Once again in the 198Us. suicide among American Indian and Alaska native (hereafter. "Indian") adolescents was prominent in the popular and professional literature. Sparked in part by widely publicized clusters of Indian adolescent suicide (Tulsa Daily World. September 29. 1 985). as well as by a general raising of consciousness about adolescent suicide in American society (The Washington Post. April 25. 198b). lay persons and professionals alike were again asking the basic questions that have been asked for years: How serious is the problem? Why do young Indians kill themselves? What are the contributing factors? How can Indian adolescent suicide be prevented?
This article assesses the present state of knowledge about Indian adolescent suicide, evaluates progress or lack of progress during the 1 98Us in understanding and dealing with this issue, and suggests future directions in addressing this phenomenon in the 1990s. In doing so. we selectively examine the literature on epidemiology and on causality and contributing factors, and discuss clinical and prevention programs.
In 1975. Shore1 published the landmark paper "American Indian Suicide - Fact and Fantasy." Prior to this, a number of articles had been written about suicide in Indians, usually reporting a very high suicide rate.2,1 As Shore described, a stereotype of "the suicidal Indian" had developed. May4 suggested that this stereotype was enhanced in I9b8. when Senator Robert K Kennedy made a widely publicized visit to a western Indian reservation, which was subsequently followed by a lederai report suggesting a high suicide rale on the reservation. The report - implied that this suicide rate might be similar for all tribes.
In contrast to this overgeneralization, Shore demonstrated thai lhe suicide rate for Indian tribes varies widely, from higher Io lower, than thai of the general population. He' further questioned the popular assumption that all Indian tribes have the same health problems and a uniform pattern of suicide. Shore showed that different tribes and age groups vary greatly as to health.
problems and suicide patterns. Finally. Shore cautioned that the use of only a few cases of suicide in a small population base (which is true for many Indian tribes) has often led to misinterpretation of suicide rates.
The findings of Shore confirmed an earlier discussion on rate variability by May and Dizmang in 1974.5 May and Dizmang5 and Dizmang et al6 also stressed that suicide in Indians was largely a problem within the male adolescent subgroup. On one reservation in the northwestern United Stales, over half oï the suicide completions were in persons under the age oi' 25.6
Levy et al,7 who have provided some oi the most comprehensive work on Indian suicide, found that suicide and homicide are interrelated in some Indian tribes, a finding also suggested by Shore,1 who described the phenomenon as selfprecipitated death by homicide in young Indian males.
In the 1980s, more sophisticated epidemiologic methodologies allowed for a deeper scientific analysis of Indian suicide, for instance, in reviewing the Indian literature, Mcintosh and Santos8 pointed out that undue emphasis had been placed on tribes with especially high suicide rates, creating the incorrect impression that all Indian groups had high rates. Levy and Kunitzq suggested that Indian suicide rates often fluctuate with those oi' surrounding community areas, bringing into locus the possibility that some high Indian rates may in part reflect general rates in the geographic area being studied. In 1985. Hochkirchen and Jelik, working in British Columbia, showed that Indian suicide in Canada was also a male adolescent phenomenon.
In a 1985 article that analyzed the methods of suicide death in more detail than in most previous studies. Kost-Grant" presented ease studies that suggested a high incidence oi' suicide by gunshot wounds in Alaska natives. Van Winkle and May12 examined 25 years of state vital statistics data on Indian suicide in New Mexico. Their work affirmed that young males, using particularly lethal means such as guns, were the most common victims. Methodologically, this study demonstrated the importance of longitudinal data by showing that in small populations, wide fluctuation in suicide rales over time could be partially corrected by calculating 5-year average rates. May13 also reviewed suicide and self-destruction among American Indian youth in an article lor American Indian and Alaska Native Mental H calili Research. He proposed that there were interrelationships between self-destructive behaviors, such as suicide, suicide attempts, and single-driver vehicle accidents.
In 1988. American Indian and Alaska Native Mental Health Research devoted a full issue to Indian suicide, including an article on cluster suicide in adolescents.'4 Although clustering in Indian suicide has been mentioned in past literature.15 this was the first such article dealing specifically with Indian adolescents.
Harras,11-1 a researcher with the Indian Health Service, in 1987 wrote a monograph on issues in adolescent Indian suicide, in which she examined problems related to the population base used to derive suicide rates. Her findings substantiated those of Levy and Kunitz.4 again indicating that Indian suicide rates should be compared with the general population living in areas adjacent to reservations or with demographically similar populations. Thompson, Larson, and Harras (unpublished data, 1990) made a similar point, indicating that it is difficult to use nationally collected data sets to form meaningful conclusions about Indian suicide. They suggested a mechanism ol local community surveillance as a preferred methodology.
Unfortunately, however, even though methodologic advances were made in the 1980s, the "suicidal Indian"' stereotype remains. A 1985 cluster of adolescent suicides on a reservation in the western United States sent the news media scrambling for data and commentary on "the Indian suicide problem" (Tulsa Daily World. September 29. 1985: National Public Radio. October 5. 1985) and the Centers for Disease Control rushed to study the *"epidemic." It still seems that little distinction is made by the news media or by federal policymakers between a cluster of suicides in a small community and a national epidemic of suicide among Indian people.
This continuing stereotype is lostered. in part, by the scientific literature, which sii)] publishes studies that make much of few cases.17 Perhaps more importantly, the Indian Health Service continues to report national Indian suicide data iiom the National Center for Health Statistics. IK which are widely quoted in the news media as representing all Indians.
Given repeated Undings in the literature during the last 1 5 years, it appears clear that within some tribal groups the suicide rates are higher than the national average, whereas in other tribal groups the suicide rates are lower. The lime has now come to move beyond simply measuring rates and to study risk and protective factors associated with suicide in order to develop more effective intervention strategies.
CAUSALITY AND CONTRIBUTING FACTORS
Etiologic theories oi' Indian suicide have changed little over the years. Walker and LaDue19 reviewed several factors long postulated as causing destructive behavior in Indians. These factors include cultural ambivalence (in which a person does not have a sense of belonging to either the majority or minority culture), loss oï traditional culture, loss of control over one's life, and a learned pattern of passive survival behavior.
Kiev-0 suggested that cultural factors determine which psychological defenses may be most prominent in members oï a defined society. Levy and Kunitz.21 however, questioned whether cui ture- related factors should ever be regarded as causal. They agreed with Graves,22 whom they quote, '"recourse to a groups' culture' for explaining their behavior simply serves to conceal our ignorance of the underlying processes in operation."
An interrelationship between Indian suicide and psychopathology has also long been suggested. Shore and Manson23 have reviewed the literature concerning a link between suicide and depression in Indians, and Harías111 has noted that "excessive drinking. . . has traditionally taken the blame for most violent behavior among Native Americans." including suicide. Abuse of a variety of drugs other than alcohol also has been implicated. Articles published on Indian suicide often end with a discussion of these and other possible causes of the phenomenon. Seldom, however, has there been scientific study o\' these factors to discover whether they are indeed causal. Where data have been collected, the suicides arc usually presented in the form of case reports or very small study samples.017 In addition, distinctions between adult and adolesceni causal factors are usually not made.
A few recent studies do hold promise for the 199Us. For example. Shore et al.24 in a study on depression, compared several Indian groups with a non-Indian group, using the Research Diagnostic Criteria (RDC). Several items in the RDC are of interest, with "thoughts oi death" being one of the most relevant. The appearance of carefully designed studies such as this may augur well for the study of causality and contributing factors in Indian suicide.
CLINICAL AND PREVENTION PROGRAMS
Within the general population, intervention and prevention of suicide in adolescents is based on effective early assessment oi suicide risk potential in the individual or family. If risk potential is high, clinical decisions are made about the treatment, and one of a variety of interventions is used. These include inpatient admission, crisis drop-in centers, close outpatient monitoring, family therapy, or placement of a child in a supportive foster home. Further. public and private school systems have become major sites for the provision of education about suicide risk, including teaching adolescents how to seek clinical help. There is, however, some question about the effectiveness of these programs, especially when applied to Indian people in either a reservation or an urban setting. Problems with this model emerge, relating largely to the lack of access by Indians to quality clinical care.
Many reservation communities are isolated and far away from agencies providing assessment, treatment, and prevention services. In urban settings, where 60% of the Indian population now live, the few agencies available to assist Indians are overloaded. Although many tribes have the right to health and education benefits derived from long-standing treaty obligations, adequate funds for these services have not been forthcoming. Recent federal budget cuts and the trend toward block grants and service provision by stale agencies have not helped. The result has often been fragmentation ol health services or worse, competition for dwindling health services. Finally, fewer and fewer professional mental health staff are available to assess and treat persons at high suicide risk in Indian communities because oí changes in Indian Health Service recruitment and retention policies.
Despite difficulties in funding, access to health care, and reductions in an already small professional staff, suicide intervention programs have developed within Indian communities. Reports ol these programs have dominated the literature prior to and throughout the 1 98Us. Shore et al25 describe one such program on a reservation in the Pacific Northwest. Patients admitted to this center had made a recent suicide attempt or threat. The services available in the center involved an initial professional evaluation oi' suicide risk, an overnight holding facility for those at highest risk, and follow-up planning involving the patient's family and social network.
Such intervention programs have not been totally successful, however. Reporting on a second program. Shore et al25 found that most suicide behaviors occur in people who had sought help within 2 weeks of the attempted or completed suicide, demonstrating that contact with the caregiving system does not necessarily protect against suicidal behavior. Another intervention approach is suggested by May and Dizmang. ' They indicate that in addition to specific treatment for high-risk individuals, crisis intervention, and counseling, education programs are needed to stimulate motivation and improved self-image in Indian families and in the community.
Such community suicide prevention and intervention programs for youth on reservations not only have made up the bulk of the literature on intervention, but also have been the major focus of healthcare funding in recent years. As Neligh26 points out. this emphasis on suicide prevention programs has led to the redirection of many mental health resources in the Indian Health Service toward education, recreational programs, and health promotion, all of which are seen as preventive. Unfortunately, this focus on broad community educational and health promotion programs has taken away from clinical intervention.
The move toward broad community programs and away from clinical care also is reflected in the professional literature oï the 198Us. A recent example is an article by Levy and Kunitz. q who express concern that most suicide prevention programs are designed to intervene after an individual has made a suicide attempt or otherwise identified him- or herself as having suicidal impulses (eg. by having called a suicide hotline). They argue that prevention programs for Indians must be deflected away from crisis intervention and must not label the recipient of services as deviant. These authors recommend that programs not take a clinical approach, not be called suicide prevention programs, and not be part of the tribal or federal health delivery system.
The movement of resources from Indian Health Service clinical programs to fund prevention represents a serious problem in already underfunded Indian mental health programs. At the heart of the problem is a mistaken belief that moving away from crisis intervention also means moving away from clinical care for persons at high risk. The implicit (but incorrect) assumption is that we are preventing suicides with primary prevention programs, so funding for secondary and tertiary prevention is no longer necessary.
Hope for a change in this situation in the 199Us comes from the recent literature. Neligh20 emphasizes that there is little evidence that suicide is prevented by prevention programs and that mounting evidence indicates that these programs may increase the number of suicides. Alternately, clinical intervention provided for persons with psychiatric disorders associated with a high risk of suicide (eg. depression and substance abuse) clearly is effective and has a good chance of decreasing suicidal acts.27 28
There is ample documentation that clinical interventions work. Neligh2l? and Thompson2'1 argue that in order to prevent Indian youth suicide, recognition and treatment of underlying psychiatric disorders is needed. Neligh stresses the importance of strong, competent mental health programs serving reservations and Indian communities. Thompson discusses the need to provide Indians with high-quality mental health services that are adequately staffed with professionals and that are coordinated with substance abuse and general health services. Refocusing efforts toward the provision of effective clinical interventions and away from broad and vaguely formulated education and health promotion programs offers the best hope for progress in intervention in the next decade.
To understand issues related to suicide in Indian adolescents, a primary epidemiologic task for the 199Us will be to translate advancements in methodology into a revamped statistical reporting system, especially in the Indian Health Service. Statistics on Indian suicide could be greatly enhanced by gathering and reporting data that reflect the mosaic of rates and characteristics of Indian suicide. Such an approach would provide more accurate information for the lav media and. perhaps more important, for Indians themselves. As Shore1 suggested, the worst aspect of a public image of artificially high Indian adolesceni suicide rates is that Indians begin to believe the stereotype. This stereotype may translate into a negative sell-image on the part oi Indians and fosters unnecessary programs to prevent "epidemics" that may not even exist in a particular community.
Epidemiologic research on Indian suicide will also be improved in lhe 199Us if enough cases can be assembled to provide statistically valid data, while not blurring important social and cultural differences by combining data from diverse groups. In addition, a continued locus on adolescents (especially males), rather than on all Indian suicides. will greatly improve our knowledge base for use in understanding this high-risk group.
In epidemiologic and risk factor research, adolescent suicide in areas other than reservations needs to be studied (eg. urban areas and nonrcservation rural areas), as the majority of Indians do not live on reservations. The characteristics of Indian youth suicide may he different in these areas than on reservations. Also, communities with low rates of suicide should be studied. Such communities could be used as control groups for studies oi communities with high rates, thus lending more credibility to research findings. Communities with low rales also mav help us understand what factors "protect" against suicide.
Research on suicide causality4 would be greatly advanced in the coming decade if studies on suicide risk factors were conducted based on large sample sizes and included prospective, longitudinal cohorts. Such studies could have direct implications for planning clinical programs and could help the field move beyond its present locus on primary prevention, education, and health promotion, by demonstrating links between particular risk factors and Indian youth suicide.
Perhaps the most important goal for the 1990s is to adequately fund Indian mental health, alcoholism, and substance abuse programs and to insist that these programs work together (and with general health programs) for the benefit of the patient. These programs will require more well-trained professional stall in order to apply the best treatment psychiatry has to offer. Resources would then be directed toward the fundamental problems, rather than being misdirected toward society in general via education or health promotion programs or only toward emergency intervention.
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