Presenter Disclosures

1. Presenter Disclosures Iwalani Else “No relationships to disclose” (1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

2. Native Hawaiian Adolescents and Suicide by ‘Iwalani Else, Ph.D. Pūlama I Ke Ola (Life is Precious) Approaching 2010 – Addressing Hawai‘i’s Health Disparities May 22, 2008 Department of PsychiatryJohn A. Burns School of MedicineUniversity of Hawai‘i at Mānoa

3. Suicide in the United States – A Public Health Issue • 10.74 per 100,000 (2000-2004) • 3 times higher than homicide • Twice as high as deaths from HIV/AIDS • Males higher completion rates than females (4:1) • Females higher rates of attempts than males (3:1) (CDC, 2007 and NIMH, 2003 & 2004)

4. Suicide in the United States – A Public Health Issue • Ninety percent (90%) of people who die by suicide have a diagnosable mental illness and/or substance abuse disorder.1 • The annual cost of untreated mental illness is $100 billion.2 • Rates are affected by the data • Quality/accuracy • Coding/definitions 1National Center for Health Statistics, 2004 2 Bazelon Center for Mental Health Law, 1999

5. Youth Suicide in the United States • Suicide is the fastest growing cause of death among U.S. youth in the past 60 years • Youth suicide rates tripled from 1952-1996 • From 1980-1996 • Rates among 15-19 year olds increased by 14% • Rates among 10-14 year olds increased by 100% (U.S. Public Health Service, 1999)

6. Suicide in Hawai‘i • Suicide is the single leading cause of injury death in Hawai‘i1 • 128 lives to suicide each year (about one every 3 days)1 • 10.16 per 100,000 for 2000-20042 1 Hawai‘i State Department of Health 2 CDC WISQARS

7. Causes of fatal injuries among Hawaii residents, 2000 - 2004 (Galanis, 2006 – Department of Health)

8. Injury Pyramid for Suicide and Attempts in Hawai‘i 2000 - 2004 Deaths(128/yr.) Ambulance calls ~500 (?) (~4:1 ratio to deaths) Non-fatal attempts/ self-inflicted injuries Emergency department visits ~560 (~5:1 ratio to deaths) Hospitalizations ~870 (7:1 ratio to deaths) (Hawai‘i State Department of Health)

9. Suicide Numbers and Rates (per 100,000) by County in Hawai‘i 2001 - 2006 Suicide Numbers and Rates (per 100,000) by County in Hawai‘i 2000 - 2004 (Galanis, 2006 – Department. of Health, revised to annual rates)

10. Negative Life Events in Autopsy Records 2000 - 2004

11. Native Hawaiians • Native Hawaiians (Kanaka Maoli) • 60% live in the state of Hawai‘i • Make up 20% of the state’s population • Ethnically diverse • Two-thirds (~67%) of Native Hawaiians claimed more than one race/ethnic group • Compared with 38% of Whites and 32% of Japanese

12. Native Hawaiians Source: PASE REPORT, 03-04:12. Policy Analysis & System Evaluation Kamehameha Schools. Koren Ishibashi, December 2003.

13. 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 (Douglas Jacobs, 2003 and R. Dale Walker, 2003)

14. History of Cultural Loss • Loss of land • 1845 - The Great Mahele • Plantation economy • Loss of life • By 1893, 90% of the native population had died from introduced, communicable diseases • Loss of self-determination • 1893 - Overthrow of the monarchy • 1898 – Formal annexation to the United States • 1959 - Statehood

15. History of Cultural Loss, cont’d • Loss of language • Hawaiian language has an oral tradition • Missionaries, 1820s • Hawaiian was banned as a language between 1896 and 1986 • In public and private schools • In the early 1900’s, children were severely punished for speaking Hawaiian

16. Annual Unadjusted Rates (per 100,000) of Suicides among Hawaii Residents by Ethnicity, 2000 - 2004 Annual U.S. Rate Groups with the same letters have statistically comparable rate estimates (p>.05) (Galanis, 2006 – Department. of Health, revised to annual rates)

17. Annual Suicide Rates (per 100,000) among Hawai‘i Residents by Age Group & Ethnicity, 2000 - 2004 (Galanis, 2006 – Dept. of Health, revised to annual rates)

18. Suicides & Attempts in Hawai‘i • Suicides (fatal) • Males at risk (77% of victims) • Youth have lowest risk, elderly highest • Most commonly hangings (45%) • Firearms 2nd (23%) • Decreasing trends (males only) • Higher risk on Neighbor Islands • Why? (from autopsy records): mental illness, negative events, substance use, previous attempts Attempts (non-fatal) • Females predominate (60%) • Youth have highest risk, elderly lowest • Predominantly (68%) poisonings from drugs/medicinal substances • Trends? (lack of injury coding) • NI vs Oahu? (lack of injury coding) • Why? (other studies)

19. Suicide Attempt* in Hawai‘i Youth (39 states reporting) • 2nd highest percent of youth (nearly 20%) who reported that they “seriously considered attempting suicide” • Highest percent of youth (17%) who reported “making a suicide plan” • 2nd highest percent of youth (13%) who reported “attempted suicide” • 4th highest (4%) who reported “suicide attempt treated by a doctor or nurse” *In the past 12 months (Youth Risk Behavior Surveillance System [YRBSS], 2005 )

20. Trends in self-reported suicide risk factor prevalence among high school students, Hawaii vs. U.S., 1999-2005

21. National Center on Indigenous Hawaiian Behavioral Health • Reflects over 20 years of research on Native Hawaiians in the Department of Psychiatry, JABSOM, UH Mānoa • Two epidemiologic studies • Native Hawaiian Mental Health Research Development Program (NIMH-R25) • 1992-1996 • Pacific Peoples’ Mental Health Research Support Program (NIMH-R25) • 2001-2004

22. Native Hawaiians 12.9% Risks/Predictors Depression Substance use Lower education of main wage earner Higher Hawaiian cultural affiliation Attempted suicide, 1992-1996 • Non-Hawaiians • 9.6% • Risks/Predictors • Depression • Substance use • Aggression Yuen, et al. 2000. Cultural identification and attempted suicide in Native Hawaiians. Journal of American Academy of Child and Adolescent Psychiatry, 39: 360-366.

23. Native Hawaiians (n=700) 9.2% Females – 12%, depression, aggression, substance use, low family support, Hawaiian culture 47% drank alcohol 27% smoked pot 14% smoked cigarettes Males – 5%, depression, anxiety, aggression, cigarettes, low family support, Hawaiian culture 20% smoked cigarettes Attempted suicide, 2001-2004 • Non-Hawaiians (n=472) • 6.4% • Females – 9%, depression, aggression, substance use, low family support • 52% drank alcohol • 39% smoked pot • 17% smoked cigarettes • Males – 5%, lifestyles, language • 43% smoked pot (Else, Andrade & Nahulu, 2007)

24. Lifetime Suicide Attempts, 2001-2004 • Resilience and protective factors • Talking with mothers and fathers, family cohesion and organization, parental bonding, and family support • Risk factors • Sexual activity, having sex with both males and females, family conflict, and witnessing or hearing family violence • Family conflict: 7.4 times more likely to have made a suicide attempt in the past year • Sexual activity: 6.9 times more likely to have made a suicide attempt during the past year. (Else, Andrade & Nahulu, 2007)

25. Intervention Points • Suicide • Mental illness, depression, ideation and previous attempts, negative life events (relationship ending, serious illness), alcohol and drug use. • Attempted suicide (youth) • Anxiety, depression, substance use, family conflict, sexual activity • Promote family cohesion, bonding and support

26. Resources • National Suicide Prevention Lifeline • 1-800-273-TALK (8255) • www.suicidepreventionlifeline.org • ACCESS Line: Crisis line (808) 832-3100 Neighbor Islands – 1-800-753-6879 • Department of Health, Injury Prevention and Control Program – Art Tani, Hawai‘i State Suicide Prevention Coordinator • (808) 733-9238 • ASIST (Applied Suicide Intervention Skills Training)