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
1
One Sky
Center
2
One Sky Center Partners
Cook Inlet Tribal Council
Alaska Native Tribal
Health Consortium
Northwest Portland Area
Indian Health Board
Tribal Colleges
and Universities
Prairielands ATTC
Red Road
One Sky
Center
United American
Indian Involvement
Harvard Native
Health Program
Jack Brown
Adolescent
Treatment Center
National Indian Youth
Leadership Project
Tri-Ethnic Center for
Na'nizhoozhi Center Prevention Research
3
One Sky Center Outreach
4
5
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
6
Native Health/ Educational
Problems
1.
2.
3.
4.
5.
6.
7.
8.
9.
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
American Indians
• Have same disorders as general
population
• Greater prevalence
• Greater severity
• Much less access to Tx
• Cultural relevance more challenging
• Social context disintegrated
8
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
5. State and Local Agencies
6. Federal Agencies: SAMHSA, Edn
9
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
10
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
11
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.
12
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.
Center for Health Statistics, 2004.
3 Bazelon Center for Mental Health Law, 1999.
2 National
13
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
5 National
Center for Health Statistics, 1999.
Institute of Mental Health, 2003.
14
Denise Middlebrook 1-5-2006R. Dale
Walker, M.D., 2003
15
Suicide Rates by Age, Race, and
Gender 1999-2001
AI Male
Black Male
AI Female
50
40
30
20
Age Groups
16
Source: National Center for Health Statistics
85+
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
0
10-14
10
5-9
Rate/100,000 .
60
White Male
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
Historical Trauma
Douglas Jackobs 2003
R. Dale Walker, M.D., 2003
Psychodynamics/
Psychological Vulnerability
Suicidal
Behavior
17
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
18
The Intervention Spectrum
for Behavioral Disorders
Case
Identification Standard
Treatment
for Known
Indicated—
Disorders
Diagnosed
Youth
Selective—
Health Risk
Groups
Universal—
General Population
Compliance
with Long-Term
Treatment
(Goal:Reduction in
Relapse and Recurrence)
Aftercare
(Including
Rehabilitation)
Source: Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of
Medicine, Washington, DC: National Academy Press, 1994.
19
An Ideal intervention
• Includes individual, family, community, tribe
and society
• Comprehensive:
Universal
Selective
Indicated
Treatment
Maintenance
20
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
21
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
22
Ecological Model
Society
Community/
Tribe
Peer/Family Individual
23
Suicide: Individual Factors
Risk
•
•
•
•
•
Mental illness
Age/Sex
Substance abuse
Loss
Previous suicide
attempt
• Personality traits
Incarceration
• Failure/academic
problems
Protective
• 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
24
Individual Intervention
• Identify risk and protective factors
counseling
skill building
improve coping
support groups
• Increase community awareness
• Access to hotlines other help resources
25
Suicide: Peer/Family Factors
Risk
• History of
interpersonal
violence/abuse/
• Bullying
• Exposure to
suicide
• No-longer married
• Barriers to health
care/mental health
care
Protective
• Family cohesion (youth)
• Sense of social support
• Interconnectedness
• Married/parent
• Access to
comprehensive health
care
26
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.
27
Suicide: Community Factors
Risk
• Isolation/social
withdrawal
• Barriers to health
care and mental
health care
• Stigma
• Exposure to
suicide
• Unemployment
Protective
• 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
28
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
29
Suicide: Societal Factors
Risk
• Western
• Rural/Remote
• Cultural values and
attitudes
• Stigma
• Media influence
• Alcohol misuse and
abuse
• Social disintegration
• Economic instability
Protective
• Urban/Suburban
• Access to health care &
mental health care
• Cultural values affirming
life
• Media influence
30
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)
31
32
Lifetime, Annual and 30 Day
Prevalence of Intoxication Among
224* Urban Indian Youth
100
Percentage
80
60
40
20
0
T1
T2
T3
T4
T5
T6
T7
T8
T9
(n=224) (n=221) (n=215) (n=213) (n=206) (n=203) (n=199) (n=195) (n=186)
Ever intoxicated
R. Dale Walker, M.D. (4/99)
Intoxicated past year
Intoxicated past 30 days
*100% completion sample
33
Changes in Lifetime Substance Use Among
Urban Indian Youth * Over Nine Years
Chewing Tobacco
T1
T2
T3
T4
T5
T6
T7
T8
T9
Marijuana
Smoking Tobacco
Alcohol
0
20
40
60
80
(n=224)
(n=221)
(n=215)
(n=213)
(n=206)
(n=203)
(n=199)
(n=195)
(n=186)
100
Percentage ever used
Percentage ever used
R. Dale Walker, M.D. (4/99)
34
* 100% Completion Sample
Age of Onset of Substance Use Among Urban
American Indian Adolescents, by Substance
Used
16
14
12
10
Age 8
6
4
2
0
Alcohol
Smokeless
Cigarettes
Marijuana
Age Range
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
R. Dale Walker, M.D. (5/2000) *Cohorts 4 & 5 were sampled every third year; recall and sampling bias apply
35
Reasons for Use
• Momentary power
•
•
•
•
•
Freedom
Love
Euphoria
Peer acceptance
Alleviate pain
•
•
•
•
•
•
•
Boredom
Self concept problems
Loneliness
Loss
Nothingness
Depression
Shame
36
How Teens View Counseling
• Witch Hunt
• Helpless
• Target
• Danger
• Waste of time
What to do:
• Non - judgmental
• Honesty
• Consistency
• Confidentiality
• Always a ? of
accuracy
37
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.
38
Scientifically-Based Approaches
to Addiction Treatment
•
•
•
•
•
•
•
Cognitive–behavioral interventions
Community reinforcement
Motivational enhancement therapy
12-step facilitation
Contingency management
Pharmacological therapies
Systems treatment
1.
2.
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
39
Prevention Programs Should . . . .
Target all Forms of Drug Use
. . .and be Culturally Sensitive
40
Prevention Programs Reduce
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
41
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
42
Implications for Treatment
•
•
•
Teach adolescents how to cope with
difficulties and adversity
Increase their repertoire of coping
strategies
Cognitive therapy is most effective
approach
43
WHAT ARE SOME
PROMISING SCHOOLBASED STRATEGIES?
44
Comprehensive school
planning
• Prevention and behavioral health
programs/services on site
• Handling behavioral health crises
• Responding appropriately and
effectively after an event occurs
45
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
46
Promising Strategies
•
•
•
•
•
Home visitation
Parent training
Mentoring
Social cognitive
Cultural
47
Recommendations
•
•
•
•
Make information accessible
Make resources/services more accessible
Increased screening
Target adolescents
48
Partnered Collaboration
Grassroots
Groups
Community-Based
Organizations
Research-Education-Treatment
49
Potential Organizational
Partners
• Education
• Law Enforcement
• Family Survivors
• Juvenile Justice
• Health/Public Health
• Medical Examiner
• Mental Health
• Faith-Based
• Substance Abuse
• County, State, and
Federal Agencies
50
Contact us at
503-494-3703
E-mail
Dale Walker, MD
[email protected]
Or visit our website:
www.oneskycenter.org
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