Native Adolescent Suicide: Emerging

Community Based Integrative Care

Models

One Sky CenterR Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer

AAIP 38th Annual Meeting

Alexandria, Virginia July 25, 2009

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One Sky

Center

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One Sky Center Outreach

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Goals for Today

• An Environmental Scan• Fragmentation and Integration• Gain understanding of youth health issues• Examine Native youth suicide data• Discuss suicide prevention and intervention

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How are we functioning?(Carl Bell and Dale Walker 7/03 )

One size fits allOne size fits all

Different goals Different goals Resource silosResource silos

Activity-drivenActivity-driven

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We need Synergy and an Integrated System (Carl Bell and Dale Walker 7/03)

Culturally Specific

Culturally Specific

Best Practice

Best Practice

IntegratingResources

IntegratingResources

Outcome Driven

Outcome Driven

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Age Distribution American Indians 2004

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Adolescent Problems In Schools

School

Environment

Bullying

Fighting and

Gangs

Alcohol Drug Use

Weapon Carrying

Sexual Abuse

Truancy

Domestic Violence

Drop Outs

Attacks

on Teachers

Staff

Unruly Students

Sale of Alcohol

and Drugs

1. School Admin

2. Law

3. FBI

4. DEA

5. State MH

6. State A&D

7. Courts

8. Child Services

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Key Adolescent Risk Factors

Aggressive/Impulsive

DepressionSubstance Abuse

Trauma

Poverty Status by Race and Age 2000

Six behaviors that contribute to serious health problems:

• Tobacco use• Poor nutrition• Alcohol and other drug abuse• Behaviors resulting in intentional or unintentional

injury• Physical inactivity• Risky sex

Barriers to Health Care for American Indian Youth

• Waiting may be 2 to 6 months• Great distances to travel to reach facilities • Trust is difficult to establish• Some services, depending on the provider,

require the presence of a parent/adult• Lack of transportation• Lack of privacy in community health clinics

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Suicide: A Multifactorial Event

Edu., Econ., Rec.Edu., Econ., Rec.

Family Disruption/Domestic ViolenceFamily Disruption/Domestic Violence

ImpulsivenessImpulsiveness

Negative Boarding SchoolNegative Boarding School

HopelessnessHopelessness

Historical TraumaHistorical Trauma

Family HistoryFamily History

SuicidalBehaviorSuicidal

Behavior

Cultural DistressCultural Distress

Psychiatric Illness& StigmaPsychiatric Illness& Stigma

Psychodynamics/Psychological VulnerabilityPsychodynamics/Psychological Vulnerability

Substance Use/AbuseSubstance

Use/Abuse

Individual

Suicide Decedents with BAC ≥0.08 by Ethnicity and Age

16MMWR June 19, 2009

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Suicide: A National Crisis

• In the United States, more than 30,000 people die by suicide a year.1

• Ninety percent of people who die by suicide have a diagnosable mental illness and/or substance abuse disorder.2

• The annual cost of untreated mental illness is $100 billion.3

1 The President’s New Freedom Commission on Mental Health, 2003.2 National Center for Health Statistics, 2004.3 Bazelon Center for Mental Health Law, 1999.

Blog # 1

• I started smoking at the age of eight.Provoking my life of sin to a life of hate, drinking was what made it worse.Thinking of myself while my family hurt.Coming home at late nights with a liquored up shirt, so now I bring it home for my future isn't set in stone.

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Blog #2

• Jealousy,Frustration,Emptiness,Loneliness,Not dependable at all times,Laziness, Pain

• There Is A Boy Named xxxx. He Always Tries To Fight Me.

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Blog # 3

• My Dad Is Dead.• I Struggle With Wanting to Drink or to take

Control of My life And Do Whatever I want even if It Hurts Me Emotionally.I will Struggle When I Have Kids One Day, How They Will turn out.

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Blog #4

• There are so many deaths because of stuffLike diabetes, heart diseases, and notTaking good care of your self.And all The drugs and Alcohol…

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0

2

4

6

8

10

12

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Suicide Among ages 15-17, 2001Death rate per 100,000

0

Source: National Vital Statistics System - Mortality, NCHS, CDC.

2010 Target

TotalAmeric

an

IndianAsian

HispanicBlack

White Females Males

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Suicide: A Native Crisis

Source: National Center for Health Statistics 2001

0

10

20

30

40

50

605-

9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85+

Age Groups

Rat

e/10

0,00

0 .

White Male AI Male Black Male AI Female

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Suicide Rate per 100,000 Population1981–1998

CDC Suicide Rate 1981-1998

Denise Middlebrook 1-5-2006R. Dale Walker, M.D., 2003

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North Dakota Teen Suicide Rates

(2000-2004 rate per 100,000 teens 13-19 years old)

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Disaster Defined• FEMA: A natural or man-made event that negatively

affects life, property, livelihood or industry often resulting in permanent changes to human societies, ecosystems and environment.

• NHTSA: Any occurrence that causes damage, ecological destruction, loss of human lives, or deterioration of health and health services on a scale sufficient to warrant an extraordinary response from outside the affected community area.

• NOAA: A crisis event that surpasses the ability of an individual, community, or society to control or recover from its consequences.

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Models of Care

Suicide Prevention Programs Among American Indian Youth :

Three Main Approaches – Do them All

• Adoption of mental health focus on Risk and Protection factors across life span

• Adaptation of public-health based interventions that promote opportunities for youth to gain self-esteem and avoid substance abuse/risky behavior

• Incorporation of traditional tribal responses as effective prevention strategies

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Domains Influencing Suicidal Behavior: A Native Ecological

Model

Individual Peers/Family Society/Cultural

Community/Tribe

Risk

Protection

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Risk

Mental illnessAge/genderSubstance abuseLossPrevious suicide attemptPersonality traitsIncarcerationFailure/academic problems

Protective

Cultural/religious beliefsCoping/problem solving skillsOngoing health and mental health care Resiliency, self esteem, direction, mission, determination, perseverance, optimism, empathyIntellectual competence, reasons for living

Risk and Protective Factors: Individual

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Individual Intervention

• Identify risk and protective factors counseling skill building improve coping support groups • Increase community awareness• Access to hotlines other help resources

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80%80% No No

ProblemsProblems

Universal/Selective Universal/Selective PreventionPrevention

Brief InterventionBrief Intervention

TreatmentTreatment

Mild Mild ProblemsProblems

Moderate Moderate ProblemsProblems

5% Severe 5% Severe ProblemsProblems

Thresholds for ActionThresholds for Action

Spectrum of Intervention Responses

15%15%

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Sources of Strength

Family Support

Positive Friends

Caring Adults

Positive ActivitiesGenerosity/Leadership

Spirituality

Access to Medical

Access to Mental Health

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Indigenous Knowledge

• Is local knowledge unique to a given culture or society; it has its own theory, philosophy, scientific and logical validity, which is used as a basis for decision-making for all of life’s needs.

Definitions:

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ID Best Practice

Best Practice

Clinical/servicesResearch

TraditionalMedicine

MainstreamPractice

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What are some promising strategies?

AI/AN Prevention, Treatment, and

Rehabilitation Interventions• Story Telling• Talking Circles• Sweat Lodge• Ceremonies and Ritual

– Purification– Passages– Naming– Grieving

• Drumming, singing, dancing

• Vision Quest

• Flute playing/meditation

• Reconciliation

• Mentoring

• Service learning

• Traditional Experiences

Preservation38

Adapted Interventions

• American Indian Life Skills• Canoe Journey• Gathering of Native Americans• Project Venture• Helping Our People Endure (HOPE)

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Native Interventions

• American Indian Life Skills• Gathering of Native Americans (GONA)• Native Helping Our People Endure (HOPE)• Crisis Response Teams• Family Canoe Journey• Community Readiness Model• Peer Counselors• Mentoring• Suicide Prevention Camp• Contests/races/special events

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Integrated Treatment

Premise: treatment at a single site, featuring coordination of treatment philosophy, services and timing of intervention will be more effective than a mix of discrete and loosely coordinated services

Findings:• decrease in hospitalization• lessening of psychiatric and substance abuse

severity• better engagement and retention

(Rosenthal et al, 1992, 1995, 1997; Hellerstein et al 1995.)

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Partnered Collaboration

Research-Education-Treatment

Grassroots Groups

Community-BasedOrganizations

State/Federal

Reasons for Not Seeking Formal Help When Suicidal

REASON % Example

Did not perceive needfor help

28.8 Nothing really happened

Stigma, embarrassment 23.7 Care what people think

Had other support 23.7 went to friends for help

Self-reliance 15.3 figured it out on my own

Felt hopeless, alone 15.2 didn’t think they could help

Fear of consequences 11.9 someone might put mein a hospital

Costs 3.4 No money

No services available 1.7 No help around43

Reasons for Not Seeking Informal Help When Suicidal

Reason % Example

Stigma, embarrassment

34.8 Think I was weird

Felt hopeless, alone 16.6 Felt no one cared

Fear of consequences 16.6 They might lock me up

Did not perceive needfor help

10.8 Didn’t need them

Self-reliance 10.8 It was my problem

Had other support 2.7 All alone. Find someone whose job it is to help

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Common Characteristics of Successful Native Programs

• Leadership

• Mobilization Community driven

• Public health approach

• Strength based

• Culturally informed

• Proactive

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Five Key PrinciplesEvidence-based predictors of

change

• Understand & Involve the Community

• Focus on major problems

• Select the right change agent

• Seek ideas from outside the field and

organization

• Do evaluation47

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Contact us at503-494-3703

E-mail Dale Walker, MDonesky@ohsu.edu

Or visit our website:www.oneskycenter.or

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