1. Presenter Disclosures (1)The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Iwalani Else “No relationships to disclose”

2. Native Hawaiian Adolescents and Suicide by ‘Iwalani Else, Ph.D. Pūlama I Ke Ola (Life is Precious) Approaching 2010 – Addressing Hawai‘i’s Health Disparities May 22, 2008 Department of Psychiatry John A. Burns School of Medicine University of Hawai‘i at Mānoa

3. Suicide in the United States – A Public Health Issue 10.74 per 100,000 (2000-2004) 3 times higher than homicide Twice as high as deaths from HIV/AIDS Males higher completion rates than females (4:1) Females higher rates of attempts than males (3:1) (CDC, 2007 and NIMH, 2003 & 2004)

4. Suicide in the United States – A Public Health Issue Ninety percent (90%) of people who die by suicide have a diagnosable mental illness and/or substance abuse disorder. 1 The annual cost of untreated mental illness is $100 billion. 2 Rates are affected by the data  Quality/accuracy  Coding/definitions 1 National Center for Health Statistics, 2004 2 Bazelon Center for Mental Health Law, 1999

5. Youth Suicide in the United States Suicide is the fastest growing cause of death among U.S. youth in the past 60 years  Youth suicide rates tripled from 1952-1996 From 1980-1996  Rates among 15-19 year olds increased by 14%  Rates among 10-14 year olds increased by 100% (U.S. Public Health Service, 1999)

6. Suicide in Hawai‘i Suicide is the single leading cause of injury death in Hawai‘i 1 128 lives to suicide each year (about one every 3 days) 1 10.16 per 100,000 for 2000-2004 2 1 Hawai‘i State Department of Health 2 CDC WISQARS

7. Causes of fatal injuries among Hawaii residents, 2000 - 2004 (Galanis, 2006 – Department of Health)

8. Injury Pyramid for Suicide and Attempts in Hawai‘i 2000 - 2004 Deaths (128/yr.) Hospitalizations ~870 (7:1 ratio to deaths) Ambulance calls ~500 (?) (~4:1 ratio to deaths) Emergency department visits ~560 (~5:1 ratio to deaths) (Hawai‘i State Department of Health) Non-fatal attempts/ self-inflicted injuries

9. Suicide Numbers and Rates (per 100,000) by County in Hawai‘i 2001 - 2006 Suicide Numbers and Rates (per 100,000) by County in Hawai‘i 2000 - 2004 (Galanis, 2006 – Department. of Health, revised to annual rates)

10. Negative Life Events in Autopsy Records 2000 - 2004

11. Native Hawaiians Native Hawaiians (Kanaka Maoli)  60% live in the state of Hawai‘i  Make up 20% of the state’s population  Ethnically diverse  Two-thirds (~67%) of Native Hawaiians claimed more than one race/ethnic group Compared with 38% of Whites and 32% of Japanese

12. Native Hawaiians Source: PASE REPORT, 03-04:12. Policy Analysis & System Evaluation Kamehameha Schools. Koren Ishibashi, December 2003.

13. Native Suicide: A Multi-factorial Event -Edn,-Econ,-Rec Family Disruption Domestic Violence Family Disruption Domestic Violence Impulsiveness Negative Boarding School Hopelessness Historical Trauma Family History Suicidal Behavior Suicidal Behavior Cultural Distress Psychiatric Illness & Stigma Psychodynamics/ Psychological Vulnerability Psychodynamics/ Psychological Vulnerability Substance Use/Abuse Suicide (Douglas Jacobs, 2003 and R. Dale Walker, 2003)

14. History of Cultural Loss Loss of land  1845 - The Great Mahele  Plantation economy Loss of life  By 1893, 90% of the native population had died from introduced, communicable diseases Loss of self-determination  1893 - Overthrow of the monarchy  1898 – Formal annexation to the United States  1959 - Statehood

15. History of Cultural Loss, cont’d Loss of language  Hawaiian language has an oral tradition  Missionaries, 1820s  Hawaiian was banned as a language between 1896 and 1986  In public and private schools  In the early 1900’s, children were severely punished for speaking Hawaiian

16. (Galanis, 2006 – Department. of Health, revised to annual rates) Annual Unadjusted Rates (per 100,000) of Suicides among Hawaii Residents by Ethnicity, 2000 - 2004 Groups with the same letters have statistically comparable rate estimates (p>.05) Annual U.S. Rate

17. Annual Suicide Rates (per 100,000) among Hawai‘i Residents by Age Group & Ethnicity, 2000 - 2004 (Galanis, 2006 – Dept. of Health, revised to annual rates)

18. Suicides & Attempts in Hawai‘i Suicides (fatal) Males at risk (77% of victims) Youth have lowest risk, elderly highest Most commonly hangings (45%)  Firearms 2nd (23%) Decreasing trends (males only) Higher risk on Neighbor Islands Why? (from autopsy records): mental illness, negative events, substance use, previous attempts Attempts (non-fatal) Females predominate (60%) Youth have highest risk, elderly lowest Predominantly (68%) poisonings from drugs/medicinal substances Trends? (lack of injury coding) NI vs Oahu? (lack of injury coding) Why? (other studies)

19. Suicide Attempt* in Hawai‘i Youth (39 states reporting) (Youth Risk Behavior Surveillance System [YRBSS], 2005 ) 2nd highest percent of youth (nearly 20%) who reported that they “seriously considered attempting suicide” Highest percent of youth (17%) who reported “making a suicide plan” 2nd highest percent of youth (13%) who reported “attempted suicide” 4th highest (4%) who reported “suicide attempt treated by a doctor or nurse” *In the past 12 months

20. Trends in self-reported suicide risk factor prevalence among high school students, Hawaii vs. U.S., 1999-2005

21. National Center on Indigenous Hawaiian Behavioral Health Reflects over 20 years of research on Native Hawaiians in the Department of Psychiatry, JABSOM, UH Mānoa Two epidemiologic studies  Native Hawaiian Mental Health Research Development Program (NIMH-R25)  1992-1996  Pacific Peoples’ Mental Health Research Support Program (NIMH-R25)  2001-2004

22. Attempted suicide, 1992-1996 Native Hawaiians  12.9% Risks/Predictors  Depression  Substance use  Lower education of main wage earner  Higher Hawaiian cultural affiliation Non-Hawaiians  9.6% Risks/Predictors  Depression  Substance use  Aggression Yuen, et al. 2000. Cultural identification and attempted suicide in Native Hawaiians. Journal of American Academy of Child and Adolescent Psychiatry, 39 : 360-366.

23. Attempted suicide, 2001-2004 Native Hawaiians (n=700)  9.2% Females – 12%, depression, aggression, substance use, low family support, Hawaiian culture  47% drank alcohol  27% smoked pot  14% smoked cigarettes Males – 5%, depression, anxiety, aggression, cigarettes, low family support, Hawaiian culture  20% smoked cigarettes (Else, Andrade & Nahulu, 2007) Non-Hawaiians (n=472)  6.4% Females – 9%, depression, aggression, substance use, low family support  52% drank alcohol  39% smoked pot  17% smoked cigarettes Males – 5%, lifestyles, language  43% smoked pot

24. Lifetime Suicide Attempts, 2001-2004 Resilience and protective factors Talking with mothers and fathers, family cohesion and organization, parental bonding, and family support Risk factors Sexual activity, having sex with both males and females, family conflict, and witnessing or hearing family violence Family conflict: 7.4 times more likely to have made a suicide attempt in the past year Sexual activity: 6.9 times more likely to have made a suicide attempt during the past year. (Else, Andrade & Nahulu, 2007)

25. Intervention Points Suicide  Mental illness, depression, ideation and previous attempts, negative life events (relationship ending, serious illness), alcohol and drug use. Attempted suicide (youth)  Anxiety, depression, substance use, family conflict, sexual activity  Promote family cohesion, bonding and support

26. Resources National Suicide Prevention Lifeline 1-800-273-TALK (8255) www.suicidepreventionlifeline.org ACCESS Line: Crisis line (808) 832-3100 Neighbor Islands – 1-800-753-6879 Department of Health, Injury Prevention and Control Program – Art Tani, Hawai‘i State Suicide Prevention Coordinator (808) 733-9238 ASIST (Applied Suicide Intervention Skills Training)

27. Acknowledgments Department of Psychiatry – National Center on Indigenous Hawaiian Behavioral Health Department of Health, Injury Prevention & Control  Dan Galanis, Ph.D., State Epidemiologist  Art Tani, Suicide Prevention Coordinator  Suicide Steering Committee & Task Force National Center on Minority Health and Health Disparities Conference planners