Suicide is at crisis levels among American Indian and Alaska Native (AI/AN) youth and young adults. In 2000-2010, suicide was the second leading cause of death for AI/ANs ages 10-34, while rates for AI/ANs younger than 25 years are up to 6 times higher than for Whites of similar ages. AI/ANs also suffer a disproportionate burden of suicide risk factors, including mental health disorders, traumatic life events, and substance abuse. Most research has been limited to rural reservation settings, yet 71% of AI/ANs reside in urban areas. Urban AI/AN youth and young adults are at notably higher risk than their non-AI/AN counterparts for attempted suicide (21% vs. 7%), as well as for serious mental health problems, substance abuse, gang activity, teen pregnancy, and interpersonal abuse. Given this exacerbated risk, stakeholders identified an urgent need for suicide prevention research in urban AI/AN youth and young adults.
Most people who die by suicide have contact with a primary care provider in the prior year, and 45% are seen in the month before their death. Consequently, the Joint Commission, which accredits US healthcare organizations, requires the detection and management of suicidal thoughts or behaviors in primary care. “Screening, Brief Intervention, and Referral to Treatment” (SBIRT), an evidence-based practice that co-locates behavioral health clinicians in primary care teams, is an effective response to this requirement. Despite its success, SBIRT has not achieved widespread adoption or been rigorously tested in urban AI/ANs to screen for suicidality (suicidal thoughts or behaviors).
Suicide Prevention for Urban Native Kids and Youth (SPUNKY)
In 2017, the National Institute on Minority Health and Health Disparities (NIMHD) funded CAIANH and its partners through a Specialized Centers of Excellence on Minority Health and Health Disparities (U54) grant. With this funding, CAIANH has partnered with two of the largest Urban Indian Health Organizations (UIHO) in the US−First Nations Community Healthsource (FNCH) in Albuquerque and the Seattle Indian Health Board (SIHB) in Seattle–to comprehensively evaluate their existing SBIRT programs for suicidality screening. In addition to evaluating their SBIRT programs, the study will test a novel enhancement that sends caring text messages, which are the preferred method of communication among AI/AN youth and young adults, and are adapted from empirically-based, effective interventions for suicide prevention. The text messages are intended to improve SBIRT retention and increase social and cultural connectedness, which are strong protective factors against suicidality and death.
The study is a randomized controlled trial with 2,400 AI/AN primary care patients ages 12-34 who screen positive for suicidal ideation during the 3-year study period. Participants will be randomly assigned to usual care (SBIRT with referral to existing resources) or SBIRT with either 6 months (SBIRT+6) or 12 months (SBIRT+12) of text messages. Primary outcomes will be self-reported suicidal ideation, attempts, and suicide-related hospitalizations for 1 year after randomization. Secondary outcomes will include perceived social connectedness, and retention. For patients randomized during years 1 and 2, we will also collect data 2 years post-randomization to evaluate longer-term effects. Given the critical importance of sustainability, the study will also conduct a comprehensive economic evaluation.
The study has three aims:
1) Evaluate existing SBIRT programs at each study site to identify and address factors that affect successful implementation in urban Native primary care organizations. We expect these factors to vary by site and to require systems-specific enhancements to maximize intervention fidelity.
2) Compare the effectiveness of SBIRT+6 and SBIRT+12 to usual care for reducing suicidal ideation, attempts, and hospitalizations; and for increasing social connectedness and retention in SBIRT. We expect that SBIRT+6 and SBIRT+12 will improve all outcomes, and that social connectedness and SBIRT retention will mediate the intervention’s effect on primary outcomes.
3) Perform a systematic economic evaluation of SBIRT+6 and SBIRT+12 compared to usual care to examine their relative effects on use of healthcare resources and quality of life. We expect both will be more cost-effective than usual care, and that SBIRT+12 will be the most cost-effective option.