1. 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. 2 One Sky Center Opportunity, Research Excellence Tribal Leadership Training, Consultation, Technical Assistance Education Mentorship

3. 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

4. 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. 5 INDIGENOUS PEOPLE WORLD MAP - 370 million indigenous peoples living in more than 70 countries

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8. Native Healthcare Resource Disparities 8

9. 9 How are we functioning? (Carl Bell and Dale Walker 7/03) One size fits all Different goals Resource silos Activity-driven

10. 10 Behavioral Health Care Issues

11. 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 prevalence 3.Greater severity 4.Much less access to Tx 5.Cultural relevance more challenging 6.Social context disintegrated 11

12. 12 SAMHSA Office of Applied Studies, 2001 Adult Serious Mental Illness By Race/Ethnicity: 2001

13. 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. 14 Suicide: A Multi-factorial Event Edu., 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 Individual

15. 15 Key Adolescent Risk Factors Aggressive/Impulsive DepressionSubstance Abuse Trauma

16. 16 Suicide: A Native Crisis Source: National Center for Health Statistics 2001

17. 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

18. 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

19. 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

20. 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… 20

21. 21 Models of Care

22. 22 No Problems Universal/Selective Prevention Brief Intervention Treatment Mild Problems Moderate Problems Severe Problems Thresholds for Action Spectrum of Intervention Responses

23. 23 Domains Influencing Behavioral Health: A Native Ecological Model IndividualPeers/FamilySociety/CulturalCommunity/Tribe Risk Protection

24. 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. 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. 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. 27 Protective Factors Help Important personal resources Strong sense of self-worth & self- esteem Good cognitive skills Sense of personal control Self-management skills Important social resources Cultural/religious beliefs Coping/problem solving skills Ongoing health and mental health care Strong interpersonal bonds Social support, sense of belonging

28. 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. 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

30. Culture-Based Interventions Story telling Sweat Lodge Talking circle Vision quest Wiping of tears Drumming Smudging Traditional Healers Herbal remedies Traditional activities 30

31. 31 What are some promising strategies?

32. 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…. 32 www.thelancet.comwww.thelancet.com Dec 9, 2006. Marmot Amartya Sen 1998 Nicholas Stern 2004

33. 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

34. Conceptual Framework of Health Determinants 34

35. 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. 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

37. Six Key Principles Evidence-based predictors of change Leadership Mobilization Community driven Public health approach Strength based Culturally informed Proactive 37

38. 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 Action

39. 39 Contact us at 503-494-3703 E-mail Dale Walker, MD onesky@ohsu.edu Or visit our website: www.oneskycenter.org