Integrating Intergenerational Cultural Knowledge Exchange With Zero Suicide

Across the nation, suicide is the second leading cause of death in youth 10-24 years old. This public health crisis is particularly acute in American Indian (AI) communities where the suicide rate is 50% higher than that of non-Hispanic Whites. From 2009-2012, the age-adjusted suicide rate for American Indian/Alaska Native youth ages 10-24 years old was alarmingly higher than the overall rate for youth in this same age group nationally (14.66/100,000 vs. 8.25/100,000). In New Mexico (NM), the youth suicide rate is consistently at least 1.5 times the U.S. rate at 14.2/100,000, which is 75% higher than the national average. Importantly, NM has the highest proportionate AI population in the continental USA, and among the 22 tribes in NM the youth suicide rate is even greater (21.4/100,000). Also in NM, the percent of deaths due to suicide among AI youth by age range compared to all races is 29% vs.13% for ages 10-14, 32% vs.18% for ages 15-19, and 25% vs.16.5% for ages 20-24.3 The Pueblo of San Felipe, a tribal nation in NM and the target population for the proposed study, has incredibly high rates of suicidal ideation and behavior with 21.8% of students reporting that they seriously considered suicide, 14.9% reporting that they made a suicide plan, and 11.6% reporting that they attempted suicide in the past year compared to 19%, 11.3%, and 7% respectively statewide. A recent school needs assessment of over 300 students found even higher rates, as 40% of youth expressed feeling frequently depressed within the last year, 17% reported feeling sad or depressed most or all of the time within the last month, and 30% noted they attempted suicide one or more times within the last month. Thus, suicide is of grave concern to tribal communities in NM, especially the Pueblo of San Felipe, and developing systematic strategies for reducing suicide among AI youth is of utmost importance.

Risk Factors Associated with Youth Suicide. The probability of attempting suicide has been found to dramatically increase as the number of risk factors increases. Research on suicidal behavior in youth indicates that the odds of experiencing suicidal ideation and/or suicide attempts are nearly three times more likely if the youth is using alcohol. Even more concerning is that the odds of a completed suicide are five to 13 times greater for youth diagnosed with a substance use disorder.6 Furthermore, lethality of suicide attempts increases with alcohol use, and 40% of suicide attempts and 37% of suicides preceded by acute use of alcohol. While depression is associated with suicidal behavior, depression predicts suicide attempts significantly less well when controlling for substance use. Similarly, exposure to violence, including domestic and intimate partner violence, increases the probability of suicidal ideation and behaviors, as does historical trauma (defined as the cumulative emotional and psychological wounding across generations which emanates from massive group trauma). Unfortunately, AI youth experience exceptionally high rates of these risk factors, including substance abuse, exposure to violence, and the profound repercussions of historical trauma (domestic violence, abuse, etc.). The proposed study addresses risk factors by incorporating these topics into the cultural component of the intervention known as Katishtya Intergenerational Culture Knowledge Seminars (KICKS), as they are NOT addressed in Zero Suicide.

Resiliency as a Buffer. Resilience is also a critical component of suicide prevention. Buffering is the idea that having resources, such as social support or cultural grounding, can mitigate against adverse stressful events.16 The Buffering Hypothesis is a model linking resilience to suicidality that focuses on beliefs, which buffer individuals in the face of stressors. Resilience factors are viewed as existing on a separate dimension to risk which act to moderate the impact of suicidality. The presence of these factors results in resilience and the absence increases risk for suicidality. Resiliency factors include internal protective factors (positive beliefs or feelings about oneself and satisfaction with life), external protective factors (ability to seek resources helpful when faced with personal difficulties), and emotional stability (positive beliefs about one's ability to regulate suicide-related thoughts and behaviors when confronting emotionally distressing events). Importantly, research shows that increasing protective factors can be more effective at reducing the probability of suicide attempts for AI youth then decreasing risk factors, and other studies indicate that interventions are only effective to the extent that they recognize and promote AI cultural values, traditional practices, and cultural identity development. Thus, to improve suicide prevention program acceptability and adoption it is critical to include culturally relevant strength-based and resilience focused components to suicide prevention models.

Relationship between Suicide and Health Disparities. Health disparities are "preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations". Barriers to mental health care utilization for AI youth include: lack of culturally competent treatment providers, a general mistrust in services provided within a Western medical model, and personal experiences of discrimination in health care settings. These barriers have been found to reduce the likelihood of seeking care, even when suicidal ideation or behaviors are present, thus, contributing to the higher incidence of youth suicide in AI communities. The proposed study addresses disparities in access and acceptability by adding a cultural component to the Zero Suicide model.

Call to Develop and Test Innovative Suicide Prevention Models. In 2014, the National Action Alliance for Suicide Prevention's Research Prioritization Task Force published strong recommendations regarding the need to develop and test feasible and effective suicide prevention interventions. Although there have been considerable studies focusing on youth suicide prevention there is insufficient evidence to know which strategies are most effective in preventing suicide among AI populations. Importantly, AI adolescents experience significant risk factors for suicide, including substance abuse and exposure to violence (e.g., physical and sexual violence, domestic violence, intimate partner violence, and premature death of relatives due to violence, accidents, or suicide).5 Although suicide prevention has been shown effective in reducing suicidal ideation and behaviors with youth, there are limited Randomized Control Trials (RCTs) focused on preventing suicide attempts in AI youth populations, thus it is unclear whether the results of previous studies are generalizable. Critically, examining the effect of suicide prevention interventions in AI primary care settings is vital as the majority of individuals who die by suicide (80%) have contact with a primary care clinician or Emergency Department (ED) in the year prior to death. There is promising research on the effectiveness of Zero Suicide (ZS), a population-based model implemented through a large HMO system in the Midwest. However, ZS has not been studied with AI populations or in tribally-based Indian Health Service (IHS) primary care settings. Additionally, ZS does not include culturally-adapted interventions, which have been found to produce larger effect sizes than un-adapted interventions for minority populations.