JULY 20: CLINICAL PRACTICE TRANSFORMATION TEAM
Welcome to the 5 Things Digest from the NTTAC Clinical Practice Transformation Team, bringing you 5 things to know about Youth Suicidality in 2021: Considering Culture.
#1: Suicide remains the second leading cause of death in young people (ages 10-24), and youth suicide rates have increased across different cultural groups, indicating a need for culturally tailored suicide prevention.

According to Centers for Disease Control (CDC) data, suicide rates in young people aged 10-24 in the United States increased 57% from 2007 to 2018, the most recent year of available comparative data.* The evidence has shown fluctuating increases in suicidality during some months of the pandemic (such as January and March), but the CDC data to compare suicide rates in youth is not yet available.

Wide variation in suicidality exists across different racial/ethnic groups (each reported below). Deaths from the pandemic in adults are approximately twice as great for American Indian/Alaska Native, Black, and Hispanic/Latinx adults as for the general population, increasing the risk of loss of family members for these young people (CDC).

Cultural competence is the ability to provide effective services responsive to the unique needs of culturally distinct populations. This includes personal awareness of one’s different culture and practices; knowledge about other cultures, and particularly regarding behavioral health; and skills to work across cultures different and beyond one’s own. In building systems of care in diverse communities, it is important to integrate evidence-based practices with culturally sensitive approaches, such as using relevant tools for communicating information (storytelling approaches), integrating important rituals and ceremonies, and respecting spiritual practices.
Examples of Culturally Tailored Interventions: SAMHSA’s Suicide Prevention Resource Center (SPRC) collaborates with the American Foundation for Suicide Prevention (AFSP) to provide a list of Resources and Programs for suicide prevention, available at Resources and Programs (this also includes the list, up to 2016, of programs on the Best Practices Registry). This site provides filters by age, racial/ethnic group, setting, strategies, and state, and includes programs for (1) Life Skills Development; (2) Screening and Suicide Assessment; (3) Public Awareness/Gatekeeper Training for parents, friends, teachers, providers; (4) Counseling and Support Services; and (5) Response to Suicide Attempts.
*6.8 per 100,000 to 10.7 per 100,000

REFERENCES

Curtin SC. State suicide rates among adolescents and young adults aged 10–24: United States, 2000–2018. National Vital Statistics Reports; vol 69 no 11. Hyattsville, MD: National Center for Health Statistics. 2020.
 
Hill RM, Rufino K, Kurian S, et al. Suicide Ideation and Attempts in a Pediatric Emergency Department Before and During COVID-19. Pediatrics. 2021;147(3): e2020029280
 
U.S. Department of Health and Human Services. To Live To See the Great Day That Dawns: Preventing Suicide by American Indian and Alaska Native Youth and Young Adults. DHHS Publication SMA (10)-4480, CMHS-NSPL-0196, Printed 2010. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2010.
#2: Culturally Sensitive Strategies to Address Suicidality in American Indian/Alaska Native (AI/AN) Youth

Compared to the general population, the suicide rate for youth aged 15-24 is about 3.5 times greater for AI/AN males and 6 times greater for AI/AN females (American Indian and Alaska Native Populations).* While much research has focused on rural reservation settings, approximately 75% of AI/AN now reside in urban areas, so it is important to recognize risk factors associated with transition and engagement in settings where cultural identity may be lost or diminished.

Strategies

  • Cultural awareness is vital and nuanced within AI communities. Inquiring about the meaning of death and suicide in each community is important, as taboos can vary. For example, in some AI communities, discussion of an individual’s death is perceived to impede that person’s transition to the next place after life here, and in others, discussion of suicide has been perceived as preparation for a suicidal event. For example, instead of a suicide awareness or prevention event, sometimes a resilience walk or framework may be more appropriate.

  • Some communities have been reluctant to share information or data because of how that information may be used against them, so it is important to address with the community how such reporting of events will benefit that community/family.

  • Appreciate and work with the strengths in different communities. Too often, descriptions of suicidality in AI communities focus on stereotypes of poverty, substance use, chronic disease, and lack of interest in engagement. Strong cultural identification and finding one’s purpose in life make adolescents less vulnerable to risk factors for substance use.

  • Appreciate the value and significance of ceremonies and rituals, including the participation of elders, the transmission of Tribal history/values/beliefs/spirituality, social and sacred dances, eating/fasting, relevance of dreams, traditional attire and crafts, and traditional forms of living (such as the relevance of hunting/fishing, tribal sports, camping, farming/harvesting). Core to the adaptation of program components is recognizing the worldview, or collective thought process, of the group’s culture.

*59 per 100,000; 20 per 100,000.

RESOURCES
Working with Native Communities by Doreen Bird (Aug 2016)
https://www.sprc.org/news/working-native-communities
 
Mental Health in our Native Communities (Spring 2020): website of resources from the Mental Health Technology Transfer Center Network (MHTTC) specific to American Indians/Alaska Natives
 
TIP 61: Behavioral Health Services for American Indians and Alaska Natives: a 220 page document for health service providers, program administrators, clinical supervisors, and researchers from SAMHSA
#3: Culturally Sensitive Strategies to Address Suicidality in Asian American Youth

Suicide is the leading cause of death among Asian American young adults aged 15-24 (CDC) and is responsible for about one-third of deaths among Asian Americans aged 20-24 (NAMI).

Challenges
Unfortunately, there is insufficient research on how to prevent suicide among Asian Americans, youth in particular. Part of the reason for this is that Asian Americans are also the least likely racial group to seek and utilize mental health services (APA).

Additional research into suicide rates amongst the U.S. Asian population is recommended. The only study that examines national epidemiological prevalence estimates of mental disorders in the Asian American community was published nearly 20 years ago (Massachusetts General Research Institute). Since the time of that study, the U.S. Asian population has grown considerably, making Asians the fastest-growing racial or ethnic group in the U.S. (Pew).

Part of the issue of underutilization of mental health services is related to access to culturally competent providers. The APA Commission of Ethnic Minority Recruitment, Retention, and Training found that 1 in 2 Asian Americans suffering from mental illness will not seek help due to a language barrier, and only approximately 4.5% of all psychologists are of Asian descent (APA).

In addition, many Asian Americans born in the United States are at a higher risk for mental illness as a result of pressure to assimilate to American culture despite its conflicts with traditional Asian values (APA). Compounding this risk factor, many psychological screening tools have linguistic and cultural biases, making it difficult to accurately diagnose Asian Americans (Weisman et al.).

Strategies

  • Encourage research designed to collect disaggregated health data on Asian Americans aimed at identifying important cultural nuances within the U.S. Asian population and then use those data to craft responsive public health policies to better support the mental health needs of this population.

  • Increase access to affordable, evidence-based, and culturally responsive mental health services for all Americans.

  • Work to mitigate language and stigmatic barriers to mental health services by providing culturally competency training for clinicians and ease access to culturally competent language interpretation services. 
#4: Culturally Sensitive Strategies to Address Suicidality in African American or Black Youth

Suicide rates among African American or Black youth have been identified as a growing crisis and have been rising at alarming rates in recent years (NIMH, Taskforce, Bridge et al.). Suicide has become the second and third leading cause of death among Black children between the ages of 10-14 and 15-19, respectively (NIMH). Studies have also indicated that Black children are more likely to die as a result of suicide than their White counterparts (NIMH), and that suicide death rates are increasing faster for this population than any other racial or ethnic group (Taskforce). There has also been an acknowledgement of the disparities that exist with regard to the amount and type of attention that this crisis has received.

Challenges

There are numerous factors that increase risk for this population and negatively impact mental health outcomes. Some of the major factors are racism/racial injustice, exposure to trauma, health disparities, disproportionate impact of the COVID-19 pandemic, higher rates of unemployment, financial and food insecurity, and limited access to care (NIMH, Taskforce, Bridge et al.). Many of these factors are not new to Black populations and they have contributed to numerous health disparities. However, historically, Black populations had lower suicide rates. It is imperative to note that this trend has changed over the past few years, resulting in higher suicide rates among Black youth.

Given the sociocultural factors compounded by identified social determinants, suicide risk must be addressed at multiple levels. Aligned with our focus on clinical care, we must address a major contributing risk factor: access to mental health services (NIMH, Taskforce, Bridge et al., Ross Center).

Strategies

  • Increase targeted outreach and screening efforts, particularly by school-based mental health clinics. These efforts may enable more robust levels of engagement with Black youth who may be experiencing mental health issues (NIMH, Bridge et al., Ross Center, Central East MHTTC).

  • Engage in effective community engagement practices that can play a role in addressing multilevel barriers (Bridge et al.), and promote necessary discussions about suicide and mental illness (Ross Center).

  • Address social determinants of health, structural inequalities, stigma, and mistrust of the healthcare system/providers, all of which contribute to disparate rates in which Black youth receive mental health services (Bridge et al.).

  • Increase understanding and awareness of the role of unconscious bias and discriminatory practices in treatment referral processes (Bridge et al.).

  • Increase efforts to explore differences in race-related suicide mechanisms, which can help inform the development of more culturally appropriate and effective detection and prevention interventions for Black youth (JAMA, The Conversation).

  • Increase knowledge regarding differential symptom expression (Bridge et al.).


  • Promote and utilize evidence-based interventions and practices that are appropriate for Black youth (JAMA), and be willing to also “think outside of the box” (6).

  • Increase funding to support research that focuses specifically on Black youth suicide and mental health (JAMA). It is necessary to address funding disparities to increase engagement in research efforts designed to better understand and effectively address suicide among this population. 
#5: Culturally Sensitive Strategies to Address Suicidality in Hispanic and Latinx Youth

Hispanic/Latinx youth have higher rates of depression than any group besides American Indian/Alaskan Native youth, and higher numbers of suicide than any group besides White youth (Guzman, Koons, & Postolache, OMH). Suicide is the second leading cause of death among Hispanic/Latinx adolescents ages 15-19, and the third leading cause of death among Hispanic/Latinx children (10-14) and young adults (20-24) (CDC). Public education campaigns and clinical programs need to be developed to reduce stigma, increase help-seeking, and disseminate culturally responsive clinical interventions to support this important population.

Important risk factors for suicide in this population may include untreated depression or anxiety, minimal or no feelings of family connectedness, challenges related to acculturation and cultural dissonance, and difficult migration experiences. Equally important protective factors may include access to effective and culturally responsive clinical interventions; family connectedness; and participating in physical activities with peers, such as school sports.

Cultural factors are critical considerations in understanding family context for mental health challenges in Hispanic/Latinx youth, particularly related to factors such as how families navigate challenges related to acculturation and/or assimilation, and how families maintain connectedness and positive relationships (Goldston et al.).

Challenges

Hispanic/Latinx youth access mental health services less than their white counterparts, for complex reasons that include stigma and fear felt by recent immigrant families around seeking out health care services (Marrast, Himmelstein, & Woolhandler). Help-seeking may increase as families live longer in the U.S. Culturally specific gender roles and challenges may specifically limit families’ willingness to seek out services for female youth.

Structural factors intervene to limit Hispanic/Latinx youth access to appropriate mental health services as well. Youth with mental health challenges may be more likely to receive school discipline and to be involved with the criminal justice system, and less likely to receive timely mental health and addiction services, compared with other populations (Marrast, Himmelstein, & Woolhandler).

Strategies

  • Increase access to affordable, evidence-based, and culturally responsive mental health services designed specifically for Hispanic/Latinx youth and their families.

  • Address barriers related to culture and language by training clinicians in culturally responsive care, improving access to culturally competent language interpretation services, and committing resources to developing opportunities for Hispanic/Latinx individuals to join the mental health workforce.

  • Enhance universal strategies in schools, including educational approaches to educate youth and reduce stigma related to mental wellbeing and mental illness; curricular approaches to build self-help skills in critical domains, including stress management and emotional regulation; and screening for depression and suicidal ideation to identify youth requiring support and intervention.
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This announcement is supported by SAMHSA of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $15,000,000 over five years (2020-2025) with 100 percent funded by SAMHSA/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by SAMHSA/HHS, or the U.S. Government.