Native Suicide: Emerging Community Based

Integrative Care Models

One Sky Center

R Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer National IHS Behavioral Health Conference

Sacramento, California July 29, 2010

2

One Sky

Center

Opportunity, Research

ExcellenceTribal Leadership

Training, Consultation, Technical Assistance

Education

Mentorship

3

Goals for Today

• Review An Environmental Scan for Natives• Discuss Fragmentation and Integration• Present Some Behavioral Health Care Issues• Define Social Determinants of Health • Summarize Critical Issues for Native Peoples

WHO ARE INDIGENOUS PEOPLES?

“Indigenous peoples remain on the margins of society: they are poorer, less educated, die at a younger age, are much more likely to commit suicide, and are generally in worse health than the rest of the population."

(Source: The Indigenous World 2006, International Working Group on Indigenous Affairs (IWGIA) WHO

4

5

INDIGENOUS PEOPLE WORLD MAP - 370 million indigenous peoples living in more than 70 countries

6

7

Native Healthcare Resource Disparities

8

9

How are we functioning?(Carl Bell and Dale Walker 7/03)

One size fits allOne size fits all

Different goals Different goals Resource silosResource silos

Activity-drivenActivity-driven

10

Behavioral Health Care Issues

Native Health Issues

1. Alcoholism 6X

2. Tuberculosis 6X

3. Diabetes 3.5 X

4. Accidents 3X

5. Poverty 3x

6. Depression 3x

7. Suicide 2x

8. Violence?

1. Same disorders as general population

2. Greater prevalence3. Greater severity4. Much less access

to Tx5. Cultural relevance

more challenging6. Social context

disintegrated

11

12SAMHSA Office of Applied Studies, 2001

Adult Serious Mental Illness By Race/Ethnicity: 2001

13

Frequent Mental Distress by Race/Ethnicity and Year

Percent

* Zahran HS, et al. Self-Reported Frequent Mental Distress Among Adults — United States, 1993–2001. Centers for Disease Prevention and Control, MMWR 2004;53(41):963-966.

American Indian/ Alaskan Native**

Hispanic African-American**

White**

Asian, Pacific Islander**

** Non-Hispanic

Year

14

Suicide: A Multi-factorial Event

Edu., Econ., Rec.Edu., Econ., Rec.

Family Disruption/Domestic ViolenceFamily Disruption/Domestic 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

Individual

15

Key Adolescent Risk Factors

Aggressive/Impulsive

DepressionSubstance Abuse

Trauma

16

Suicide: A Native Crisis

Source: National Center for Health Statistics 2001

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

Blog # 1

• I started smoking at the age of eight.Provoking my life of sin to a life of hate, drinking was what made it worse.Thinking of myself while my family hurt.Coming home at late nights with a liquored up shirt, so now I bring it home for my future isn't set in stone.

17

Blog #2

• Jealousy,Frustration,Emptiness,Loneliness,Not dependable at all times,Laziness, Pain

• There Is A Boy Named xxxx. He Always Tries To Fight Me.

18

Blog # 3

• My Dad Is Dead.• I Struggle With Wanting to Drink or to

take Control of My life And Do Whatever I want even if It Hurts Me Emotionally.I will Struggle When I Have Kids One Day, How They Will turn out.

19

Blog #4

• There are so many deaths because of stuffLike diabetes, heart diseases, and notTaking good care of your self.And all The drugs and Alcohol…

20

21

Models of Care

22

No No ProblemsProblems

Universal/Selective Universal/Selective PreventionPrevention

Brief InterventionBrief Intervention

TreatmentTreatment

Mild Mild ProblemsProblems

Moderate Moderate ProblemsProblems

Severe Severe ProblemsProblems

Thresholds for ActionThresholds for Action

Spectrum of Intervention Responses

23

Domains Influencing Behavioral Health: A Native Ecological Model

Individual Peers/Family Society/CulturalCommunity/Tribe

Risk

Protection

24

Risk Factors

• A prior suicide attempt• Suicide threats & ideation• Exposure to suicide, directly or via media• Detailed intentions for an attempt• Depression, hopelessness• Drug involvement and binge drinking• Stressful life events• Risky or impulsive behaviors• Perceived school problems (perceived problems)

25

WARNING: IS PATH WARM?

• I Ideation (ideas/plans about suicide)• S Substance Abuse• P Purposelessness• A Anxiety/Agitation• T Trapped• H Hopelessness• W Withdrawal• A Anger• R Recklessness• M Mood Changes

American Association of Suicidology, 2006 Expert Consensus Statement, www.suicidology.org

26

Suicide is Usually Impulsive in Youth

• 25% of 153 survivors of near lethal suicide attempts acted within 5 minutes of the impulse to do so

• 71% acted within one hour

• Factors associated with the medical severity of suicide attempts in youths and young adults, Swahn MH, Potter LB, 2001

27

Protective Factors Help • Important personal resources

Strong sense of self-worth & self- esteem Good cognitive skillsSense of personal controlSelf-management skills

• Important social resources Cultural/religious beliefs

Coping/problem solving skills

Ongoing health and mental health care Strong interpersonal bondsSocial support, sense of belonging

28

Individual Intervention

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

29

Effective Interventions for Adults

• Cognitive/Behavioral Approaches• Motivational Interventions• Psychopharmacological Interventions• Modified Therapeutic Communities• Assertive Community Treatment• Vocational Services• Dual Recovery/Self-Help Programs• Consumer Involvement• Therapeutic Relationships

Culture-Based Interventions

• Story telling• Sweat Lodge• Talking circle• Vision quest• Wiping of tears• Drumming• Smudging• Traditional Healers• Herbal remedies• Traditional activities

30

31

What are some promising strategies?

Social Determinates of Health: Whitehall Studies

• Within a hierarchical society, there is a social gradient for morbidity and mortality. (Poverty, sanitation, nutrition, and shelter are controlled.)

• Higher status folks live longer and healthier.

Health Care Improvement Needs More Than Money:

• Opportunity, Empowerment, Security, Control, and Dignity….

32www.thelancet.com Dec 9, 2006. MarmotAmartya Sen 1998 Nicholas Stern 2004

The Social Determinants of Health

• The conditions in which people are born, grow, live, work and age.

• Shaped by the distribution of money, power and resources at global, national and local levels.

• Are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries.

33

WHO Commission on Social Determinants of Health | August 28 2008

Conceptual Framework of Health Determinants

34

Critical Elements for Native Peoples

• Self determination• Ecology and environment• Economic prosperity, fairness and equity• Leadership and capacity strengthening• Racism / dominance / imperialism• Healing, services, systems, structures• Cultural sustainability, protection, stewardship• Land• Human rights

35

36

An Ideal Intervention• Broadly based:

Includes individual, family,

community, tribe, and society

• Comprehensive:

Prevention: Universal, Selective,

Indicated

Treatment

Maintenance

• Addresses opportunity, empowerment, security, control and dignity

Six Key PrinciplesEvidence-based predictors of

change

• Leadership

• Mobilization Community driven

• Public health approach

• Strength based

• Culturally informed

• Proactive

37

Early child development and education

Healthy Places Fair Employment Social Protection

Universal Health Care

Health Equity in all Policies

Fair Financing Good Governance

Responsibility

Gender Equity

Political empowerment – inclusion and voice

Areas for ActionAreas for Action

39

Contact us at

503-494-3703

E-mail

Dale Walker, MD

onesky@ohsu.ed

u

Or visit our

website:

www.oneskycent

er.org