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Strength in the Face of Challenge: Youth Suicide Prevention Research Among the White Mountain Apache and the Navajo Nation in the Time of COVID-19


DAWN MORALES: Greetings, everyone, and good morning, afternoon, or evening to you, depending on your local time. Welcome to the National Institute of Mental Health webinar series presented by the Office for Disparities Research and Workforce Diversity. I am Dr. Dawn Morales, chief for American Indian, and Alaska Native Mental Health, and the moderator for today's webinar, titled, Strength in the Face of Challenge: Youth Suicide Prevention Research Among the White Mountain Apache and the Navajo Nation in the Time of COVID-19. To help us, we have Dr. Joshua Gordon, Director of the National Institute of Mental Health, to give us some opening remarks. Dr. Gordon.

JOSHUA GORDON: Thank you, Dr. Morales, and thank you to everyone, speakers and attendees, for joining us today. Research on preventing suicides has been and continues to be a top priority at NIMH. Although we have made considerable progress in understanding how to prevent suicide, much remains to be done. Much remains to be done especially in vulnerable communities, and amongst the most vulnerable are individuals in American Indians and Alaska Native communities who face much higher toll, a much higher burden, from suicide and mental illness more generally than the general population.

Suicide though, is not just about burden and statistics. Suicides create terrible losses for all involved, and the effects on the individual's loved ones, and on their communities are truly devastating. Despite these devastating losses, the American Indian and Alaskan Native communities have shown, and continue to show tremendous resilience. And that is what makes conducting research within these communities so important, and so fruitful. Because, number one, the need is great, and number two, the resilience is equally great.

It is important that we recognize the key role for conducting community engaged research both in Native American communities in general, and also particularly so, in the context of the COVID-19 pandemic which has impacted these communities so much more than the average community, elsewhere.

The pandemic has also dramatically affected our abilities to conduct research in these communities, and the scientists you will hear from today, have had to adapt their approach in concert with the communities that they serve. So, I think it will be illustrative for us to hear about that work today. I want to thank again, everyone for coming. I want to thank the researchers, and community members who are going to speak with us today about the research, about the results, and about the promise for the future. With that, I will turn it back over to Dr. Morales. Thank you.

DAWN MORALES: Thank you. First a few housekeeping notes. Please submit your questions via the Q&A box at any time. Also, please use the Q&A box to indicate any technical difficulties you may experience with hearing or seeing the webinar at any time. Our webinar series continues throughout the summer and fall, and you may register for them on the same website you used to register for this one. And now that that is out of the way, let me introduce the research team who will present today.

Each of them is associated with the Johns Hopkins Center for American Indian Health, and in many cases have an additional affiliation, which they may mention, as he, she, or they speak. The researchers speaking today are Dr. Allison Barlow, Dr. Mary Cwik, Mr. Mitchell Garcia, Ms. Rose Suttle, Dr. Emily Haroz, Dr. Jerreed Ivanich, and Dr. Victoria O'Keefe.

The webinar will begin with Allison Barlow, who will provide some background and context that informs the research approach and methodology. Allison.

ALLISON BARLOW: Thank you so much Dr. Morales, and Dr. Gordon. We are so honored to be with all of you today and to share our work, and the outstanding innovations that are coming from the White Mountain Apache, and Navajo Nations.

First, I want to direct our attention as we gather together virtually, from across the country, that together we humbly acknowledge the indigenous peoples of our homelands. We are all on traditional and contemporary native lands. We encourage you all to go to this site when you can, to know and honor the native lands where you reside and work.

Our Center was founded in 1991 at Johns Hopkins Bloomberg School of Public Health by Dr. Mathuram Santosham. He had spent over 10 years prior to that working with the White Mountain Apache and Navajo nations as well as some other Southwestern tribal communities to address (Audio lost). Our mission remains the same, to work in partnership with native communities to raise the health, education, and health leadership to the highest possible level. And we do that by working in partnership with tribal communities, community members, to co-create strengths-based solutions that honor and promote tribal sovereignty.

The Center has three core arms. Very important, and integral to all of the arms is our training and scholarship program, where we are singularly focused on right now on developing and supporting early career Indigenous scientists through their professional development. We know that their leadership is incredibly important to the future of, not only science, but really the planet. I will explain more what I mean as we go on. We also have an active infectious disease prevention group. This is our oldest group at our Center, and they were critical to the COVID response. And our behavioral mental health promotion group, we are all representing our mental health group, led at our Center by Dr. Mary Cwik.

So, our Center has focused on building interventions, co-creating interventions in partnership with tribal communities that plug-in across the life course. You are seeing many of them on this slide, but those that are highlighted in yellow all have a mental health focus. So, you will see that these overlap many stages of the life span.

We have had a four-decade partnership with Southwestern Tribal Communities, and that foundation has provided the trust to do the incredibly sensitive work that it takes to address youth suicide and other behavioral health issues.

We have been able to work on interventions with the White Mountain Apache and Navajo Nation that have now scaled to over 140 tribal communities across 21 states. This youth suicide prevention work is our latest example, and as you will hear today, we are working with almost 10 different tribal communities on this work.

COVID significantly expanded the scope of our Center’s work. As we began to work with the Southwestern Tribal Communities to address COVID, and to learn from the Navajo Nation and White Mountain Apache what could be effective, we were contacted by dozens more tribes to help with their support. We also were able to partner with national agencies, including the National Indian Health Board, NCAI, and the National Council of Urban Indian Health, to be able to support programs across every tribal community in the country.

In spite of the highest rates in Southwestern Tribal Communities, you're looking now at publicly available graphs from the White Mountain Apache Tribe as an example, but you can see the exact same graphs from the Navajo nation. In spite of the highest rates, and the most severe conditions to address the pandemic, from poor water access, to overcrowded homes, to long distances to healthcare, in spite of all of that, tribes have been able to wrestle COVID to the ground, ahead of every other US community. We adopted a mantra during this work which was, "all we can do is everything that we can do", as COVID was shedding light on long-standing inequities.

The New York Times covered the incredible work that the White Mountain Apache during the pandemic, and they really zeroed in on saying, what is it that is working so well to mitigate disease after these very high rates? And they landed initially on contact tracing, and it is true that contact tracing that was done within the White Mountain Apache community was world-class. But really, it took incredible wraparound services, connected to that contact tracing that really made the difference.

For example, with both White Mountain Apache, and Navajo, we knew that many homes, 30 to 40 percent on Navajo, did not have running water. So, it took employing folks to build handwashing stations. The White Mountain Apache came up with the idea of employing local folks to sell masks because there is so little PPE. There are wellness boxes and food boxes delivered to all people who were in quarantine isolation, really prioritizing the elders and people with young families, who could be more at risk.

Finally, task shifting, this is a huge part of our suicide prevention work. Training up para-professionals who could do testing, and eventually they ended up helping with vaccination as well.

We know that, what is coming behind us is an enormous mental health burden, and our Center has tried very hard to get out in front of it. So, on the left-hand side, you see a wellness box that includes things for communities under stress. Not just food, but getting out children's toys and books. The book you are seeing in the foreground, Our Smallest Warriors, Our Strongest Medicine, was led Dr. O’Keefe and Dr. Haroz, with a tribal advisory group to help young parents address COVID with their children and give them the strengths of their ancestors and their traditions to make that journey.

Culture Forward is a brand-new toolkit for tribal communities that is strengths-based, again led by Dr. O'Keefe, with our team. In the bottom left-hand corner, you are seeing new indigenous Psychological First Aid that this team developed and is now using to train front-line workers who experience incredible stress. In the meantime, we are turning toward new proposals that are helping address comorbid mental health with chronic diseases like diabetes, and cancers.

This is just a picture to honor Novalene Goklish, she could not be with us today, she is an incredible team member, and is experiencing a family medical emergency right now, but I know she would want to be with us. And I just wanted to honor her.

So, as we have begun to think about these wraparound services, we thought about a model which we are calling Tri-Protect. That is really integrating support of isolation, quarantine, contact tracing, diagnostic testing, and now vaccinations. And as this churns more and more, we are thinking about contact tracing as a means to actually reach people who are experiencing mental distress as a result of COVID. We are building modules that plug into other interventions that we have, that will help those families who are experiencing grief burdens, PTSD, anxiety, and other mental health issues.

I really just want to take a moment to celebrate today, this incredible success of Native Americans now lead the country in vaccination. Even though they started under such duress, and Victoria O'Keefe captured this in a recent Washington Post article. What is at the heart of this is the sense of collective responsibility, collective will. That is actually informing suicide prevention work as well.
I just wanted to embed this, in an indelible way, in your minds that what we are learning from indigenous communities about the power of collective will is what we need to address mental, behavioral, and infectious disease challenges across the globe.

So, the experiences of COVID has really sharpened our Center’s strategic directions, we are actually undergoing a large strategic planning process. But we just wanted to share with you research focus in the next 5 to 10 year horizon. In particular, we know that we have to continue to follow the arc of rigor of previous research. We will be showing you today that we have been working with the White Mountain Apache tribe on suicide prevention since 1993. We have learned so much to bring to bear on this issue, especially as with the youth suicide becoming an issue across the globe in a way that been seen before.

We also are really interested in standing up exemplars of next-generation CBPR. What we mean by that is, not only sharing our community will and directions for research, but actually continuing to iterate this research based on community input, and data input that is coming in an iterative process. We are thinking a little bit about precision public health methods, as I talk about this. But how can we continue to use the power of CBPR, to continually improve the quality of the research and interventions and then the implementation science.

Third, we are wholly committed to strength-based approaches. We know from the work in the Culture Forward guide, that we shared earlier, is really all about what tribal communities have known since time immemorial. And that is, if we start, even before health promotion, even before that, how do we stand on the strengths of the community to power generations forward with the strengths of their ancestors, traditions, or cultures that protect them against these inherent risks.

And then lastly, a commitment to a rapid translation of evidence to practice. We will be explaining more about that, but we learned a lot about how to do that in a quicker way. And just in terms of methods, that again we are finding are really guiding forces in our work as we move forward, is the need for new explanatory models. This is really hinged on the idea of strengths-based work. What kinds of frameworks do we need to continue to iterate, or design from the ground up? And what measures that are reliable, can we fit into those new frameworks to ensure that we are understanding what is happening in indigenous communities that is working?

Secondly, is from the onset, design for sustainability, and as one example of this, almost all of our work has been designed so it is sustainable in local communities because of the workforce who are available and being trained. So, in this case, the idea of community mental health workers, as the frontline workers, in much of the mental health work that we are doing, that is both around promotion and prevention.

Third, implementation science. So how can we draw implementation science to ensure rapid translation scaling of the work that we find to be effective through this hub research, and other research that we are working on.

Fourth, machine learning, we really feel grateful that we received supplemental funding for the hub, to really dive into a machine learning as a way to predict risk, and to then be able to allocate our resources in the most critical and efficient ways to help those who need help most, in the moment. And finally, precision science and systems thinking approaches for maximum impact. We will go into each, more in-depth.

Just before I hand it over to my colleague, Dr. Mary Cwik, this is a long horizon, when you think about youth suicide prevention research. In 1993, I started with our Center in 1991, in 1993, the head of the Tribal Health Division made a call out to us at an advisory board meeting. She said, we need your help, we have lost 11 young people from suicide, we do not know what to do. That was the beginning of the work. We learned very quickly about how important tribal specific data is, to understand rates and patterns locally. We could not get that data regionally, we needed to get it from the local tribal area.

Secondly, really working to understand the risk and protective factors, through quantitative and qualitative research with youth who attempted suicide. We are learning from them directly, what were the precipitants of their suicide, what kind of care did they think would help. What did they think would keep them safe? Next, to really do a case control study, where we are understanding what was the difference between healthy youth who were visiting the ED and youth who were at risk for binge drinking. Which, the tribe did an amazing thing, which was to understand binge drinking and drug use is on the spectrum of self-harm, so that now their community-based surveillance systems track both binge streaking and drug use through suicide ideation attempts, and non-suicidal self-injury.

Next, we went through a long phase of working through CBPR to develop grief interventions for suicide, both in terms of identifying those at risk and connecting them to care. You will hear more about that. And also around mental health promotions through an elders curriculum. And we continue to develop new models such as these Entrepreneurship Prevention and Outcome Study, I was showing that actually engaging youth in entrepreneurship activities that are culturally based is really helping them to reduce binge drinking, drug use, suicide risk, and violence.

So, I am so happy to turn it over to Dr. Cwik, and thank you for your time today.

MARY CWIK: Thank you, Dr. Barlow. I am excited to transition this part of the webinar to really talk about our portfolio of NIH research. I have the honor of starting with talking about our Southwest Hub.

So, our Southwest Hub is really a U-19 collaborative mechanism, and it is really focused around these brief interventions that Dr. Barlow mentioned. Really focusing on preventing suicide, but also promoting mental health.

Our research core for this collaborative hub is really built on a long-standing partnership, that Allison described previously. This work includes 10 years plus of suicide prevention with the White Mountain Apache tribe. This work is named Celebrating Life. It really is built on a foundation of community-based suicide surveillance, follow-up, and case management. The system has been recognized nationally by different agencies. In addition, linked to this system is really a public health approach to suicide prevention that is comprehensive, and covers universal, indicated, and selected tiers of prevention.

The important foundation of all of this work is our community mental health workers as well, who are really implementing all aspects of this program. What we have learned over these 10 plus years, and what we continue to learn through our current hub trial, is that we are really in need of culturally based, healing modalities to fit native cultural understanding of mental health to target culturally-informed protective factors, and to bridge gaps left by our traditional models of Western mental health care.

What I want to highlight next is some data, from the Celebrating Life system, that really preceded our application for the U 19 hub. This surveillance system, and comprehensive approach that the White Mountain Apache enacted, actually was associated with a significant decrease in suicide deaths. You can see here, as you look at the bar graph, and as other rates were increasing or staying steady over time, the White Mountain Apache rate, in the dark blue, went down significantly. This is really a landmark finding, as it is one of only a few studies to find an association with suicide deaths decreasing.

In addition, we actually had similar findings for suicide attempts, as well. As you can see here, by looking at the graph, there is a trend for suicide attempts going down over time, when this comprehensive public health approach was active. This was true for both males and females. This really poised us for our current Southwest Hub trial and led to our current study design.

What our current hub is doing, is using a factorial design to evaluate four different combinations of interventions. The first intervention is called New Hope, it is a risk reduction approach. The second intervention is called Elders Resilience, and this is really focused on mental health promotion. In addition, we have Case Management, which is really the standard of care in this community and that is what is attached to that suicide surveillance system that we have described.

The group that we are targeting with our Southwest Hub are White Mountain Apache adolescents ages 10-24, that is the highest risk age range in this population. They are at risk for suicide because they have come through the surveillance system for suicide ideation, suicide attempts, or binge substance use with recent suicide ideation. Our hub trial will allow us to really examine the short- and longer-term effects on suicide ideation, which is our primary outcome, and resilience, which is our secondary outcome.

A little bit more about our interventions. Our first intervention that we are going to talk about is New Hope. This is a culturally adapted intervention. It is important to really hone in on that. What it means is, we took a Western evidence-based intervention that was developed by Mary Jane Rotheram Borisand adapted by Joan Asarnow and Tony Spirito and others, and we really adapted it to fit the White Mountain Apache context and community. Again, it is really focused on the time after suicide attempt or risk event, to really provide psychoeducation, and to connect that at-risk youth, to traditional healers, caring adults, give them a safety plan, and get them motivated to continue in longer-term treatment.

This intervention typically takes place over one session, and is 2-4 hours. Again, it is delivered by our local community mental health workers.

The second intervention, is really, we see it as a complementary and different approach. This is our Elders Curriculum. The aim of this is really to promote mental health and resilience among our Apache youth. Again, it also is a brief intervention, and it is focused solely on cultural strengths, Apache knowledge, language, and stories. Elders deliver this intervention with one of our community mental health workers, and you can see, it is a similar length. In this intervention, the elders likely will not even talk about suicide. It is a very different type of intervention, it is really promoting strength.

Here you can see the study design for our trial. So, a couple of things that are important to highlight here. You can see that the surveillance system is how we are identifying the at-risk youth. You can see, I will try to use my mouse here to show you guys that the first randomization point here, youth are randomized to either get New Hope plus case management, or case management alone. Then they are followed some more over time and continue to receive case management. Then there is a second randomization point. At that second randomization point, they are randomized to Elders plus case management, or case management alone, and then followed longer over time. You can see, that ends up in four different combinations that youth may receive. Our target sample size is 304.

In our study, we will also be able to look at some secondary aims to really understand mediators, and moderators of treatment effectiveness. So we might hypothesize that males for example, might respond to one intervention better than the other, or that older youth versus younger youth may respond differently. Our study design will allow us to look at that. In addition, we are really harnessing some of the power of implementation science, under Dr. Haroz's leadership, to look at acceptability, feasibility, and capacity for sustainability of these interventions with our Apache community, but also with our different partnering sites.

So, in summary, this Southwest Hub research trial, some takeaways that we really want you to hone in on. It is really, these decisions about culturally adaptive intervention, like New Hope, versus a culturally grounded, or built from the ground up intervention like our Elders Intervention, should really be made collaboratively with the communities. There is not a one-size-fits-all approach. This community-based approach has been the bedrock of everything we do.

In addition, that the partnership that the U 19 continues to support and to grow, and that infrastructure is really critical, for our Apache-JHU partnership. It is really fostering and leading to culturally tailored public health approaches to suicide prevention where we really have the time, and breadth, and depth, to really design interventions with the community, that are really going to impact and be sustainable and feasible there.

In addition, at the end of the study, we will really be able to understand locally, what combination of interventions best meet the needs of the youth in the community. As we talked about earlier, they had a comprehensive public health approach, but this study will really help us unpack which piece of that public health approach are most impactful for them.

Lastly, and importantly, we have a lot of partners across the Southwest and across the United States, who are really interested in the suicide prevention interventions. So, through our hub grant we were able to engage them in learning about what we are doing and then adapting the interventions for themselves, with possible evaluation in their communities in the future.

And I have the honor of turning it over, next, to Dr. Victoria O'Keefe, who is going to talk about that administrative core, and some of those key partnerships.

VICTORIA O’KEEFE: Thank you, Dr. Cwik. It is my pleasure to talk about our Southwest Hub administrative core. Our administrative core includes the White Mountain Apache tribe, the Navajo Nation, San Carlos Apache tribe, Wailaki tribe, Cherokee nation, and the Fort Peck Tribes. We just want to say from our whole team, that we are so grateful from all of the families and all the communities who have partnered with us in this work.
The goal of the Administrative Core is to build a collaborative network of tribal leaders, investigators, interventionist, service providers, and service users to reduce suicide among American Indian youth and promote mental health and wellness. On this slide, you will see many photos. These are photos of just some of our partners, in this important work. This took place during our first annual, in person meeting, together that was hosted by the White Mountain Apache tribe.

We worked together to achieve the goal of the Administrative Core by sharing knowledge. This includes things like sharing best practices and policies. For example, sharing what we know from the White Mountain Apache tribes amazing Celebrating Life suicide surveillance, and case management, and comprehensive public health approach to suicide prevention among all of the tribal partners, to learn how can they have a similar system within their context.

We also share information about the brief interventions, and how communities may also adapt those within their context. We also share resources, so if we see grants that may be of interest, that are focused on suicide prevention, or substance abuse, we will share those with our tribal partners. We also share conferences that we think they might be interested in. Of course, over the last year, we have had a number of COVID-19 materials and resources that we have been sharing.

There is also a focus on implementation and sustainability among our Administrative Core to ensure sustainability of these programs within our tribal community partners. We also provide technical assistance. So, there are various activities that we do with all of the partners. We have regular phone or virtual meetings with each of our tribal partners. We also have one annual in person meeting and one annual phone and virtual meeting, so that all of the partners can really interact with one another.

Then, there is also a lot of training and support between tribal partners themselves. For example, the White Mountain Apache tribe might go out to the Cherokee Nation, and do some training and support with them or the Wailaki tribe might travel down to the White Mountain Apache tribe partners for training and support. There is a lot of co-learning that is constantly happening among this group. Then again, ongoing resource sharing as we see things that pertain to all of our tribal partners.

We have some research that is also embedded within the Administrative Core, and this is a K01 award led by Dr. Emily Haroz, with the goal of maintaining the gains made in suicide prevention and helping other tribes to achieve and maintain these as well. Aim one of this K01 study is to identify actionable sustainment strategies to promote the sustainment of the Celebrating Life program across tribal settings. Aim two is to use a community-based systems dynamic model of Celebrating Life implementation and sustainability to help in prioritizing sustainment strategies to implement. And aim three is to measure the effects of the sustainment strategies on sustaining Celebrating Life in each tribal setting. So very important work within our Administrative Core.

Now, I will shift slightly, and briefly discuss my K01 award, that builds upon the decades of amazing collaborative work between our Center for American Indian Health and the White Mountain Apache tribe. It is focused on the Elders Resilience Curriculum and building empirical evidence around this culturally grounded American Indian youth suicide prevention intervention.

Just to give you some background and some context, Allison mentioned this earlier as well, but indigenous knowledges, values, and traditions support the health, well-being, and daily life of communities and they have been promoted and practiced for generations.

More and more indigenous communities and indigenous researchers are calling for culturally grounded interventions. And these interventions have a focus and are centered in indigenous culture, values, and worldviews, and that should be at the forefront of intervention design, implementation, and evaluation.

However, there are some current research gaps. For example, we have a lack of research identifying and understanding the core components of culturally grounded native youth suicide prevention interventions. We also do not have as many theoretical models that are cocreated with indigenous communities, and that privilege indigenous voices, communities, values, about youth strengths that protect against suicide. Finally, we do not have as much evaluation of culturally grounded native youth suicide prevention interventions with culturally appropriate and relevant measures.

So, the Elders Resilience Curriculum, you heard Dr. Mary Cwik speak earlier about a brief intervention that elders deliver to youth. That brief intervention was adapted from a longer school-based program that is one year long. In this longer school-based program, elders go into schools, and they teach a curriculum focused on White Mountain Apache culture, values, traditions, and language to youth ages 11 to 14. Since 2014, the elders have taught this curriculum to more than 1000 youth.

So, this K01 research is an exploratory mixed method study in collaboration with our White Mountain Apache tri partners, focused on the Elders Resilience Curriculum. Aim one, is to gather individual, family, and community perspectives on cultural protective factors of suicide, and how those map onto core components of the Elders Resilience Curriculum to inform a cocreated theoretical model.

Aim two to is to select and culturally adapt measures to assess outcomes and key causal mechanisms of the Elders Resilience Curriculum. And then aim three, is to pilot the Elders Resilience Curriculum theoretical model, culturally informed measures, and the feasibility and acceptability of a culturally acceptable evaluation that we will decide collaboratively, between myself and the community, about what is the best evaluation for this study.

The future goals of this study is to test the effectiveness in a larger trial, and the overall hope is that we can scale this intervention to other tribes, including our Southwest tribal partners.

And now, I am going to turn it over to Dr. Jerreed Ivanich, who will begin talking about some of our Southwest Hub supplements. Thank you so much.

JERREED IVANICH: Thank you so much for introducing some of that work. As mentioned, I am Jerreed Ivanich. I am an affiliate with the Center. I am an assistant professor at the University of Colorado, with the Centers for American Indian Alaska Native Health. And I am a member of the Navajo community, I am excited to be in this space with you all today, to talk about some of our supplements. The first of which I will be talking about is the cost-effectiveness supplement.

As you can imagine, as we have been listening to all of the amazing work that has been coming out of the partnership between the White Mountain Apache tribe and Johns Hopkins, many other communities hear about these efforts, and want to understand what would it cost for them to implement those? One aspect of this supplement is to be able to better understand the costs associated with implementing some of these brief interventions. Today, we will be focusing a little more on the second aim of the cost-effectiveness supplement, which is to better understand the burden associated with suicide and depression.

To this end, we enrolled 200 native youth in a vignette study to rate their quality of life of two separate characters. One of which, in the vignette, was described in an individual that likely had suicide ideation, or risk for suicide. And the second was an individual characterized as having depression. And so, we had some innovations around implementing the survey with our community partners, that we heard from them on how we could better improve on some of the prior methods that typically are implemented to get this kind of data.

We implemented an audio recorded implementation of these vignettes to participants, so they would not have to read. They were recorded by community members, so they sounded and were in concert with community understanding of their local understanding of their world. And it was developed through an iterative process with local staff, and community members, so we made several trips out to the tribe, and worked with them to develop what these scenarios and these vignettes will look like.

The ratings that individuals did were around the health status of this character, rather than oneself, which is the typical approach that many take when trying to collect this type of quality-of-life measure and to assess this burden. To give you a little understanding and flavored of what one of these vignettes look like, I am going to go ahead and turn it over to one of our community partners, Rose, for a brief reading of one of those vignettes. I will turn it over to Rose, for that.

ROSEMARIE SUTTLE: Good afternoon, my name is RoseMarie I am a White Mountain Apache, I work with Johns Hopkins Celebrating Life suicide prevention. One of the vignettes is, Sarah has been thinking that life is not worth living, especially when she is alone. She feels like no one really loves her and that her family and friends would be happier if she were not around. She thinks a lot about death and dying and has even thought about how she would end her life. Sometimes she feels like suicide is the only option. That it would solve all her problems. She is having trouble getting these thoughts to stop, they are like a broken record playing over and over. When she has trouble at school, trouble finding a job, and has a disagreement with her family and friends, she thinks that no one would care if she died. She feels guilt, and shame, and sometimes has given her things away, and said goodbye to friends and family as if it were the last time she would see them. She has had these thoughts on and off in the past month.

So, that is one of the vignettes that was read to the individual. Go ahead, Jerreed.

JERREED IVANICH: Thank you so much, Rose. I hope you can all can see in that briefing that there was a lot of effort made by our partnerships with the community to make sure that what we captured in that vignette was a reflection of how the community understands and recognizes what the risk for suicide ideation is.

To give you a brief overview of some of the results from that study, you can see here, we have around the box, on the timeline, what looks like a timeline here, is the ratings, the average ratings that we gathered from these vignettes. So you can see, suicide ideation average score was 15.8. As a reminder, zero is worst health, and 100 is best possible health. Depression was rated at 25.1, on average, of these 200 participants. Which you can see, compared to some other similar methods that have been implemented in other communities, these are significantly heavier rated burdens and for other populations.

I think that this also goes to show that culturally specific quality of life values allow for comparison and identification of the most effective interventions to reduce suicide among American Indian Alaskan Natives. We think this is really valuable because no studies to date have estimated depression or suicide weights among this population, and we have the opportunity now to better understand the effectiveness of some of these brief interventions in reducing this burden in the committee.

With that, I will go ahead and turn the time back over to my colleague, Dr. Cwik.

MARY CWIK: Thanks, Jerreed, I really appreciate that. Our next supplement that we are going to talk about is about opioid use, and this is really focused again, on our sample of participants in the hub study that I talked about earlier. So, what we did, is we did a series of qualitative interviews. When I say we, I mean our community partners like Mitchell and Rose, that are on the webinar today, did in-depth qualitative interviews with these participants. And again it was a subset who endorsed on our quantitative measures that they had themselves engaged in recent opioid use or that they had a close family member or friend engage in use. And so, if you look at our sample, at the time we looked at the data, it was preliminary, about nine percent of our study participants reported using prescription medications not as prescribed.

As you will remember, these are 10 through 24-year-olds in the community. You can see here, by looking at the table, that we tried to aim for equal representation in the older age group, and the younger age group. We had more females participate in the qualitative interviews. And then we had about equal number of participants who engaged personal use, versus use by others in their lives.

On the next slide, what you are going to see here are some quotes from the data. I will summarize them first, and we will have Rose read to you guys some of the quotes. Our interview guide was structured around getting descriptions of use in the community, because we saw this as formative work to understand opioid use among younger age groups in the Apache community. We had a theme around the role of family, which came out as very strong, and important, including an important resource.

In addition, one thing we learned during the study is that participants in this age group didn't just talk not just about opioid use, even though it was the focus of the interview, they talked about using substances of all kinds. There was some confusion about what opioids were so that is something we can apply in our future research.

Rose, I am going to invite you to read your two quotes. Thank you!
(Rose Suttle lost connection)

MARY CWIK: I can read them on her behalf, since she is unable to read them to you guys. The first quote is, "Just anytime of the day, like I would just do it.” Meaning take opioids.” It was not because I was depressed, it was just because I wanted to get high."

Regarding the role of family. “And we would talk about the ways they were feeling in life … and if they tell somebody, it will probably bring a whole light of hope”. We are really grateful to NIH for this opioid supplement and it is really providing some foundational information for future work in this community around this important topic.

Next, I will pass it back to Dr. Ivanich, we are doing a bit of back and forth here, who is going to talk about his diversity supplement.

JERREED IVANICH: Thank you Mary. I have been so supported by both the community and the team at Hopkins, in terms of the research, and training that needs to take place. With her support, we wrote a diversity supplement, which many of you know, has a research component and a training component.

The first research component has two aims, the first of which is to understand the individual characteristics associated with the co-occurrence of suicide and opioid use, using individual characteristics. The second aim of that research is to understand and assess the geospatial factors associated with the unique co-occurrence of opioid and suicide risk. Which leads to that training component, so the diversity is something that will allow for training around spatial analysis and better understanding of place-based interventions where we hope to be able to move to more targeted place-based interventions. And has also allowed for extra training and resources to support grant writing, which led to the submission of R21, which I just submitted and was just awarded, that focuses on social network analysis. This diversity supplement will continue both in terms of research and training for next year. I am so grateful for NIH, and for the community partners, and team at Hopkins for allowing me to do this. Thank you.

With that, I will turn it over to Dr. Haroz for her discussion.

EMILY HAROZ: Thank you so much, everybody. Really grateful to be here with all of you and share this exciting work we have been doing. I will be talking about developing and implementing predictive algorithms to identify those at risk for suicide. This was supported through a supplement to the hub, as well as an internal grant that got the project up and running. I have been spending time on this through my K01.

As you have heard, the backbone of much of our suicide prevention work and the White Mountain Apache suicide prevention efforts has focused on the Celebrating Life Suicide Surveillance System. Just to give you a brief sense of what this program looks like, there is a tribal mandate which requires all community members to report individuals at risk for self-injurious behaviors to a central registry system. This system is maintained by the Celebrating Life team. The reportable behaviors include suicide death, suicide attempt, suicide ideation, non-suicidal self-injury, and binge substance use. Once that initial report is made, the Celebrating Life team follows up on each report and provides case management.

They verify the surveillance data, so they verify that report data with the individual to check on what actually happened and understand the circumstances around the event. They provide case management, and sometimes this is often provided on an ongoing basis consistent with brief contact interventions. They aid that person in getting referrals.

As Dr. Cwik pointed out earlier, not only has the system provided locally relevant data to inform public health suicide prevention initiatives, but the use of this local surveillance, combined with case management, has contributed to significant decreases of suicide in this population. If you look at the six years before and six years after the surveillance system was established, the Celebrating Life program contributed to a 38.3 percent decrease overall.

With that being said, as knowledge of the surveillance system has grown and the case managers continue to provide additional services, referral numbers have also increased. This points to a need to enhance efficiency, and a method to quickly identify those at risk to help prioritizing getting to the right people, as fast as possible.

For this project, the initial research question was, how can we identify and reach people who are most at risk for suicide on the White Mountain Apache reservation?

We know that suicide is incredibly complex. If you think about patients or people we know who have died, the factors that contribute to their death are not ever a single factor, but rather an interaction of factors and circumstances that happen over time. It turns out that despite 50 years of research, our ability to identify those at risk for suicide is only slightly better than chance.

Here is a meta-regression plot showing the log odds ratios for all types of suicidal thought and behaviors across decades of research. This was published in 2017 by Joe Franklin and colleagues. You can see that this red line hovers slightly over zero, indicating across all these studies, each of the blue circles is a study, we actually know very little about what predicts suicide ideology.

With this evidence in mind, given that what leads somebody to suicide is incredibly complex, many in the field have turned to machine learning approaches to try and leverage and manage this complexity and identify those at risk. However, to date, most predictive modelling for suicide risk has been developed in healthcare settings with predominantly white, or Hispanic populations, and with limited evidence of implementations of these models to actually improve care. There is also evidence that models developed in other contexts may actually exacerbate suicide related health disparities. This was published in a JAMA article just recently.

With that background in mind, and think to a small internal funding through JHU initially, we were able to apply machine learning methods to 10 years of data from the White Mountain Apache Tribe Surveillance System. What we found was that our accuracy in predicting suicide attempts in the next year was promising, and much better than our best-known single predictor, having a previous attempt, which performed no better than chance.

Here are AUCs or Areas Under the Curve, which is a measure of accuracy, and you can see that these algorithms which are these machine learning based algorithm called Ridge regression, Lasso, et cetera, have AUCs of .8 or better, which is substantially better than our previous attempt, which was only about .5, which indicates no better than chance at predicting future suicide risk.

This work was published about a year [ago], and we are honored to be highlighting Dr. Joshua Gordon's blog on health disparities back in January 2020. It seems like a lifetime ago. Ultimately, we developed these risk production algorithms to actually inform care and improve care. We undertook a small qualitative study to inform our implementation of these algorithms. This diagram here, on the right, actually shows the process by which our case managers use the risk flags. This pink form completed is the follow-up form that the case manager completes when they go out and meet someone who has been reported to the system. That form asks about verifying the data and the circumstances around the event. The notification of the algorithm is done at the time of the visit completion. The time of the pink form completion, that risk flag is generated. That risk flag – based on feedback from the case managers, is dichotomized to show low risk or high-risk.

But also what also emerged from the qualitative study was that it was very important to also trust case manager evaluation. Many of our case managers have worked for years in the field and also have intimate knowledge about the community, and the way people express suicidal risk. We wanted to honor that and respect that wisdom. So we made a pathway for a case manager to actually be able to override the algorithm assessment and provide a high risk rating.

Anybody who is flagged as high-risk or deemed at high risk by the case manager is then provided with a mandatory wellness check. We try to do these wellness checks longitudinally in line with brief contact interventions, and the evidence for brief contact interventions. These case lists and these high-risk case lists, are reviewed biweekly with the team and we discuss each high-risk case on a biweekly basis.

With that, I will turn it to Mitchell, who will discuss how we use those lists.

MITCHELL GARCIA: Good afternoon. I am Mitchell Garcia. I work with the Celebrating Life program here with Hopkins in the White River Office. My experience with the algorithm is once we collect, just as Emily spoke, that we go and complete a pink form with these individuals that we are seeing from the ER or referred from PD, or just family that has referred them. People are worried about these individuals, we will go and meet with these individuals, once we do that, we put that into our Redcap system and when they are deemed high risk, we try to make it to where we will try and both see them every week, pretty much, at the beginning or the end. Typically, myself and Rose, we go and meet with these individuals that are at risk. If they are uncomfortable with a male presence, we respect the boundaries of the people. There is a certain etiquette that people follow here. Sometimes when these individuals disclose that – depending on the information they shared during the follow-up visit, we tend to deem them high-risk on some occasions for ourselves. Even though the algorithm does not put them at high risk, but what they just told us makes us where it is more of an intuitive guess, on some occasions.

This algorithm is helpful when it comes to individuals that have disclosed they have attempted in the past six months. That is an automatic red flag because we do not know how the next six months will go, or how the next year will go for them. Typically, some of the people that are struggling with suicidal ideations, they tend to have minor triggers. Things that we see as minor inconveniences, is a big tipping point for them. We try our best to accommodate these people when they are struggling with ideations, we tell them that we will check on you on this day, this time. Typically, we let them know we are just here to help relieve pressure.
The back side, behind the scenes, we are trying to get them to get counseling through ABHS, the Behavioral Health Center here on the reservation, or treatment through the binge substance use facility here on the reservation. We are trying to create avenues of people that they are not just seeing us or they are not just depending on us, but they understand there is an entire community behind them that they do want them to try and see the better side of life.

That is typically what I work on, and what I do. Hopefully that answers it, Emily? I will turn it back to Emily.

EMILY HAROZ: That was great, thank you so much, Mitchell, that was really helpful to hear your perspective. The next steps for this is the predictive algorithm, and connection to what Mitchell mentioned as the systems of care. As this work with the Celebrating Life team has continued, the local health facilities, and some of our hub partners, have become very interested in this work in thinking about how do you expand this to the healthcare system? And not only how do you expand it to the healthcare system but how does this predictive algorithm link to existing resources, and providing community care?

We submitted an RO1 focused on service ready tools for individuals at risk of suicide with this idea of how we can embed this in the healthcare system now and how does this connect to the existing valuable resources in the community in different ways that are efficient and effective?

With that, that brings us back to this idea of multi-level systems of care, which was our original framework. Individual families and communities at risk of suicide really identifying risk, linking to care, and prevention and treatment, and ultimately promoting recovering resilience and how these processes are connected to all these different resources in the community. Just as Mitchell mentioned, the whole community is here to support this individual or this family, rather than this one person feeling alone.

With that, Mary, I will hand it back to you.

MARY CWIK: Thank you so much Mitchell and Emily. I have the honor of summarizing some of our future directions on behalf of the whole team and our partnering communities. Several other things that we really want to leave you with, and that we are really feeling passionate about, in the next phase of our work, is to develop explanatory frameworks and conceptual models that are indigenous-led and indigenous-based. We feel that starting with Western models and trying to adapt them to our communities, is not a bad place to start, but it is not enough. We really need to develop models from the ground up to really be able to develop the most effective interventions for these communities and these health disparities.

In addition, we really feel that there are community-based participatory approaches, and indigenous research methodologies that can really lend to this model development. In addition, we need to develop assessments that go along with these models and go along with the constructs that we are needing to measure in our studies. We all know that often we will use Western measures, or measures used in another context, and try to adapt them. Again, it is a starting place but we feel strongly that developing measures from the ground up is also a really, really important next research step to address health disparities.
In addition, as Dr. O’Keefe and Dr. Barlow and others have talked about today, we really believe in strength-based approaches. We really need to start with promoting mental health, not just preventing problems or strengthening resilience, starting even before upstream preventions, we might say.

Thirdly, we really have also seen in our research – the research we have not highlighted even today, the power of early childhood interventions. I think many of us who work with children, or might have developmental backgrounds, understand the power of parenting, early childhood, and intergenerational cycles. We believe that starting young – and there is data to show this in Western context, as well, can impact mental health, and suicide in the long term.

Fourth, we are honing in on precision approaches, based on precision medicine and precision health approaches, to take that and apply it to mental health. We feel this is very important to suicide prevention, it is a complex problem and we know that in every community, that individuals who think about suicide, who attempt suicide, and die from suicide, are very heterogeneous and there is not a one-size-fits-all solution to help these individuals and we feel these precision health approaches also can really help address cultural and contextual factors that are important in native, and other communities.

Lastly, we think that implementation science has a lot to bring to bear and the work that Dr. Emily Haroz is leading. We know that if we think about implementation after the research studies and after we design our interventions, it is almost too late. We need to think about this upfront. This needs to be the foundation of our formative work and our intervention development. We really believe in the power of community mental health worker models. As you can hear today briefly from our powerful community partners, Rose and Mitchell, they are the change agents in these communities. They really fill critical gaps and provide such important services in these communities. We cannot thank them and appreciate them enough. Thank you, Cindy and thank you, Mitchell.

On that note, we would love to have some time for some questions. We have our contact information here on the slides for you. You can see here, our colleague Novalene Goklish, who could not be with us today, represents our White Mountain Apache team at the site. We thank NIH for this invitation to present today and for all of you listening, in attendance.

Now I believe that we are going to transition and open it up for questions.

DAWN MORALES: Hello everyone. Excellent. I cannot seem to start my video, but I will use the audio instead. It is time for questions. We have already seen quite a few questions posted in the Q&A. We request that all the registrants, please continue those questions.

I will start by asking if Dr. Gordon has any questions for our panelists.

JOSHUA GORDON: I do. First, I wanted to thank all the panelists for really crystal clear and compelling presentations and also for the work you have put in to create a system that not only will answer questions for the future, but also provides services for the here and now, at the same time. While looking to address issues that I think are really key for NIMH to address across our portfolio, I am particularly impressed with the focus on cost-effectiveness and the recognition that demonstrating cost-effectiveness is not just about keeping costs down but also keep the effects high. I love the idea that you are using alternative methods to measure the impacts of the work that you are doing.

One of the questions that arises out of that is actually based on this fact that you are measuring a variety of outcomes. What sort of outcomes can we anticipate improving given the comprehensiveness of the interventions? One of the outcomes we are looking for is decreases is deaths from suicide, or suicide attempts and other suicide related behaviors that you are seeing for example, in the White Apache. You are creating a system that although it intervenes in those most at risk, it does not just focus, as you have quite eloquently stated, on suicide per se, but really tries to build resilience more globally. I am wondering what other kinds of outcomes you are seeing or you are measuring or you are planning on measuring, and how you anticipate they might be impacted by the systems of care that you are developing and improving upon?

DAWN MORALES: I was going to nominate Allison to answer that one, but you all may self-nominate.

ALLISON BARLOW: I will start and the I will pitch it over to my colleagues. I think what is so novel about this community-based surveillance system is we are getting population level data constantly through all the iterations of these randomized controlled trials, and other trials. I think that alone gives us an amazing platform to understand what is going on the population level. And be able to compare that to other populations in the United States, including American Indian/Alaskan Native, but also non-native populations that may be experiencing very different trends at the same time.

In terms of the outcomes that we are collecting directly from the hub, I will turn it over to Emily who is our evaluator to mention what those are.<.p>

EMILY HAROZ: The outcome measures, we have a pretty lengthy battery of assessment measures, but actually we did some initial qualitative work to adapt and to develop these measures. Our main outcome is the SIQ, suicide ideation, and our secondary resilience outcome is Prince-Embury scales, but those have been pretty heavily adapted. We are also focused on impulsivity, substance use, depression, and hopefulness, as well, and connectedness and cultural issues and interest and self-esteem. So we try and balance our assessment measures always with measuring strengths and mental health promotion protective factors with our risk scales.

Finally, one of the measures we developed locally similar to some of the depression vignette adaptation or ideation adaptations, was when our initial qualitative work showed that some of the items that our case managers brought up, is really important to focus on were not captured by existing scales. We put them into an existing secondary index to measure locally relevant outcomes. So some of the questions on there are related to – I take care of my health, I care about others, I like to understand how others are feeling, I have respect for tribal elders. These were outcomes that were really locally important to include and capture, and what case managers who had had experience piloting some of these interventions saw as changes in youth, positive changes in youth, due to the interventions. We will be measuring and tracking those as well.

ALLISON BARLOW: I think it is due to tribal sovereignty, and the forward thinking of the Apache community that this is again, against the backdrop of population suicide rates. So death rates, attempts, in addition to this measuring as our primary measure ideation and those who are participating.

DAWN MORALES: Super. Dr. Gordon, do you have any follow-up questions?

JOSHUA GORDON: I think it would be great to hear the panel respond to some of the questions from the audience.

DAWN MORALES: Great. This question might be for Dr. Cwik, we will see. What definition are you using for resilience? How is this measured as a secondary outcome in the study?

MARY CWIK: Thanks Dawn. I think that this is such a timely and pertinent question. To be honest, I don’t know if we have a great answer. We can tell you what scale we are using in our study. One thing we are struggling with, I think Victoria O'Keefe is really going to lead the future of some of this work at our Center, we use a lot of similar terms for things. We talk about protective factors, we talk about resilience, we talk about strength-based approaches. We think there are some overlaps there, but also some differences. When we first conceptualized the study, we thought resilience was the best thing capturing what the elder’s intervention is trying to do. We are refining now how we think about that. I really appreciate the audience members question about this, and I do not know – I know that Dr. Haroz and Dr. O’Keefe are also thinking a lot about this, I do not know if you guys would like to add anything here?

VICTORIA O’KEEFE: Sure. I think the way that indigenous communities define resilience or strengths is what we need to focus on. I think that is where some of our future work is going to really understand what are those mobile definitions within communities. I think within a lot of communities, you hear things like I am strong because of my ancestors. I am strong because of my family. I am connected to both my ancestors, in the past, and I’m connected to the current generation, and we are also doing this work for our future generations. There is this aspect of intergenerational connectedness that I do not think is always captured in Western definitions of resilience. We are excited to explore this new area in the future.

DAWN MORALES: Next question, which might be for Maryann and Allison. Who has control of the data collected and are the participants information and identification kept confidential? Who owns the end report? Again, you may self-nominate.

DR. BARLOW: The tribe owns the data. Which is true for every tribal community in the United States. If you ever learned that there is something arrived and it is really important that you investigate. But tribes are sovereign nations, they own their community’s data. The tribe has nominated our Center and the Celebrating Life team to manage that data. We are managing a secure database. All participant IDs are kept confidentially. What is unique, and this is a big evolution that I remember back in 2000 when this work started, we had people at NIH saying, this is crazy. This is a breach of confidentiality to understand someone attempted suicide, now you are sending out case managers to their home.

We had a delegation of White Mount Apache leaders who came to NIH to speak at the time, Dr. Cliff Guidry(phonetic) and others to say no, we are a sovereign nation. Every life is essential to our future. Our networks and our strengths depend on every individual living out the life that was intended by the creator, for that person.
I think now, the rest of the world is catching up to this idea of community-based surveillance and how powerful that can be. In a way, the participant, their specific data is protected but their identity in terms of follow-up in case management can't be. It is a balance in terms of – there is always the research side of looking at those risk protection factors and outcomes, which is an aggregate. In terms of the service, those participant IDs cannot be kept confidential. Which leads to a stigma question, I think is in the chat.

MARY CWIK: Allison, just to add, I think this goes without saying. All of the papers that you guys have seen cited throughout the presentation, there is a health board and a tribal Council that reviews all of those manuscripts when we are about to publish them, that gives us permission. They could deny that data to be published, they could ask for additions or changes that are obviously relevant. They have control of that process, as well.

DAWN MORALES: Our next question from our listeners is related to opioid use and assisted suicide risk. The question is could the panelist please speak to remaining evidence gaps with respect to opioid use and suicide risk?

MARY CWIK: You know who I would love to call on is Dr. Ivanich, to answer this. We have been working on some manuscripts around this topic and I am happy to tag team with you, Jerreed, if you like.

JERREED IVANICH: In terms of the remaining gaps, I think there is a lot to learn. To be honest, I think there is a lot of regional variations, community variations. I think one caveat to doing indigenous research is that everything has a big asterisk at the end that no community is the same. To assume that we know something that always generalizes everybody is somewhat naive at times, so I think there are commonalities and things we can learn and things that definitely may translate across communities. I think there is a lot for us to learn. We are trying are doing some work around understanding this as something that is intertwined, and related in terms of overdose, in terms of intentionality. I think there is a lot to learn, but I think that it is often times regionally specific, rates in one community don’t often transfer to what we understand in different communities for region around culture, how urban a community is, access to different drugs, and a host of other factors. I think there are factors both in terms of resilience that we do not really know, and I also think there are also some risk factors that we do not understand. I think there is some amazing work coming out of Oklahoma, but their communities look much more heterogeneous than some of the other communities that we work in, so what may work in Oklahoma for opioids and suicide risk may not work the same in the Southwest. I know it is a big punt to say that there is a lot to learn, but Mary, I don’t know if there is something you wanted to add to that as well.

MARY CWIK: I think you really did a nice summary. The one thing to add is there are some really innovative approaches happening across Indian country already, for opioid use. I don’t know that there are always out there in the research literature, and I think that could be a next step to really evaluate and highlight some of these innovative approaches that are already occurring. I wanted to add that.

ALLISON BARLOW: Our colleague Dr. Melissa Wells is leading a large opioid study that is really focusing on learning directly from opioid users and then working with tribal leaders to create new policies and going back to learn again from opioid users to see if those policies changed behaviors in access to care.

DAWN MORALES: Our next question might be for Dr. O'Keefe or for Mr. Garcia. How do you address the issue of stigma in helping the individual get help?

VICTORIA O’KEEFE: I wonder if Mitchell or Rose would be willing to talk about the question?

MITCHELL GARCIA: I can touch on it. I am sure, like a lot of other native communities, speaking about death or suicide is taboo for us. You do not talk about something in a way that you should not like talk about, and a lot of times the way my parents grew up was that you do not talk about suicide. It is something that you are not supposed to talk about.

But now, the way things are going, it seems a lot of youth are now opening up to talking about what exactly bothers them, and that is something we had to build rapport with these people, or individuals that are struggling. Just constantly seeing us and knowing that we are not just there for one time, and we are not going back again. We are constantly checking in on them, even outside of work, if we see them at the store, we still say hello to them.

We are not just here for the research purposes. Me and Rose live here. Because of that, we will do our best to be sure that these people know that we really care about them, we are not just here just to get paid. If we are here just for that, this job would have treated us like gum and spit us out easy because it does get difficult, and hard here on the reservation when it comes to suicide. Some people that we try to go see, like I shared earlier, we try to keep the community basis here and some of these staff leapfrog, so to speak, on individuals who are still struggling. So the more that they see us constantly trying to go and meet with these individuals, the more that ideation kind of dies down a little bit to where people want help, and it is no longer seen as something that is bad, but knowing that there are people who are willing to listen. Hopefully I answered that question.

DAWN MORALES: Thank you very much. I think you have done a great job. This next question might well suit Jerreed or Victoria, I am not sure. The question is I am thinking of an example of a young man who was taking opioids just to get high. Have there been interventions based on healthy traditional ways to alter the mind? i.e., chanting, ceremony, dancing, et cetera, and presented to the youth in that way, this will alter your mind. I am thinking of my culture of mindfulness, meditation, and guided meditation. Does anybody want to try for that?

VICTORIA O'KEEFE: I can start. There are a lot of outside of our Center, there are a lot of culturally grounded interventions. One that I am thinking of is Dr. Karina Walters Yappalli Project, which is re-walking the Trail of Tears for Choctaw community members and really understanding their history, and their culture, and what it means for their lives, as an intervention for substance use, as well as healthy behaviors to prevent diabetes, and other outcomes. I think there are a lot of interventions that are really harnessing some traditions, and then of course there are a lot of communities that have their own ceremonies, and their own ways of addressing any type of health or wellness issue. Those are things we may not see in the literature, or things that are open to study, I think that is something we also have to respect with a lot of our communities, is are there things we can pull out for an intervention. Are there things we can study? And we really have to learn from our elders and traditional healers about what is appropriate, and what is not appropriate to share.

DAWN MORALES: Thank you very much, Dr. O'Keefe. Next question, how do we transition from adapted Western models to ground up models? What are potential barriers to overcome in order to do so?

JERREED IVANICH: I would love to chime in quickly. I think it is this right here, us talking about it. Us acknowledging that is an important avenue of research that we need to change that trajectory. Far too often, it has been rooted in this idea of evidence-based large-scale randomized control trials, as the gold standard. As we learn more from our community members as we work in amazing teams like this, to do important work with community members, I think we are finding that there is strength there and that there are different approaches that can be taken.

I think that things like this, these efforts are leading to the next generation. It is an exciting time to see what that would look like. As Victoria mentioned, I think there are other colleagues already doing that in Hawaii, New Zealand, and elsewhere, that we can also learn from. I think it is not just an us thing, I think we have lots of partners. I think it is exciting.

EMILY HAROZ: I would also mention, JD, some of this approach, this very movement that JD just highlighted, I think it is really relevant to other communities and populations across the country and the world. I think we have been very stuck in this Western framework and paradigm. That does not always resonate. I am thinking about some of these panel discussions we just participated on on black preteen suicide, and the same idea of these models sometimes don’t always fit communities. So just always thinking about that and questioning where do the models come from? Is this the right model? Does this actually explore? And be very open to qualitative methods and inquiry and doing that through real authentic partnership I think that is something to really start moving this field in that direction, as well.

DAWN MORALES: One minute left, but I think we can fit one last one. Is there anything that has been gained in your study that can be applied to the general populations in reducing suicide? Anything that stands out?

ALLISON BARLOW: Everything! That is the answer. That is what we are trying to tell the story of COVID. Native communities have led our country in developing really creative innovations to address COVID on a community basis. The same is happening now with suicide. I think getting down to individual mechanisms is not going to solve the problem. We have to fan out, listen to communities, and do community-based efforts that are embedded in the strengths, and our forecasting for the future. There is so much to learn from indigenous peoples about suicide prevention. I hope the world will listen.

DAWN MORALES: Thank you, very much, Dr. Barlow, those are very splendid words. That is all the time we have for questions. We do have the ability to download the questions and comments from the Q&A and we do intend to read those. We may be able to generate a general set of answers for them, and share those with the email list generated by the registrants.

With that, I would like to solemnly thank all of the people, community members, indigenous knowledge holders, scientists, families, tribal leaders, and so many others who have contributed to this work, and shown the strength in the face of challenge, as well as to our speakers and all the staff involved in this webinar. Anyone else? Thank you very much.

(The webinar adjourned.)