Deaths by suicide among the White Mountain Apache in Arizona dropped by nearly 40 percent between 2006 and 2012 compared to the previous six-year period, new research from the Johns Hopkins Bloomberg School of Public Health and the tribe finds.
The substantial reduction came after tribal leaders responded to the high number of suicides occurring in their community by passing legislation to develop a surveillance system and intensive prevention program, which tracks and triages those with suicide attempts and suicidal thoughts.
The findings are published in the November issue of the American Journal of Public Health. These results bolster the results of a handful of studies to show that suicide is preventable with comprehensive, community-based efforts, and one of the only to show reduction in both attempts and deaths.
"Suicide is a public health problem that many don't see as preventable," says study leader Mary Cwik, PhD, a clinical psychologist and researcher at the Johns Hopkins Center for American Indian Health at the Bloomberg School. "In recent years, suicide deaths have surpassed deaths due to motor vehicle crashes, and suicide is the leading cause of death globally for girls between the ages of 15 and 19. This study shows how a courageous community, the White Mountain Apache Tribe, used legislation and community mental health workers to successfully address suicide as a public health crisis."
The work of the tribe also included training for adults to identify at-risk youth; two school-based programs — one enlisting elders to promote cultural engagement, and the other promoting coping and problem-solving skills — screening and interventions in the tribe's emergency rooms to connect those who attempt suicide or experience a binge drinking or drugging episode with counseling; and a community-based media campaign to promote prevention education.
"We are proud of our Tribal Council for passing a law in support of a community-based suicide prevention surveillance system," says Novalene Goklish, BS, outreach team supervisor and member of the White Mountain Apache Tribe who was involved in the study. "We are determined to let our Apache people who are hurting know that there is real help for them."
From 2001 to 2006, the suicide rate among the White Mountain Apache members between the ages of 15 and 24 was 13 times that of the general U.S. population, and seven times the rate for all American Indians and Alaska Natives. When the tribe realized the extent of the disparity, they reached out to their long-time partner, the Johns Hopkins Center for American Indian Health, to analyze surveillance data and design and implement a comprehensive prevention program.
The current study found that in the wake of the new programs, suicide deaths and attempts fell significantly among tribe members. Overall, they found, suicide rates dropped by 38.3 percent, while national rates remained stable or rose. This included a 60-percent decrease among the 25-to-34-year-old group and a 37-percent decline among those between the ages of 20 and 24.
While the disparity remains, the trend is encouraging. From 2001 to 2006, 41 Apache tribal members died of suicide, while 29 died from 2007 to 2012. The downward trend in deaths during the study period appeared to be mirrored in suicide attempts. The annual number of attempts decreased from 75 in 2007 to 25 in 2012.
To achieve these successes, the tribe developed a unique community surveillance system that tracks and triages suicide deaths, attempts, and suicidal thoughts with technical assistance from the Johns Hopkins researchers. After an incident is reported, Apache outreach workers follow up with in-person visits to verify what happened, listen to the individual's story, provide emotional support, and connect individuals to care. These staff members also follow up to monitor the individual's welfare over time.
The secure, password-protected surveillance system allows the tribe to develop and deliver a comprehensive youth suicide prevention program, which they call Celebrating Life. Among the elements of the program:
- Outreach messages to the tribal community promote awareness about the sacredness of life and availability of a 24-hour help line, the National Suicide Prevention Lifeline (1-800-273-TALK ).
- Culturally tailored educational messages are shared through posters, newspaper ads, radio talk shows, door-to-door campaigns, workshops, and health fairs.
- Outreach workers and Apache elders teach youth at risk for self-harm coping skills and resiliency through two school-based programs.
- The Celebrating Life team provides Applied Suicide Intervention Skills Training (ASIST) for fire fighters, teachers, EMTs, social workers, and other community members to create a network of support throughout the tribe.
- To immediately assist those in crisis, community mental health specialists conduct in-person follow-ups and offer culturally tailored interventions to all youth and adults reported to the surveillance system as having expressed suicidal thoughts or carried out self-harming behaviors like binge drinking.
"Suicide is a multifaceted and complicated public health problem," Cwik says. "There is still a lot of work to do, particularly in understanding how to prevent clusters of deaths, or what we call 'contagion,' especially among young people. It is imperative to sustain locally driven efforts, especially after seeing these promising results. The surveillance system and linked prevention programs have shown they can save many young lives."
The researchers and the tribe have been approached by at least 10 other tribes in need. They believe their program will not only help American Indians, but other communities at high risk for suicide.
"Decreases in Suicide Deaths and Attempts Linked to the White Mountain Apache Suicide Surveillance and Prevention System, 2001- 2012" was written by Mary F. Cwik, PhD; Lauren Tingey, PhD; Alexandra Maschino, MPH; Novalene Goklish, BS; Francene Larzelere-Hinton, BA; John Walkup, MD; and Allison Barlow, PhD.
This study was supported by the Native American Centers in Health initiative, which received grants from the National Institutes of Health's National Institute of General Medical Science and Indian Health Service (U26IHS300013, U26IHS300286 and U26IHS300414) and the Substance Abuse and Mental Health Services Administration's youth suicide prevention initiative (U79SM057835, U79SM059250, and U79SM061473).