Native Adolescent Suicide/Comorbidity: Prevention and Treatment Best Practices

1. 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, California June 5, 2006 Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD

2. Native Communities Advisory Council / Steering Committee One Sky Center

3. One Sky Center Partners Tribal Colleges and Universities Cook Inlet Tribal Council Alaska Native Tribal Health Consortium Prairielands ATTC Red Road Northwest Portland Area Indian Health Board One Sky Center Harvard Native Health Program United American Indian Involvement Jack Brown Adolescent Treatment Center National Indian Youth Leadership Project Tri-Ethnic Center for Prevention Research Na'nizhoozhi Center

4. One Sky Center Outreach

6. 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

7. Native Health/ Educational Problems Alcoholism 6X Tuberculosis 6X Diabetes 3.5X Accidents 3X Suicide 1.7 to 4x Health care access -3x Poverty 3x Poor educational achievement Substandard housing

8. AmericanIndians • Have same disorders as general population • Greater prevalence • Greater severity • Much less access to Tx • Cultural relevance more challenging • Social context disintegrated

9. Agencies Involved in Edn. & B.H. 1. Bureau of Indian Affairs (BIA) A. Education B. Vocational C. Social Services D. Police 2. Indian Health Service (IHS) A. Mental Health B. Primary Health C. Alcoholism / Substance Abuse 3. Tribal Education/Health 4. Urban Indian Education/Health • State and Local Agencies • Federal Agencies: SAMHSA, Edn

10. 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

11. 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

12. 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.

13. 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.

14. 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.

16. Suicide Rates by Age, Race, and Gender 1999-2001 Source: National Center for Health Statistics

17. Native Suicide: A Multi-factorial Event Psychiatric Illness& Stigma -Edn,-Econ,-Rec Cultural Distress Impulsiveness Substance Use/Abuse Hopelessness Family Disruption Domestic Violence Suicide Family History Negative Boarding School Psychodynamics/ Psychological Vulnerability Historical Trauma Suicidal Behavior

18. 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

19. The Intervention Spectrum for Behavioral Disorders T r e a t m e n t C a s e I d e n t i f i c a t i o n S t a n d a r d T r e a t m e n t n o f o r K n o w n i Indicated— Diagnosed Youth M t D i s o r d e r s n a e i n v t e r e P n C o m p l i a n c e a Selective— Health Risk Groups n w i t h L o n g - T e r m c e T r e a t m e n t ( G o a l : R e d u c t i o n i n R e l a p s e a n d R e c u r r e n c e ) A f t e r c a r e Universal— General Population ( I n c l u d i n g R e h a b i l i t a t i o n ) Source: Mrazek, P.J. and Haggerty, R.J. (eds.),Reducing Risks for Mental Disorders, Institute of Medicine, Washington, DC: National Academy Press, 1994.

20. An Ideal intervention • Includes individual, family, community, tribe and society • Comprehensive: Universal Selective Indicated Treatment Maintenance

21. 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

22. 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

23. Ecological Model Society Community/Tribe Peer/Family Individual

24. Suicide: Individual FactorsRiskProtective • 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 • Mental illness • Age/Sex • Substance abuse • Loss • Previous suicide attempt • Personality traits Incarceration • Failure/academic problems

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

26. Suicide: Peer/Family FactorsRiskProtective • Family cohesion (youth) • Sense of social support • Interconnectedness • Married/parent • Access to comprehensive health care • History of interpersonal violence/abuse/ • Bullying • Exposure to suicide • No-longer married • Barriers to health care/mental health care

27. Effective Family Intervention Strategies: Critical Role of Families • Parent training • Family skills training • Family in-home support • Family therapy Different types of family interventions are used to modify different risk and protective factors.

28. Suicide: Community FactorsRiskProtective • 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 • Isolation/social withdrawal • Barriers to health care and mental health care • Stigma • Exposure to suicide • Unemployment

29. 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

30. Suicide: Societal FactorsRiskProtective • Urban/Suburban • Access to health care & mental health care • Cultural values affirming life • Media influence • Western • Rural/Remote • Cultural values and attitudes • Stigma • Media influence • Alcohol misuse and abuse • Social disintegration • Economic instability

31. 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)

33. Lifetime, Annual and 30 Day Prevalence of Intoxication Among 224* Urban Indian Youth R. Dale Walker, M.D. (4/99) *100% completion sample

34. Changes in Lifetime Substance Use Among Urban Indian Youth * Over Nine Years Percentage ever used Percentage ever used R. Dale Walker, M.D. (4/99) * 100% Completion Sample

35. 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

36. Momentary power Freedom Love Euphoria Peer acceptance Alleviate pain Boredom Self concept problems Loneliness Loss Nothingness Depression Shame Reasons for Use

37. How Teens View Counseling What to do: • Witch Hunt • Helpless • Target • Danger • Waste of time • Non - judgmental • Honesty • Consistency • Confidentiality • Always a ? of accuracy

38. 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.

39. Scientifically-Based Approaches to Addiction Treatment • Cognitive–behavioral interventions • Community reinforcement • Motivational enhancement therapy • 12-step facilitation • Contingency management • Pharmacological therapies • Systems treatment • L. Onken (2002). Personal Communication. National Institute on Drug Abuse. • Principles of Drug Addiction Treatment: A research-based guide (1999). National Institute on Drug Abuse

40. PreventionPrograms Should . . . . Target all Forms of Drug Use . . .and be Culturally Sensitive

41. Prevention ProgramsReduce Risk Factors • 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

42. Prevention ProgramsEnhance 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

43. Implications for Treatment • Teach adolescents how to cope with difficulties and adversity • Increase their repertoire of coping strategies • Cognitive therapy is most effective approach

44. WHAT ARE SOME PROMISING SCHOOL-BASED STRATEGIES?

45. Comprehensive school planning • Prevention and behavioral health programs/services on site • Handling behavioral health crises • Responding appropriately and effectively after an event occurs

46. 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

47. Promising Strategies • Home visitation • Parent training • Mentoring • Social cognitive • Cultural

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

49. Partnered Collaboration Community-Based Organizations Grassroots Groups Research-Education-Treatment

50. Education Family Survivors Health/Public Health Mental Health Substance Abuse Law Enforcement Juvenile Justice Medical Examiner Faith-Based County, State, and Federal Agencies Potential Organizational Partners