Zero Suicide Plus KICKS
Condition: Suicide; Suicidal Ideation; Suicidal Intention; Suicidal and Self-injurious Behavior
MeSH terms: Suicide; Suicidal Ideation; Self-Injurious Behavior
Study type: Interventional

Summary: 
      Integrating Intergenerational Cultural Knowledge Exchange with Zero Suicide is an innovative
      study in a Southwestern tribal nation that incorporates Zero Suicide into Indian Health
      Services (IHS) primary care settings. The goal of this study is to determine the
      effectiveness of Zero Suicide plus a cultural component (ZS+) (experimental group) compared
      to Zero Suicide (ZS) alone (control group) on suicidal ideation, behaviors, and resiliency in
      a randomized control trial of 138 AI youth ages 12-24 at two rural IHS clinics on the Pueblo
      of San Felipe. The long-term goal of this study is to determine which is more effective at
      reducing suicidal ideation and behaviors and increasing resiliency, ZS+ or ZS alone. Year 1
      will focus on training providers on the Zero Suicide model and manualizing the Katishtya
      Intergenerational Culture Knowledge Seminars (KICKS) curriculum that was piloted and
      positively evaluated over the past three summers as a cultural module to improve the adoption
      and acceptability of Zero Suicide. Years 2-4 will focus on participant recruitment,
      assignment to experimental and control groups, and implementation. Year 5 will focus on data
      analysis and dissemination. Data will be collected from all experimental and control group
      participants at 4 time points: baseline, 12-weeks, 6-months and 9-months to explore the
      effects of the intervention over time. The central hypothesis is that ZS+ will be more
      effective then ZS alone. The investigators propose three aims: (1) Specific Aim 1: Using
      Community Based Participatory Research (CBPR), partner with tribal stakeholders and
      researchers to formally manualize the KICKS cultural module for Zero Suicide (ZS+); (2)
      Specific Aim 2: To determine if adding a cultural component to the Zero Suicide model is more
      effective at reducing risk factors and increasing resiliency in AI youth than Zero Suicide
      alone; and (3) Specific Aim 3: Determine the essential features of the KICKS module for
      adaptation by other tribes and disseminate the model.
    

Detailed description: 
      Across the nation, suicide is the second leading cause of death in youth 10-24 years old.
      This public health crisis is particularly acute in American Indian (AI) communities where the
      suicide rate is 50% higher than that of non-Hispanic Whites. From 2009-2012, the age-adjusted
      suicide rate for American Indian/Alaska Native youth ages 10-24 years old was alarmingly
      higher than the overall rate for youth in this same age group nationally (14.66/100,000 vs.
      8.25/100,000). In New Mexico (NM), the youth suicide rate is consistently at least 1.5 times
      the U.S. rate at 14.2/100,000, which is 75% higher than the national average. Importantly, NM
      has the highest proportionate AI population in the continental USA, and among the 22 tribes
      in NM the youth suicide rate is even greater (21.4/100,000). Also in NM, the percent of
      deaths due to suicide among AI youth by age range compared to all races is 29% vs.13% for
      ages 10-14, 32% vs.18% for ages 15-19, and 25% vs.16.5% for ages 20-24.3 The Pueblo of San
      Felipe, a tribal nation in NM and the target population for the proposed study, has
      incredibly high rates of suicidal ideation and behavior with 21.8% of students reporting that
      they seriously considered suicide, 14.9% reporting that they made a suicide plan, and 11.6%
      reporting that they attempted suicide in the past year compared to 19%, 11.3%, and 7%
      respectively statewide. A recent school needs assessment of over 300 students found even
      higher rates, as 40% of youth expressed feeling frequently depressed within the last year,
      17% reported feeling sad or depressed most or all of the time within the last month, and 30%
      noted they attempted suicide one or more times within the last month. Thus, suicide is of
      grave concern to tribal communities in NM, especially the Pueblo of San Felipe, and
      developing systematic strategies for reducing suicide among AI youth is of utmost importance.

      Risk Factors Associated with Youth Suicide. The probability of attempting suicide has been
      found to dramatically increase as the number of risk factors increases. Research on suicidal
      behavior in youth indicates that the odds of experiencing suicidal ideation and/or suicide
      attempts are nearly three times more likely if the youth is using alcohol. Even more
      concerning is that the odds of a completed suicide are five to 13 times greater for youth
      diagnosed with a substance use disorder.6 Furthermore, lethality of suicide attempts
      increases with alcohol use, and 40% of suicide attempts and 37% of suicides preceded by acute
      use of alcohol. While depression is associated with suicidal behavior, depression predicts
      suicide attempts significantly less well when controlling for substance use. Similarly,
      exposure to violence, including domestic and intimate partner violence, increases the
      probability of suicidal ideation and behaviors, as does historical trauma (defined as the
      cumulative emotional and psychological wounding across generations which emanates from
      massive group trauma). Unfortunately, AI youth experience exceptionally high rates of these
      risk factors, including substance abuse, exposure to violence, and the profound repercussions
      of historical trauma (domestic violence, abuse, etc.). The proposed study addresses risk
      factors by incorporating these topics into the cultural component of the intervention known
      as Katishtya Intergenerational Culture Knowledge Seminars (KICKS), as they are NOT addressed
      in Zero Suicide.

      Resiliency as a Buffer. Resilience is also a critical component of suicide prevention.
      Buffering is the idea that having resources, such as social support or cultural grounding,
      can mitigate against adverse stressful events.16 The Buffering Hypothesis is a model linking
      resilience to suicidality that focuses on beliefs, which buffer individuals in the face of
      stressors. Resilience factors are viewed as existing on a separate dimension to risk which
      act to moderate the impact of suicidality. The presence of these factors results in
      resilience and the absence increases risk for suicidality. Resiliency factors include
      internal protective factors (positive beliefs or feelings about oneself and satisfaction with
      life), external protective factors (ability to seek resources helpful when faced with
      personal difficulties), and emotional stability (positive beliefs about one's ability to
      regulate suicide-related thoughts and behaviors when confronting emotionally distressing
      events). Importantly, research shows that increasing protective factors can be more effective
      at reducing the probability of suicide attempts for AI youth then decreasing risk factors,
      and other studies indicate that interventions are only effective to the extent that they
      recognize and promote AI cultural values, traditional practices, and cultural identity
      development. Thus, to improve suicide prevention program acceptability and adoption it is
      critical to include culturally relevant strength-based and resilience focused components to
      suicide prevention models.

      Relationship between Suicide and Health Disparities. Health disparities are "preventable
      differences in the burden of disease, injury, violence, or opportunities to achieve optimal
      health that are experienced by socially disadvantaged populations". Barriers to mental health
      care utilization for AI youth include: lack of culturally competent treatment providers, a
      general mistrust in services provided within a Western medical model, and personal
      experiences of discrimination in health care settings. These barriers have been found to
      reduce the likelihood of seeking care, even when suicidal ideation or behaviors are present,
      thus, contributing to the higher incidence of youth suicide in AI communities. The proposed
      study addresses disparities in access and acceptability by adding a cultural component to the
      Zero Suicide model.

      Call to Develop and Test Innovative Suicide Prevention Models. In 2014, the National Action
      Alliance for Suicide Prevention's Research Prioritization Task Force published strong
      recommendations regarding the need to develop and test feasible and effective suicide
      prevention interventions. Although there have been considerable studies focusing on youth
      suicide prevention there is insufficient evidence to know which strategies are most effective
      in preventing suicide among AI populations. Importantly, AI adolescents experience
      significant risk factors for suicide, including substance abuse and exposure to violence
      (e.g., physical and sexual violence, domestic violence, intimate partner violence, and
      premature death of relatives due to violence, accidents, or suicide).5 Although suicide
      prevention has been shown effective in reducing suicidal ideation and behaviors with youth,
      there are limited Randomized Control Trials (RCTs) focused on preventing suicide attempts in
      AI youth populations, thus it is unclear whether the results of previous studies are
      generalizable. Critically, examining the effect of suicide prevention interventions in AI
      primary care settings is vital as the majority of individuals who die by suicide (80%) have
      contact with a primary care clinician or Emergency Department (ED) in the year prior to
      death. There is promising research on the effectiveness of Zero Suicide (ZS), a
      population-based model implemented through a large HMO system in the Midwest. However, ZS has
      not been studied with AI populations or in tribally-based Indian Health Service (IHS) primary
      care settings. Additionally, ZS does not include culturally-adapted interventions, which have
      been found to produce larger effect sizes than un-adapted interventions for minority
      populations.

      The Zero Suicide Model. ZS is a population health-based approach to suicide prevention
      underscoring the belief that suicide deaths are preventable and that individuals are often
      not recognized in fragmented, busy health care systems.27 Studies of the Perfect Depression
      Care program, the precursor to ZS, showed significant findings including an 82% decrease in
      suicide deaths between baseline and intervention in a large urban Midwest health System. ZS
      has seven essential elements for health care systems, including: (1) Lead- create a
      leadership-driven, safety-oriented culture committed to reducing suicide for people under
      care; (2) Train- develop a workforce that understands and responds to depression and suicidal
      behaviors; (3) Identify- universally screen and assess suicide risk; (4) Engage- ensure every
      individual has timely and adequate pathways to care and includes a brief safety plan (5)
      Treat- use effective, evidence-based treatment, such as Cognitive Behavioral Therapy-Suicide
      Prevention (CBT-SP), to target suicidal ideation and behaviors; (6) Transition- provide
      continuous contact and support, especially after acute care; and (7) Improve- apply a
      data-driven quality improvement approach to inform system change and improve patient
      outcomes. The ZS toolkit provides resources on these elements, including training manuals, an
      organizational self-study, work plan template, and consumer engagement strategies. The need
      for consideration of cultural adaptation is indicated (zerosuicide.sprc.org) but not
      specified.

      Importantly, data is available on the effectiveness of each of the ZS elements. For instance,
      training with booster sessions for healthcare professionals in primary care and ED settings
      has been found to improve identification of suicide warning signs and willingness to refer
      patients for mental health services, and to reduce suicidal behavior in situations where the
      roles of gatekeepers are formalized and access to treatment is readily available. Findings
      also support the importance of integrating brief universal screening in primary care settings
      to quickly identify at-risk individuals and prompt healthcare professionals to make
      referrals. Research found that there was a four-fold increase in the detection of suicidal
      ideation by pediatricians when screening tools were used in outpatient clinics. Additionally,
      pediatric ED studies show screening for suicide risk can reveal previously undetected
      suicidal ideation in youth presenting with medical complaints. Importantly, screening must
      confidently rule out patients with no appreciable risk, and balance feasibility with
      effectiveness. Finally, research supports the importance of feasible and acceptable treatment
      such as CBT-SP for those identified as being at risk for suicidal ideation or behaviors.
      CBT-SP has been found to result in a greater reduction of suicidal ideation than treatment as
      usual, and consists of a chain analysis of the index suicide attempt, and development of a
      safety plan and individualized treatment plan to reduce reattempts.

      Implementation of ZS in AI Communities is NOT Enough. Importantly, implementing ZS in tribal
      communities requires cultural adaptation. As noted earlier, culturally-adapted interventions
      have been found to produce larger effect sizes than un-adapted interventions for minority
      populations. In addition, research indicates that substance abuse and exposure to trauma are
      significant risk factors impacting suicide in AI youth. Finally, strengthening protective
      factors may be more important than reducing risk factors in addressing suicide for AI youth.
      ZS does not focus on reducing risk factors and increasing resiliency. The proposed study
      incorporates all of these elements into the KICKS component, thereby increasing the
      appropriateness and acceptability of ZS for AI populations.

      Importance of Cultural Adaptations to Improve Suicide Outcomes among AI Youth. For ZS to be
      adopted, implemented, and sustained in tribal communities, cultural consideration is
      critical. Two large studies found that for AI youth strengthening protective factors may be
      more important than reducing risk factors in addressing suicide, and mentoring from parents,
      extended family, teachers, and friends helps AI youth overcome failure, succeed in school,
      and develop resiliency. Engaging youth in teachings on traditional narratives, beliefs and
      practices, and intergenerational approaches that focus on communication and awareness across
      generations have also been found to increase resiliency. Moreover, research demonstrates that
      elders play a critical role in fostering resilience by providing mentoring, teaching, and
      social support to AI youth through transmission of valuable cultural beliefs, traditions, and
      practices. The proposed study incorporates all of these elements to reduce suicidal ideation
      and behaviors and increase resiliency.

      Katishtya Intergenerational Culture Knowledge Seminars (KICKS) Cultural Adaptation. The
      cultural adaptation proposed in this study is the Katishtya Intergenerational Culture
      Knowledge Seminars (KICKS), an intergenerational program to promote resiliency and positive
      connections between San Felipe youth and elders. Over the past three years, San Felipe
      developed and piloted KICKS, where elders share traditional culture, language, lifeways, and
      history with San Felipe youth in an eight-week daily seminar. KICKS was developed to improve
      resiliency through exposure to intergenerational cultural teachings, and preliminary data
      indicates that over 90% of youth felt they acquired substantial knowledge of each of the
      traditional activities, indicating that KICKS fostered learning and resiliency. Well received
      by tribal members and tribal leadership, KICKS is a perfect cultural module to increase
      resiliency and improve acceptability and adoption of ZS.

      Partnership as a Predictor of Behavioral Health Outcomes. Another potential variable is the
      quality of stakeholder partnerships. In the last decade, the literature on CBPR has moved
      beyond a focus on partnership processes and improved success at recruiting participants, to
      recognizing the significant evidence of its impact on health outcomes. Adherence to CBPR
      principles and strategies show positive impacts on health behavior, self-efficacies,
      perceived social support, empowerment, and improved health status; as well as improved
      policies to reduce health inequities. Mental health outcomes in particular have been shown in
      the community engagement arm of an extensive RCT. UNM's ten-year study on quantitative and
      qualitative methods to assess partnering processes and their associations with outcomes will
      prove invaluable for measuring the quality and impact of the community partnership in San
      Felipe. These assessments will be critical to determine the partnership's impact on the
      identified outcomes. They will also support a mutual iterative learning process that will
      contribute to ongoing research capacity building within the tribe itself for greater
      sustainability of the intervention over time.

      Benefits of Transdisciplinary, Multi-Level and Multi-Domain Interventions. Finally, in
      perfect alignment with the mission of the Transdisciplinary Research, Equity and Engagement
      Center for Behavioral Health (TREE Center), Integrating Intergenerational Cultural Knowledge
      Exchange with Zero Suicide is a transdisciplinary, multi-level suicide prevention
      intervention study that addresses resiliency and risk factors related to AI youth suicidal
      ideation and behaviors. Effective health disparities interventions benefit from
      transdisciplinary, multi-level and multi-domain components. The transdisciplinary research
      team represents disciplines across the University (e.g., Psychology, Psychiatry, Public
      Health, Clinical and Translational Sciences) as well as community partners across
      child-serving tribal programs (e.g., Primary Care, Behavioral Health, Education, Social
      Services) collaborating on the creation of an innovative AI youth suicide prevention model.
      This also study employs a multi-level intervention approach. The first level is the
      Individual level (youth who receive universal screens and participate in the ZS or ZS+
      intervention). The second is the Group level (KICKS is provided in a group format), and the
      third is the Community level (elders who participate in the KICKS module, school impacted by
      providing universal screens at the SBCH, and larger community impacted through ZS
      implementation in all primary care settings). This multi-level approach enables us to
      understand issues of inequities in health and monitor the outcome of the intervention across
      levels. This study also aims to reduce behavioral health disparities by simultaneously
      addressing the needs and stressors of AI youth across multiple domains including behavioral,
      sociocultural and health care system.

      Summary. Because suicide is a low base rate behavior, very large samples are needed to
      conduct adequately powered suicide prevention trials. Suicidal ideation and behavior,
      however, are often warning signs of completed suicide, making it especially important to
      target in intervention studies. Given the research supporting ZS and the fact that Indian
      Health Services (IHS) identified "Zero Suicide [as] a call to relentlessly pursue a reduction
      in suicide for those who come to us for care," there is a clear recognition that ZS is a
      promising practice for tribal behavioral health. However, resilience-focused approaches, such
      as KICKS, must be included, as must reduction of risk factors related to substance abuse and
      violence. Thus, the current proposal will examine differences in reducing suicidal ideation
      and behaviors, and increasing resiliency for AI youth who participate in ZS vs. ZS+.

      APPROACH Study Overview. The proposed project will manualize the KICKS module and then
      conduct a Randomized-Controlled Trial (RCT) of Zero Suicide (ZS) and Zero Suicide plus
      Katishtya Intergenerational Culture Knowledge Seminars (ZS+) in AI youth ages 12-24 years old
      from the Pueblo of San Felipe. It is transdisciplinary and multi-level collaborative research
      project between the University of New Mexico, the Pueblo of San Felipe, IHS clinics; and
      community stakeholders (e.g., youth, elders, family members, health care providers, tribal
      leadership).

      Community Advisory Committee. The investigators will form a Community Advisory Committee
      (CAC) for this study in San Felipe comprised of tribal program representatives from
      Behavioral Health, Primary Care, Social Services, Schools, Recreation, Tribal Leadership, UNM
      researchers, other stakeholders. Dr. Altschul (MPI) and Ms. Tenorio (PD) will use a CBPR
      approach to co-facilitate the CAC and guide all aspects of the study including, refining data
      collection methods, participant recruitment, implementation, data analysis, and
      dissemination. One CAC member will also serve on the NM TREE Center Community Scientific
      Advisory Council.

      Specific Aim 1: Using CBPR, partner with tribal stakeholders and researchers to formally
      manualize the KICKS cultural module for Zero Suicide (ZS+). The objective of Specific Aim 1
      is to develop a manual for the KICKS cultural module of ZS+ using a CBPR approach. To obtain
      this objective the investigators will develop a community-based workgroup, the KICKS Review
      Committee, to collaboratively formalize the KICKS module. The rationale for this Aim is that
      having a manualized intervention will increase fidelity to the KICKS module, and ensure
      delivery that is culturally appropriate, feasible, and effective. When the proposed research
      for this Aim has been completed, the investigators expect to have a formalized manual that
      will be used to consistently implement KICKS and to test Specific Aim 2 to compare
      implementation of ZS+ vs. ZS alone in the San Felipe IHS clinics.

      Research Design and Method. KICKS was developed in 2014 for youth to see that cultural
      knowledge is key to resiliency, language is vital to maintain traditions, and Native people
      were given many gifts from the Creator, including natural supports and protective factors,
      that enabled their survival for centuries. Youth and elders met daily for 8-weeks and
      participated in Keres language instruction, traditional storytelling, Pueblo history,
      traditional dances, crafts, and visiting traditional and cultural sites. Youth learned about
      proper introductions using AI name and clan; the traditional naming process; family
      extensions/kinship; types and uses of corn; Pueblo history including emergence, migration and
      settlement; traditional prayer; clan responsibilities; traditional crafts (pouches, arrows,
      dance regalia); language and item identification; respect, acknowledgement, acts of kindness,
      and cultural responsibilities; traditional dances, including regalia
      identification/significance; and traditional cooking, sewing, and pottery making. In
      exchange, youth taught elders about modern technology, including email access, use of iPads,
      etc. This intergenerational knowledge sharing created positive outcomes for both youth and
      elders, including increased self-reported resiliency.

      Development of the KICKS module will occur through the KICKS Review Committee, including the
      KICKS Coordinator, elders and youth who participated in the KICKS pilot, university
      researchers, and other interested parties. The Committee will meet twice monthly for 8 months
      to review agendas from the KICKS pilot, discuss successes and challenges noted during the
      pilot, identify core content areas, consider potential additions, and discuss flow of the
      curriculum. Although there are agendas for each KICKS session, it is important to manualize
      the program so that the module can be followed with fidelity throughout the study. In
      addition, certain topics, such as historical trauma and substance abuse, were not explicitly
      included but will be added due to their importance as potential risk factors for suicidality.
      This process will use CBPR strategies to ensure collaboration with community partners during
      all phases of research, including study design, implementation, data collection,
      interpretation, and dissemination. UNM data collectors will gather detailed qualitative
      meeting minutes to document progress made and identify themes that emerge for inclusion in
      the manual. The final manual will be presented to Tribal Leadership and the Tribal Council
      for review and approval. This CBPR process recognizes the significance of culture in research
      design and implementation to facilitate relevance to the community, ethical conduct, external
      validity, and effectiveness.

      Specific Aim 2: To determine if adding a cultural component to the Zero Suicide model (ZS+)
      is more effective at reducing risk factors and increasing resiliency in AI youth than Zero
      Suicide alone (ZS). The objective of Specific Aim 2 is to assess the effectiveness of ZS
      enhanced with a cultural module (ZS+) compared to ZS alone at reducing suicidal ideation and
      behaviors and increasing resiliency. To achieve this objective, the investigators will test
      the working hypothesis that ZS+ will be more effective then ZS alone in reducing suicidal
      ideation, behaviors and attempts. The rationale for Aim 2 is that successful completion of
      the proposed research will contribute a missing, fundamental element to the suicide
      prevention knowledge base critical to the development of a youth suicide prevention program
      designed and tested with AI youth and found to be culturally appropriate, feasible, and
      effective. Achieving these outcomes will collectively inform the suicide prevention field
      about the effectiveness and feasibility of implementing ZS and ZS+ in IHS primary care
      settings, and provide a greater understanding of the potential mechanisms that reduce
      suicidal ideation and behaviors and increase resiliency for AI youth, a much-needed finding
      in Indian Country. Achieving these outcomes will also inform the field about the adoption and
      acceptability of the ZS model; and whether the quality of the community stakeholder
      partnership is a predictor of behavioral health outcomes.
    

Intervention name(s): Intergenerational Knowledge Sharing group; Support group
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Participants will attend a CBPR developed 12-session individual treatment for suicidal behavior. In addition to receiving the 12-session individual treatment, participants that are assigned to the Intergenerational Knowledge Sharing group will attend 12 weekly groups taught by tribal elders that focuses on sharing knowledge about the tribe.; Participants will attend a CBPR developed 12-session individual treatment for suicidal behavior. In addition to receiving the 12-session individual treatment, participants that are assigned to the support group will attend 12 weekly support groups led by a behavioral health specialist that focuses on social support of the youth.
Allocation: Randomized
Intervention model: Crossover Assignment
Intervention model description: This study will utilize a between-subjects design with random assignment to the control (ZS) and the experimental groups (ZS+).
Masking: None (Open Label)
Primary purpose: Treatment