Keywords

Suicide is a serious and universal public health challenge, yet significant disparities have been observed in suicide and attempt rates across a variety of cultural, racial, and ethnic subgroups. A better understanding of differences among cultural, racial, and ethnic subgroups with regard to suicide and suicidal behavior has the potential to inform suicide prevention efforts, not only within these specific subgroups but in general populations as well. This chapter will focus on the American Indian and Alaska Native (AI/AN) population as illustrative of several best practices and lessons learned with implications for other underserved communities, as well as calls to action for the field more broadly.

Epidemiology of Suicide in AI/AN Communities

AI/AN communities have some of the highest suicide rates among youth (see Ruch and Bridge, Chap. 1, this volume), although there is considerable heterogeneity in rates across AI/AN communities. Suicide was the leading cause of death in 10–14-year-old AI/AN males in the United States in 2019. Notably, the suicide rate among AI/AN males has increased from 17.3 per 100,000 in 2001 to 20.3 per 100,000 in 2019 and 3.9 per 100,000 to 6.9 per 100,000 in AI/AN females—a 77% increase for females vs. a 17% increase for males. Suicide rates in all male race/ethnicity groups increase sharply to age 20–24, with AI/AN male suicide rates far surpassing those of all other groups at this age bracket. Comparing across all male racial/ethnic groups, AI/AN males have the highest suicide rate until age 40–44.

Despite these significant disparities in suicide rates, suicide prevention in underserved populations has been limited by critical gaps in research, training, and program implementation. Moreover, these underserved populations, such as AI/AN communities, are often not represented in national epidemiological studies in a meaningful way. This underrepresentation contributes to invisibility. Native Americans, for example, are often put in an “other” category or lumped together with other racial/ethnic groups with small numbers in the sample. Consequently, large-scale data describing suicide in a Native context are relatively lacking, making it difficult to appropriately direct funding and to further make an argument to purposively include Natives and other underrepresented minorities in large-scale clinical trials. As a result, there appears to be a lack of “evidence-based” interventions for underserved communities, even though AI/AN populations have championed several important innovations that have often been ignored by the larger suicide prevention field, including being early advocates for strengths-based and community-based approaches, developing frugal interventions, harnessing the power of early identification in community settings, and emphasizing culture and spirituality as part of holistic approaches.

Best Practices in Underserved Communities

Strengths- and Community-Based Approaches

A shift from a deficits-based approach to suicide prevention, which focuses on individual-level risk factors and psychopathology, to a strengths-based approach is underway in underserved communities and timely for the rest of the field (Tingey et al., 2016; Yuan et al., 2015). While deficits-based approaches can guide individual risk mitigation efforts, they also have the potential to inadvertently contribute to individual and group stigmatization and overemphasize problems in communities. Deficit models are not always effective either; decades of suicide prevention work and federal government-funded programs applying deficit models have not reduced the high prevalence of suicide in Indian country. Utilizing a deficits-based approach might even prove harmful to marginalized communities and hinder their ability to adequately address suicide. Conversely, strengths-based approaches highlight community and cultural protective factors and involve community members to promote well-being and positive health outcomes. For example, one strengths-based approach for addressing substance use and suicide utilizes a positive youth development framework to provide an entrepreneurship education intervention for White Mountain Apache youth (Tingey et al., 2016). Additionally, the Sources of Strength program employs effective public health messaging and stories of personal resilience in managing emotions for upstream suicide prevention (Thiha et al., 2016). The field of suicide prevention, in general, can learn from the community-based participatory research process that is the foundation for many strengths-based approaches, which has building trust as the foundation of successful research, regardless of whether the researchers are considered “insiders” or “outsiders” (Wallerstein & Duran, 2010).

Frugal Interventions

The scarcity of mental health services and providers has required underserved communities to develop “frugal innovations.” Frugal innovations in mental or public health sectors can be thought of as interventions that do more with less, capable of reaching the many. There are few sustained programs that address community mental health needs, especially those that focus on suicide prevention. Programs tend not to detail specific risk and protective factors identified in remote, resource-poor settings. The frugal intervention development process—whereby, in limited resources settings, creativity and imagination have better opportunities to develop—goes beyond addressing limitations based upon external resource constraints. Such a model enhances an understanding of self-reliant processes and internal resources that are often overlooked. The suicide prevention field needs to develop new solutions in resource-challenged settings rather than relying on untested adaptations often developed far away in well-resourced communities (Lorini, 2016). One type of frugal intervention model that Native and other underserved communities support is a brief intervention delivered by community health workers. For example, a pilot study evaluated the potential effectiveness of a specific brief intervention, New Hope, with findings indicating reductions in negative thinking, depression, and suicidal thoughts among youth with a history of suicide attempt (Cwik et al. 2016a).

Early Identification in Community Settings

Suicide surveillance is often viewed as an important way to identify individuals at risk for suicide. Community-based identification is especially important in underserved communities relative to hospital- and clinic-based approaches to case identification since there are many barriers to vulnerable youth accessing care. The White Mountain Apache Tribe has developed an innovative and effective system that mandates any person who lives or works on the reservation to report any suicide-related incident (ideation, attempt, and death) to a central task force called Celebrating Life (CL). After a report is made, a CL staff member follows up in person to gather more information on risk and protective factors, enable a warm handoff to services, and provide case management. This is both an innovative and culturally acceptable way of delivering services to those most at risk for suicide. This system gives the Tribe accurate, timely, and thorough data on suicide in their community, allowing them to target suicide prevention efforts. Over time, surveillance has raised community awareness, identified many individuals at risk for suicide, and increased the percentage of those getting referrals for treatment. The initial surveillance data resulted in a comprehensive program that included universal, selected, and indicated suicide prevention activities; this multitiered approach was associated with a significant reduction in suicide attempts and deaths (Cwik et al., 2016b).

Holistic Approaches

Approaches that incorporate culture and/or spirituality have potential to contribute to both prevention and treatment, particularly in AI/AN communities. Elders from the White Mountain Apache Reservation, for example, have focused on the importance of their culture and language to prevent suicide, developing a standardized curriculum that they have been teaching in schools since 2014 (Cwik et al., 2019). The Elders believe that language provides youth with a solid sense of self, tribal identity, and connection to the community, all of which serve as protective factors. Respect is a core value addressed across all the lessons, and the monthly content corresponds with what is traditionally taught at that time of year with a different theme for each lesson/month. Youth learn Apache words, stories, and seasonal responsibilities related to that month’s theme. Students reported high program satisfaction and displayed knowledge of their culture and language on written assessments after participating (Cwik et al., 2019). Finally, many underserved communities are already implementing programs which they believe to be effective in their settings, and do not feel a need for evidence in the form of a randomized clinical trial. As a larger scientific field, we often do not know about community perceptions about the success of these local efforts or dismiss them, with potentially negative consequences for developing and advancing evidence-based suicide prevention efforts in underserved communities. Some traditional suicide prevention approaches, terminology, and interventions are not viewed as acceptable or culturally congruent. For instance, “gatekeeper” programs have been implemented in tribal communities, often with adaptations, but this terminology has been replaced with “caretaker” to avoid negative conations associated with the idea that “gatekeepers” might exclude some individuals. Examples of culturally congruent, strength-based programs can be found in the Culture Forward guide (https://caih.jhu.edu/programs/cultureforward) and include the Healing of the Canoe project, the Qungasvik Toolbox, the Yappali Project and Culture Camps, and Native H.O.P.E. (Helping Our People Endure).

Call to Action

There are two overarching calls to action for what suicide prevention research, policy, and practice can learn from underserved communities. First and most importantly, we need to diversify the suicide prevention field, both in terms of who is being included in our study populations and who is conducting the research. It is imperative to include underserved communities in research so that we have better data (and interventions) moving forward. Furthermore, developing more independent investigators and funded researchers from underserved communities has potential to advance suicide prevention efforts, not just in vulnerable populations but in general. Researchers and clinicians from the same racial/ethnic group are more likely to be sensitive to, understand, and appreciate the cultural norms and values, past and current traumas, and language issues relevant to the study of suicide risk and protective factors and preventive interventions. From a clinical perspective, training more providers from underserved communities has potential to be an important contribution to the continuum of care relevant to suicide prevention efforts. In addition, having a provider from the same racial/ethnic group can provide comfort and security for some individuals at risk for suicide, and may feel less stigmatizing, enhancing the likelihood that individuals will reach out for help and stay in treatment. Additionally, providers from other communities need more training on the process and content specific to addressing suicide in underserved communities. Many providers lack suicide prevention training generally, but the nuances of working with underserved communities are rarely addressed in training programs. Policies with funding and specific programs attached to it are urgently needed to focus on increasing the diversity of the workforce and mandating these types of trainings at the federal, state, and institutional level.

Second, suicide prevention programs need to be developed with sustainability in mind, which is critically important in underserved communities. Although seeking community buy-in would intuitively seem to be an important first step in suicide prevention, policy makers, funders, and researchers have often failed to put this principle into action. We need to begin with an approach that includes listening to the community with a sense of openness and curiosity, tailoring prevention efforts to the community at risk instead of fitting the community to an established program. It is also vital to understand the effort, training, and supervision required for local communities to enact best practices. Implementing a “train the trainer” approach is often more productive than relying exclusively on “outsiders”; there is wisdom in being open to community health worker delivery models for practical and cultural reasons. Finally, policy makers, researchers, and individuals in clinical leadership roles need to identify sustainable funding streams and innovative service delivery models (O’Keefe et al., 2021)—as prevention programs may be particularly challenging to deliver with fidelity in underserved communities, who may feel a sense of abandonment when initial grant funding comes to an end.

Conclusions

The study of underserved communities has potential to contribute to suicide prevention efforts for both underserved communities and the general population. Researchers, policy makers, and clinicians can no longer afford to ignore what is happening in underserved communities. Focused research can inform the efforts of health policy experts and lawmakers to mitigate disparities and improve access to high-quality, evidence-based mental health and substance use services for all. Priority research targets should include ensuring that Native American and other racial/ethnic groups are represented in large-scale or national epidemiological studies in a meaningful way; understanding root causes of suicide beyond individual-level factors (e.g., past and current traumas, socioeconomic conditions); and innovative models of prevention and intervention focused on holistic well-being. Our shared humanity makes suicide a problem that transcends specific cultural, ethnic, or racial groups; however, it is also true that cultural, ethnic, and racial differences can be associated with differences in rates of suicide and suicidal behaviors, suggesting the need for both universal and targeted approaches to suicide prevention in subpopulations of individuals at risk, particularly in the underserved. A better understanding of suicide in underserved communities has potential to improve the quality and effectiveness of interventions in those communities, inform the adaptation of successful suicide prevention strategies to specific subpopulations, motivate the creation of new programs, and contribute to our understanding of suicide and suicide prevention in general.