Suicide Clusters within Ame rican Indian a nd Alaska Nati v e C o m m unities: A R e v i e w o f t he L iterature a nd R e comm endat ions [This page intentionally left blank] Suicide Clusters within American Indian and Alaska Native Communities: A Review of the Literature and Recommendations U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration i Acknowledgements This report was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) under contract number HHSS280201400002C with SAMHSA, U.S. Department of Health and Human Services (HHS). Richard McKeon, Ph.D., Chief, Suicide Prevention Branch, served as the Task Lead and Angela Nunley, M.S.Ed., served as the Contracting Officer’s Representative (COR). Disclaimer The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the views, opinions, or policies of SAMHSA or HHS. Nothing in this document constitutes a direct or indirect endorsement by SAMHSA or HHS of any non-federal entity’s products, services, or policies, and any reference to non-federal entity’s products, services, or policies should not be construed as such. Public Domain Notice All material appearing in this report is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS. Electronic Access This publication may be downloaded at http://store.samhsa.gov/SMA17-xxxx. Recommended Citation Substance Abuse and Mental Health Services Administration. Suicide Clusters within American Indian and Alaska Native Communities: A review of the literature and recommendations. HHS Publication No. SMA17-5050. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2017. Originating Office Suicide Prevention Branch, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, MD 20857. HHS Publication No. SMA17-5050. Printed 2017 Originating Office: Nondiscrimination Notice SAMHSA complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. SAMHSA cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. ii Table of Contents AI/AN Suicide and Suicide Clusters Background .......................................................................... 1 Prevalence ....................................................................................................................................... 2 Suicide Clusters and Contagion: Terminology and Concepts ........................................................ 6 Risk and Protective Factors ............................................................................................................ 8 The Role of Media and Other Communication Sources during Suicide Clusters ........................ 11 AI/AN Community Involvement .................................................................................................. 14 Considerations for Suicide Cluster Identification and Intervention with AI/AN Communities ... 16 Proposed Recommendations: Suggestions to Better Support AI/AN Communities .................... 18 References ..................................................................................................................................... 27 Appendix A: Data Sources for Identifying and Assessing Suicide Clusters in American Indian and Alaska Native Communities .................................................................................................. 33 Appendix B: Additional Acknowledgments ................................................................................. 50 iii [This page intentionally left blank] 1 AI/AN Suicide and Suicide Clusters Background The purpose of this report is to examine what is known about suicide clusters within American Indian and Alaska Native (AI/AN) populations and to use that information to develop recommendations for stakeholders working to prevent and contain suicide clusters within AI/AN communities. This paper provides the results of the review based on: (1) the research on suicide clusters and contagion in general and within AI/AN communities; (2) discussions with several subject matter experts; and (3) interviews with representatives from the Centers for Disease Control and Prevention (CDC) and the Indian Health Service (IHS). The authors also reviewed the CDC Recommendations for a Community Plan for the Prevention and Containment of Suicide Clusters (“CDC Guidelines”) and made recommendations on how the CDC Guidelines could be updated to address the specific needs of AI/AN communities. AI/AN adolescents and young adults, who—in some tribes—have alarmingly high suicide rates, are at greater risk for suicide contagion and cluster formation than other age demographics. Suicide clusters within typically close-knit, rural AI/AN communities can be devastating to AI/AN youth, families, and communities. Yet, the existing research on suicide clusters and contagion is limited and in some cases is several years old, particularly for this population. Any strategies that address suicide clusters and their impact on AI/AN communities must consider the factors that contribute to, and mitigate, suicide cluster formation, and must include solutions that reflect the traditions, culture, and diversity of AI/AN peoples. Prevalence Suicide American Indian and Alaskan Native communities have strikingly higher suicide rates compared to the overall U.S. population. In 2010, the CDC reported suicide as the eighth leading cause of death among AI/AN, at a rate of 16.93/100,000 compared to an overall U.S. rate of 12.08/100,000 (as reported in SPRC, 2013). Yet unlike the general U.S. population, in which suicide rates increase with age, suicide rates decline with age for AI/AN (see chart A). The IHS Trends in Indian Health report (2014), which provides data on the approximately 58 percent of AI/AN who reside in IHS service areas, identified suicide as the second leading cause of death for AI/AN youth between the ages of 5 and 24 years old. This same report indicated that the adjusted suicide rate for AI/AN individuals between 15 and 24 years old was 39.7 per 100,000 compared with the U.S. all-race rate of 9.9 per 100,000. The adjusted suicide rate accounts for misrepresentation of race on state death certificates. The data in the report underscores the vulnerability of 15-24 year old AI/AN males, whose adjusted suicide rate of 58.7/100,000 was more than three and a half times the suicide rate for males of all races in that age group (16.0/100,000). While the adjusted suicide rate for AI/AN females in that age group was lower than males (20.2/100,000), it was still nearly six times the rate for females of all races (3.5/100,000). 2 Chart A: Suicide Prevention Resource Center (SPRC): http://www.sprc.org/basics/scope/disparities Although the suicide rate for all AI/AN people in the U.S. is undoubtedly high, this general data on AI/AN suicide does not reflect widespread variations in suicide by region and tribe. A study that linked death certificate data (1999-2009) to IHS patient registration data identified geographic differences, with the highest suicide rates occurring in Alaska (42.5/100,000) and the Northern Plains (26.2/100,000) (Herne, Bartholomew & Weahkee, 2014). The lowest suicide rates were in the East (11.6/100,000) and Southwest (19.7/100,000). Males had higher rates of suicide than females, which is consistent with rates for the overall U.S. population. Tribal surveillance data further highlight some of the differences and similarities in suicidal behaviors among tribes. For example, significantly higher suicide rates have been found for Apache and some Alaska Native youth (10-25 years old) compared to all U.S. and all AI/AN populations (Mullany et al., 2009; Wexler, Silveira, & Bertone-Johnson, 2012). In a rural northwestern Alaskan region, the suicide rate was five times higher than the U.S. rate and slightly higher than the rate reported in a study from the previous decade (Wexler et al., 2012). Similar to other U.S. races and ethnicities, Apache and Alaska Native males were more likely to die by suicide than females (Mullany et al., 2009; Wexler et al., 2012). In contrast to the overall U.S. population and other AI/AN communities in which females are more likely to attempt suicide than males (CDC, 2012; SPRC, n.d.; Center for Behavioral Health Statistics and Quality, 2015), males and females from these two tribes had similar suicide attempt rates. In addition, the majority of Apache youth suicides were by hanging (80 percent), which contrasts with the use of 3 a firearm in 52 percent of suicides by U.S. (all race) and AI/AN (aggregated) youth. However, a CDC trends report (Sullivan, Annet, Simon, Luo, & Dahlberg, 2015) indicated an increase in suffocation as a method by both females and males. According to the report, the largest suffocation suicide rate increases were among AI/AN youth ages 15 to 19 and youth living in the Midwest. Suicidal Behaviors AI/AN high school students also have higher rates of serious thoughts of suicide, suicide plans, and suicide attempts overall, with AI/AN