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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. - PowerPoint PPT Presentation
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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, CaliforniaJune 5, 2006
Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD
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Jack Brown Adolescent Treatment Center
Alaska Native Tribal Health Consortium
United American Indian Involvement
Northwest Portland Area Indian Health Board
Na'nizhoozhi Center
Tribal Colleges and Universities
One Sky Center
National Indian Youth Leadership Project
Cook Inlet Tribal Council
Tri-Ethnic Center for Prevention Research
Red Road
Prairielands ATTC
Harvard Native Health Program
One Sky Center Partners
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
Native Health/ Educational Problems
1. Alcoholism 6X
2. Tuberculosis 6X
3. Diabetes 3.5X
4. Accidents 3X
5. Suicide 1.7 to 4x
6. Health care access -3x
7. Poverty 3x
8. Poor educational achievement
9. Substandard housing
8
American Indians
• Have same disorders as general population
• Greater prevalence• Greater severity• Much less access to Tx• Cultural relevance more challenging• Social context disintegrated
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Agencies Involved in Edn. & B.H.1. Bureau of Indian Affairs (BIA)
A. EducationB. VocationalC. Social ServicesD. Police
2. Indian Health Service (IHS)A. Mental HealthB. Primary HealthC. Alcoholism / Substance
Abuse3. Tribal Education/Health4. Urban Indian Education/Health5. State and Local Agencies6. Federal Agencies: SAMHSA, Edn
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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
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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
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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.
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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.
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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.
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Suicide Rates by Age, Race, and Gender 1999-2001
Source: National Center for Health Statistics
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
Douglas Jackobs 2003 R. Dale Walker, M.D., 2003
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Native Suicide: A Multi-factorial Event
-Edn,-Econ,-Rec-Edn,-Econ,-Rec
Family DisruptionDomestic ViolenceFamily DisruptionDomestic 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
Suicide
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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
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The Intervention Spectrum for Behavioral Disorders
CaseIdentification Standard
Treatmentfor KnownDisorders
Compliancewith Long-TermTreatment(Goal: Reduction inRelapse and Recurrence)
Aftercare(Including
Rehabilitation)
Prev
entio
n
TreatmentM
aintenance
Source: Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of Medicine, Washington, DC: National Academy Press, 1994.
Indicated—Diagnosed Youth
Selective—Health RiskGroups
Universal—General Population
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An Ideal intervention
• Includes individual, family, community, tribe and society
• Comprehensive: Universal Selective Indicated Treatment Maintenance
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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
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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
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Suicide: Individual FactorsRisk Protective
• Mental illness• Age/Sex• Substance abuse• Loss• Previous suicide
attempt• Personality traits
Incarceration• Failure/academic
problems
• 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
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Individual Intervention
• Identify risk and protective factors counseling skill building improve coping support groups • Increase community awareness• Access to hotlines other help resources
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Suicide: Peer/Family FactorsRisk Protective
• History of interpersonal violence/abuse/
• Bullying
• Exposure to suicide
• No-longer married
• Barriers to health care/mental health care
• Family cohesion (youth)
• Sense of social support
• Interconnectedness
• Married/parent
• Access to comprehensive health care
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Effective Family Intervention Strategies: Critical Role of
Families
• Parent training• Family skills training• Family in-home support• Family therapyDifferent types of family interventions are used
to modify different risk and protective factors.
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Suicide: Community FactorsRisk Protective• Isolation/social
withdrawal
• Barriers to health care and mental health care
• Stigma
• Exposure to suicide
• Unemployment
• 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
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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
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Suicide: Societal FactorsRisk Protective
• Western
• Rural/Remote
• Cultural values and attitudes
• Stigma
• Media influence
• Alcohol misuse and abuse
• Social disintegration
• Economic instability
• Urban/Suburban
• Access to health care & mental health care
• Cultural values affirming life
• Media influence
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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)
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Lifetime, Annual and 30 Day Prevalence of Intoxication Among
224* Urban Indian Youth
0
20
40
60
80
100
T1(n=224)
T2(n=221)
T3(n=215)
T4(n=213)
T5(n=206)
T6(n=203)
T7(n=199)
T8(n=195)
T9(n=186)
Per
cent
age
Ever intoxicated Intoxicated past year Intoxicated past 30 days
R. Dale Walker, M.D. (4/99) *100% completion sample
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Changes in Lifetime Substance Use Among Urban Indian Youth * Over
Nine Years
R. Dale Walker, M.D. (4/99) * 100% Completion Sample
0 20 40 60 80 100
Chewing Tobacco
Marijuana
Smoking Tobacco
Alcohol
T1 (n=224)T2 (n=221)T3 (n=215)T4 (n=213)T5 (n=206)T6 (n=203)T7 (n=199)T8 (n=195)T9 (n=186)
Percentage ever used
Percentage ever used
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0
2
4
6
8
10
12
14
16
Age
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
Alcohol Smokeless Cigarettes Marijuana Age Range
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
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Reasons for Use
• Momentary power• Freedom• Love• Euphoria• Peer acceptance• Alleviate pain
• Boredom• Self concept problems• Loneliness• Loss• Nothingness• Depression• Shame
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How Teens View Counseling
• Witch Hunt
• Helpless
• Target
• Danger
• Waste of time
• Non - judgmental
• Honesty
• Consistency
• Confidentiality
• Always a ? of accuracy
What to do:
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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.
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Scientifically-Based Approaches to Addiction Treatment
• Cognitive–behavioral interventions
• Community reinforcement
• Motivational enhancement therapy
• 12-step facilitation
• Contingency management
• Pharmacological therapies
• Systems treatment
1. L. Onken (2002). Personal Communication. National Institute on Drug Abuse.
2. Principles of Drug Addiction Treatment: A research-based guide (1999). National Institute on Drug Abuse
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• 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
Prevention Programs Reduce Risk Factors
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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
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
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Comprehensive school planning
• Prevention and behavioral health programs/services on site
• Handling behavioral health crises• Responding appropriately and
effectively after an event occurs
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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
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Promising Strategies
• Home visitation
• Parent training
• Mentoring
• Social cognitive
• Cultural
48
Recommendations
• Make information accessible• Make resources/services more accessible• Increased screening• Target adolescents
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Partnered Collaboration
Research-Education-Treatment
Grassroots Groups
Community-BasedOrganizations
50
Potential Organizational Partners
• Education
• Family Survivors
• Health/Public Health
• Mental Health
• Substance Abuse
• Law Enforcement
• Juvenile Justice
• Medical Examiner
• Faith-Based
• County, State, and Federal Agencies
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