Suicide Among American Indian and Alaska Native Veterans Who Use Veterans Health Administration Care: 2004-2018.

BACKGROUND: American Indian and Alaska Natives (AI/ANs) veterans may be at elevated risk for suicide, but little is known about suicide among this population. METHODS: We conducted a retrospective cohort analysis of AI/AN veterans who received health care services provided or paid for by the Veterans Health Administration (VHA) between October 1, 2002, and September 30, 2014, and who were alive as of September 30, 2003. Age-specific and age-adjusted suicide rates through 2018, per 100,000 person-years (PY) at risk and 95% confidence intervals were computed. RESULTS: Age-adjusted suicide rates among AI/AN veterans in this cohort more than doubled (19.1-47.0/100,000 PY) over the 15-year observation period. In the most recent observation period (2014-2018), the age-adjusted suicide rate was 47.0 per 100,000 PY, with the youngest age group (18-39) exhibiting the highest suicide rate (66.0/100,000 PY). The most frequently used lethal means was firearms (58.8%), followed by suffocation (19.3%), poisoning (17.2%), and other (4.7%). CONCLUSIONS: Results suggest that: (1) suicide is an increasing problem among AI/AN VHA veterans; and (2) younger AI/AN VHA veterans are at particularly high risk and warrant focused prevention efforts. Findings are similar to those observed in general AI/AN population. There is a compelling need to review and strengthen VHA suicide prevention efforts directed towards AI/AN veterans.

Suicide-related behaviors among American Indian and Alaska Native Veterans: A population-based analysis.

American Indian and Alaska Native (AI/AN) Veterans are at elevated risk for suicide, but currently, no population-based research exists on precursors, including ideation, plans, or attempts. We employed two large national surveys to investigate the occurrence of suicide-related behaviors among AI/AN Veterans. Using cross-sectional data from the Behavioral Risk Factor Surveillance System (BRFSS, 2010-2012) and National Survey on Drug Use and Health (NSDUH, 2010-2015), we compared weighted frequencies of suicide ideation in AI/AN Veterans and non-Hispanic White (NHW) Veterans. Suicide ideation among AI/AN Veterans was 9.1% (95%CI = 3.6%, 21.5%) and 8.9% (95%CI = 1.9%, 15.9%) in BRFSS and NSDUH, respectively, compared to 3.5% (95%CI = 3.0%, 4.1%) and 3.7% (95%CI = 3.0%, 4.4%) for NHW Veterans. Logit analysis suggested higher odds of ideation among AI/AN Veterans in both samples (NDSUH: OR = 2.68, 95%CI = 1.14-6.31; BRFSS: OR = 2.66, 95% CI 0.96-7.38), although sample sizes were small and confidence intervals were wide. Consistent findings from two national samples suggest AI/AN Veterans have more than twice the risk of suicide ideation relative to NHW Veterans. Ongoing efforts include weighing these results together with data on suicide deaths from medical and death records to develop effective suicide prevention approaches in collaboration with AI/AN Veterans and their communities.

"We're Afraid to Say Suicide": Stigma as a Barrier to Implementing a Community-Based Suicide Prevention Program for Rural Veterans.

Suicide is a significant public health concern for veterans residing in rural communities. Although various initiatives have been implemented to prevent suicide among veterans, efforts specific to rural veterans remain limited. To aid such efforts, we examined stigma as a potential barrier to community readiness in the implementation of a community-based suicide prevention program for rural veterans. In this qualitative study, community readiness interviews were conducted with 13 participants in a rural community. Themes included lack of awareness regarding veteran suicide, rare discussions of veteran suicide, and suicide-related stigma within the community. Results suggest that prioritizing destigmatization may be particularly important to implementing community-based suicide prevention programming in rural communities. In particular, addressing community misconceptions regarding veteran suicide, while increasing knowledge of the extent to which veteran suicide occurs locally may facilitate increased awareness and thus community readiness to prevent suicide among rural veterans.

A community's response to suicide through public art: stakeholder perspectives from the Finding the Light Within project.

Suicide is a preventable public health problem and a leading cause of death in the United States. Despite recognized need for community-based strategies for suicide prevention, most suicide prevention programs focus on individual-level change. This article presents seven first person accounts of Finding the Light Within, a community mobilization initiative to reduce the stigma associated with suicide through public arts participation that took place in Philadelphia, Pennsylvania from 2011 through 2012. The stigma associated with suicide is a major challenge to suicide prevention, erecting social barriers to effective prevention and treatment and enhancing risk factors for people struggling with suicidal ideation and recovery after losing a loved one to suicide. This project engaged a large and diverse audience and built a new community around suicide prevention through participatory public art, including community design and production of a large public mural about suicide, storytelling and art workshops, and a storytelling website. We present this project as a model for how arts participation can address suicide on multiple fronts-from raising awareness and reducing stigma, to promoting community recovery, to providing healing for people and communities in need.

A scoping review of veteran suicide prevention programs in Native American communities and in the general population.

Suicide is a major public health problem that disproportionately impacts veterans in the general U.S. population. Recent analyses indicate that American Indian and Alaska Native (AI/AN) veterans may be two to three times as likely as non-Hispanic White veterans to experience suicidal ideation. Although suicide prevention programs have been successfully implemented for many at-risk populations, to our knowledge, none have been designed or implemented for AI/AN veterans. To address this gap, we conducted a scoping review of suicide prevention programs with the objective of identifying promising strategies and lessons learned to identify promising practices for preventing suicide among AI/AN veterans. We conducted two parallel literature searches-a review of suicide prevention programs for the general U.S. adult population and AI/AN communities. We rated programs on 16 criteria, covering five domains-best practices in suicide prevention, U.S. Department of Veterans Affairs (VA) Office of Rural Health Promising Practice criteria, cultural fit, care coordination, and outcomes. Our findings indicate that many of the VA evidence-based or best practice programs are available system-wide, but none have been tailored for AI/AN veterans or the communities in which they live. Conversely, we found that many culturally specific programs implemented in AI/AN communities were rarely disseminated beyond tribal land and none were specifically developed for veterans. Based upon these findings, and to advance suicide prevention programs for AI/AN veterans, we propose a suicide prevention model that builds upon existing VA infrastructure to disseminate best practices to AI/AN communities and integrate tribal-specific cultural approaches to suicide prevention. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Assessment of awareness of connectedness as a culturally-based protective factor for Alaska native youth.

Research with Native Americans has identified connectedness as a culturally based protective factor against substance abuse and suicide. Connectedness refers to the interrelated welfare of the individual, one's family, one's community, and the natural environment. We developed an 18-item quantitative assessment of awareness of connectedness and tested it with 284 Alaska Native youth. Evaluation with confirmatory factor analysis and item response theory identified a 12-item subset that functions satisfactorily in a second-order four-factor model. The proposed Awareness of Connectedness Scale (ACS) displays good convergent and discriminant validity, and correlates positively with hypothesized protective factors such as reasons for living and communal mastery. The measure has utility in the study of culture-specific protective factors and as an outcomes measure for behavioral health programs with Native American youth.

Engaging Those Living With Moderate to Severe TBI and Their Caregivers in Research.

Despite the fact that millions of individuals living in the United States are coping with disabilities associated with traumatic brain injury (TBI), limited work has explored strategies for patient engagement in research among those with such injuries. The Coalition for Recovery and Innovation in Traumatic Brain Injury Care Across the Lifespan (CRITICAL) brought together those living with TBI, caregivers, clinicians, researchers, and advocates with the goal of developing a new patient-centered research agenda. This platform was also used to explore strategies to engage those with moderate to severe TBI in the research process. The CRITICAL was formed of 6 survivors of moderate to severe TBI, 2 caregivers of survivors of moderate to severe TBI, and 8 TBI professionals. The CRITICAL identified 3 priority topic areas: Relationship Quality, Caregiver Needs, and Thriving. Furthermore, strategies associated with Communication, Preparation, and the Environment facilitated research engagement. Employing the strategies outlined in this article is expected to promote patient engagement in clinical research, which can improve patient-centered interventions and outcomes for individuals living with TBI.

Veteran peer suicide prevention: A community-based peer prevention model.

OBJECTIVE: The purpose of this study was to develop a conceptual model of community-based veteran peer suicide prevention. METHOD: We conducted a qualitative study in which semi-structured interviews were followed by three focus groups. Participants (n = 17) were chosen from community-based organizations who had peers working on veteran suicide prevention; the sample included veteran peers, non-peers, program managers, and community stakeholders. Interview data were analyzed thematically and inductively to identify key components and subcomponents of veteran peer suicide prevention. A draft model was shared with each focus group to elicit feedback and refine key concepts. RESULTS: A conceptual model containing nine components and twenty-six subcomponents was developed. Participants emphasized key organizational, relational, and practical elements needed to achieve positive outcomes. In addition, they described critical contextual and cultural factors that impacted veteran peers' ability to prevent suicide and promote overall wellness. CONCLUSIONS: Community-based veteran peer efforts are a promising public health approach to preventing veteran suicide. Provided veteran peers are supported and fully allowed to contribute, these efforts can complement existing clinic-based efforts. Future research on community-based veteran peer suicide prevention should document a range of outcomes (e.g., clinical, wellness, financial) and allow for considerable flexibility in peer approaches.

Reducing rural veteran suicides: Navigating geospatial and community contexts for scaling up a national Veterans Affairs program.

OBJECTIVE: To develop and use planning maps to prioritize and facilitate county-level recruitment for Together With Veterans (TWV), community-based rural Veteran suicide prevention program. METHOD: Choropleth maps were created for 49 U.S. states, with four mutually exclusive categories indicating eligibility for the TWV program and increasing levels of need assigned to each county based on (a) percent Veterans Health Administration enrollees residing in rural communities, (b) percent population that are Veterans, and (c) crude suicide mortality rate. RESULTS: Of 3113 counties, 78.2% were eligible for TWV and 25.8% met our highest priority definition. A national map and state map were provided to demonstrate final products used to engage stakeholders. A table of recommendations for creating and using planning maps was provided for future projects to reference. CONCLUSIONS: Geographic information system (GIS) is useful for identifying and prioritizing counties that may benefit most from a rural Veteran suicide prevention program. Choropleth maps allow for dissemination of information about county suicide risk and need for suicide prevention to community members, researchers, and others with a vested interest in suicide reduction. The maps are one tool among many which can support decision-makers in focusing available resources on populations with the most need.

A Systematic Review of Factors Impacting Suicide Risk Among Rural Adults in the United States.

PURPOSE: Suicide rates continue to be significantly higher in rural compared to urban communities in the United States, with the suicide rate disparity continuing to grow since 1999. This systematic review synthesizes rural-specific factors related to increased suicide risk. METHODS: OVID Medline, EMBASE, OVID PsycINFO, Web of Science, SocINDEX, Cochrane Library, and Google Scholar were searched for articles published after 2003 investigating rural adult suicide in the United States. Selection criteria were: (1) study participants > 18 years old; (2) included rural participants or communities; (3) included suicidal self-directed violence outcomes; (4) within the United States; (5) published after 2003; (6) presented peer-reviewed original data; (7) identified rural-specific risk or protective factors for suicide or barriers to treatment. FINDINGS: Of the 1,058 records screened, 34 studies were included. The strength of evidence was relatively stronger for individual level factors including lethal means, alcohol and substance use. CONCLUSIONS: Access to firearms is strongly related to elevated rural US suicide rates, with substance use, economic stress, and behavioral health care utilization as additional individual level factors that may contribute to the disparity. At the community level, economic distress and access to care were commonly identified factors. Future research should better quantify how risk factors contribute to rural suicide and examine interdependence across social-ecological levels. Suicide prevention efforts for the rural United States must address access to lethal means, in particular the use of firearms, and navigate limited access to quality behavioral health care.

Together With Veterans: VA National Strategy Alignment and Lessons Learned from Community-Based Suicide Prevention for Rural Veterans.

BACKGROUND: Rural veterans are at increased risk for dying by suicide compared with urban veterans, yet interventions for preventing suicide among rural veterans have been limited. OBJECTIVES: (1) Describe how Together With Veterans (TWV), a community-based intervention to prevent suicide among veterans in rural communities, aligns with the VA National Strategy for Preventing Veteran Suicide; (2) share lessons learned while beginning to implement TWV in rural communities. METHODS: Together With Veterans is being implemented in four rural communities and comprises six suicide prevention best practices: (1) reducing stigma and promoting help-seeking; (2) lethal means safety, with an emphasis on firearms; (3) gatekeeper training; (4) training primary care providers; (5) improving access to crisis services; and (6) enhancing support for high-risk veterans. RESULTS: Together With Veterans best practices align with most, but not all, of the strategies in the VA National Strategy for Preventing Veteran Suicide. Community veteran partners have shown a willingness to collaborate and provide local leadership, enthusiasm, and a sense of duty. CONCLUSIONS: By supporting and facilitating local veteran leaders and their community partners in increasing suicide prevention knowledge, public awareness, and resources, we propose that TWV offers an acceptable and feasible approach that builds on the strengths of rural communities. Systematic evaluation is warranted.

A menu of options: Resources for preventing veteran suicide in rural communities.

Suicide rates are higher in rural communities than in their urban counterparts. Of particular concern are veterans residing in rural communities, who have a 20% higher risk of dying by suicide than veterans who live in urban areas. The objective of this manuscript is to assess the availability of evidence-based and promising practices to support a community-based suicide prevention effort for rural veterans. We compiled a compendium of evidence-based and promising practices-the "menu of options"-with resources across 4 levels: increasing access to crisis services, enhancing primary care suicide prevention, training community members, and raising public awareness. We compiled resources from multiple sources, then reviewed and rated each one to arrive at consensus on the final selections. The final menu includes 70 resources. However, only 20 are tailored for veterans, only one for rural communities, and none for rural veterans. More research is needed to identify effective strategies and develop rural-tailored resources for preventing suicide among this unique and often underserved population. The menu of options represents a first step toward developing an approach to rural veteran-suicide prevention that aligns with evidence-based practice, theory, and a public health model for suicide prevention. (PsycINFO Database Record