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>> Good afternoon.

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I'm Dr. Phoebe Thorpe, and
it's my pleasure to welcome you

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to CDC Public Health Grand
Rounds for March 2019,

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suicidal behavior
in American Indian

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and Alaska Native communities,
a health equity issue.

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This is an important
and informative session.

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So, let's get started.

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First, a few housekeeping
slides.

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Public Health Grand Rounds has
continuing education available

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for physicians, nurses,
pharmacists, veterinarians,

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health educators, and others.

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The course code is PHGR10.

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Please see our website for
additional information.

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Talking about suicide
can be difficult,

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but there are lots
of tools to help.

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We have additional
resources listed

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at the end of this presentation.

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But we felt it was important
to include this number early.

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New guidelines were recently
released about how best

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to portray suicide in TV
shows and in the media.

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These will help shift
the national dialogue.

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At the individual level,
some are afraid to talk

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about suicide, leading to a
silence that surrounds it,

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and perhaps a lack
of understanding

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of why individuals thinking

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about suicide have
difficulty asking for help.

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One of the cruel
tricks of deep sadness

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and depression is
the loss of interest

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in friends and activities.

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I'm told they are not as
much fun as they used to be.

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This withdrawal can lead
to isolation and a cycle

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of deepening sadness,
withdrawal, and more isolation.

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We can break the silence.

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This is a national hotline
number that anyone can call

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to help prevent a suicide.

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Grand Rounds is available
on the web

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and on your social media sites.

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Please send questions
for today's session

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to grandrounds@cdc.gov,
and we'll try

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to include your questions
in the Q&A today.

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Want to know more?

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We have a featured
video segment on YouTube

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and our website called
Beyond the Data,

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which is posted after
the session.

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This month's segment,
it features my interview

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with Dr. Spero Manson.

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We also have partnered with
the CDC Public Health Library

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to feature scientific
articles about this session.

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The full listing is available
at cdc.gov/scienceclips.

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Here is a preview of
our upcoming topics.

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Please join us live or on
the web at your convenience.

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In addition to our
outstanding speakers,

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I'd also like to acknowledge
the important contributions

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of individuals listed here.

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Thank you.

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And now for a few words

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from CDC's Deputy
Director, Dr. Anne Schuchat.

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>> Well, thanks, Phoebe.

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And thank you all
for being here.

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And thank you to our
speakers for traveling in.

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Welcome to today's Public
Health Grand Rounds.

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Suicide is a difficult issue,
affecting too many individuals,

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their families, and their
surrounding communities.

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Increasing insights into
factors that influence risk for,

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as well as protection
against suicidal behavior,

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are providing greater
opportunities

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to tackle this public
health concern.

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Last June, through a vital
signs release, CDC reported

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on surveillance data
for suicide,

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which found that since 1999,
suicide rates had increased more

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than 30% in half of the
states in the country.

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The report also found that more
than half of people who died

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by suicide had no recognized
mental health condition.

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Many preceding situational
stresses were common among

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people who committed suicide.

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CDC has synthesized the evidence
space on prevention of suicide

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in a technical package of
policy, programs, and practices,

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which you'll hear
more about today.

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Today's Grand Rounds will review
recent epidemiological data,

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including recent trends.

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The presentations focus on one

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of the hardest hit population
groups, American Indians,

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and Alaska Native communities.

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While factors contributing
to recent trends may differ

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across communities,
effective strategies

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that can make a difference
can be adapted

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to appropriate cultural
contexts.

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Our presenters will describe
interventions targeted

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for schoolchildren,
primary healthcare,

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and occupational settings.

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Today, you'll also learn about
resources for public health,

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clinicians, and members
of the public.

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Whether you live and
work with American Indian

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and Alaska Native people,
or in other settings,

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whether you are focused
on health of young people

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or older populations, you should
gain insight into strategies

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that can contribute
to resilience

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and inoculate communities
against suicidal behavior.

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CDC's director, Dr. Redfield,
reminds us frequently

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that stigma is the
enemy of public health.

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Today's Public Health Grand
Rounds helps us advance the

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agency's work on prevention
of suicidal behavior,

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and I hope will empower each
of you to make a difference

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in your own communities.

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Thank you.

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[ Applause ]

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>> Thank you, Dr. Schuchat.

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And now for our first speaker.

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Dr. Alex Crosby.

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>> Well, good afternoon
to all of you.

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Thank you for coming.

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And I wanted to thank the
Office of Minority Health

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and Health Equity for
organizing this Grand Rounds,

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and also for the invitation to
come and to talk with you today.

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What I'll deal with is
understanding suicide

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in American Indian and
Alaska Native youths,

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as why this is an important
issue is we've noticed

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for the first time,
the National Center

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for Health Statistics
noted that life expectancy

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in the United States decreased
for three consecutive years.

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This is almost unprecedented.

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The last time that they saw
two consecutive years was

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over 50 years ago.

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And one of the leading causes as
to why life expectancy is going

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down has to do with the
increasing suicide rates

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across the country.

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So, it's important for us
to understand this problem,

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try to figure out what
we can do about it

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so that we can reverse
those trends.

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What I'll do today is I'll talk
about describing the patterns

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of suicidal behavior
among American Indian

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and Alaska Native populations.

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I'll give a little bit
about discussing the risk

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and protective factors for
those particular populations.

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And then lastly,
give some information

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about the evidence based or
the best available evidence

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that we have in regards
to programs and policies

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for dealing with this
particular problem.

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One of the things that we
know about suicidal behaviors,

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looking at the most recent data

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that we've got the full United
States for, which is 2017,

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suicide was the 10th leading
cause of death during that year.

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Over 47,000 deaths occurred
in the United States.

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That's an average of
about a suicide every 11

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or 12 minutes in
the United States.

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And while it's the 10th
leading cause of death overall,

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you can see that it
disproportionately affects

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certain populations.

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And you can look kind of in the
middle of this slide and look

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at non Hispanic American
Indian and Alaska Natives,

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that suicide is the
eighth leading cause

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of death in that population.

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So, from 10th overall,

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to 8th among this
particular population.

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Another way that you can also
try to look at the measure

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of the magnitude of this
particular problem is

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which age groups within those
populations seem to be affected?

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You can see in the gold
line that suicidal behavior,

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especially deaths
due to suicide,

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really impact young adult and
adolescent American Indian

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and Alaska Natives,
especially that 15

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to 34 year old age group.

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And you can see that in other
populations, other racial

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and ethnic groups, it
affects different kinds

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of populations among
non Hispanic whites.

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It tends to affect
middle aged adults,

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those in their 40s and 50s.

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So, different populations
affecting different kinds

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of age groups.

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Suicides really only measure
one portion of the burden

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of suicidal behavior
in our population.

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This pyramid tries to illustrate
how this problem affects not

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just those that die as
a result of suicide,

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but also non fatal injuries,
and also those who self report.

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You can see at the top of the
pyramid that looking at 18

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to 25 year old American Indian
and Alaska Natives in 2016,

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that there were 151 deaths.

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Looking at those that
were hospitalized due

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to more severe suicide
attempts, 340.

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Those who report on surveys
that they made a suicide attempt

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in the past 12 months,
about 2,000.

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And then those that say

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that they've seriously
considered suicide

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in the past 12 months,
over 12,000.

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And there in the parentheses,
you can see the ratio.

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So, for every 1 death,
about 2 hospitalizations,

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13 suicide attempts, and
over 80 persons that say

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that they had seriously
considered suicide

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in the past 12 months.

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So, the burden becomes
even bigger.

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And we know that those that
have attempted suicide are

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at the greatest risk
of subsequently dying

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as a result of suicide.

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Suicide rates, as you
heard from Dr. Schuchat,

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have been increasing
in the United States

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over the past 10 to 15 years.

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One of the things to
see here is pointing

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at that gold line again
is in most recent years,

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those rates among
American Indian

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and Alaska Natives have
increased even faster than some

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of the other racial
and ethnic groups.

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We also know something about
the risk and protective factors

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in various groups,

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and specifically among American
Indian and Alaska Natives.

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One way of looking at
this problem is looking

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at the socio ecological model.

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And I'll talk about some of the
different factors in this model

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and not try to go
through all of them here.

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But one of the ways that this
model tries to identify risk

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and protective factors
is at certain levels;

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at the individual level, at
the family and peer level,

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at the community level,
and at the societal level.

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And I'll talk about a
little bit of those.

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At the individual level, you can
see age and sex are different.

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And when we look at age, just
as I talked about, adolescents

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and young adults among American
Indians and Alaska Natives,

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males die as a result of
suicide at much higher rates,

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about four times
higher than females.

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But when you look at non fatal
injuries, females attempt

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and report more non fatal
suicidal behavior than males do.

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Looking at the examples
within the family and peer

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and neighborhood
level, identifying

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and assisting persons at risk
is one of the protective factors

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within that particular group.

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We also know that a risk
factor is a family history

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of interpersonal or
self directed violence.

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If there's been someone in the
family that has died as a result

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of suicide or has attempted
suicide, that puts other members

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of that family at greater risk.

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At the community level,

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spirituality is a
protective factor.

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And then reducing social
isolation is also a protective

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factor, including something
that we call connectedness.

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How can you make sure

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that a person has a
strong social network

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of friends and family?

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That's a protective factor.

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Looking at examples at the
societal level, reducing access

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to lethal means is
a protective factor.

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Intergenerational trauma, which
is something that has occurred

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in many American Indian and
Alaska Native communities,

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the loss of land, the
inability to practice religion,

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inability to use the
language, having children

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that have been taken away
and put in boarding schools,

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all introduced trauma
into those communities

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and increased the risk
for suicidal behavior.

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Another way of trying
to look at the risk

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and protective factors is a
framework that was developed

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by the World Health
Organization,

250
00:12:19,734 --> 00:12:22,367
looking at the social
determinants of health.

251
00:12:22,367 --> 00:12:23,633
And I won't go through
all of this,

252
00:12:23,633 --> 00:12:25,133
but looking down at
the bottom there,

253
00:12:25,133 --> 00:12:27,967
the structural determinants
of health and equities,

254
00:12:27,967 --> 00:12:31,967
and then also the intermediate
determinants of health.

255
00:12:31,967 --> 00:12:34,633
The one that we'll try to
focus on a little bit today is

256
00:12:34,633 --> 00:12:38,967
at that socioeconomic position,
especially looking at occupation

257
00:12:38,967 --> 00:12:41,867
as one of the social
determinants of health

258
00:12:41,867 --> 00:12:46,133
that might be influencing
suicidal behavior among American

259
00:12:46,133 --> 00:12:48,500
Indian and Alaska
Native communities.

260
00:12:48,500 --> 00:12:53,233
In response to what we saw
was going on in suicide

261
00:12:53,233 --> 00:12:55,834
and the increasing
suicide rates, the Division

262
00:12:55,834 --> 00:12:58,700
of Violence Prevention
developed a technical package

263
00:12:58,700 --> 00:13:02,900
that did a systematic review
of evidence based programs

264
00:13:02,900 --> 00:13:06,467
and policies to try to identify
those that had been successful

265
00:13:06,467 --> 00:13:09,467
and had a good track record
of what they were doing

266
00:13:09,467 --> 00:13:13,767
in making sure that there was a
strong rigorous evidence base.

267
00:13:13,767 --> 00:13:16,233
We looked at it for suicide
prevention for child abuse

268
00:13:16,233 --> 00:13:18,867
and neglect, for sexual
violence, youth violence,

269
00:13:18,867 --> 00:13:21,533
and intimate partner violence.

270
00:13:21,533 --> 00:13:24,667
We identified seven different
strategies in regards

271
00:13:24,667 --> 00:13:26,266
to suicide prevention.

272
00:13:26,266 --> 00:13:29,734
And the ones that you can see
highlighted are those approaches

273
00:13:29,734 --> 00:13:33,033
in which we'll talk about
them directly or indirectly

274
00:13:33,033 --> 00:13:35,767
in regards to some of the
other presentations today.

275
00:13:35,767 --> 00:13:39,333
Those seven different strategies
identified were strengthening

276
00:13:39,333 --> 00:13:42,433
economic supports, strengthening
access and delivery

277
00:13:42,433 --> 00:13:46,567
of suicide care, creating
protective environments,

278
00:13:46,567 --> 00:13:49,200
promoting connectedness,
teaching coping

279
00:13:49,200 --> 00:13:53,467
and problem solving skills, and
identifying support, identifying

280
00:13:53,467 --> 00:13:56,500
and supporting people at
risk, and then lessening harms

281
00:13:56,500 --> 00:13:58,633
and preventing future risk.

282
00:13:58,633 --> 00:14:03,033
In conclusion, some of the
things that were important

283
00:14:03,033 --> 00:14:05,300
about understanding the problem

284
00:14:05,300 --> 00:14:07,900
of suicide among American
Indians Alaska Natives is

285
00:14:07,900 --> 00:14:11,033
that suicidal behavior
disproportionately affects

286
00:14:11,033 --> 00:14:13,734
American Indian and
Alaska Native populations,

287
00:14:13,734 --> 00:14:17,433
especially youths age
15 to 34 years of age.

288
00:14:17,433 --> 00:14:20,467
A comprehensive approach
is needed in order

289
00:14:20,467 --> 00:14:22,633
to reduce this serious
health problem.

290
00:14:22,633 --> 00:14:24,967
One of the things we've
found when we developed

291
00:14:24,967 --> 00:14:27,767
that technical package is that
communities that used more

292
00:14:27,767 --> 00:14:30,367
than one strategy were
oftentimes the one

293
00:14:30,367 --> 00:14:33,533
that were more successful in
reducing suicide prevention

294
00:14:33,533 --> 00:14:36,200
than those that just
tried to use just one.

295
00:14:36,200 --> 00:14:39,333
Suicide prevention strategies
should include culturally

296
00:14:39,333 --> 00:14:41,333
appropriate services
and programs.

297
00:14:41,333 --> 00:14:43,300
And you'll hear a little
bit more about that

298
00:14:43,300 --> 00:14:44,834
in the next presentations.

299
00:14:44,834 --> 00:14:47,233
And then together, we can
reduce this health equity,

300
00:14:47,233 --> 00:14:50,467
that it really does take a
collaboration and partnership

301
00:14:50,467 --> 00:14:55,367
at the community level in order
to really make a difference.

302
00:14:55,367 --> 00:14:58,600
Next will be Dr. Teresa
LaFromboise that will talk

303
00:14:58,600 --> 00:15:01,467
about some of the
specific strategies to try

304
00:15:01,467 --> 00:15:04,200
to address suicidal behavior
among American Indians

305
00:15:04,200 --> 00:15:06,500
and Alaska Native youth.

306
00:15:06,500 --> 00:15:11,600
[ Applause ]

307
00:15:11,600 --> 00:15:13,600
>> Thank you very much, Alex.

308
00:15:13,600 --> 00:15:15,834
This is a wonderful
opportunity to be able to talk

309
00:15:15,834 --> 00:15:19,066
about school based suicide
prevention with native youth.

310
00:15:19,066 --> 00:15:20,633
So, let me begin.

311
00:15:20,633 --> 00:15:25,166
Schools are second to families
in their, the potential impact

312
00:15:25,166 --> 00:15:27,400
that they have on
children's mental health.

313
00:15:27,400 --> 00:15:29,734
Ideally, schools are places

314
00:15:29,734 --> 00:15:31,533
where the healthy
development of children.

315
00:15:31,533 --> 00:15:34,934
Not only are we imparting
knowledge and learning,

316
00:15:34,934 --> 00:15:40,233
but also providing nurturance
and opportunities for children

317
00:15:40,233 --> 00:15:44,600
to build good healthy respectful
interpersonal relations.

318
00:15:44,600 --> 00:15:45,834
I know that sounds ideal.

319
00:15:45,834 --> 00:15:48,734
But, certainly, schools
are the place

320
00:15:48,734 --> 00:15:51,934
where we can instill a sense of
belongingness and connectedness

321
00:15:51,934 --> 00:15:55,033
that Alex referred to as a very
important protective factor

322
00:15:55,033 --> 00:15:56,000
for suicide.

323
00:15:56,000 --> 00:16:00,533
School based suicide
prevention really began

324
00:16:00,533 --> 00:16:03,900
in around 1984 or so.

325
00:16:03,900 --> 00:16:07,533
And as a result of the
escalating suicide rate,

326
00:16:07,533 --> 00:16:10,433
suicidal behavior
among adolescents

327
00:16:10,433 --> 00:16:13,700
in Western industrialized
nations.

328
00:16:13,700 --> 00:16:18,633
In 19 towards the end of
the 80s, I was invited

329
00:16:18,633 --> 00:16:23,166
by the Pueblo Zuni to develop a
suicide prevention intervention

330
00:16:23,166 --> 00:16:26,633
because there had been deaths,
there had been five deaths

331
00:16:26,633 --> 00:16:29,667
in the high school, and this
was a relatively small community

332
00:16:29,667 --> 00:16:33,100
at that time with a
population of 7,000.

333
00:16:33,100 --> 00:16:34,834
Over the period of three years,

334
00:16:34,834 --> 00:16:40,800
we developed an evaluated an
intervention that was focused

335
00:16:40,800 --> 00:16:45,533
in a large part on social
cognitive theory with the idea

336
00:16:45,533 --> 00:16:49,233
that a behavior is really
influenced by modeling

337
00:16:49,233 --> 00:16:53,266
and direct learning, as well
as individual characteristics,

338
00:16:53,266 --> 00:16:57,967
as a person mediates
decisions about risk behavior.

339
00:16:59,233 --> 00:17:01,000
There's the Pueblo there.

340
00:17:01,000 --> 00:17:08,533
Okay, social cognitive theory is
the basis of many interventions

341
00:17:08,533 --> 00:17:11,133
and social and behavioral
skills training,

342
00:17:11,133 --> 00:17:14,133
classroom based curriculum
to prevent substance abuse,

343
00:17:14,133 --> 00:17:17,734
aggressive behavior,
risky sexual behavior,

344
00:17:17,734 --> 00:17:19,967
and the prevention
of depression.

345
00:17:19,967 --> 00:17:22,800
And given its influence
on modeling and the fact

346
00:17:22,800 --> 00:17:25,500
that there is so much
suicide in many communities,

347
00:17:25,500 --> 00:17:29,000
it seemed to be an appropriate
theoretical approach.

348
00:17:29,000 --> 00:17:32,867
In addition to that
theory, we also look

349
00:17:32,867 --> 00:17:35,900
at stress coping model.

350
00:17:35,900 --> 00:17:38,033
In a way, this is
our logic model

351
00:17:38,033 --> 00:17:40,734
for the curriculum development.

352
00:17:40,734 --> 00:17:43,200
But as you can see
in this figure,

353
00:17:43,200 --> 00:17:46,100
I have enumerated a
number of risk factors,

354
00:17:46,100 --> 00:17:48,734
many of them historical,
but looking

355
00:17:48,734 --> 00:17:50,567
and there could be this
could be a backdrop.

356
00:17:50,567 --> 00:17:52,667
As you know, in the field
of suicide prevention

357
00:17:52,667 --> 00:17:55,233
of other risk factors, but
this is what I have selected

358
00:17:55,233 --> 00:17:56,600
for the image.

359
00:17:56,600 --> 00:17:59,600
But thinking of ecological
factors in the air,

360
00:17:59,600 --> 00:18:03,500
such as historical trauma
or intergenerational trauma,

361
00:18:03,500 --> 00:18:05,600
pervasive poverty,
acculturation stress,

362
00:18:05,600 --> 00:18:06,633
and then it goes on down.

363
00:18:06,633 --> 00:18:11,133
But, so, let's say that there
is a backdrop of risk factors.

364
00:18:11,133 --> 00:18:12,834
And according to the
stress coping model,

365
00:18:12,834 --> 00:18:15,367
a stressful event
happens, people choose

366
00:18:15,367 --> 00:18:18,734
to either avoid the situation

367
00:18:18,734 --> 00:18:22,266
and use avoidant coping
or approach coping.

368
00:18:22,266 --> 00:18:23,300
In the work that we've done,

369
00:18:23,300 --> 00:18:27,066
we seem to see a pretty rampant
pattern of avoidant coping

370
00:18:27,066 --> 00:18:29,333
where a person who
has a stressful event,

371
00:18:29,333 --> 00:18:32,767
I'm talking about American
Indian and Alaska Native youth,

372
00:18:32,767 --> 00:18:36,333
often self medicate,
self isolate,

373
00:18:36,333 --> 00:18:41,100
and eventually engage
in suicidal behavior.

374
00:18:41,100 --> 00:18:44,533
Interventions, such as
American Indian life skills,

375
00:18:44,533 --> 00:18:50,667
try to encourage approach
coping, taking direct action,

376
00:18:50,667 --> 00:18:52,834
seeking social support,
talking to others,

377
00:18:52,834 --> 00:18:56,967
monitoring emotional arousal,
discussing problems, et cetera.

378
00:18:56,967 --> 00:19:01,834
And in some, we use,
in this curriculum,

379
00:19:01,834 --> 00:19:05,033
primarily emphasizing
effective problem solving

380
00:19:05,033 --> 00:19:08,133
and positive thinking, with
the idea that it would lead

381
00:19:08,133 --> 00:19:10,934
to resilient adaptation.

382
00:19:10,934 --> 00:19:12,734
This is a lot of words,

383
00:19:12,734 --> 00:19:15,600
and basically it's describing
the different sections

384
00:19:15,600 --> 00:19:18,033
of American Indian life skills.

385
00:19:18,033 --> 00:19:20,934
I'm shifting now
from Zuni life skills

386
00:19:20,934 --> 00:19:23,333
to American Indian life skills
because over a period of time,

387
00:19:23,333 --> 00:19:25,767
then we work with
other communities,

388
00:19:25,767 --> 00:19:33,867
and it became more inclusive in
terms of the different tribes.

389
00:19:33,867 --> 00:19:37,200
But, basically, what I
want you to see here is

390
00:19:37,200 --> 00:19:41,333
that through the course of
some 44 lessons over a period

391
00:19:41,333 --> 00:19:45,734
of time, people move from
learning the various skills,

392
00:19:45,734 --> 00:19:49,066
like understanding emotions
and stress and communicating,

393
00:19:49,066 --> 00:19:52,166
problem solving, et cetera,
to suicide prevention,

394
00:19:52,166 --> 00:19:55,800
it was a major lesson learned

395
00:19:55,800 --> 00:19:59,467
that we couldn't address
suicide prevention at the onset.

396
00:19:59,467 --> 00:20:01,567
We had to gradually
work up to it.

397
00:20:01,567 --> 00:20:04,700
And then we didn't want to
bring students to that point

398
00:20:04,700 --> 00:20:08,700
and then leave them, you know,
and so we have several lessons

399
00:20:08,700 --> 00:20:11,900
at the end on individual
and community goal setting.

400
00:20:11,900 --> 00:20:18,400
To put it more simply, I've just
outlined here the core skills

401
00:20:18,400 --> 00:20:19,300
of the curriculum.

402
00:20:19,300 --> 00:20:23,033
But emphasizing across, then
with every one of these skills,

403
00:20:23,033 --> 00:20:27,433
we do address those
through positive thinking

404
00:20:27,433 --> 00:20:28,767
and effective problem solving.

405
00:20:28,767 --> 00:20:31,066
And these, you know, I guess
you would consider active

406
00:20:31,066 --> 00:20:34,800
ingredients, or mediating
factors are present in a number

407
00:20:34,800 --> 00:20:37,667
of interventions for resilience.

408
00:20:37,667 --> 00:20:41,433
The first evaluation of
the curriculum occurred

409
00:20:41,433 --> 00:20:45,266
at with the Zuni community
in the high school.

410
00:20:45,266 --> 00:20:49,633
In that situation, we were able
to we had intervention groups

411
00:20:49,633 --> 00:20:55,133
and comparison groups, and we
found significant differences

412
00:20:55,133 --> 00:20:57,600
in those in the intervention
group and hopelessness,

413
00:20:57,600 --> 00:21:00,700
their confidence
to manage anger,

414
00:21:00,700 --> 00:21:02,734
their problem solving skills,

415
00:21:02,734 --> 00:21:06,633
and their peer suicide
intervention skills.

416
00:21:06,633 --> 00:21:11,266
In another study
conducted by Dr. Phil May

417
00:21:11,266 --> 00:21:14,900
in a different reservation
in New Mexico,

418
00:21:14,900 --> 00:21:16,834
they used the comprehensive
approach

419
00:21:16,834 --> 00:21:18,500
that Alex is talking about,

420
00:21:18,500 --> 00:21:20,934
and American Indian life
skills was included in that.

421
00:21:20,934 --> 00:21:24,066
So, but, we cannot
attribute these findings

422
00:21:24,066 --> 00:21:25,667
to American Indian life skills.

423
00:21:25,667 --> 00:21:27,000
But we can say that that,

424
00:21:27,000 --> 00:21:31,734
in addition to training natural
helpers in neighborhoods,

425
00:21:31,734 --> 00:21:35,433
and providing and screening and
doing outreach in conventional

426
00:21:35,433 --> 00:21:38,667
and unconventional places
within the community,

427
00:21:38,667 --> 00:21:41,200
that there was a strong impact.

428
00:21:41,200 --> 00:21:43,133
As you can see, when
the intervention began

429
00:21:43,133 --> 00:21:47,633
in the late 80s, a big
drop in suicidal attempts

430
00:21:47,633 --> 00:21:52,266
and suicidal gestures
some 11 years later

431
00:21:52,266 --> 00:21:55,467
when this article was written.

432
00:21:55,467 --> 00:21:58,066
Okay, another study
is very interesting.

433
00:21:58,066 --> 00:22:00,400
This is one where, you
know, you say 44 lessons,

434
00:22:00,400 --> 00:22:01,467
how would I ever do it?

435
00:22:01,467 --> 00:22:05,700
We ask people, interventionists,
to select the lessons

436
00:22:05,700 --> 00:22:07,667
that are most relevant
to their students.

437
00:22:07,667 --> 00:22:11,133
But in this case, this community
said, we only have 10 lessons.

438
00:22:11,133 --> 00:22:14,233
We can get into schools
for 10 times.

439
00:22:14,233 --> 00:22:17,200
And so they did they
conducted their own evaluation.

440
00:22:17,200 --> 00:22:19,033
And now this is not
a comparison group.

441
00:22:19,033 --> 00:22:20,367
It's pre and post.

442
00:22:20,367 --> 00:22:24,000
But we do find decreased
levels of hopelessness,

443
00:22:24,000 --> 00:22:26,433
decreased suicide
risk, increased sense

444
00:22:26,433 --> 00:22:28,734
of public collective esteem,

445
00:22:28,734 --> 00:22:32,400
what students felt other
groups think of their group,

446
00:22:32,400 --> 00:22:38,900
and increased self efficacy
and increased self awareness.

447
00:22:38,900 --> 00:22:43,333
We've been asked many
times, when we think

448
00:22:43,333 --> 00:22:44,834
about the staggering rates

449
00:22:44,834 --> 00:22:47,367
of suicidal behavior
now among pre teens,

450
00:22:47,367 --> 00:22:51,734
and even the behavior
occurring with children

451
00:22:51,734 --> 00:22:54,133
about the relevance
of this curriculum

452
00:22:54,133 --> 00:22:55,734
with younger age groups.

453
00:22:55,734 --> 00:22:58,867
So, in this effort,
we conducted a number

454
00:22:58,867 --> 00:23:03,900
of classroom observations
and had interventionists

455
00:23:03,900 --> 00:23:07,100
that are experienced in child
trauma focused care look

456
00:23:07,100 --> 00:23:10,000
at the curriculum, and
we decided that we needed

457
00:23:10,000 --> 00:23:11,667
to develop a simpler version.

458
00:23:11,667 --> 00:23:13,533
So, we do have two
versions going.

459
00:23:13,533 --> 00:23:17,000
But the middle school version
focused on the kinds of problems

460
00:23:17,000 --> 00:23:19,600
that are more appropriate
at early adolescence.

461
00:23:19,600 --> 00:23:23,133
It simplified the language,
simplified the model,

462
00:23:23,133 --> 00:23:27,667
and was reduced down to
just 30, 35 minute lessons.

463
00:23:27,667 --> 00:23:30,233
There's only one evaluation
of the middle school version,

464
00:23:30,233 --> 00:23:32,133
and hopefully someday
we'll do another.

465
00:23:32,133 --> 00:23:35,300
But in this particular
evaluation, we were able

466
00:23:35,300 --> 00:23:39,100
to go back to the Zuni
Pueblo some 20 years later

467
00:23:39,100 --> 00:23:43,100
and evaluate the
middle school version.

468
00:23:43,100 --> 00:23:46,433
We were only able to
give the curriculum

469
00:23:46,433 --> 00:23:48,233
over a six week period of time.

470
00:23:48,233 --> 00:23:51,800
So, it was heavy dosage
every single day, 30 lessons,

471
00:23:51,800 --> 00:23:54,266
and the post test was conducted

472
00:23:54,266 --> 00:23:56,200
at the very end of
the curriculum.

473
00:23:56,200 --> 00:24:00,700
And we did see that there was
a difference between the pre

474
00:24:00,700 --> 00:24:05,100
and post test with
the intervention group

475
00:24:05,100 --> 00:24:07,166
in which there were
increases in self efficacy

476
00:24:07,166 --> 00:24:12,233
to manage depression, efficacy
to manage coping with stress,

477
00:24:12,233 --> 00:24:15,500
efficacy to enlist community
support, and efficacy

478
00:24:15,500 --> 00:24:18,633
to enlist social resources.

479
00:24:18,633 --> 00:24:22,800
In conclusion, I guess what
I would want you to think

480
00:24:22,800 --> 00:24:25,367
about in this presentation is
the fact that unfortunately,

481
00:24:25,367 --> 00:24:29,467
schools are often overlooked as
sites for suicide prevention.

482
00:24:29,467 --> 00:24:32,800
The emphasis, of course, is in,
you know, healthcare settings,

483
00:24:32,800 --> 00:24:34,600
maybe correctional settings,

484
00:24:34,600 --> 00:24:40,300
and emergency rooms,
health facilities.

485
00:24:40,300 --> 00:24:43,533
But we've seen that school based
suicide prevention has shown

486
00:24:43,533 --> 00:24:46,033
many positive outcomes
with American Indian

487
00:24:46,033 --> 00:24:48,033
and Alaska Natives,
and also students

488
00:24:48,033 --> 00:24:52,033
across the country
in Aurora settings.

489
00:24:52,033 --> 00:24:54,533
American Indian and Alaska
Native youth have benefited

490
00:24:54,533 --> 00:24:56,266
from school based
suicide preventions.

491
00:24:56,266 --> 00:24:58,066
Hopefully you see that
from what I've shared,

492
00:24:58,066 --> 00:25:00,066
at least in these small studies.

493
00:25:00,066 --> 00:25:03,100
And I think that what I want
to say is that, you know,

494
00:25:03,100 --> 00:25:05,934
and the trend now is to
two generation studies.

495
00:25:05,934 --> 00:25:10,734
And approaches to include
families in this work.

496
00:25:10,734 --> 00:25:13,100
And to do major community
wide change

497
00:25:13,100 --> 00:25:15,567
in suicide prevention
is certainly increasing,

498
00:25:15,567 --> 00:25:17,333
but it's under study.

499
00:25:17,333 --> 00:25:18,500
Thank you.

500
00:25:18,500 --> 00:25:27,500
[ Applause ]

501
00:25:31,000 --> 00:25:32,333
>> [ Foreign Language Spoken ]

502
00:25:32,333 --> 00:25:35,567
I'm Spero Manson.

503
00:25:35,567 --> 00:25:37,667
I'm on faculty at the University

504
00:25:37,667 --> 00:25:41,200
of Colorado Anschutz
Medical Campus in Aurora

505
00:25:41,200 --> 00:25:43,934
where I direct the
Centers for American Indian

506
00:25:43,934 --> 00:25:47,767
and Alaska Native Health.

507
00:25:47,767 --> 00:25:51,934
My remarks today will cover
five particular points.

508
00:25:51,934 --> 00:25:57,000
First, I will be emphasizing
the conspiracy of silence

509
00:25:57,000 --> 00:26:00,700
that surrounds suicide and the
discourse that characterizes

510
00:26:00,700 --> 00:26:03,000
that subject in native
communities

511
00:26:03,000 --> 00:26:05,266
and the consequences thereof.

512
00:26:05,266 --> 00:26:07,200
Secondly, I'll point
out the importance

513
00:26:07,200 --> 00:26:10,700
of primary care setting, as Dr.
LaFromboise did with respect

514
00:26:10,700 --> 00:26:16,033
to the schools as a unique
and timely opportunity for us

515
00:26:16,033 --> 00:26:18,367
to intervene, especially
in the context

516
00:26:18,367 --> 00:26:21,133
of tribal healthcare systems
in native communities.

517
00:26:21,133 --> 00:26:25,200
Thirdly, I'll identify a
particular evidence based

518
00:26:25,200 --> 00:26:29,033
practice that has a well
founded history with respect

519
00:26:29,033 --> 00:26:31,667
to the detection and management
of a series of problems

520
00:26:31,667 --> 00:26:35,367
in primary care that will
serve us well with respect

521
00:26:35,367 --> 00:26:37,934
to intervening around
suicide risk.

522
00:26:37,934 --> 00:26:41,767
Four, I will illustrate
three exemplar programs

523
00:26:41,767 --> 00:26:45,500
across Indian country that have
established this particular

524
00:26:45,500 --> 00:26:47,500
initiative with respect
to detecting

525
00:26:47,500 --> 00:26:50,934
and managing behavioral health
problem, suicide among them,

526
00:26:50,934 --> 00:26:54,367
among their patient populations
to illustrate that, in fact,

527
00:26:54,367 --> 00:26:58,300
such translations were
possible, indeed, desirable.

528
00:26:58,300 --> 00:27:00,734
And lastly, I'll
end with a series

529
00:27:00,734 --> 00:27:03,734
of points regarding the
challenges and opportunities

530
00:27:03,734 --> 00:27:06,233
that face us in the
continued extension

531
00:27:06,233 --> 00:27:09,834
of this evidence based
practice into such settings

532
00:27:09,834 --> 00:27:12,567
as they relate to both improving
the health of patients,

533
00:27:12,567 --> 00:27:15,100
as well as enhancing
the power of the systems

534
00:27:15,100 --> 00:27:18,200
that are available
to deliver that care.

535
00:27:18,200 --> 00:27:22,333
So, let's begin then with
stigma and the nature of stigma.

536
00:27:22,333 --> 00:27:25,900
You know quite well here at CDC,
the power of stigma in terms

537
00:27:25,900 --> 00:27:28,166
of closing down the
kinds of conversations

538
00:27:28,166 --> 00:27:34,100
that are absolutely essential
to the discourse with respect

539
00:27:34,100 --> 00:27:38,367
to suicide and other kinds
of conditions of this nature

540
00:27:38,367 --> 00:27:44,000
that contribute so much to
the challenges that we face.

541
00:27:44,000 --> 00:27:48,333
In 1999, we concluded
the largest psychiatric

542
00:27:48,333 --> 00:27:50,900
epidemiologic study in
American Indian communities

543
00:27:50,900 --> 00:27:52,200
in the country.

544
00:27:52,200 --> 00:27:55,800
And in this particular study,
we asked the study participants,

545
00:27:55,800 --> 00:27:58,667
over 3,000 of them, from three

546
00:27:58,667 --> 00:28:01,333
of the largest reservation
based tribal communities

547
00:28:01,333 --> 00:28:04,333
in the country about
their perceptions

548
00:28:04,333 --> 00:28:06,633
of the relative stigma
surrounding a series

549
00:28:06,633 --> 00:28:07,467
of conditions.

550
00:28:07,467 --> 00:28:10,367
And this particular study
underscored the fact

551
00:28:10,367 --> 00:28:15,734
that attempted suicide ranked
only behind HIV AIDS in terms

552
00:28:15,734 --> 00:28:18,033
of the power of stigma
surrounding it

553
00:28:18,033 --> 00:28:19,700
and the consequences thereof.

554
00:28:19,700 --> 00:28:23,233
Now, in primary care
settings, you know, of course,

555
00:28:23,233 --> 00:28:25,900
I don't see anybody wearing a
white coat here in the audience,

556
00:28:25,900 --> 00:28:28,633
but you know the power of
the white coat in terms

557
00:28:28,633 --> 00:28:30,500
of the patient provided
relationship.

558
00:28:30,500 --> 00:28:35,000
And what the power of that
relationship does to encouraging

559
00:28:35,000 --> 00:28:38,166
in a nurturing and
supporting manner conversations

560
00:28:38,166 --> 00:28:40,900
that are otherwise
very difficult to have.

561
00:28:40,900 --> 00:28:43,400
And so given the nature
of delivery systems

562
00:28:43,400 --> 00:28:45,734
in Indian country, which
are, for the most part,

563
00:28:45,734 --> 00:28:48,233
akin to health maintenance
organizations in terms

564
00:28:48,233 --> 00:28:51,600
of the universal availability
of that care and reducing,

565
00:28:51,600 --> 00:28:55,700
in many instances, the cost
and other types of barriers,

566
00:28:55,700 --> 00:29:01,667
it makes a relatively
potent opportunity

567
00:29:01,667 --> 00:29:05,333
for such intervention.

568
00:29:05,333 --> 00:29:08,800
Since nearly 20 years ago
began to fund a series

569
00:29:08,800 --> 00:29:11,200
of initiatives focusing on
detection and management

570
00:29:11,200 --> 00:29:13,333
of behavioral health
problems in primary care,

571
00:29:13,333 --> 00:29:16,533
that evidence based practice
eventually became known

572
00:29:16,533 --> 00:29:18,467
as screening brief
intervention and referral

573
00:29:18,467 --> 00:29:21,667
for treatment, S B I R T, SBIRT.

574
00:29:21,667 --> 00:29:24,934
SBIRT is essentially a two step
process in which an individual

575
00:29:24,934 --> 00:29:27,300
in the detection phase
is identified at risk

576
00:29:27,300 --> 00:29:28,633
for the conditions concerned.

577
00:29:28,633 --> 00:29:30,734
In this particular
case, suicide.

578
00:29:30,734 --> 00:29:35,800
And then in the second step
is counselled with respect

579
00:29:35,800 --> 00:29:38,800
to a series of behavioral
strategies that are designed

580
00:29:38,800 --> 00:29:42,834
to reduce that risk, as
well as refer the individual

581
00:29:42,834 --> 00:29:46,834
to the necessary services that
might assist them in dealing

582
00:29:46,834 --> 00:29:48,600
with and coping with that risk.

583
00:29:48,600 --> 00:29:52,734
Indeed, it was in 2012 in
the Surgeon General's report,

584
00:29:52,734 --> 00:29:55,667
on the national strategy for
suicide prevention and goals

585
00:29:55,667 --> 00:29:59,700
and objectives that SBIRT
was identified as a robust

586
00:29:59,700 --> 00:30:01,934
and potentially powerful
intervention

587
00:30:01,934 --> 00:30:05,300
that might be extended
beyond the prevention

588
00:30:05,300 --> 00:30:08,767
of substance abuse and
alcoholism to suicide.

589
00:30:08,767 --> 00:30:14,900
Now, as I've noted, suicide,
stigmatizing conditions,

590
00:30:14,900 --> 00:30:17,834
such as suicide, are more
rarely discussed in these kinds

591
00:30:17,834 --> 00:30:19,767
of primary care settings.

592
00:30:19,767 --> 00:30:22,800
Especially when it's done
in a non judgmental fashion.

593
00:30:22,800 --> 00:30:26,433
And, as a part of this
particular intervention,

594
00:30:26,433 --> 00:30:29,500
typically one co locates a
behavioral health consultant,

595
00:30:29,500 --> 00:30:31,266
again, consultant,
not clinician,

596
00:30:31,266 --> 00:30:34,266
meant to underscore the
destigmatizing nature

597
00:30:34,266 --> 00:30:37,300
of this particular feature
of the intervention,

598
00:30:37,300 --> 00:30:41,633
and is assigned to the primary
care team to work hand and glove

599
00:30:41,633 --> 00:30:44,967
with the various primary
care providers there.

600
00:30:44,967 --> 00:30:47,867
What this does is it, although
it recognizes on the part

601
00:30:47,867 --> 00:30:50,467
of the primary care provider
the risk that the individual is

602
00:30:50,467 --> 00:30:54,066
at with respect to suicide, it
relives him or her of the burden

603
00:30:54,066 --> 00:30:57,400
of having to intervene
immediately and allows

604
00:30:57,400 --> 00:31:02,600
for a more pointed and extensive
follow up with that individual.

605
00:31:02,600 --> 00:31:05,633
It provides more time.

606
00:31:05,633 --> 00:31:07,433
You needn't tell an
audience like this

607
00:31:07,433 --> 00:31:11,467
about how little time there is
presently available to providers

608
00:31:11,467 --> 00:31:14,400
and the process of care
during clinical encounters.

609
00:31:14,400 --> 00:31:17,533
It's an opportunity to
raise patients' awareness

610
00:31:17,533 --> 00:31:19,834
about suicide as a
plausible concern.

611
00:31:19,834 --> 00:31:22,633
One of the major challenges
is initially the recognition

612
00:31:22,633 --> 00:31:23,300
in that regard.

613
00:31:23,300 --> 00:31:26,300
It's an opportunity to enhance
their readiness to change

614
00:31:26,300 --> 00:31:27,700
through motivational
interviewing.

615
00:31:27,700 --> 00:31:31,133
It enables the development
of a patient contract

616
00:31:31,133 --> 00:31:34,633
between provider and
patient about the next steps

617
00:31:34,633 --> 00:31:36,633
in this process of change.

618
00:31:36,633 --> 00:31:41,166
And it provides a very explicit
structure for specific actions

619
00:31:41,166 --> 00:31:44,767
that can be taken in follow up
through referral and other forms

620
00:31:44,767 --> 00:31:47,734
of intervention in
addressing those concerns.

621
00:31:47,734 --> 00:31:51,166
And our experience is
that these elements

622
00:31:51,166 --> 00:31:54,133
of the SBIRT intervention
are readily adaptable,

623
00:31:54,133 --> 00:31:56,734
both at the patient
organizational cultures

624
00:31:56,734 --> 00:31:57,867
in which we worked.

625
00:31:57,867 --> 00:32:01,934
I want to briefly identify
three specific examples

626
00:32:01,934 --> 00:32:03,600
and call them to your attention.

627
00:32:03,600 --> 00:32:05,867
We've published about
them extensively.

628
00:32:05,867 --> 00:32:07,033
They're well represented
in the literature.

629
00:32:07,033 --> 00:32:09,934
I won't go into the greater
details, but encourage you

630
00:32:09,934 --> 00:32:11,700
to look at those publications.

631
00:32:11,700 --> 00:32:15,133
I think a series of
citations were provided.

632
00:32:15,133 --> 00:32:17,066
The first is located

633
00:32:17,066 --> 00:32:20,233
on the Alaska Native Medical
Center in Anchorage, Alaska.

634
00:32:20,233 --> 00:32:24,867
It's the medical home for
over 65,000 Alaska Natives

635
00:32:24,867 --> 00:32:27,800
and American Indians living
in South Central Alaska

636
00:32:27,800 --> 00:32:32,333
in which those primary care
teams now have co located one

637
00:32:32,333 --> 00:32:33,667
behavioral health consultant,

638
00:32:33,667 --> 00:32:36,400
typically a master's level
clinician who is attached

639
00:32:36,400 --> 00:32:40,233
to each primary care
provider team.

640
00:32:40,233 --> 00:32:42,567
They use the classic
initial screening

641
00:32:42,567 --> 00:32:44,700
as an opportunity to detect.

642
00:32:44,700 --> 00:32:48,066
And then once detected, they
call that to the attention

643
00:32:48,066 --> 00:32:50,600
of the primary care
provider, who then activated

644
00:32:50,600 --> 00:32:52,834
and mobilizes the
behavioral health consultant

645
00:32:52,834 --> 00:32:55,000
to follow up as appropriate.

646
00:32:55,000 --> 00:32:58,100
Since 2001, my colleagues there

647
00:32:58,100 --> 00:33:01,433
and I have screened nearly
58,000 unique patients.

648
00:33:01,433 --> 00:33:04,500
I think the particularly telling
point here is that, in fact,

649
00:33:04,500 --> 00:33:07,500
not only were a substantial
number of them deemed to be

650
00:33:07,500 --> 00:33:10,266
at risk for behavioral health
problems, including suicide,

651
00:33:10,266 --> 00:33:13,667
but we were able to successfully
triage them to different levels

652
00:33:13,667 --> 00:33:17,934
of care that enabled them
to address that risk.

653
00:33:17,934 --> 00:33:21,467
And, indeed, this initiative was
so successful after three years

654
00:33:21,467 --> 00:33:24,133
that the State of Alaska
revised its CBT codes

655
00:33:24,133 --> 00:33:27,734
so that this SBIRT intervention
is now fully sustained

656
00:33:27,734 --> 00:33:28,734
by the stable asked.

657
00:33:28,734 --> 00:33:31,266
It's Medicaid reimbursement.

658
00:33:31,266 --> 00:33:35,400
Second example is also located
in Alaska, in Fairbanks,

659
00:33:35,400 --> 00:33:37,633
in the Chief Andrew
Isaac Health Center,

660
00:33:37,633 --> 00:33:39,066
the Tanana Chiefs Conference.

661
00:33:39,066 --> 00:33:42,533
Now we move into the interior of
Alaska, which is a medical home

662
00:33:42,533 --> 00:33:46,333
for nearly 15,000 Alaska Natives
and American Indians living in

663
00:33:46,333 --> 00:33:49,934
and around the confluence of
the Yukon and Tanana Rivers,

664
00:33:49,934 --> 00:33:52,667
where our series, again,
primary care team is there

665
00:33:52,667 --> 00:33:55,734
who have co located a
behavioral health consultant.

666
00:33:55,734 --> 00:33:59,467
They employ the very same
kind of two step detection

667
00:33:59,467 --> 00:34:02,500
and management process as does
the South Central Foundation.

668
00:34:02,500 --> 00:34:06,967
And since 2012, we screened
11,000 unique patients there.

669
00:34:06,967 --> 00:34:11,033
Again, 26% of them were
deemed at risk and followed

670
00:34:11,033 --> 00:34:13,467
up with appropriate referral.

671
00:34:13,467 --> 00:34:16,467
And it is now also
sustained by stable ask

672
00:34:16,467 --> 00:34:19,300
and medication, Medicaid
funding.

673
00:34:19,300 --> 00:34:24,266
The third example moves us out
of Alaska into the Southwest

674
00:34:24,266 --> 00:34:28,000
and out of the rural context
into the urban context.

675
00:34:28,000 --> 00:34:30,900
And specifically, the First
Nations Community HealthSource

676
00:34:30,900 --> 00:34:33,600
in Albuquerque, New Mexico is
the country's largest Urban

677
00:34:33,600 --> 00:34:35,166
Indian health program.

678
00:34:35,166 --> 00:34:37,567
And you can see here that
the distinct features

679
00:34:37,567 --> 00:34:40,200
of this very large Urban
Indian health program,

680
00:34:40,200 --> 00:34:42,333
they too use this
two step process.

681
00:34:42,333 --> 00:34:46,200
Since 2011, they've screened
over 4,000 unique patients,

682
00:34:46,200 --> 00:34:48,767
and have been certified and are
now a full partner in the State

683
00:34:48,767 --> 00:34:50,867
of New Mexico as
SBIRT initiative,

684
00:34:50,867 --> 00:34:53,800
which funds their entire effort.

685
00:34:53,800 --> 00:34:56,266
We face a series of challenges
and opportunities, though,

686
00:34:56,266 --> 00:34:58,734
as we think about extending
this particular intervention

687
00:34:58,734 --> 00:35:01,834
to other settings in Indian
and Native communities.

688
00:35:01,834 --> 00:35:05,233
The challenges have to do with
engaging eligible patients,

689
00:35:05,233 --> 00:35:07,133
realizing the stigma
surrounding that,

690
00:35:07,133 --> 00:35:09,000
and ensuring their
confidentiality,

691
00:35:09,000 --> 00:35:12,567
maintaining the fidelity
of how SBIRT is implemented

692
00:35:12,567 --> 00:35:15,734
within the clinical workflow,
and in the face of the multitude

693
00:35:15,734 --> 00:35:17,367
of demands that providers
experience.

694
00:35:17,367 --> 00:35:20,800
And lastly, ensuring patient
transition through the process

695
00:35:20,800 --> 00:35:23,066
of care and maximizing
their retention.

696
00:35:23,066 --> 00:35:25,433
Ultimately, with respect
to the system of care,

697
00:35:25,433 --> 00:35:27,834
we face the challenge of
documenting these services

698
00:35:27,834 --> 00:35:30,900
and linking them to the external
resources beyond the program.

699
00:35:30,900 --> 00:35:32,900
Each of the three
examples that I've shared

700
00:35:32,900 --> 00:35:35,467
with you today refer
the individuals not only

701
00:35:35,467 --> 00:35:36,900
to biomedical resources,

702
00:35:36,900 --> 00:35:39,400
but also to traditional
healing resources that exist

703
00:35:39,400 --> 00:35:41,233
within their particular
programs,

704
00:35:41,233 --> 00:35:43,033
as well as the ecology outside.

705
00:35:43,033 --> 00:35:47,166
Next, the systems issue is
how to marry an intervention

706
00:35:47,166 --> 00:35:50,033
such as SBIRT with other kinds
of intervention approaches

707
00:35:50,033 --> 00:35:53,033
to maximize the prevention
gains, and ultimately

708
00:35:53,033 --> 00:35:58,166
to acquire rigorous evaluation
data that we can use to document

709
00:35:58,166 --> 00:36:01,400
and support program
and policy advocacy.

710
00:36:01,400 --> 00:36:03,533
So, I think it's
a bright example

711
00:36:03,533 --> 00:36:06,233
of how we can translate
an evidence based practice

712
00:36:06,233 --> 00:36:09,600
into these settings with
good benefit to patients,

713
00:36:09,600 --> 00:36:11,367
providers, and programs.

714
00:36:11,367 --> 00:36:12,000
Thank you.

715
00:36:12,000 --> 00:36:13,033
[ Applause ]

716
00:36:13,033 --> 00:36:18,800
Our next, our next speaker
is Mr. Michael Flynn,

717
00:36:18,800 --> 00:36:22,667
Coordinator of the Occupational
Health Equity Program at NIOSH.

718
00:36:22,667 --> 00:36:23,967
Michael?

719
00:36:26,300 --> 00:36:27,433
>> Good afternoon.

720
00:36:27,433 --> 00:36:29,433
Thank you all for coming,
and thanks to the Office

721
00:36:29,433 --> 00:36:31,100
of Minority Health
and Health Equity

722
00:36:31,100 --> 00:36:34,000
for inviting me to speak today.

723
00:36:34,000 --> 00:36:36,900
I'll be providing an
occupational health perspective

724
00:36:36,900 --> 00:36:40,066
on suicide among American
Indian and Alaska Native youth,

725
00:36:40,066 --> 00:36:42,233
and will discuss
the role of work

726
00:36:42,233 --> 00:36:44,567
in improving population
health outcomes,

727
00:36:44,567 --> 00:36:46,233
including preventing suicide.

728
00:36:46,233 --> 00:36:50,066
As evidenced by the Surgeon
General's call to action

729
00:36:50,066 --> 00:36:52,233
on community health
and prosperity,

730
00:36:52,233 --> 00:36:54,033
there's growing recognition
of the need

731
00:36:54,033 --> 00:36:56,700
for public health
professionals to be conversant

732
00:36:56,700 --> 00:37:00,834
in the relationship between
economic development and health.

733
00:37:00,834 --> 00:37:03,900
Given the elevated rates of
unemployment and underemployment

734
00:37:03,900 --> 00:37:06,734
in American Indian and
Alaska Native communities,

735
00:37:06,734 --> 00:37:10,900
which can reach up to 95% in
some areas, improving access

736
00:37:10,900 --> 00:37:13,033
to good jobs is an
essential piece

737
00:37:13,033 --> 00:37:15,000
to any comprehensive strategy

738
00:37:15,000 --> 00:37:18,400
for reducing suicide
in these communities.

739
00:37:21,633 --> 00:37:24,667
Increased poverty
has been associated

740
00:37:24,667 --> 00:37:26,734
with higher suicide
rates in American Indian

741
00:37:26,734 --> 00:37:28,467
and Alaska Native communities.

742
00:37:28,467 --> 00:37:31,834
A recent study recorded
significant decreases

743
00:37:31,834 --> 00:37:34,233
in psychiatric symptoms
among a sample

744
00:37:34,233 --> 00:37:36,667
of Eastern Band Cherokee
children aged 9

745
00:37:36,667 --> 00:37:39,834
to 13 whose families
had moved out of poverty

746
00:37:39,834 --> 00:37:43,633
after a casino was opened
on the local reservation.

747
00:37:43,633 --> 00:37:45,967
Data analysis from the
behavioral risk factor

748
00:37:45,967 --> 00:37:47,834
surveillance system found

749
00:37:47,834 --> 00:37:50,667
that unemployed emerging
adults aged 18

750
00:37:50,667 --> 00:37:55,133
to 25 had three times greater
odds of reporting depression

751
00:37:55,133 --> 00:37:58,233
than their counterparts
who were employed.

752
00:37:59,333 --> 00:38:01,734
This is particularly the
[inaudible] given the extremely

753
00:38:01,734 --> 00:38:05,333
limited economic opportunities
for American Indian

754
00:38:05,333 --> 00:38:07,533
and Alaska Native
emerging adults,

755
00:38:07,533 --> 00:38:10,000
especially in rural areas.

756
00:38:10,000 --> 00:38:12,533
While these examples suggest
that economic development

757
00:38:12,533 --> 00:38:15,333
and access to good jobs
is an important piece

758
00:38:15,333 --> 00:38:18,700
of suicide prevention
strategies, formative research

759
00:38:18,700 --> 00:38:21,734
on work life balance among
American Indian women

760
00:38:21,734 --> 00:38:24,300
in the Southwest
and Upper Midwest,

761
00:38:24,300 --> 00:38:27,834
reminds us that the
definition of good job may vary

762
00:38:27,834 --> 00:38:30,533
by socioeconomic context.

763
00:38:30,533 --> 00:38:33,400
Many of these women reported
additional stresses from having

764
00:38:33,400 --> 00:38:36,367
to balance their traditional
roles as caregivers

765
00:38:36,367 --> 00:38:39,767
with their new responsibilities
on their job.

766
00:38:39,767 --> 00:38:42,734
As you can see by the solid
yellow line, unemployment rates

767
00:38:42,734 --> 00:38:45,633
for American Indian and
Alaska Native youth are high.

768
00:38:45,633 --> 00:38:47,800
And rates remain higher
throughout their lives

769
00:38:47,800 --> 00:38:50,300
than for any other
racial or ethnic group.

770
00:38:50,300 --> 00:38:53,433
Conversely, the purple line
shows unemployment rates

771
00:38:53,433 --> 00:38:56,633
for non Hispanic whites,
and is highest for youth.

772
00:38:56,633 --> 00:38:59,900
However, suicide rates for this
group are highest among middle

773
00:38:59,900 --> 00:39:01,100
aged individuals.

774
00:39:01,100 --> 00:39:03,734
While we know that economic
stability is protected

775
00:39:03,734 --> 00:39:06,700
for suicide, we do not have
a nuanced understanding

776
00:39:06,700 --> 00:39:09,233
of the relationship
between work and suicide

777
00:39:09,233 --> 00:39:11,567
across racial and ethnic groups.

778
00:39:11,567 --> 00:39:14,667
The variation and patterns of
unemployment and suicide rates

779
00:39:14,667 --> 00:39:16,700
by race, ethnicity and age,

780
00:39:16,700 --> 00:39:18,600
suggest that more
research is needed

781
00:39:18,600 --> 00:39:20,900
to better understand the
relationship between work

782
00:39:20,900 --> 00:39:23,500
and suicide across these groups.

783
00:39:23,500 --> 00:39:29,967
What has long been recognized
by socio ecological models is

784
00:39:29,967 --> 00:39:33,834
that the influence of job,
or lack thereof, on health,

785
00:39:33,834 --> 00:39:37,934
goes beyond physical, emotional
and social conditions at work.

786
00:39:37,934 --> 00:39:40,800
Indeed, one's job or career
exerts significant influence

787
00:39:40,800 --> 00:39:44,567
over other aspects of life
that contribute or detract

788
00:39:44,567 --> 00:39:47,367
from an individual's health
and that of their families,

789
00:39:47,367 --> 00:39:51,867
such as income, social status,
housing, access to healthcare,

790
00:39:51,867 --> 00:39:53,867
and free time to socialize.

791
00:39:53,867 --> 00:39:57,133
As a result, work is seen
as a principle mechanism

792
00:39:57,133 --> 00:40:00,367
for securing the needs to
adjust health and equities.

793
00:40:00,367 --> 00:40:03,066
However, despite
conceptual acknowledgement

794
00:40:03,066 --> 00:40:06,233
that work influences health
through numerous pathways,

795
00:40:06,233 --> 00:40:08,867
it remains largely absent
from examinations of health

796
00:40:08,867 --> 00:40:14,033
and equities in the
United States.

797
00:40:14,033 --> 00:40:17,400
Despite common historical roots
in social approaches to health,

798
00:40:17,400 --> 00:40:18,967
occupational health and the rest

799
00:40:18,967 --> 00:40:23,266
of public health has largely
developed on parallel tracks.

800
00:40:23,266 --> 00:40:26,667
Today, the classification of
work, non work related exposures

801
00:40:26,667 --> 00:40:30,133
and outcomes often separates
occupational health research

802
00:40:30,133 --> 00:40:32,533
and practice from the
rest of public health.

803
00:40:32,533 --> 00:40:36,533
As a result, work related
variables are largely absent

804
00:40:36,533 --> 00:40:38,900
from health equity
research, and the domain

805
00:40:38,900 --> 00:40:42,667
of work is underrepresented
in public health practice.

806
00:40:42,667 --> 00:40:45,000
This current approach
works well for identifying

807
00:40:45,000 --> 00:40:47,300
and controlling workplace
hazards, like exposures

808
00:40:47,300 --> 00:40:49,767
to asbestos, for example.

809
00:40:49,767 --> 00:40:52,734
However, it has limited our
understanding on how work

810
00:40:52,734 --> 00:40:56,367
or unemployment impacts
overall health

811
00:40:56,367 --> 00:40:59,400
in the inequitable
distribution of health outcomes.

812
00:40:59,400 --> 00:41:02,033
For example, how might
chronic unemployment contribute

813
00:41:02,033 --> 00:41:05,233
to the distribution of heart
disease, substance abuse,

814
00:41:05,233 --> 00:41:09,233
or suicide among different
racial and ethnic groups?

815
00:41:11,533 --> 00:41:14,333
Since Durkheim's seminal
study over 100 years ago,

816
00:41:14,333 --> 00:41:16,300
the potential relationship
between work

817
00:41:16,300 --> 00:41:19,000
and suicide has been
acknowledged.

818
00:41:19,000 --> 00:41:21,400
But research on this
relationship is limited,

819
00:41:21,400 --> 00:41:25,600
especially among American Indian
and Alaska Native communities.

820
00:41:25,600 --> 00:41:27,567
Research on work and
suicide has tended

821
00:41:27,567 --> 00:41:30,367
to has traditionally
focused on three main areas;

822
00:41:30,367 --> 00:41:32,467
suicide that occurs
at the workplace,

823
00:41:32,467 --> 00:41:36,166
which often explores access
to lethal means at work,

824
00:41:36,166 --> 00:41:37,867
rates of suicide by occupation,

825
00:41:37,867 --> 00:41:39,567
which often explores
characteristics

826
00:41:39,567 --> 00:41:41,734
of different occupations
that might contribute

827
00:41:41,734 --> 00:41:44,600
to elevated rates,
and the relationship

828
00:41:44,600 --> 00:41:46,767
between unemployment
and suicide,

829
00:41:46,767 --> 00:41:47,800
which may be the most relevant

830
00:41:47,800 --> 00:41:50,667
to this presentation given
the high unemployment rates

831
00:41:50,667 --> 00:41:52,667
in these communities.

832
00:41:54,033 --> 00:41:59,300
However, simply increasing the
number of jobs is not enough.

833
00:41:59,300 --> 00:42:02,300
Increasing reliance on
temporary employment agencies

834
00:42:02,300 --> 00:42:05,200
and other contingent
employment arrangements has led

835
00:42:05,200 --> 00:42:09,233
to growing recognition that
not all jobs are created equal.

836
00:42:09,233 --> 00:42:12,467
Estimates suggest that nearly
one in five U.S. workers are

837
00:42:12,467 --> 00:42:15,333
in non standard job
arrangements.

838
00:42:15,333 --> 00:42:18,700
Rates are even higher for racial
and ethnic minority populations

839
00:42:18,700 --> 00:42:20,567
who are often concentrated

840
00:42:20,567 --> 00:42:22,934
in the most exploitative
contingent jobs.

841
00:42:22,934 --> 00:42:26,100
As Alex mentioned
earlier, job quality,

842
00:42:26,100 --> 00:42:29,500
or how jobs are structured,
is an important variable

843
00:42:29,500 --> 00:42:31,000
in understanding
the relationship

844
00:42:31,000 --> 00:42:33,233
between work and suicide.

845
00:42:33,233 --> 00:42:36,700
Recent research suggests that
a lack of supervisor support

846
00:42:36,700 --> 00:42:40,767
and job insecurity are
linked to suicidality.

847
00:42:40,767 --> 00:42:44,367
Therefore, in addition to job
availability, it is important

848
00:42:44,367 --> 00:42:48,266
to consider factors such as
job stability, compensation,

849
00:42:48,266 --> 00:42:51,100
and social support when
evaluating the relationship

850
00:42:51,100 --> 00:42:53,600
between suicide and work.

851
00:42:55,734 --> 00:42:58,133
Like schools, the
workplace offers a venue

852
00:42:58,133 --> 00:43:01,567
for broad prevention and
population health interventions.

853
00:43:01,567 --> 00:43:04,133
Under the mental health model,
the workplace can be used

854
00:43:04,133 --> 00:43:07,000
to train employees to recognize
the warning signs and risks

855
00:43:07,000 --> 00:43:10,834
for suicide and provide them
with access to resources,

856
00:43:10,834 --> 00:43:13,633
particularly in high
risk occupations.

857
00:43:13,633 --> 00:43:16,900
Interventions can also be
implemented to reduce access

858
00:43:16,900 --> 00:43:18,233
to lethal means at work.

859
00:43:18,233 --> 00:43:22,967
Under the public health
model, increasing the number

860
00:43:22,967 --> 00:43:25,433
and quality of jobs
that can serve as a,

861
00:43:25,433 --> 00:43:27,700
can serve as a prevention
strategy,

862
00:43:27,700 --> 00:43:30,934
by increasing economic
security, self esteem,

863
00:43:30,934 --> 00:43:33,066
and social connectedness.

864
00:43:33,066 --> 00:43:35,000
This is easier said than done,

865
00:43:35,000 --> 00:43:38,433
as public health professionals
generally don't control

866
00:43:38,433 --> 00:43:41,734
or engage with local
development projects.

867
00:43:41,734 --> 00:43:44,600
However, seeing work
as a social determinant

868
00:43:44,600 --> 00:43:48,734
of health provides public health
officials a lens through which

869
00:43:48,734 --> 00:43:52,166
to evaluate development
projects, the jobs they propose

870
00:43:52,166 --> 00:43:54,400
to create, and their
potential impact

871
00:43:54,400 --> 00:43:56,467
on the community's health.

872
00:43:56,467 --> 00:43:59,567
Jobs are a shared concern
among public health officials

873
00:43:59,567 --> 00:44:02,166
and other stakeholders,
such as tribal governments

874
00:44:02,166 --> 00:44:05,133
and tribal employment
rights organizations

875
00:44:05,133 --> 00:44:08,433
who can often influence
either through negotiation,

876
00:44:08,433 --> 00:44:12,266
legislation, or regulation,
how jobs are structured

877
00:44:12,266 --> 00:44:15,900
so that they better contribute
to the health of the community.

878
00:44:17,867 --> 00:44:21,033
Improving while understanding
of the relationship between work

879
00:44:21,033 --> 00:44:22,467
and suicide in American Indian

880
00:44:22,467 --> 00:44:25,533
and Alaska Native communities
will require better data

881
00:44:25,533 --> 00:44:29,500
on work related variables
by public health researchers

882
00:44:29,500 --> 00:44:32,500
and better collection of data
related to race and ethnicity

883
00:44:32,500 --> 00:44:35,233
by occupational health
researchers.

884
00:44:35,233 --> 00:44:38,233
For example, the National
Academies Consensus Report

885
00:44:38,233 --> 00:44:40,900
on Occupational Health
Surveillance recommends

886
00:44:40,900 --> 00:44:44,000
that all HHS surveys
begin to collect data

887
00:44:44,000 --> 00:44:46,700
on industry and occupation.

888
00:44:46,700 --> 00:44:49,567
Improving access to
good jobs can form part

889
00:44:49,567 --> 00:44:52,033
of a moral holistic
suicide prevention efforts

890
00:44:52,033 --> 00:44:54,934
for American Indian and
Alaska Native youth.

891
00:44:54,934 --> 00:44:56,867
There should be greater
recognition of work

892
00:44:56,867 --> 00:45:00,700
as an intervention site to
improve the access to resources

893
00:45:00,700 --> 00:45:03,367
and improve other social
determinants of health,

894
00:45:03,367 --> 00:45:07,934
like income, housing,
and social connectedness.

895
00:45:07,934 --> 00:45:10,900
Work can be understood as a
primary vehicle for responding

896
00:45:10,900 --> 00:45:12,633
to the Surgeon General's
call to action

897
00:45:12,633 --> 00:45:15,367
on community health
and prosperity.

898
00:45:15,367 --> 00:45:19,100
Discussions of job quality,
not just job quantity,

899
00:45:19,100 --> 00:45:21,633
could help public health
professionals engage more

900
00:45:21,633 --> 00:45:25,700
established initiatives on
such a sustainable development

901
00:45:25,700 --> 00:45:27,600
and corporate responsibility

902
00:45:27,600 --> 00:45:30,834
that are increasingly
influencing development projects

903
00:45:30,834 --> 00:45:34,567
and how businesses and
jobs are structured.

904
00:45:34,567 --> 00:45:36,967
This engagement can not
only help leverage technical

905
00:45:36,967 --> 00:45:41,667
resources, political support and
funding for suicide prevention,

906
00:45:41,667 --> 00:45:44,033
but can help ensure that
these development projects

907
00:45:44,033 --> 00:45:47,367
and the jobs they create
are designed to contribute

908
00:45:47,367 --> 00:45:49,667
to healthier communities.

909
00:45:50,767 --> 00:45:55,867
In conclusion, works potential
as an intervention site

910
00:45:55,867 --> 00:45:59,266
to provide access to resources
and improve social determinants

911
00:45:59,266 --> 00:46:03,100
of health is a powerful,
yet underutilized tool,

912
00:46:03,100 --> 00:46:05,300
in addressing health
and equities,

913
00:46:05,300 --> 00:46:08,166
like the elevated rates of
suicide among American Indian

914
00:46:08,166 --> 00:46:09,867
and Alaska Native youth.

915
00:46:09,867 --> 00:46:11,500
Thank you.

916
00:46:11,500 --> 00:46:17,700
[ Applause ]

917
00:46:17,700 --> 00:46:20,800
As promised, we have
some resources available

918
00:46:20,800 --> 00:46:23,467
on preventing suicides
and suicidal behavior.

919
00:46:23,467 --> 00:46:27,233
I'm going to scroll through them
in the interest of time to see

920
00:46:27,233 --> 00:46:29,533
if we have question and answers.

921
00:46:29,533 --> 00:46:33,533
There are these were resources
and the slides will be posted

922
00:46:33,533 --> 00:46:36,967
at our website in
about two days.

923
00:46:41,333 --> 00:46:43,867
And now I'd like to
open it up to the Q&A.

924
00:46:48,367 --> 00:46:50,433
>> And I know we had
received some questions

925
00:46:50,433 --> 00:46:51,433
through our mailbox.

926
00:46:51,433 --> 00:46:54,600
And I think we'll start off
with these, and then we'll go

927
00:46:54,600 --> 00:46:57,834
to those who are
in the audience.

928
00:47:00,700 --> 00:47:07,834
>> cdc.gov, or post in the Facebook Live stream.

929
00:47:07,834 --> 00:47:15,533
We have a question from our
comment from Avril that states

930
00:47:15,533 --> 00:47:19,467
that she's read somewhere
that suicide is contagious,

931
00:47:19,467 --> 00:47:21,166
is the isolated community

932
00:47:21,166 --> 00:47:26,300
of the indigenous population
exacerbating suicides.

933
00:47:28,867 --> 00:47:33,400
>> Dr. Manson or
Dr. LaFromboise?

934
00:47:33,400 --> 00:47:35,033
>> I think you could say

935
00:47:35,033 --> 00:47:39,133
that every culture
has gifts and burdens.

936
00:47:39,133 --> 00:47:44,100
And one of the most wonderful
gifts about many American Indian

937
00:47:44,100 --> 00:47:47,600
and Alaska Native
communities is the closeness

938
00:47:47,600 --> 00:47:49,066
of the extended family.

939
00:47:49,066 --> 00:47:53,333
But we also know that suicide
is contagious, and, therefore,

940
00:47:53,333 --> 00:47:57,834
is a burden as well,
because when someone dies,

941
00:47:57,834 --> 00:47:59,967
it affects most everyone
in the community,

942
00:47:59,967 --> 00:48:01,600
or many in the community.

943
00:48:01,600 --> 00:48:05,800
Someone can jump off an overpass
in the Bay Area, and it's just,

944
00:48:05,800 --> 00:48:07,834
you know, a clip
in the newspaper,

945
00:48:07,834 --> 00:48:09,333
which is out where I live,

946
00:48:09,333 --> 00:48:12,867
so I think that's what
I would say to that.

947
00:48:15,500 --> 00:48:17,633
>> Yes?

948
00:48:17,633 --> 00:48:21,834
>> To Dr. LaFromboise, thank
you so much for the work

949
00:48:21,834 --> 00:48:23,667
that you've been doing.

950
00:48:23,667 --> 00:48:28,166
You described the invitation
into the school system

951
00:48:28,166 --> 00:48:32,133
after events had occurred after
the cluster of five children.

952
00:48:32,133 --> 00:48:36,667
I wonder if you could comment
on the value or the openness

953
00:48:36,667 --> 00:48:38,800
to introducing the
curriculum in schools

954
00:48:38,800 --> 00:48:41,600
that haven't experienced
a student suicide,

955
00:48:41,600 --> 00:48:43,934
whether there's sort
of a different track

956
00:48:43,934 --> 00:48:47,433
for peer prevention
versus the interventions

957
00:48:47,433 --> 00:48:50,333
after events that
are locally now?

958
00:48:50,333 --> 00:48:53,667
>> Well, I think certainly
when there has been, you know,

959
00:48:53,667 --> 00:48:57,500
a death or deaths by suicide,
people are much more eager

960
00:48:57,500 --> 00:48:59,233
to embrace an intervention.

961
00:48:59,233 --> 00:49:04,767
However, I think that
the behavior that,

962
00:49:04,767 --> 00:49:07,800
if you count ideation,
as well as gestures,

963
00:49:07,800 --> 00:49:12,166
is so prevalent now, that
I think almost every parent

964
00:49:12,166 --> 00:49:17,133
and teacher or community
member is real, you know,

965
00:49:17,133 --> 00:49:22,400
are very responsive and
ready to embrace it.

966
00:49:22,400 --> 00:49:27,166
The difficulty about getting us
into the school system is really

967
00:49:27,166 --> 00:49:30,000
because of the emphasis
on making grade

968
00:49:30,000 --> 00:49:32,133
and academic content

969
00:49:32,133 --> 00:49:36,433
and educators are
reluctant to give up time.

970
00:49:36,433 --> 00:49:39,166
But then it's very difficult
for children to learn

971
00:49:39,166 --> 00:49:42,734
where they're all in grief
over their recent friend's,

972
00:49:42,734 --> 00:49:44,633
you know, death by suicide.

973
00:49:44,633 --> 00:49:46,767
So, I think it's a mixed bag.

974
00:49:46,767 --> 00:49:51,200
I think people that are
more forward thinking

975
00:49:51,200 --> 00:49:53,000
and administrators that think

976
00:49:53,000 --> 00:49:55,900
about the whole child
embrace it slowly.

977
00:49:55,900 --> 00:49:58,967
I wouldn't even say slowly.

978
00:49:58,967 --> 00:50:00,000
Reluctantly.

979
00:50:00,000 --> 00:50:02,100
They know they need to
do it and will do it.

980
00:50:02,100 --> 00:50:06,433
But I think it takes that
for people to be open

981
00:50:06,433 --> 00:50:10,000
to this kind of, honestly,
this kind of intervention.

982
00:50:10,000 --> 00:50:11,600
>> I'll add one other thing too,

983
00:50:11,600 --> 00:50:15,333
along with what Dr. LaFromboise
said, is, you know, oftentimes,

984
00:50:15,333 --> 00:50:18,266
principals, or superintendents
over school districts,

985
00:50:18,266 --> 00:50:22,800
if they are exposed to the
data or made aware of the data,

986
00:50:22,800 --> 00:50:26,266
when we look at surveys like
the Youth Risk Behavior Survey,

987
00:50:26,266 --> 00:50:28,300
and I know the Bureau
of Indian Education,

988
00:50:28,300 --> 00:50:31,066
Bureau of Indian Affairs,
has also done some surveys.

989
00:50:31,066 --> 00:50:32,934
And you look at the
questions that ask about,

990
00:50:32,934 --> 00:50:35,433
have you seriously considered
suicide in the past 12 months,

991
00:50:35,433 --> 00:50:37,600
have you made an attempt,
have you made an attempt

992
00:50:37,600 --> 00:50:40,333
that required medical attention,
have you made a suicide plan

993
00:50:40,333 --> 00:50:44,000
that oftentimes you will see
that there's a high percentage

994
00:50:44,000 --> 00:50:46,800
of adolescents in high
schools, or in middle schools,

995
00:50:46,800 --> 00:50:49,500
that are self reporting that
they've thought about it.

996
00:50:49,500 --> 00:50:52,133
So, while the deaths
may not have occurred

997
00:50:52,133 --> 00:50:55,600
in those particular communities,
you see a number of the youth

998
00:50:55,600 --> 00:50:58,066
that are thinking about
it or have made attempts

999
00:50:58,066 --> 00:51:00,767
in which they didn't go and
tell anybody, so, oftentimes,

1000
00:51:00,767 --> 00:51:02,500
that burden is there
in the community.

1001
00:51:02,500 --> 00:51:05,433
It's just a matter of making,
you know, those that are

1002
00:51:05,433 --> 00:51:08,100
in leadership aware of
what that problem is

1003
00:51:08,100 --> 00:51:10,166
so that they can respond
to it and know kind

1004
00:51:10,166 --> 00:51:12,133
of what the things are
that are appropriate.

1005
00:51:12,133 --> 00:51:14,667
I think we've got
one person there.

1006
00:51:14,667 --> 00:51:16,667
And others, you know,
we'll make sure

1007
00:51:16,667 --> 00:51:19,500
that you use your microphone
when you go to the back room.

1008
00:51:25,200 --> 00:51:29,467
>> And thanks for highlighting
schools and workplaces

1009
00:51:29,467 --> 00:51:31,867
as a place to make
interventions.

1010
00:51:31,867 --> 00:51:33,600
I'm wondering if you
could talk a bit more

1011
00:51:33,600 --> 00:51:36,400
about what the intervention
looks like for providers.

1012
00:51:36,400 --> 00:51:39,467
Are there gaps in
training providers

1013
00:51:39,467 --> 00:51:40,834
who identify or intervene?

1014
00:51:40,834 --> 00:51:43,700
Do we feel like providers
know what to do?

1015
00:51:43,700 --> 00:51:45,834
And is that a gap area
for us to think about it

1016
00:51:45,834 --> 00:51:47,667
from the health system
perspective?

1017
00:51:47,667 --> 00:51:49,500
>> Actually, I think that
Dr. Manson would probably be

1018
00:51:49,500 --> 00:51:51,734
in the best place
to answer that.

1019
00:51:51,734 --> 00:51:53,934
>> It's a great question.

1020
00:51:53,934 --> 00:51:57,834
So that, for example, in the
South Central Foundation,

1021
00:51:57,834 --> 00:52:00,266
expert initiative,
you may have seen it.

1022
00:52:00,266 --> 00:52:03,467
I think there was 27% of the
individuals were screened

1023
00:52:03,467 --> 00:52:06,200
over that period of time,
were identified at high risk,

1024
00:52:06,200 --> 00:52:08,734
and then referred to the
management processes.

1025
00:52:08,734 --> 00:52:10,667
We went to the electronic
health record

1026
00:52:10,667 --> 00:52:13,967
of that particular healthcare
system and discovered that of

1027
00:52:13,967 --> 00:52:21,300
that 27% of, what, 58,000
individuals, 91% had no note

1028
00:52:21,300 --> 00:52:25,333
in the health record
about the risk of suicide.

1029
00:52:25,333 --> 00:52:29,467
So, it's not surprising that the
providers themselves were ill

1030
00:52:29,467 --> 00:52:33,100
equipped to either detect,
much less manage those at risk.

1031
00:52:33,100 --> 00:52:37,033
So, a part of this process in
building it in a team fashion is

1032
00:52:37,033 --> 00:52:38,767
that these behavioral
health consultants

1033
00:52:38,767 --> 00:52:41,367
through weekly case
conferencing, the debriefing

1034
00:52:41,367 --> 00:52:43,900
around individuals at
particularly high risk,

1035
00:52:43,900 --> 00:52:46,233
who required crisis
intervention,

1036
00:52:46,233 --> 00:52:49,500
led to a bidirectional
educational process among all

1037
00:52:49,500 --> 00:52:51,533
of the staff from receptionists

1038
00:52:51,533 --> 00:52:54,667
through the primary care
provider team themselves.

1039
00:52:54,667 --> 00:52:56,834
And I think that that
really is what speaks

1040
00:52:56,834 --> 00:52:59,200
to the widespread success
of that intervention

1041
00:52:59,200 --> 00:53:00,967
and that setting and the others

1042
00:53:00,967 --> 00:53:03,333
that I've had the
privilege of working in.

1043
00:53:03,333 --> 00:53:05,266
I'll add one other
thing to that too.

1044
00:53:05,266 --> 00:53:07,600
I agree with what
Dr. Manson said.

1045
00:53:07,600 --> 00:53:10,200
One of the initiatives
that has been started

1046
00:53:10,200 --> 00:53:12,100
around the country is
what's called Zero Suicide.

1047
00:53:12,100 --> 00:53:15,033
That was based on an
intervention that was done

1048
00:53:15,033 --> 00:53:18,100
in the Henry Ford Maintenance
Organization in Detroit,

1049
00:53:18,100 --> 00:53:21,467
and then also Magellan out
in Phoenix, in which part

1050
00:53:21,467 --> 00:53:24,633
of what they did was just as
he was describing, you know,

1051
00:53:24,633 --> 00:53:29,667
educating every provider
within their healthcare network

1052
00:53:29,667 --> 00:53:32,266
about if there's an individual
at risk, you're making sure

1053
00:53:32,266 --> 00:53:35,633
that the rheumatologist, you
know, that the pulmonologist,

1054
00:53:35,633 --> 00:53:38,934
that the pediatrician, they
all know that this person needs

1055
00:53:38,934 --> 00:53:42,033
to the continuity of care
needs to be maintained,

1056
00:53:42,033 --> 00:53:43,433
and that we try to make sure

1057
00:53:43,433 --> 00:53:45,233
that this person is
receiving the kind

1058
00:53:45,233 --> 00:53:46,500
of services that they need.

1059
00:53:46,500 --> 00:53:48,400
And they were able to
drop their suicides

1060
00:53:48,400 --> 00:53:50,734
within their patient
population to almost zero.

1061
00:53:50,734 --> 00:53:53,567
So, it is a matter of educating
those within the network,

1062
00:53:53,567 --> 00:53:55,400
the providers, as
well as patients,

1063
00:53:55,400 --> 00:53:58,033
as well as family members
about what's going on,

1064
00:53:58,033 --> 00:54:00,633
and to make sure that things
are being followed up on.

1065
00:54:00,633 --> 00:54:03,100
I think there was a
question here first.

1066
00:54:03,100 --> 00:54:05,200
Oh, we've got one, another
one from the mailbox.

1067
00:54:05,200 --> 00:54:07,000
And then we'll come back here.

1068
00:54:07,000 --> 00:54:08,166
>> Thank you.

1069
00:54:08,166 --> 00:54:09,567
Kristina on Facebook.

1070
00:54:09,567 --> 00:54:12,900
Does the CDC have research
on the effectiveness

1071
00:54:12,900 --> 00:54:18,433
of postvention efforts in the
AIAN communities after a suicide

1072
00:54:18,433 --> 00:54:19,867
or a string of suicides?

1073
00:54:19,867 --> 00:54:23,133
Here in Alaska, we
had 16 suicides

1074
00:54:23,133 --> 00:54:26,633
within a two week period in one
small community of Hooper Bay.

1075
00:54:26,633 --> 00:54:30,767
And it pointed to the need to
respond quickly after suicide,

1076
00:54:30,767 --> 00:54:32,600
wondering if there
is research out there

1077
00:54:32,600 --> 00:54:35,600
and support for postvention
work.

1078
00:54:35,600 --> 00:54:37,400
>> There has been some
work done in that area,

1079
00:54:37,400 --> 00:54:39,433
but I think in terms of
the evaluation of it,

1080
00:54:39,433 --> 00:54:40,767
that's still pretty lacking.

1081
00:54:40,767 --> 00:54:44,000
But there have been
some protocols developed

1082
00:54:44,000 --> 00:54:46,266
that have tried to
look at postvention.

1083
00:54:46,266 --> 00:54:48,467
And basically what
postvention is is

1084
00:54:48,467 --> 00:54:51,033
after there's been a death,
one other way that you bring

1085
00:54:51,033 --> 00:54:54,233
in services, how do you focus
on particular populations,

1086
00:54:54,233 --> 00:54:56,300
those who are closest
to the person that died,

1087
00:54:56,300 --> 00:54:59,533
how do schools address a
particular death, how do,

1088
00:54:59,533 --> 00:55:02,133
you know, occupations
address a particular death.

1089
00:55:02,133 --> 00:55:03,767
So, there are protocols
for doing that.

1090
00:55:03,767 --> 00:55:06,333
The evaluation of how well
they work, I think many

1091
00:55:06,333 --> 00:55:08,734
of them are based
on strong theory

1092
00:55:08,734 --> 00:55:10,867
and the best available evidence.

1093
00:55:10,867 --> 00:55:14,400
But the strong evaluation
is probably lacking.

1094
00:55:14,400 --> 00:55:16,033
I'm not sure if anybody else
wants to also address that.

1095
00:55:16,033 --> 00:55:21,300
>> Alaska actually is probably
the most advanced Indian country

1096
00:55:21,300 --> 00:55:24,233
in terms of the acquisition
around data run in regard

1097
00:55:24,233 --> 00:55:26,834
to this, as well as
related questions.

1098
00:55:26,834 --> 00:55:32,333
What's the most predictive
risk factor for suicide?

1099
00:55:32,333 --> 00:55:33,734
It's past attempt.

1100
00:55:33,734 --> 00:55:36,100
So, it makes absolute
sense, not only in terms

1101
00:55:36,100 --> 00:55:38,700
of predicted validity of
one's efforts, but the cost

1102
00:55:38,700 --> 00:55:41,367
and the efficiency of
programming to ensure

1103
00:55:41,367 --> 00:55:43,800
that the kinds of
services that are necessary

1104
00:55:43,800 --> 00:55:45,166
to reduce the likelihood

1105
00:55:45,166 --> 00:55:49,033
of subsequent attempt
focus on such individuals.

1106
00:55:49,033 --> 00:55:51,233
And there are a number
of examples.

1107
00:55:51,233 --> 00:55:54,600
The Native Connections
Program I think was cited among

1108
00:55:54,600 --> 00:55:55,567
the materials.

1109
00:55:55,567 --> 00:55:58,767
And there's several
Alaska Native communities

1110
00:55:58,767 --> 00:56:01,834
that have been focusing on
postvention intervention

1111
00:56:01,834 --> 00:56:04,033
with those that have attempted.

1112
00:56:04,033 --> 00:56:08,000
So, it's a very well
considered approach.

1113
00:56:08,000 --> 00:56:12,533
Let me go to here, if
you had a question here.

1114
00:56:12,533 --> 00:56:14,300
I know we've only got about
a couple minutes left,

1115
00:56:14,300 --> 00:56:17,500
so we might have time
for maybe one more.

1116
00:56:22,633 --> 00:56:25,367
>> Can I ask two questions?

1117
00:56:25,367 --> 00:56:30,233
Okay, one if we still have time.

1118
00:56:30,233 --> 00:56:34,100
Commander Crosby, you mentioned
that there's more young males

1119
00:56:34,100 --> 00:56:35,533
that complete suicide but there're

1120
00:56:35,533 --> 00:56:37,667
more women that attempt.

1121
00:56:37,667 --> 00:56:41,066
Can you explain a little
more detail about that?

1122
00:56:41,066 --> 00:56:43,166
>> Generally, when we've
looked at mortality,

1123
00:56:43,166 --> 00:56:45,900
as well as morbidity,
we see that males die

1124
00:56:45,900 --> 00:56:48,066
of suicide much more
than females.

1125
00:56:48,066 --> 00:56:50,800
There's a number of
different factors

1126
00:56:50,800 --> 00:56:52,066
that play a role in that.

1127
00:56:52,066 --> 00:56:54,734
Some of it has to do
with a choice of method.

1128
00:56:54,734 --> 00:56:58,266
Some of it has to do with,
you know, the lethality.

1129
00:56:58,266 --> 00:57:00,500
Some of it has to do with other
kinds of things that happen

1130
00:57:00,500 --> 00:57:03,667
in terms of socialization and
some of the other risk factors.

1131
00:57:03,667 --> 00:57:05,834
Whereas when you
look at morbidity,

1132
00:57:05,834 --> 00:57:10,266
non fatal self inflicted injury
that females report more.

1133
00:57:10,266 --> 00:57:12,433
And then when you look at
Emergency Department records,

1134
00:57:12,433 --> 00:57:15,900
as well as hospitalizations, you
see females have higher rates

1135
00:57:15,900 --> 00:57:18,233
of non fatal suicidal behavior.

1136
00:57:18,233 --> 00:57:19,767
So, there are a number
of different factors

1137
00:57:19,767 --> 00:57:20,533
that play a role in that.

1138
00:57:20,533 --> 00:57:22,100
But at least in terms
of the demographics,

1139
00:57:22,100 --> 00:57:24,567
that's kind of how
it kind of plays out.

1140
00:57:24,567 --> 00:57:27,767
>> Okay, another question I have
is for you, Dr. LaFromboise.

1141
00:57:27,767 --> 00:57:30,667
You mentioned two terms
that I'm interested in.

1142
00:57:30,667 --> 00:57:34,000
You mentioned public
collective esteem.

1143
00:57:34,000 --> 00:57:34,367
>> Yes.

1144
00:57:34,367 --> 00:57:36,834
>> And then you mentioned
disturbed eating.

1145
00:57:36,834 --> 00:57:37,867
Can you

1146
00:57:37,867 --> 00:57:41,900
>> I didn't I don't remember
mentioning disturbed eating.

1147
00:57:41,900 --> 00:57:43,166
>> It was on one of your slides.

1148
00:57:43,166 --> 00:57:44,433
>> Oh, on one of the slides.

1149
00:57:44,433 --> 00:57:44,633
>> Yeah.

1150
00:57:44,633 --> 00:57:50,266
>> Okay, on one of the slides,
I was talking about the factors,

1151
00:57:50,266 --> 00:57:52,333
you know, that are the
issues and problems

1152
00:57:52,333 --> 00:57:55,900
that might be somewhat different
at different age groups.

1153
00:57:55,900 --> 00:57:57,066
And certainly there
are, you know,

1154
00:57:57,066 --> 00:58:00,400
eating disorders
in all communities.

1155
00:58:00,400 --> 00:58:03,633
And there are eating disorders
in native communities, right?

1156
00:58:03,633 --> 00:58:05,533
Okay, so, it's just, you know,

1157
00:58:05,533 --> 00:58:08,767
thinking about disturbed
eating is one of the beginnings

1158
00:58:08,767 --> 00:58:13,567
of risk, or you could say even
theoretically you could say self

1159
00:58:13,567 --> 00:58:15,400
injury, to some extent.

1160
00:58:15,400 --> 00:58:18,967
So, it's a matter of looking at
the problems that people focus

1161
00:58:18,967 --> 00:58:21,100
on or are dealing with
and how they progress

1162
00:58:21,100 --> 00:58:24,500
and become more challenging
to work

1163
00:58:24,500 --> 00:58:25,900
with at different age groups.

1164
00:58:25,900 --> 00:58:26,567
That was that one.

1165
00:58:26,567 --> 00:58:29,967
In terms of public collective
esteem, that is a term

1166
00:58:29,967 --> 00:58:32,734
that I believe was coined by
Robert Sellers in his work

1167
00:58:32,734 --> 00:58:35,600
on racial ethnic identity,
basically, you know,

1168
00:58:35,600 --> 00:58:38,133
African American
racial identity.

1169
00:58:38,133 --> 00:58:40,400
But it's widely used.

1170
00:58:40,400 --> 00:58:46,033
And it is a perception of
what other groups think

1171
00:58:46,033 --> 00:58:51,467
about my ethnic racial group,
what others think of my group.

1172
00:58:51,467 --> 00:58:53,934
So, in this case,
the situation was

1173
00:58:53,934 --> 00:58:55,800
that people felt more positive

1174
00:58:55,800 --> 00:58:59,166
on what they think other
people think of my group.

1175
00:58:59,166 --> 00:59:03,266
>> I know we are this is
probably the last one,

1176
00:59:03,266 --> 00:59:04,233
and I think we're out of time.

1177
00:59:04,233 --> 00:59:06,934
>> Yes, it is, from
Jenny on Facebook.

1178
00:59:06,934 --> 00:59:09,667
Are committees working to
implement job growth or bringing

1179
00:59:09,667 --> 00:59:13,367
in business to these
communities, maybe incentives?

1180
00:59:13,367 --> 00:59:14,600
>> I don't know.

1181
00:59:14,600 --> 00:59:16,900
Mike, if you'd want
to answer that.

1182
00:59:16,900 --> 00:59:20,467
>> What was the question
exactly, though?

1183
00:59:20,467 --> 00:59:23,834
>> Are committees working to
implement job growth or bringing

1184
00:59:23,834 --> 00:59:27,433
in business to these
communities, maybe incentives?

1185
00:59:27,433 --> 00:59:30,367
>> Yeah, I think the idea would
be, how do you when we talk

1186
00:59:30,367 --> 00:59:31,633
about job growth,
like I was saying,

1187
00:59:31,633 --> 00:59:34,867
it's more than just creating
jobs, but it's also engaging

1188
00:59:34,867 --> 00:59:36,934
with the folks creating
those jobs on what type

1189
00:59:36,934 --> 00:59:38,433
of jobs they're going to be.

1190
00:59:38,433 --> 00:59:40,600
Are these permanent, you
know, are they personality,

1191
00:59:40,600 --> 00:59:44,500
or contingent work, is there
going to be good, you know,

1192
00:59:44,500 --> 00:59:46,200
what are the benefits,
what are the salaries,

1193
00:59:46,200 --> 00:59:48,166
what are the time constraints,
all of these things,

1194
00:59:48,166 --> 00:59:52,166
to see how the job not only
brings in economic income

1195
00:59:52,166 --> 00:59:55,867
to folks, but also is structured
in a way that contributes

1196
00:59:55,867 --> 01:00:00,166
to the overall health of the
individual in the community.

1197
01:00:00,166 --> 01:00:03,633
>> This is actually very active
dialogue in tribal communities

1198
01:00:03,633 --> 01:00:06,700
because one of the challenges
we face in terms of established

1199
01:00:06,700 --> 01:00:09,233
and sustaining tribal
business enterprises is not

1200
01:00:09,233 --> 01:00:13,500
recapitulating the negative
and aversive consequences

1201
01:00:13,500 --> 01:00:15,567
of other corporate models.

1202
01:00:15,567 --> 01:00:17,600
And I think there's
some wonderful examples

1203
01:00:17,600 --> 01:00:18,800
out there that suggest that.

1204
01:00:18,800 --> 01:00:22,934
And we see associated with
those examples an array of kinds

1205
01:00:22,934 --> 01:00:26,667
of supportive services
that are pretty remarkable

1206
01:00:26,667 --> 01:00:29,100
in how they mobilize
the necessary resources

1207
01:00:29,100 --> 01:00:32,133
to tribal employees who may
be at risk of the problems

1208
01:00:32,133 --> 01:00:35,467
that we've been talking
about today.

1209
01:00:35,467 --> 01:00:35,867
>> Thank you.

1210
01:00:35,867 --> 01:00:37,166
That's all we have time for.

1211
01:00:37,166 --> 01:00:39,433
Please join me in
a round of applause

1212
01:00:39,433 --> 01:00:41,500
for the excellent
presentation by the speakers.

1213
01:00:41,500 --> 01:00:45,834
[ Applause ]

1214
01:00:45,834 --> 01:00:47,900
We'll see you in the next
Public Health Grand Rounds.

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