Transcript Document

Native Adolescent Suicide:
Emerging Community Based
Integrative Care Models
One Sky Center
R Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer
Navajo Nation
Window Rock, Arizona
November 6, 2009
One Sky
Center
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One Sky Center Outreach
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Goals for Today
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An Environmental Scan
Fragmentation and Integration
Gain understanding of youth health issues
Examine Native youth suicide data
Discuss suicide prevention and intervention
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Different goals
Resource silos
One size fits all
Activity-driven
How are we functioning?
(Carl Bell and Dale Walker 7/03 )
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Culturally
Specific
Best
Practice
Outcome
Driven
Integrating
Resources
We need Synergy and an Integrated System
(Carl Bell and Dale Walker 7/03)
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Age Distribution American Indians
2004
Adolescent Problems In Schools
Fighting
and
Gangs
1. School Admin
2. Law
Alcohol
Drug
Use
Weapon
Carrying
Bullying
3. FBI
4. DEA
7. Courts
8. Child Services
Sexual
Abuse
Environment
5. State MH
6. State A&D
School
Sale of
Alcohol
and Drugs
Unruly
Students
Truancy
Attacks
on Teachers
Staff
Drop
Outs
Domestic
Violence
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Key Adolescent Risk Factors
Aggressive/Impulsive
Substance Abuse
Depression
Trauma
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Poverty Status by Race and Age
2000
Six behaviors that contribute to
serious health problems:
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Tobacco use
Poor nutrition
Alcohol and other drug abuse
Behaviors resulting in intentional or unintentional
injury
• Physical inactivity
• Risky sex
Barriers to Health Care for
American Indian Youth
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Waiting may be 2 to 6 months
Great distances to travel to reach facilities
Trust is difficult to establish
Some services, depending on the provider,
require the presence of a parent/adult
• Lack of transportation
• Lack of privacy in community health clinics
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Suicide: A Multifactorial Event
Psychiatric Illness
& Stigma
Edu., Econ., Rec.
Cultural Distress
Impulsiveness
Substance
Use/Abuse
Family Disruption/
Domestic Violence
Individual
Negative Boarding School
Historical Trauma
Hopelessness
Family History
Psychodynamics/
Psychological Vulnerability
Suicidal
Behavior
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Suicide Decedents with BAC ≥0.08 by
Ethnicity and Age
MMWR June 19, 2009
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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.
Center for Health Statistics, 2004.
3 Bazelon Center for Mental Health Law, 1999.
2 National
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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.
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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.
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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.
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Blog #4
• There are so many deaths because of stuff
Like diabetes, heart diseases, and not
Taking good care of your self.
And all The drugs and Alcohol…
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Suicide Among ages 15-17, 2001
Death rate per 100,000
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10
8
6
4
2010
Target
2
00
Total
Females Males
Source: National Vital Statistics System - Mortality, NCHS, CDC.
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Suicide: A Native Crisis
AI Male
Black Male
AI Female
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40
30
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Age Groups
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Source: National Center for Health Statistics 2001
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 .
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White Male
CDC
Suicide Rate 1981-1998
Suicide Rate per 100,000 Population1981–1998
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Denise Middlebrook 1-5-2006R. Dale
Walker, M.D., 2003
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North Dakota Teen Suicide Rates
(2000-2004 rate per 100,000 teens 13-19 years old)
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Disaster Defined
• FEMA: A natural or man-made event that negatively
affects life, property, livelihood or industry often
resulting in permanent changes to human societies,
ecosystems and environment.
• NHTSA: Any occurrence that causes damage,
ecological destruction, loss of human lives, or
deterioration of health and health services on a scale
sufficient to warrant an extraordinary response from
outside the affected community area.
• NOAA: A crisis event that surpasses the ability of an
individual, community, or society to control or recover
from its consequences.
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Models of Care
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Suicide Prevention Programs Among
American Indian Youth : Three Main
Approaches – Do them All
• Adoption of mental health focus on Risk and
Protection factors across life span
• Adaptation of public-health based interventions
that promote opportunities for youth to gain selfesteem and avoid substance abuse/risky behavior
• Incorporation of traditional tribal responses as
effective prevention strategies
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Domains Influencing Suicidal Behavior:
A Native Ecological Model
Risk
Individual
Protection
Peers/Family Community/Tribe
Society/
Cultural
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Risk and Protective Factors:
Individual
Risk
Mental illness
 Age/gender
 Substance abuse
 Loss
 Previous suicide attempt
 Personality traits
 Incarceration
 Failure/academic
problems
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Protective
Cultural/religious beliefs
• Coping/problem solving skills
• Ongoing health and mental
health care
• Resiliency, self esteem, direction,
mission, determination, empathy
perseverance, optimism,
• 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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Spectrum of Intervention Responses
Thresholds for Action
80%
No
Problems
Mild
Problems
15% Moderate
Problems
5% Severe
Problems
Treatment
Brief Intervention
Universal/Selective
Prevention
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Sources of Strength
Access to Mental Health
Access to Medical
Spirituality
Generosity/Leadership
Family Support
Positive Friends
Caring Adults
Positive Activities
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Definitions:
Indigenous Knowledge
• Is local knowledge unique to a given
culture or society; it has its own theory,
philosophy, scientific and logical validity,
which is used as a basis for decisionmaking for all of life’s needs.
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ID Best Practice
Best Practice
Clinical/services
Research
Mainstream
Practice
Traditional
Medicine
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What are some promising strategies?
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AI/AN Prevention, Treatment,
and Rehabilitation Interventions
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Story Telling
Talking Circles
Sweat Lodge
Ceremonies and Ritual
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Purification
Passages
Naming
Grieving
• Drumming, singing,
dancing
• Vision Quest
• Flute playing/meditation
• Reconciliation
• Mentoring
• Service learning
• Traditional Experiences
Preservation
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Native Interventions
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American Indian Life Skills
Gathering of Native Americans (GONA)
Native Helping Our People Endure (HOPE)
Crisis Response Teams
Family Canoe Journey
Community Readiness Model
Peer Counselors
Mentoring
Suicide Prevention Camp
Contests/races/special events
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Integrated Treatment
Premise: treatment at a single site, featuring
coordination of treatment philosophy,
services and timing of intervention will be
more effective than a mix of discrete and
loosely coordinated services
Findings:
• decrease in hospitalization
• lessening of psychiatric and substance abuse
severity
• better engagement and retention
(Rosenthal et al, 1992, 1995, 1997; Hellerstein et al 1995.)
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Partnered Collaboration
State/Federal
Grassroots
Groups
Community-Based
Organizations
Research-Education-Treatment
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Reasons for Not Seeking
Formal Help When Suicidal
REASON
%
Example
Did not perceive need
for help
28.8
Nothing really happened
Stigma, embarrassment
23.7
Care what people think
Had other support
23.7
went to friends for help
Self-reliance
15.3
figured it out on my own
Felt hopeless, alone
15.2
didn’t think they could
help
Fear of consequences
11.9
someone might put me
in a hospital
Costs
3.4
No money
No services available
1.7
No help around
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Reasons for Not Seeking Informal
Help When Suicidal
Reason
%
Example
Stigma,
embarrassment
34.8
Think I was weird
Felt hopeless, alone
16.6
Felt no one cared
Fear of consequences
16.6
They might lock me up
Did not perceive need
for help
10.8
Didn’t need them
Self-reliance
10.8
It was my problem
Had other support
2.7
All alone. Find
someone whose job it
is to help
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Common Characteristics of
Successful Native Programs
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Leadership
Mobilization Community driven
Public health approach
Strength based
Culturally informed
Proactive
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Five Key Principles
Evidence-based predictors of change
• Understand & Involve the Community
• Focus on major problems
• Select the right change agent
• Seek ideas from outside the field and
organization
• Evaluate
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Contact us at
503-494-3703
E-mail
Dale Walker, MD
[email protected]
Or visit our website:
www.oneskycenter.org
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