Suicide Prevention—We Know What to Do, but Will We Do It?

Reports of a public health event unprecedented in a high-income, industrialized nation first appeared in 2016. Absent war, famine, disease outbreak, or significant sociopolitical upheaval, life expectancy in the United States began to decline.¹ Subsequent analyses reported in AJPH identified this decline as resulting from a cluster of interrelated public health outcomes that included alcohol- and opiate-related mortality and death by suicide and posited a shared set of social determinants for these deaths of despair as a health inequity identified in only 9 of 48 US subpopulations.² Elsewhere, such patterns of disease interaction and underlying shared social determinants have been defined as syndemic.³ Responding to the research, an AJPH editorial explored what is known about this epidemic of suicide and interrelated conditions and questioned “What to do?”^4(p1564)

Off in one far corner of the rural United States, a small, culturally distinct Indigenous nation provides answers. In an AJPH report also published in 2016, while national suicide death rates increased, Cwik et al.⁵ reported that rates on the Fort Apache Indian Reservation declined following a suicide prevention program. This White Mountain Apache Tribe achievement provides public health advocates a model for effective response to the suicide syndemic through implementation of the community intervention paradigm for health inequities.⁶

The purpose of this editorial is to provide additional context on this White Mountain Apache accomplishment and describe the subsequent effect of the Cwik et al.⁵ publication, including implications for suicide prevention. The White Mountain Apache experience emphasizes the relational element in intervention science. It offers a practice-based example of the community intervention paradigm. This Indigenous model of suicide prevention based in local understandings and knowledge systems regarding health, health beliefs, and intervention also highlights ways that underrepresented ethnocultural perspectives are important, independent of their relationship to White, non-Hispanic, or other groups. Paradoxically, these not directly generalizable findings provide important direction regarding effective suicide prevention strategies for all populations.

RESEARCH BASED IN RELATIONAL METHODOLOGY

In 1993, following a 15-year effort with Johns Hopkins University to eradicate childhood infectious disease on their reservation, the White Mountain Apache tribal government expanded the collaboration to include suicide prevention. For American Indian and Alaska Native people, suicide is the second leading cause of death, with rates among 10- to 24-year-old persons the highest of any US racial/ethnic group.

In 2006, following a tragic cluster of youth suicide, the White Mountain Apache instituted a tribally mandated system of detailed reporting on suicidal ideation, suicidal attempt, and suicide deaths, as well as nonsuicidal self-injury, adding binge substance use in 2010.⁷ Also in 2006, the White Mountain Apache initiated a program⁵ of universal, selective, and indicated prevention at the community, agency, school, mental health system, family, and individual levels, directed by a Community Advisory Board and Elders’ Council. Guided by reporting system data, the community intervention includes

• Extensive community-level awareness and education activities,

• Agency-level coordinated cross-agency suicide response planning and implementation of Applied Suicide Intervention Skills Training,

• School-level implementation of the Sources of Strength and American Indian Life Skills Development Curriculum suicide prevention programs and strengths-based cultural activities led by Apache Elders,

• Community mental health system-level implementation of brief risk reduction and engagement intervention for all youths with suicidal ideation or recent attempt, followed by family-level life skills training, and

• Individual-level mental health follow-up services.

Following community intervention, suicide death rates decreased 38.3%, with a 23% decrease among 15- to 24-year-old individuals, and suicide attempts also declined.⁵

COMMUNITY INTERVENTION PARADIGM

The White Mountain Apache suicide prevention program fulfills four primary assertions of the community intervention paradigm for health inequities (see the box on this page).⁶ First, practices that include local staffing of data collection and intervention, Elder involvement, and Community Advisory Board and Elders’ Council leadership foster community capacity development; this serves as an instrumental strategy by facilitating alteration of need and deficit frameworks into strengths-based, resource-building structures.

Community Intervention Paradigm to Address Health Inequities.

Capacity	Goals are to strengthen health of communities and enhance local community capacity.
Complexity	Interventions are complex interactions between intervention process and community systems.
Collaboration	Relationship of community and intervention team is critical and based in empowering collaborative processes for sustainability.
Culture	Culture is fundamental and pervades all aspects of community intervention.

Source. Trickett et al.⁶

Second, the White Mountain Apache program is a complex intervention. Complex intervention is multilevel. Composed of separate emergent, adaptable, and incremental initiatives that change over time, its initiatives are collectively understood through an ecological model as an event in a larger system of community history, norms, settings, resources, processes, and networks. Intervention intent is to influence this larger context as well as individuals within it to foster community resilience, defined as sustained ability to use available resources in effective response to systemic disruption.

Third, the collaboration involves high local control over a tribally determined health priority, with tribal mandate for its comprehensive data system on suicide and related behavior. The value added by community-based participatory research is evident.

Finally, through local staffing and leadership, appreciation of complexity, and community-based participatory research perspective, Apache culture is fundamental, out of which all intervention flows. Intervention is developed for the culture; culture is not an add-on to services.

INFLUENCE ON HEALTH RESEARCH

The White Mountain Apache and Johns Hopkins University collaboration has been broadly influential in guiding policy, advocacy, and research. As one of the longest duration tribal–university collaborations, its relational methods are models for work with Indigenous communities. Influence is evident in the recent National Institute of Mental Health RFA-MH-17-350, Collaborative Hubs to Reduce the Burden of Suicide Among American Indian and Alaska Native Youth (U19), which establishes regional collaborative hubs for research on strengths-based and resilience-focused approaches and emphasizes community engagement to promote sustainable models in culturally congruent intervention.

Reach extends beyond suicide prevention, as emphasized in the largest National Institutes of Health initiative on Indigenous health; PAR-17-496, Intervention Research to Improve Native American Health (R01), sponsored by nine institutes, seeks to design, implement, and test culturally appropriate health interventions consistent with community values and sustainable through existing resources. This program announcement and its predecessor currently fund 27 intervention science projects focused on cultural factors, community resilience, ecological approaches, multilevel intervention, and incorporation of community-based participatory research perspectives with tribes as equal partners. These funded efforts are notable for advances in community-based participatory research, small population research and small samples analysis, culturally situated complex intervention, and incorporation of cultural knowledge systems.

IMPLICATIONS FOR EFFECTIVE SUICIDE PREVENTION

The work portrayed by Cwik et al.⁵ is generalizable beyond Indigenous communities. Although roots of deaths of despair are found in widespread social inequities,⁴ the bleeding can be stopped. The White Mountain Apache nation accomplishment shows the United States that effective solutions are possible and that the tide of suicide can be turned. In contrast to views of intervention as componential and a technology, the White Mountain Apache experience emphasizes capacity development, appreciating complexity, collaboration, and the central role of culture. Generalizability is found not in intervention procedures or their form—defined as intervention components that require identical replication in fidelity to what was delivered on the Fort Apache Indian Reservation—but instead in flexible, adaptive application of the community intervention approach. What is generalizable is the paradigm and the underlying function rather than the form of separate initiatives within the overall intervention. If culture, among all other things, embodies meaning system, then in local culture—military, rural, Indigenous, or other—are found the tools for prevention of suicide

The White Mountain Apache experience provides testament to the scope and spirit of research and intervention to effectively mount a response to the suicide syndemic. As public health advocates, policymakers, and leaders, we know what to do for effective suicide prevention; we have models of effective leadership and implementation and an intervention science knowledge base. What is required is leadership and a modest though not insubstantial public health investment. This brings us to the question: Will we do it?