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The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services

Native Adolescent Suicide/Comorbidity: Prevention and Treatment Best Practices

San Diego, CaliforniaJune 5, 2006

Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD

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One Sky Center

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Jack Brown Adolescent Treatment Center

Alaska Native Tribal Health Consortium

United American Indian Involvement

Northwest Portland Area Indian Health Board

Na'nizhoozhi Center

Tribal Colleges and Universities

One Sky Center

National Indian Youth Leadership Project

Cook Inlet Tribal Council

Tri-Ethnic Center for Prevention Research

Red Road

Prairielands ATTC

Harvard Native Health Program

One Sky Center Partners

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One Sky Center Outreach

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Presentation Overview

• Behavioral Health and Education System Issues

• Fragmentation and Integration• Discuss Suicide, Addiction, Comorbidity• Integrated Care Approaches and Interagency

Coordination are Best Overall Solutions

Native Health/ Educational Problems

1. Alcoholism 6X

2. Tuberculosis 6X

3. Diabetes 3.5X

4. Accidents 3X

5. Suicide 1.7 to 4x

6. Health care access -3x

7. Poverty 3x

8. Poor educational achievement

9. Substandard housing

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American Indians

• Have same disorders as general population

• Greater prevalence• Greater severity• Much less access to Tx• Cultural relevance more challenging• Social context disintegrated

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Agencies Involved in Edn. & B.H.1. Bureau of Indian Affairs (BIA)

A. EducationB. VocationalC. Social ServicesD. Police

2. Indian Health Service (IHS)A. Mental HealthB. Primary HealthC. Alcoholism / Substance

Abuse3. Tribal Education/Health4. Urban Indian Education/Health5. State and Local Agencies6. Federal Agencies: SAMHSA, Edn

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Disconnect Between Education/Behavioral

Health• Professionals are undertrained in one of the

two domains• Students as patients are under diagnosed

and under treated• Students have less opportunity for education• Neither system integrates well with medical,

emergency, legal, and social services

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Difficulties of System Integration

• Separate funding streams and coverage gaps• Agency turf issues• Different philosophies• Lack of resources• Poor cross training• Consumer and family barriers

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Barriers to Change

Even when we know that a change is needed and it’s OK, getting there from here can be tricky--especially if existing funding mechanisms support the current practice.

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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.

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Our Native Community Issue

• For every suicide, at least six people are affected.4

• There are higher rates of suicide among survivors (e.g., family members and friends of a loved one who died by suicide).5

• Communities are closely linked to each other, increasing the risk of cluster suicide.

4 National Center for Health Statistics, 1999.5 National Institute of Mental Health, 2003.

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

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Suicide Rates by Age, Race, and Gender 1999-2001

Source: National Center for Health Statistics

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

Douglas Jackobs 2003 R. Dale Walker, M.D., 2003

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Native Suicide: A Multi-factorial Event

-Edn,-Econ,-Rec-Edn,-Econ,-Rec

Family DisruptionDomestic ViolenceFamily DisruptionDomestic 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

Suicide

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Current Cluster Suicide Crisis in a Tribal Community

• 300+ attempts in last 12 months• 70 attempts since November• 13 completions in 12 months• 8 completions in 3 months• 4 to 5 attempts per week

– Some attempts are adult• Age range of completions: 14-24 years of

age– Most completed suicides are female– 80% Alcohol related– All hanging

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The Intervention Spectrum for Behavioral Disorders

CaseIdentification Standard

Treatmentfor KnownDisorders

Compliancewith Long-TermTreatment(Goal: Reduction inRelapse and Recurrence)

Aftercare(Including

Rehabilitation)

Prev

entio

n

TreatmentM

aintenance

Source: Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of Medicine, Washington, DC: National Academy Press, 1994.

Indicated—Diagnosed Youth

Selective—Health RiskGroups

Universal—General Population

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An Ideal intervention

• Includes individual, family, community, tribe and society

• Comprehensive: Universal Selective Indicated Treatment Maintenance

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Interventions

• To date slim data regarding evidence based suicide prevention

• More studies based on prevention instead of intervention

• Emphasis is placed on

individual

family/peer

school/community

society

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Promising Practices for Suicide Prevention

• ASIST• C-CARE/CAST • Columbia University Teen Screen• Means Reduction• Lifelines• Reconnecting Youth• ER intervention for attempters • Signs of Suicide• US Air Force program• Yellow Ribbon Suicide Prevention • American Indian Life Skills

http://www.sprc.org/featured_resources/ebpp/ebpp_factsheets.asp

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Ecological Model

IndividualPeer/FamilySociety Community/Tribe

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Suicide: Individual FactorsRisk Protective

• Mental illness• Age/Sex• Substance abuse• Loss• Previous suicide

attempt• Personality traits

Incarceration• Failure/academic

problems

• Cultural/religious beliefs

• Coping/problem solving skills• Ongoing health and mental health

care • Resiliency, self esteem, direction,

mission, determination, perseverance, optimism, empathy

• Intellectual competence, reasons for living

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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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Suicide: Peer/Family FactorsRisk Protective

• History of interpersonal violence/abuse/

• Bullying

• Exposure to suicide

• No-longer married

• Barriers to health care/mental health care

• Family cohesion (youth)

• Sense of social support

• Interconnectedness

• Married/parent

• Access to comprehensive health care

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Effective Family Intervention Strategies: Critical Role of

Families

• Parent training• Family skills training• Family in-home support• Family therapyDifferent types of family interventions are used

to modify different risk and protective factors.

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Suicide: Community FactorsRisk Protective• Isolation/social

withdrawal

• Barriers to health care and mental health care

• Stigma

• Exposure to suicide

• Unemployment

• Access to healthcare and mental health care

• Social support, close relationships, caring adults, participation and bond with school

• Respect for help-seeking behavior

• Skills to recognize and respond to signs of risk

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Community Driven/School Based Prevention Interventions

• Public awareness and media campaigns• Youth Development Services• Social Interaction Skills Training Approaches• Mentoring Programs• Tutoring Programs• Rites of Passage Programs

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Suicide: Societal FactorsRisk Protective

• Western

• Rural/Remote

• Cultural values and attitudes

• Stigma

• Media influence

• Alcohol misuse and abuse

• Social disintegration

• Economic instability

• Urban/Suburban

• Access to health care & mental health care

• Cultural values affirming life

• Media influence

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Stress Management Suggestions

• Mental health professionals with child/family training

• Information, information, information• Provide energy outlets for kids• Provide parents with time away from kids• Provide best possible sleep environment• Therapeutic play (drawing, role play)

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Lifetime, Annual and 30 Day Prevalence of Intoxication Among

224* Urban Indian Youth

0

20

40

60

80

100

T1(n=224)

T2(n=221)

T3(n=215)

T4(n=213)

T5(n=206)

T6(n=203)

T7(n=199)

T8(n=195)

T9(n=186)

Per

cent

age

Ever intoxicated Intoxicated past year Intoxicated past 30 days

R. Dale Walker, M.D. (4/99) *100% completion sample

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Changes in Lifetime Substance Use Among Urban Indian Youth * Over

Nine Years

R. Dale Walker, M.D. (4/99) * 100% Completion Sample

0 20 40 60 80 100

Chewing Tobacco

Marijuana

Smoking Tobacco

Alcohol

T1 (n=224)T2 (n=221)T3 (n=215)T4 (n=213)T5 (n=206)T6 (n=203)T7 (n=199)T8 (n=195)T9 (n=186)

Percentage ever used

Percentage ever used

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0

2

4

6

8

10

12

14

16

Age

Cohort 1 (n=224) 13.64 13.29 13.05 14.30 1.25

Cohort 2 (n=66) 13.89 13.81 13.21 14.60 1.39

Cohort 3 (n=78) 12.99 13.97 13.64 13.84 0.98

Cohort 4*(n=72) 13.32 14.88 14.12 15.14 1.82

Cohort 5*(n=79) 13.64 12.17 12.75 13.20 1.47

Alcohol Smokeless Cigarettes Marijuana Age Range

Age of Onset of Substance Use Among Urban American Indian Adolescents, by

Substance Used

R. Dale Walker, M.D. (5/2000) *Cohorts 4 & 5 were sampled every third year; recall and sampling bias apply

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Reasons for Use

• Momentary power• Freedom• Love• Euphoria• Peer acceptance• Alleviate pain

• Boredom• Self concept problems• Loneliness• Loss• Nothingness• Depression• Shame

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How Teens View Counseling

• Witch Hunt

• Helpless

• Target

• Danger

• Waste of time

• Non - judgmental

• Honesty

• Consistency

• Confidentiality

• Always a ? of accuracy

What to do:

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Evidence-Based Practices for Alcohol Treatment

• Brief intervention• Social skills training• Motivational enhancement• Community reinforcement• Behavioral contracting

Miller et al., (1995) What works: A methodological analysis of the alcohol treatment outcome literature. In R. K. Hester & W. R. Miller (eds.) Handbook of Alcoholism Treatment Approaches: Effective Alternatives. (2nd ed., pp 12 – 44). Boston: Allyn & Bacon.

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Scientifically-Based Approaches to Addiction Treatment

• Cognitive–behavioral interventions

• Community reinforcement

• Motivational enhancement therapy

• 12-step facilitation

• Contingency management

• Pharmacological therapies

• Systems treatment

1. L. Onken (2002). Personal Communication. National Institute on Drug Abuse.

2. Principles of Drug Addiction Treatment: A research-based guide (1999). National Institute on Drug Abuse

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Target all Forms of Drug Use

. . .and be Culturally Sensitive

Prevention Programs Should . . . .

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• ineffective parenting• chaotic home environment• lack of mutual attachments/nurturing• inappropriate behavior in the classroom• failure in school performance• poor social coping skills• affiliations with deviant peers• perceptions of approval of drug-using behaviors

Prevention Programs Reduce Risk Factors

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Prevention Programs Enhance Protective Factors

• strong family bonds • parental monitoring • parental involvement • success in school performance• pro social institutions (e.g. such as family,

• school, and religious organizations)• conventional norms about

• drug use

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Implications for Treatment

• Teach adolescents how to cope with difficulties and adversity

• Increase their repertoire of coping strategies

• Cognitive therapy is most effective approach

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WHAT ARE SOME PROMISING SCHOOL-BASED STRATEGIES?

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Comprehensive school planning

• Prevention and behavioral health programs/services on site

• Handling behavioral health crises• Responding appropriately and

effectively after an event occurs

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American Indian Life Skills Curriculum

• Build self-esteem • Identify emotions and stress• Increase communication, problem-solving

skills • Recognize and eliminate self-destructive

behaviors • Receive suicide information • Receive suicide intervention training • Set personal and community goals • Curriculum three times a week for 30 weeks in

a required language arts class

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Promising Strategies

• Home visitation

• Parent training

• Mentoring

• Social cognitive

• Cultural

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Recommendations

• Make information accessible• Make resources/services more accessible• Increased screening• Target adolescents

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Partnered Collaboration

Research-Education-Treatment

Grassroots Groups

Community-BasedOrganizations

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Potential Organizational Partners

• Education

• Family Survivors

• Health/Public Health

• Mental Health

• Substance Abuse

• Law Enforcement

• Juvenile Justice

• Medical Examiner

• Faith-Based

• County, State, and Federal Agencies

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Contact us at503-494-3703E-mail Dale Walker, MDonesky@ohsu.eduOr visit our website:www.oneskycenter.org