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Issue:

Alaska has a high suicide rate, but is not participating in the national programs to reduce suicide rates.

Status:

Discussion draft

Discussion:

The American Association of Suicidology ranks the states according to their suicide rate per 100,000 population. In 1995 the national rate was 11.9 and the worst rates were in Nevada (25.8), Montana, (23.1), Arizona (19.1), New Mexico (17.6), Colorado (17.5) and Alaska (17.1).
    Hence, Alaska ranked sixth from the bottom in 1995. However, because of the state's small population and number of suicides, the Alaska's suicide rate and ranking change from year to year. The important point is that Alaska has one of the poorest records in the nation.
    We need, however, to keep this in perspective. In 1995, the total number of Alaska suicides for all ages was just 103. At that rate a suicide would occur in a population of 1000 people once every five or six years. This makes designing suicide prevention programs difficult.

An effective suicide prevention program should be built on these elements:

• Develop prevention strategies based on the recommendations from the Center for Disease Control: Programs for Prevention of Suicide Among Adolescents & Young Adults and Youth Suicide prevention: Resource Guide. (New users can log on to these sites as "anonymous")
• Alaska should have a suicide research program, but one that is a part of a comprehensive program of epidemiological and services research. Since the 1980s NIMH has offered research grants with enough money available to carry on a continuing research program in Alaska. Some of the grants specifically mention Alaska Natives. See, Studies of Suicide and Suicidal Behavior, for excerpts.

Please note that the youth suicide programs are for adolescents and young adults, but a complete suicide program will cover the older age groups as well. Our Network's primary interest is from preconception care to age 22. But everyone interested in improving the system needs to remain flexible so that we develop cost-effective programs.

NAMI Alaska got involved in this issue in 1992. At that time, we found many discrepancies between Alaska's suicide prevention program and the recommendations of the national interdisciplinary research organizations, and that is still true.
   In 1992, the state's program, like many across the nation, was school-based and followed the Family Systems model that youth suicide was a "natural response to dysfunctional families and an uncaring society." Columbia University, however, had reviewed these programs four years earlier under a grant from the Center for Disease Control. Among their findings was that these programs may be increasing the suicide rate by telling the youth that suicide was a "natural response…," which some youth interpret as a noble act.
    At that time, Columbia University also questioned the use of youth as Natural Helpers in a suicide program, because it places too much responsibility and pressure on the youth, especially when a suicide occurs. They recommended that the Natural Helpers change their role to helping identify children and youth with mental disorders (which are risk factors for suicide) and helping them find professional help. However, in Alaska , at least some of the Natural Helpers programs are still "suicide prevention" programs. The role of Natural Helpers needs to be reviewed. Youth could learn social skills and help reduce suicide if they were a part of a comprehensive early identification program for mental and substance abuse disorders.

We note that the 1998 state programs have eliminated the "natural response" statements from their training materials. The state is now following a "stress model." According to the American Foundation for Suicide Prevention's section on prevention these programs are not very effective and may reduce protective taboos against suicide. Thus, our current programs may still be inadvertently encouraging suicide.
    A 1998 State of Alaska fact sheet, "Myths vs. realities," used in suicide prevention training says, "Most people who are suicidal are not mentally ill." This amounts to a denial of a major risk factor identified in the national research. For example, the National Institute of Mental Health research announcements (mentioned above) says, "Certain specific risk factors have emerged which increase an individual's risk for suicide and which can serve as a basis for further studies and carefully planned prevention efforts. For example, there is strong clinical and epidemiological evidence that psychiatric or substance abuse disorders, or their comorbid occurrence, are powerful, independent risk factors for suicidal behavior." Also, the American Association of Suicidology lists among its risks factors for adolescent suicide, (1) Presence of a psychiatric disorder (e.g. depression, manic depression, personality disorders, conduct disorder), (2) substance abuse or dependency. According to data from the Columbia University (Shaffer, et. al., 1996), (click here) of those who completed suicide, 90 percent of the males and 92 percent of the females had a psychiatric disorder, including substance abuse.
    Columbia also offers approaches that they feel will be more effective (click here).
    Obviously, the state is not following the research recommendations, but why the discrepancy? Possibly because Alaska does not have an effective early identification program for mental disorders. The Center for Mental Health Services says that 20 percent of children from birth through age 18 have a mental disorder (in their statistics substance abuse disorders are in addition to this 20 percent). A 1994 study by Norman Dingus, Ph.D., University of Alaska-Fairbanks, found that only about one-half of one percent of the students in Alaska's schools had been identified as having a mental disorder and had been referred to professionals trained to diagnose and treat childhood mental disorders. Hence, Alaska has a very poor record in identifying children and youth who have mental disorders. Since Alaska does not recognize children with mental disorders, the state agencies are unlikely to recognize the linkage between mental disorders, substance abuse disorders, and suicides.
    Substance abuse is also one of the risk factors for suicide. While there is no one cause of substance abuse among youth, for more than 10 years, the Alcohol Drug Abuse and Mental Health Administration has urged early identification and treatment of childhood mental disorders as a promising primary prevention of substance abuse disorders. Hence, early identification and treatment programs of mental disorders reduce two risk factors for suicide. Alaska, however, has not accepted these recommendations.
    Because of the linkage between mental and substance abuse disorders and suicide, one of the Center for Disease Control recommendations is to build a strong relationship between the suicide programs and appropriate mental health professionals. We believe that strategies should be based on integrating the early identification and treatment programs for mental and substance abuse disorders and suicide with treatment by professionals trained to diagnose and treat these childhood disorders. Alaska should think "integration" rather than continuing to build overlapping, incomplete, and fragmented services.
    We note that some of the disorders have a genetic component that lead to a serious emotional disturbance, substance abuse and suicide and are best treated in infancy or early childhood. In 1998, the American Academy of Child and Adolescent Psychiatry issued guidelines for diagnosing psychiatric disorders in infants and toddlers. Alaska needs to develop a screening strategy to identify the infants and toddlers that may benefit from treatment.
    The onset of many major mental disorders that lead to substance abuse and suicide occurs between puberty and age 30. Hence, any early identification strategies should consider the period from birth through the normal onset period for major mental illnesses.

We emphasize referral to professionals who are trained in diagnosing and treating childhood mental disorders because of the poor outcomes where children are treated in primary care settings without the help of professionals trained in childhood disorders: e.g., child psychiatrists and child psychologists.
    For example, in 1996 the American Academy of Pediatrics published The Classification of Child and Adolescent Mental Diagnoses in Primary Care, partly in response to a study showing that pediatricians misdiagnosed 83 percent of children presented to them that had mental disorders. That manual establishes standards for referrals to appropriate mental health professionals.
    The Neurobiology of Suicide, by J. John Mann, M.D., points out that adequate dosages of antidepressant medications reduces suicide rates among depressed patients. However, primary care physicians, according to Dr. Mann, tend to under recognize the problems associated with depression and prescribe inadequate dosages of medications.
    Further, most school psychologists and counselors lack training in diagnosing and treating childhood mental disorders, hence, the University of Alaska report on schools recommended that students be referred to mental health professionals with appropriate training. The schools in Alaska, however, are not following these recommendations.
    Many general psychiatrists say that they need the help of a child psychiatrist because of the differences between adults and children in symptoms and response to medications.
    Hence, there is ample research support for setting standards for referral to professionals trained to treat childhood mental and substance abuse disorders. As long as the state does not have such standards, neither their screening programs for mental and substance abuse disorders, nor their suicide prevention programs can be effective.

According to the state's plan, Healthy Alaskans 2000, "The terribly high rates of suicide among young Alaska Natives suggest ongoing conflict between cultures, a legacy of unresolved grief and anger, and a lack of satisfying roles for young Native men in the villages. Alaska Natives need the opportunity to address these issues themselves."
    While we agree that Alaska Natives should be involved in anything that effects them, research can help both the Natives and the state understand the risk factors involved and how these risks may be reduced. The National Institute of Mental Health's research grant announcement (cited above) lists Alaska Natives as a "special emphasis" population. Hence, there is money available to help identify risks factors that can be reduced. The University of Washington is the regional university-research-center for Alaska, and has said that they will do the research if someone in Alaska asks for their help and will provide needed logistical support. Therefore, the need, the money, and the trained researchers are available. However, as pointed out in the History of Advocacy for Epidemiological and Services Research in Alaska, we have not been able to get any state agency interested in this research.
   There are many researchable questions concerning suicide among Alaska Natives. The American Association of Suicidology reports that, nationwide, there is often an extreme variation among communities and tribes. There are a series of researchable questions around these differences.
    Additionally, a Sitka Daily Sentinel article on 2/18/98 reports, Dr. Paul Kettle, a former Indian Health Services physician in Anchorage reviewed 90 Alaska Native suicides: Natives born in the summer accounted for 33 percent of the suicides while those born in the other three quarters commit suicide in equal rates, about 22 percent each. That is a statistically significant finding and indicates an unknown environmental risk factor that merits additional research.
    As another example, in 1993 the state conducted surveys of high school students in western Alaska that found that most students had a sense of hopelessness about their future. This is another area of researchable issues, but to our knowledge, no research has been done.
    There are also a need for research into how various cultural groups utilize and respond to services. Alaska has a varied society, so the research should not be limited to just Alaska Natives.

There are state policy issues that need to be resolved at the political level. For example, the availability of firearms needs to be considered in the strategies. Obviously, public awareness of the this as a risk factor for suicide is important. However, a program to restrict access to firearms is unlikely to succeed when the legislature and gun lobby are encouraging more people to carry concealed weapons and to have hand guns readily available in the home. One possible component of a strategy is to research the use of firearms, particularly hand guns and assault weapons, in various communities for self protection versus accidents, homicide and suicide. These contradictory state policies need to be resolved, but this should not delay developing an effective program to reduce other risks.

The schools have been reluctant to identify students with mental disorders because of the fear that they will have to pay for the students treatment. That has been a significant barrier, but it is largely due to the emphasis within state government that fragments programs and makes the agencies look at how they can protect budgets. That mind set needs to be changed to one of "how do we best help children by making optimum use of all available public and private human and economic resources." That, by the way, is the current direction in Title 47. Additionally, the new State Children's Health Insurance Program makes health insurance available to children in moderate income families.

In conclusion, for children and youth, we believe the state can greatly improve their suicide prevention program with available funding by :

1. using the available interdisciplinary research-based recommendations from CDC,
2. developing a comprehensive epidemiological and services research program,
3. integrating early identification and treatment programs for mental and substance abuse disorders into age appropriate programs from birth to age 30, and
4. referring children and youth to mental health professionals trained to treat childhood disorders,
5. reassessing the role of Natural Helpers,
6. using the available NIMH research grant money,
7. accepting the help of the University of Washington in conducting research and reviewing programs, and
8. making optimum use of all public and private human and economic resources, including the new State Children's Health Insurance Program.

Recommendations:

• A small task force, including a child psychiatrist, a child psychologist, and concerned Alaska Natives and families, should review the state's suicide prevention program against the current laws and Center for Disease Control recommendations, and recommend changes to make Alaska's program more effective.

    The remaining recommendations overlap with other issues. Advocacy should seek comprehensive
    solutions, rather than piece meal ones. However, any progress is welcome.

• The state should have a strong research program using the National Institute of Mental Health's research grants, and the University of Washington's research expertise.
• The State should start an assertive early identification program for mental disorders from birth to age 30.
• The state should have a standard that all children with suspected mental disorders be diagnosed by both a child psychiatrist and child psychiatrist. While that standard may not be completely possible in all rural communities, the task force should use it in identifying approaches (telemedicine and others) to bring adequate diagnosis and treatment to all children.

Strategies:

Ask for the Department of Health and Social Services to review this issue and submit their comments, recommendations and corrections. Publish both our request and their response here.

Progress:

Click here for our 10/29/98 letter to the state Departments of Health and Social Services and Education.

For other papers and resources specific to suicide issues, click here.