Reducing the Incidence of Suicide in Indigenous Groups - Strengths United through Networks (RISING SUN): Workshop 2
Location: Tromsø, Norway
Sponsored by Office for Research on Disparities and Global Mental Health (ORDGMH), NIMH
On May 9-10 2016, the NIMH Office for Research on Disparities and Global Mental Health (ORDGMH), together with the Norwegian Institute of Public Health, convened the second workshop of an initiative aimed at suicide prevention among indigenous people in the circumpolar Arctic. This initiative, Reducing the Incidence of Suicide in Indigenous Groups – Strengths United through Networks (RISING SUN), is a collaborative effort among key international stakeholders from Arctic Council States affected by suicide, and includes mental health researchers, service providers, government officials, and indigenous community members. For RISING SUN, these diverse stakeholders are participating in a Delphi consensus-building exercise to develop a toolkit with common outcomes and measures to evaluate suicide prevention interventions among Arctic indigenous communities.
Day 1: Plan for Suicide Prevention in Sápmi (Land of Sámi)
- Mental Health Among Sámi in Sápmi
Presenters from Finland, Norway, and Sweden provided an overview of the mental health landscape among Sámi. For example, in Finland to date, there has not been much research conducted among Sámi, leading to challenges in developing and implementing culturally-appropriate mental health services. Interestingly, while the overall suicide rates in Finland have declined nationally since 1994, suicide has actually increased among northern Sami communities. Among Sámi reindeer-herding communities in Sweden, measures of depression and anxiety tend to be higher compared to both non-Sámi men and women in rural and urban settings. Measures of suicidality also tend to be higher among Sámi and a paradox seems to have emerged in that the loss of Sámi culture in this context contributes to suicidal behavior which, according to one research team’s interpretation, appears to result in a strengthening of Sámi identity. Overall, converging meanings of identity and power in relation to suicide need to be investigated further across the political boundaries of the Nordic countries where Sámi reside.
- Suicide Prevention Among Sámi
A presenter from the Sámi National Centre of Mental Health and Substance Abuse summarized the range of suicide prevention activities among Swedish Sámi communities over the previous ten years. These activities included research interventions; awareness-raising campaigns through lectures, seminars, media, art, theater, music, and videos; Sámi-led projects; suicide prevention trainings; health care interventions; and national interventions. Several specific activities highlighted among the health interventions included psychiatric patient referrals and staff education in Sámi cultural competency. At the national level, northern health care authorities are preparing a cooperative agreement on how to improve mental health among Sámi; and the Swedish Sámi parliament is producing a report on Sámi psychosocial health. Such actions demonstrate promise and a commitment towards combating suicide among Sámi.
Sámi Psychiatric Youth TeamPresenters discussed the Sámi Psychiatric Youth Team, an out-patient clinic of the Sámi Norwegian National Advisory Unit on Mental Health and Substance Use (SANKS), which primarily works with adolescents and young adults between 15 and 30 years of age who present with suicidal behavior problems and substance abuse. The 4-member team comprises a psychologist, a social worker, a nurse, and a medical doctor, with the clinic operating 5 days a week. The program has been running since 1990, and it is funded by the Norwegian Government. The team treats between 80-120 clients per year, and supports additional training opportunities in the community, such as Applied Suicide Intervention Skills Training (ASIST) and local suicide prevention programs. To date, youth have responded positively to the Sámi Psychiatric Youth Team, recommending the service to friends and discussing their use of the clinic openly among their peers. One of the strengths of the program is that most of the clinicians and employees are Sámi, and Norwegians receive cultural competence training 1) to ensure a culturally sensitive/safe treatment environment for patients, and 2) to build a cohesive approach among the team members working at the clinic. In the future, team members hope to increase the program’s visibility in the communities and promote the team more systematically to inform the public about the team both as a way to change attitudes about mental health and suicide behavior, and also to increase help-seeking among those young who need it. Overall, although Sámi adolescents follow the global trends of increasing emotional problems over the past two decades, through programs such as the Sámi Psychiatric Youth Team, Sámi youth tend to have improved mental health outcomes compared to their indigenous adolescent peers.
Suicide Prevention Among Sámi Adolescents and Young Adults in Norway.
Suicide – From Understanding to PreventionRecognizing that a considerable amount of research that has been conducted on suicide prevention, a presenter from the Norwegian Institute of Public Health reaffirmed that the absence of effective prevention of suicide among young men is considered by many scholars one of the most serious challenges in the field of mental health and suicide prevention. The presenter also reviewed psychological autopsy studies of suicide to examine an interpretative phenomenological analysis of suicide as an alternative to a traditional disease model. Following several case study examples, the presenter concluded with recommendations on approaches to suicide prevention. It was recommended that suicide prevention be conceptualized as more than just psychiatric, and should be based on knowledge beyond mental illness. Suicide prevention should include a multi-factorial perspective, focus on the interaction between the individual and his or her social context, concentrate on employing early interventions, and be knowledge-based.
Breakout Sessions – Creating a Vision for Sámi-Specific Transnational Suicide Prevention: “Dream, but Within Limits;” and Setting PrioritiesAn afternoon of breakout sessions included brainstorming and small-group discussions among clinicians, government representatives, Arctic indigenous community members, and international researchers on creating a vision for a Sámi-Specific Transnational Suicide Prevention Plan. Discussions focused on content—the challenges and needs the plan should address, and implementation—necessary actions to make the plan work. Examples of proposed plan elements included developing and actualizing improved mapping and surveillance; increasing cooperation between health care systems in Sápmi; training Sámi-speaking ASIST facilitators and implementing training in Sápmi; convening a youth conference on mental health and resiliency; conducting more research on suicide among Sámi communities from which data are lacking; utilizing media interventions; recruiting artists as role models; and using storytelling as a culturally sensitive tool in suicide prevention among Sámi. These deliberations will be an important contribution to the overall RISING SUN effort to reduce suicide among indigenous groups across the Arctic.
Day 2: RISING SUN – Envisioning the Toolkit
Dr. Pamela Collins (NIMH/ORDGMH) described proposed components of the suicide prevention toolkit that will be one of the end products of the RISING SUN initiative. These include a general introduction to suicide prevention efforts in circumpolar indigenous communities; lessons from communities that have successfully implemented effective suicide prevention interventions; why harmonizing outcome measures could help with dissemination and implementation of interventions; prioritized outcomes of suicide prevention interventions; measures associated with prioritized outcomes; and strategies for using the toolkit.
Following presentation of preliminary findings based on responses to the first round of the Delphi consensus-building exercise, attendees provided comments and suggestions on the list of outcomes that had been categorized by the NIMH team in terms of their presumed level of intervention (i.e., individual, family, community, clinical, and regional/national). Some participants expressed that a tiered view does not necessarily reflect indigenous perspectives and others felt that a spiritual element was lacking. Several participants indicated that any proposed interventions should be supported by policies and regulatory measures. In addition, there was a call to develop an appropriate set of measures for whichever outcomes are selected for the toolkit. There were also several suggestions for domains by which to rate outcomes in the third round of the Delphi; these included locally-tailored community needs; feasibility of intervention; immediacy of impact; and taking into account the scale and timeframe of interventions and their outcomes. The issue of whether or not outcomes included in the next round of the Delphi should be restricted to those for which there is a scientific/peer-reviewed evidence base also arose. A subsequent assertion was that indigenous evidence-based practices are equally valid to western scientific approaches and it may be helpful to distinguish among diverse clinical, indigenous knowledge, policy, and research values. Irrespective of the decisions made regarding the content of the toolkit, participants were in general agreement as to maintaining transparency of the analytical approach for data reduction from Delphi panel responses to the unique outcomes and measures.
Moving from Outcomes to Measures
Speakers in this session presented some examples of online resources pertaining to suicide-related interventions, their outcomes, and measures. One is the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-based Programs and Practices (NREPP), a repository and review system designed to provide reliable information on mental health and substance abuse interventions. Another is Section I of Suicide Prevention Resource Center’s (SPRC) Best Practices Registry (BPR); it lists evidence-based intervention programs that have undergone rigorous evaluation and that have demonstrated positive outcomes. A third resource is the consensus measures for Phenotypes and eXposures (PhenX) Toolkit, a catalog of recommended, standard measures of phenotypes and environmental exposures for use in biomedical research.
- National Registry of Evidence-based Programs and Practices (NREPP) - http://www.nrepp.samhsa.gov/01_landing.aspx
- Section I of Suicide Prevention Resource Center’s (SPRC) Best Practices Registry (BPR) - http://www.sprc.org/bpr/section-i-evidence-based-programs
- Phenotypes and eXposures (PhenX) Toolkit - https://www.phenxtoolkit.org/
Synthesizing Sources of Data / Timeline
The final session addressed the need to incorporate other sources of information in addition to the responses from the Delphi process, and provided a tentative outline for forthcoming activities. Findings from a Canadian focus group on mental wellness and suicide prevention, the proceedings from the Sámi Suicide Prevention Plan workshop, and results from anticipated focus group discussions in Alaska and Greenland are expected to be integrated into the final RISING SUN products. In terms of the revised timeline, the second round of the Delphi is scheduled tentatively to proceed in June 2016, with data analyses and writing completed by winter 2017. A third meeting, with the aims of launching the suicide prevention toolkit and disseminating results from the RISING SUN initiative, is scheduled tentatively to be hosted by Canada in Spring 2017.