial misclassification adjustment resulted in higher mortality rates for AI/ANs reflecting an increase from 1008 per 100 000 to 1305 per 100 000 with the linkage process. There were an estimated 3939 AI/ANs in Oklahoma who were misclassified as another race upon death in those 5 years, resulting in an underestimation of actual AI/AN deaths by nearly 29%.

CONCLUSIONS

An important result of this study is that misclassification is improving; however, this effort needs to be maintained and further improved. Continued linkage efforts and public access to linked data are essential throughout the United States to better understand the burden of disease in the AI/AN population.

Health disparities in American Indians/Alaska Natives: Implications for nurse practitioners

American Indians/Alaska Natives experience significant health disparities in many areas including metabolic and mental health disorders. The basis for these differences is grounded in the lasting effects of historical trauma. NPs have the opportunity to understand the underlying causes of these disparities and provide health interventions that promote wellness.

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.

"If you do not birget [manage] then you don't belong here": a qualitative focus group study on the cultural meanings of suicide among Indigenous Sámi in arctic Norway

Suicide is a major public health issue across the Arctic, especially among Indigenous Peoples. The aim of this study was to explore and describe cultural meanings of suicide among Sámi in Norway. Five open-ended focus group discussions (FGDs) were conducted with 22 Sámi (20) and non-Sámi (2) participants in South, Lule, Marka, coastal and North Sámi communities in Norway. FGDs were recorded, transcribed verbatim and analysed employing thematic analysis. Six themes were developed from the analysis: “Sámi are treated negatively by the majority society”, “Some Sámi face negative treatment from other Sámi”, “The historic losses of the Sámi have turned into a void”, “Sámi are not provided with equal mental health care”, “The strong Sámi networks have both positive and negative impacts” and “‘Birgetkultuvvra’ might be a problem”. The findings indicate that the participants understand suicide among Sámi in relation to increased problem load for Sámi (difficulties in life not encountered by non-Sámi) and inadequate problem-solving mechanisms on different levels, including lack of equal mental health care for Sámi and cultural values of managing by oneself (“ieš birget”). The findings are important when designing suicide prevention initiatives specifically targeting Sámi.

Encompassing Cultural Contexts Within Scientific Research Methodologies in the Development of Health Promotion Interventions

American Indians/Alaska Natives/Native Hawaiians (AI/AN/NHs) disproportionately experience higher rates of various health conditions. Developing culturally centered interventions targeting health conditions is a strategy to decrease the burden of health conditions among this population. This study analyzes characteristics from 21 studies currently funded under the Interventions for Health Promotion and Disease Prevention in Native American (NA) Populations program among investigators currently funded under this grant mechanism. Four broad challenges were revealed as critical to address when scientifically establishing culturally centered interventions for Native populations. These challenges were (a) their ability to harness culture-centered knowledge and perspectives from communities; (b) their utilization of Indigenous-based theories and knowledge systems with Western-based intervention paradigms and theories; (c) their use of Western-based methodologies; and (d) their cultural adaptation, if based on an evidence-based treatment. Findings revealed that qualitative methodologies and community-based participatory research (CBPR) approaches were very commonly used to finalize the development of interventions. Various Indigenous-based theories and knowledge systems and Western-based theories were used in the methodologies employed. Cultural adaptations were made that often used formative mixed qualitative and quantitative methods. Illustrative examples of strategies used and suggestions for future research are provided. Findings underscored the importance of CBPR methods to improve the efficacy of interventions for AI/AN/NH communities by integrating Indigenous-based theories and knowledge systems with Western science approaches to improve health.

Employing a sequential multiple assignment randomized trial (SMART) to evaluate the impact of brief risk and protective factor prevention interventions for American Indian Youth Suicide

BACKGROUND

This study is built on a long-standing research partnership between the Johns Hopkins Center for American Indian Health and the White Mountain Apache Tribe to identify effective interventions to prevent suicide and promote resilience among American Indian (AI) youth. The work is founded on a tribally-mandated, community-based suicide surveillance system with case management by local community mental health specialists (CMHSs) who strive to connect at-risk youth to treatment and brief, adjunctive interventions piloted in past research.

METHODS

Our primary aim is to evaluate which brief interventions, alone or in combination, have the greater effect on suicide ideation (primary outcome) and resilience (secondary outcome) among AI youth ages 10-24 ascertained for suicide-related behaviors by the tribal surveillance system. We are using a Sequential Multiple Assignment Randomized Trial with stratified assignment based on age and suicidal-behavior type, and randomizing N = 304 youth. Brief interventions are delivered by AI CMHSs, or by Elders with CMHS support, and include: 1) New Hope, an evidence-based intervention to reduce immediate suicide risk through safety planning, emotion regulation skills, and facilitated care connections; and 2) Elders' Resilience, a culturally-grounded intervention to promote resilience through connectedness, self-esteem and cultural identity/values. The control condition is Optimized Case Management, which all study participants receive. We hypothesize that youth who receive: a) New Hope vs. Optimized Case Management will have significant reductions in suicide ideation; b) Elders' Resilience vs. Optimized Case Management will have significant gains in resilience; c) New Hope followed by Elders' Resilience will have the largest improvements on suicide ideation and resilience; and d) Optimized Case Management will have the weakest effects of all groups. Our secondary aim will examine mediators and moderators of treatment effectiveness and sequencing.

DISCUSSION

Due to heterogeneity of suicide risk/protective factors among AI youth, not all youth require the same types of interventions. Generating evidence for what works, when it works, and for whom is paramount to AI youth suicide prevention efforts, where rates are currently high and resources are limited. Employing Native paraprofessionals is a means of task-shifting psychoeducation, culturally competent patient support and continuity of care.

TRIAL REGISTRATION

Clinical Trials NCT03543865, June 1, 2018.

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.

A Holistic Approach to Chronic Disease Prevention: Good Health and Wellness in Indian Country

The National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention funds the agency's largest investment in Indian Country, Good Health and Wellness in Indian Country. This 5-year program, launched in 2014, supports American Indian and Alaska Native communities and tribal organizations to address chronic diseases and risk factors simultaneously and in coordination. This article describes the development, funding, and implementation of the program. Dialogue with tribal members and leaders helped shape the program, and unlike previous programs that funded a small number of tribes to work on specific diseases, this program funds multiple tribal entities to reach widely into Indian Country. Implementation included culturally developed and adapted practices and opportunities for peer sharing and problem solving. This program identified approaches useful for the Centers for Disease Control and Prevention, other federal agencies, or other organizations working with American Indians and Alaska Natives.

A Narrative Review of the Literature on Insufficient Sleep, Insomnia, and Health Correlates in American Indian/Alaska Native Populations

Insufficient sleep and insomnia promote chronic disease in the general population and may combine with social and economic factors to increase rates of chronic health conditions among AI/AN people. Given that insufficient sleep and insomnia can be addressed via behavioral interventions, it is critical to understand the prevalence and correlates of these disorders among AI/AN individuals in order to elucidate the mechanisms associated with health disparities and provide guidance for subsequent treatment research and practice. We reviewed the available literature on insufficient sleep and insomnia in the AI/AN population. PubMed, PsycINFO, Google Scholar, and ProQuest were searched between June 12th and October 28th of 2018. Prevalence of insufficient sleep ranged from 15% to 40%; insomnia prevalence ranged from 25% to 33%. Insufficient sleep was associated with unhealthy diet, low physical activity levels, higher BMI, worse self-reported health, increased risk for diabetes mellitus, cardiovascular disease, frequent mental distress, smoking, binge drinking, depression, and chronic pain. Insomnia was associated with depression, childhood abuse, PTSD, anxiety, alcohol use, low social support, and low trait-resilience levels. Research on evidence-based treatment and implementation practices targeting insufficient sleep and insomnia was lacking, and only one study described the development/validation of a measure of insufficient sleep among AI/AN people. There is a need for rigorous sleep research including testing and implementation of evidence-based treatment for insufficient sleep and insomnia in this population in an effort to help eliminate health disparities. We present recommendations for research and clinical practice based on the current review.

Spatial analysis of the relative risk of suicide for Virginia counties incorporating uncertainty of variable estimates

PURPOSE

This research aimed to identify significantly elevated areas of risk for suicide in Virginia adjusting for risk factors and risk factor uncertainty.

METHODS

We fit three Bayesian hierarchical spatial models for relative risk of suicide adjusting for risk factors and considering different random effects. We compared models with and without incorporating parameter estimates' margin of error (MOE) from the American Community Survey and identified counties with significantly elevated risk and highly significantly elevated risk for suicide.

RESULTS

Incorporating MOEs and using a mixing parameter between unstructured and spatially structured random effects achieved the best model fit. Fifty-two counties had significantly elevated risk and 18 had highly significantly elevated risk of suicide. Models without MOEs underestimated relative risk and over-identified counties with elevated risk.

CONCLUSIONS

Accounting for uncertainty in parameter estimates achieved better model fit. Efficient allocation of resources for suicide prevention can be attained by targeting clusters of counties with elevated risk.

Global incidence of suicide among Indigenous peoples: a systematic review

BACKGROUND

Suicide is the second leading cause of death among adolescents worldwide, and is a major driver of health inequity among Indigenous people in high-income countries. However, little is known about the burden of suicide among Indigenous populations in low- and middle-income nations, and no synthesis of the global data is currently available. Our objective was to examine the global incidence of suicide among Indigenous peoples and assess disparities through comparisons with non-Indigenous populations.

METHODS

We conducted a systematic review of suicide rates among Indigenous peoples worldwide and assessed disparities between Indigenous and non-Indigenous populations. We performed text word and Medical Subject Headings searches in PubMed, MEDLINE, Embase, Cumulative Index of Nursing and Allied Health (CINAHL), PsycINFO, Latin American and Caribbean Health Sciences Literature (LILACS), and Scientific Electronic Library Online (SciELO) for observational studies in any language, indexed from database inception until June 1, 2017. Eligible studies examined crude or standardized suicide rates in Indigenous populations at national, regional, or local levels, and examined rate ratios for comparisons to non-Indigenous populations.

RESULTS

The search identified 13,736 papers and we included 99. Eligible studies examined suicide rates among Indigenous peoples in 30 countries and territories, though the majority focused on populations in high-income nations. Results showed that suicide rates are elevated in many Indigenous populations worldwide, though rate variation is common, and suicide incidence ranges from 0 to 187.5 suicide deaths per 100,000 population. We found evidence of suicide rate parity between Indigenous and non-Indigenous populations in some contexts, while elsewhere rates were more than 20 times higher among Indigenous peoples.

CONCLUSIONS

This review showed that suicide rates in Indigenous populations vary globally, and that suicide rate disparities between Indigenous and non-Indigenous populations are substantial in some settings but not universal. Including Indigenous identifiers and disaggregating national suicide mortality data by geography and ethnicity will improve the quality and relevance of evidence that informs community, clinical, and public health practice in Indigenous suicide prevention.

The problem of suicide among Amerindians in Camopi-Trois Sauts, French Guiana 2008-2015

BACKGROUND

Suicide within the Amerindian community of Camopi (1741 inhabitants) in French Guiana has been an increasing problem widely reported in the media leading the French Government to mandate a parliamentary mission to investigate the matter. The purpose of the study was to describe this phenomenon and identify factors associated with suicide attempts.

METHODS

A retrospective observational study was conducted from the health centers' medical records. All suicide attempts and suicides committed between 2008 and 2015 by Amerindians living in Camopi and Trois Sauts were compiled. Contextual factors and suicide representations were also analyzed.

RESULTS

During the study period, the annual attempted suicide rate and the suicide rate were higher in the last 3 years. The overall annual rate was equal to 6.9/1741 or 396 per 100, 000 inhabitants for attempted suicide and 172 per 100,000 inhabitants for suicide, which is more than 10 times higher than the suicide rate in mainland France. The mortality rate was 30.4% versus 8.2% in mainland France. The 10-20 year-old age group represented 70% of suicide deaths. There was no significant difference between genders. A recent death and interpersonal conflict were the main stressful life events reported by respondents (55 and 52%, respectively). Alcohol addiction (30% of the respondents) was associated with suicide attempts under the influence of alcohol (p = 0.03). Repetition of suicide attempts was associated with cannabis consumption (p = 0.03). Depression was reported among 45% of the respondents. A third of respondents reported having been abused during their childhood. Over half of respondents reported that their suicide attempt was motivated by a spirit (58%).

CONCLUSIONS

Despite limitations due to the small population size and limited time frame, this is the first study to describe the epidemiology of suicide among Amerindians living in Camopi. In contrast with other French territories, the suicide rate was very high, the sex ratio was balanced and younger age groups were most affected.

Suicide After Deliberate Self-Harm in Adolescents and Young Adults

OBJECTIVES

Among adolescents and young adults with nonfatal self-harm, our objective is to identify risk factors for repeated nonfatal self-harm and suicide death over the following year.

METHODS

A national cohort of patients in the Medicaid program, aged 12 to 24 years (n = 32 395), was followed for up to 1 year after self-harm. Cause of death information was obtained from the National Death Index. Repeat self-harm per 1000 person-years and suicide deaths per 100 000 person-years were determined. Hazard ratios (HRs) of repeat self-harm and suicide were estimated by Cox proportional hazard models. Suicide standardized mortality rate ratios were derived by comparison with demographically matched general population controls.

RESULTS

The 12-month suicide standardized mortality rate ratio after self-harm was significantly higher for adolescents (46.0, 95% confidence interval [CI]: 29.9-67.9) than young adults (19.2, 95% CI: 12.7-28.0). Hazards of suicide after self-harm were significantly higher for American Indians and Alaskan natives than non-Hispanic white patients (HR: 4.69, 95% CI: 2.41-9.13) and for self-harm patients who initially used violent methods (HR: 18.04, 95% CI: 9.92-32.80), especially firearms (HR: 35.73, 95% CI: 15.42-82.79), compared with nonviolent self-harm methods (1.00, reference). The hazards of repeat self-harm were higher for female subjects than male subjects (HR: 1.25, 95% CI: 1.18-1.33); patients with personality disorders (HR: 1.55, 95% CI: 1.42-1.69); and patients whose initial self-harm was treated in an inpatient setting (HR: 1.65, 95% CI: 1.49-1.83) compared with an emergency department (HR: 0.62, 95% CI: 0.55-0.69) or outpatient (1.00, reference) setting.

CONCLUSIONS

After nonfatal self-harm, adolescents and young adults were at markedly elevated risk of suicide. Among these high-risk patients, those who used violent self-harm methods, particularly firearms, were at especially high risk underscoring the importance of follow-up care to help ensure their safety.

Suicide, Resilience, and Connectedness Across the Lifespan: Lessons From American Indian and Alaska Native Elders

Rates of suicide and associated costs are high and increasing in the United States. From 1999 through 2014, the age-adjusted suicide rate increased 24%, with the pace of increase being greater since 2006. American Indian and Alaska Native persons have significantly lower rates of suicides than other ethnic groups as elders despite experiencing some of the highest rates during adolescence. This article examines literature pertaining to suicide rates in American Indian and Alaska Native communities and proposes a framework for understanding their lower rates of suicide as elders. Such understanding offers opportunities for developing strategies for suicide prevention across lifespan.

The Value of Traditional Ecological Knowledge for the Environmental Health Sciences and Biomedical Research

BACKGROUND

Traditional Ecological Knowledge (TEK) is a term, relatively new to Western science, that encompasses a subset of traditional knowledge maintained by Indigenous nations about the relationships between people and the natural environment. The term was first shared by tribal elders in the 1980s to help raise awareness of the importance of TEK. TEK has become a construct that Western scientists have increasingly considered for conducting culturally relevant research with Tribal nations.

OBJECTIVES

The authors aim to position TEK in relation to other emerging schools of thought, that is, concepts such as the exposome, social determinants of health (SDoH), and citizen science, and to explore TEK's relevance to environmental health research. This article provides examples of successful application of TEK principles in federally funded research when implemented with respect for the underlying cultural context and in partnership with Indigenous communities.

DISCUSSION

Rather than treating TEK as an adjunct or element to be quantified or incorporated into Western scientific studies, TEK can instead ground our understanding of the environmental, social, and biomedical determinants of health and improve our understanding of health and disease. This article provides historical and recent examples of how TEK has informed Western scientific research.

CONCLUSIONS

This article provides recommendations for researchers and federal funders to ensure respect for the contributions of TEK to research and to ensure equity and self-determination for Tribal nations who participate in research. https://doi.org/10.1289/EHP858.

A Socially Just Leadership Approach to Community-Partnered Research for Reducing Health Disparities

Significant health disparities continue to plague many groups of people who have been systematically oppressed and largely unrepresented in health research. Community-based participatory research (CBPR) is a collaborative research approach that has been shown to be effective in addressing health disparities; a community–university partnership approach can be used to conduct this research. Counseling psychologists are well suited to establish and lead CBPR partnerships, yet there is a paucity of research to guide them in utilizing effective leadership approaches when conducting CBPR for reducing health disparities. Therefore, the aims of the present study were to (a) review existing leadership models applicable to conducting CBPR; (b) identify guiding principles of socially just leadership that emerged from the aforementioned review; (c) offer an example of how the guiding principles were used in a community–university partnership, highlighting challenges, solutions, and lessons learned; and (d) discuss the benefits of socially just leadership for counseling psychologists.

Suicide in Illinois, 2005-2010: A reflection of patterns and risks by age groups and opportunities for targeted prevention

BACKGROUND

Suicide accounts for two thirds of all deaths from intentional or violence-related injury and is a leading cause of death in the United States. Patterns of suicide have been well described among high-risk groups, but few studies have compared the circumstances related to suicides across all age groups. We sought to understand the epidemiology of suicide cases in Illinois and to characterize the risks and patterns for suicide among different age groups.

METHODS

We used suicide data collected from the Illinois Violent Death Reporting System to assess demographics, method of suicide, circumstances, and mental health status among different age groups.

RESULTS

Between 2005 and 2010, 3,016 suicides were reported; 692 (23%) were female, and the median age (n = 3,013) was 45 years (range, 10-98 years). The most common method/weapon types were hanging/strangulation (33%), firearm (32%) and poisoning (21%). Hanging was more common (74%) among young people aged 10 to 19 years, while firearm use was more common among elderly persons age 65 years and older (55%). The percentage of victims within an age group experiencing a crisis within two weeks before committing suicide was highest among 10- to 14-year-olds, while the risk factor of having a family member or friend die in the past 5 years was highest among older victims.

CONCLUSION

The final analysis demonstrated age-related trends in suicide in Illinois, suggesting prevention programs should tailor services by age.

LEVEL OF EVIDENCE

Epidemiologic study, level IV.

Examining Multi-Level Correlates of Suicide by Merging NVDRS and ACS Data

This paper describes a novel database and an associated suicide event prediction model that surmount longstanding barriers in suicide risk factor research. The database comingles person-level records from the National Violent Death Reporting System (NVDRS) and the American Community Survey (ACS) to establish a case-control study sample that includes all identified suicide cases, while faithfully reflecting general population sociodemographics, in sixteen USA states during the years 2005-2011. It supports a statistical model of individual suicide risk that accommodates person-level factors and the moderation of these factors by their community rates. Named the United States Multi-Level Suicide Data Set (US-MSDS), the database was developed outside the RDC laboratory using publicly available ACS microdata, and reconstructed inside the laboratory using restricted access ACS microdata. Analyses of the latter version yielded findings that largely amplified but also extended those obtained from analyses of the former. This experience shows that the analytic precision achievable using restricted access ACS data can play an important role in conducting social research, although it also indicates that publicly available ACS data have considerable value in conducting preliminary analyses and preparing to use an RDC laboratory. The database development strategy may interest scientists investigating sociodemographic risk factors for other types of low-frequency mortality.

A Comparison of Early Adolescent Behavioral Health Risks Among Urban American Indians/Alaska Natives and their Peers

We sought to examine behavioral health indicators for an early adolescent population of American Indians/Alaska Natives (AI/AN) within an urban setting in Washington State. We conducted secondary data analyses from a randomized clinical trial implemented in local middle schools that compared AI/ANs (n = 43), non-Hispanic Whites (n = 620), and other racial/ethnic minority youth (n = 527) across a variety of behavioral health risks. AI/AN youth reported significantly more depressive symptoms than other racial/ethnic minorities as well as non-Hispanic Whites. They also reported more discrimination, more generalized anxiety, and were more likely to have initiated substance use, in comparison to non-Hispanic Whites. Psychosocial screening and early intervention are critically needed for AI/AN youth.

Decreases in Suicide Deaths and Attempts Linked to the White Mountain Apache Suicide Surveillance and Prevention System, 2001-2012

OBJECTIVES

We evaluated the impact of a comprehensive, multitiered youth suicide prevention program among the White Mountain Apache of Arizona since its implementation in 2006.

METHODS

Using data from the tribally mandated Celebrating Life surveillance system, we compared the rates, numbers, and characteristics of suicide deaths and attempts from 2007 to 2012 with those from 2001 to 2006.

RESULTS

The overall Apache suicide death rates dropped from 40.0 to 24.7 per 100 000 (38.3% decrease), and the rate among those aged 15 to 24 years dropped from 128.5 to 99.0 per 100 000 (23.0% decrease). The annual number of attempts also dropped from 75 (in 2007) to 35 individuals (in 2012). National rates remained relatively stable during this time, at 10 to 13 per 100 000.

CONCLUSIONS

Although national rates remained stable or increased slightly, the overall Apache suicide death rates dropped following the suicide prevention program. The community surveillance system served a critical role in providing a foundation for prevention programming and evaluation.

"I'm in this world for a reason": Resilience and recovery among American Indian and Alaska Native two-spirit women

American Indian and Alaska Native sexual minority (two-spirit) women are vulnerable to substance misuse and mental health challenges due to multiple minority oppressed status and exposure to stress and trauma. Yet, these women find pathways toward healing and wellness. We conducted a qualitative data analysis of interviews derived from a national health study and gained an understanding of 11 two-spirit women's resilience and recovery patterns. Emergent from the data, a braided resiliency framework was developed which elucidates multilayered abilities, processes, and resources involved in their resiliency. We recommend that resilience-promoting strategies be incorporated into substance misuse and mental health interventions.