Employing a sequential multiple assignment randomized trial (SMART) to evaluate the impact of brief risk and protective factor prevention interventions for American Indian Youth Suicide

摘要

BackgroundAmerican Indian/Alaska Native (AI/AN) suicide inequities are concentrated in youth, with the highest rates among 10 to 24?year olds [1]. Recent data indicate that AI/AN youth and young adults (10–24) have suicide mortality rates (crude rate 27.09 per 100,000) that are more than 2 to 3 times higher same-aged European American (crude rate 12.60 per 100,000), African American (crude rate 7.97 per 100,000), and Asian/Pacific Islander (crude rate 8.68 per 100,000) peers [2]. These rates are likely underestimates due to jurisdictional challenges for who is responsible for reporting deaths when tribal lands intersect with county and state, racial and ethnic misclassification [1], and tribal communities’ distrust of researchers and data collection processes resulting in a lack of reporting. The large loss of youth to suicide is devastating to AI/AN communities and obstructs Indigenous values and visions of youth as sacred and future leaders [3].Compounded by a federal system of severely underfunded mental health care [4], suicide risks among AI/ANs include but are not limited to: mental health problems, chronic pain [5,6,7], historical trauma [8,9,10], adverse childhood experiences [11]—including domestic violence or history of abuse, alcohol or drug misuse [10, 12, 13], and the suicide attempt or death of family or friends [7, 13]. Protection from suicide for AI/AN communities has been linked to cultural factors, including tribal spirituality, participation in cultural activities, social support from tribal leaders, and holistic connectedness to self/family/community/land [14,15,16,17,18]. Suicide rates also vary greatly based on geographic region and tribal community [19]. While some tribes experience little suicide loss, many impacted AI/AN communities are mobilizing to end this disparity through community-driven innovations and evaluations.The White Mountain Apache Tribe (WMAT) and Johns Hopkins Center for American Indian Health (JH CAIH) have been research partners addressing suicide prevention since 1994. Self-determination underscores WMAT suicide prevention efforts: In 2002, WMAT passed a tribal resolution mandating the reporting of all suicidal behaviors for all departments within the tribe’s jurisdiction. This resolution includes mandated reporting of suicide ideation, attempts, and deaths, as well as non-suicidal self-injury (added in 2008), and binge substance use (added in 2010) to the Celebrating Life suicide prevention program. This program is led by a group of White Mountain Apache community mental health specialists (CMHSs) using a common registry system (see Cwik et al., 2014 [20]). This community-wide suicide surveillance and case management follow-up system has become a nationally-recognized model with endorsements from the Academy of Child and Adolescent Psychiatry, Indian Health Service, and?The Substance Abuse and Mental Health Services Administration [20]. Two noteworthy features of the WMAT suicide prevention system are: a) a focus on community-driven solutions that are adjunct to conventional mental health treatment; and b) the employment of community-based paraprofessionals to fill gaps in services, and improve the cultural congruence and continuity of care [21, 22].Between 2001 and 2006, data collected through the tribal surveillance system documented WMAT suicide rates at 40.0 per 100,000, nearly 11 times the U.S. All Races rate [23]. The highest suicide rates were among 15 to 24?year olds at 128.5 per 100,000, which was 13 times the U.S. All Races rate and 7 times the All AI/AN rate. Since 2008, the WMAT-JH CAIH research team has completed a series of risk and protective factor studies utilizing qualitative and quantitative approaches that uncovered the critical role of substance use, specifically binge substance use, as a co-occurring risk factor for suicide attempts and deaths. In addition, impulsivity and challenges with family support were dominant risk factors for suicide attempts and related substance use [24]. Research also illustrated positive cultural identity and connectedness to family and community as strong potential protective factors [24, 25].Based on these findings, the WMAT-JH CAIH research partners have followed a tribal participatory research process to adapt, develop and pilot-test several evidence-based and culturally-informed interventions that form a comprehensive public health approach to suicide prevention [26]. In addition to surveillance and case management, key components of this public health approach include: 1) a culturally adapted brief intervention called “New Hope” focused on safety-planning and suicide risk reduction delivered to youth and a family member by a WMAT CMHS following a suicide attempt [21], and, 2) a culturally grounded, upstream suicide prevention program called “The Elders’ Resilience Curriculum,” (implemented in 2012) in which Elders teach cultural knowledge and values observed as protective against suicide. Between 2007 and