Suicide is the second leading cause of death among Indigenous youth ages 8 to 24, and Native American and Alaska Native youth aged 10-24 have the highest rate of suicide of all demographic groups.

The Association of Clinicians for the Underserved presented a panel webinar, “Preventing Suicide in Indigenous Youth: Strategies & Considerations for Primary Care Teams & Beyond,” to explore the vital opportunity primary care providers and outreach staff at federally-funded community health centers and other clinics have to intervene with patients at risk of suicide. To do so effectively, health care professionals must utilize the concept of cultural safety to understand the unique needs of their Indigenous patients to help identify those at risk.

What is Cultural Safety?

Cultural safety, a concept initiated in New Zealand in the late 1980s to deliver more appropriate health care to the Maori people, means creating and maintaining an environment where one feels physically, socially, and emotionally safe without denying one’s identity or culture. It is the experience of learning together through shared respect and knowledge.

A 2019 study, “Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition,” concluded that what determines ‘safe’ care must be defined by the recipient of the care; additionally, health practitioners must be prepared and willing to challenge their own cultural systems rather than simply prioritizing becoming ‘competent’ in the cultures of others.

Panelist Amy Stiffarm, Ph.D., MPH, program manager for Native American Initiatives, noted, “Cultural safety is really shifting from this false idea that it would be enough to take a one- or two-day training on competency. Cultural safety is really about acknowledging those power relationships, how we can address them through a reflective practice, and making sure the patient feels safe to be who they are … in your doctor’s office.”

Stiffarm has developed a Cultural Safety toolkit for Montana health care professionals who provide perinatal care, as many clinicians lack foundational knowledge about the Indigenous populations of Montana. However, she states that her toolkit could be adapted for providers in other states and specialties. “Think about this: Boarding schools weren’t that long ago. My grandparents went. My mother went. And for a lot of families, this was their first interaction with the Western health care system,” Stiffarm said.  “A lot of it is about building trust. Having that initial knowledge and taking the time to learn about the people you’re serving is really important.”

To ensure that culturally safe care is defined by the people and communities her organization serves, Mona Zuffante, Ph.D., MPH, chief public health officer at Winnebago Comprehensive Healthcare System, said her clinic engages with Indigenous youth to plan culturally appropriate programming. She shared results from a small 2023 survey the Winnebago Public Health Department conducted of 10 Indigenous youth (ages 10-19) and 10 Indigenous young adults (ages 19-24) to provide insight into activities and programs they would like the health department to provide for them.  Participants offered multiple specific suggestions, including the concept of a healing camp allowing young adults to transition from adolescence to young adulthood, as well as opportunities for Indigenous youth to learn about historical and intergenerational trauma in a safe environment. Zuffante noted the implementation of educational programming would be beneficial. “It would be good to be able to walk through that truth and have that basic understanding. Our children are not taught that in school, so we have to be sure that we are teaching our children what happened and how we can learn from those things and move forward,” she said. “We are a resilient people, and that’s why we’re still here.”

Youth Suicide

Virna Little, PsyD, LCSW-r, co-founder and special advisor for advocacy and research of Concert Health and co-founder and chief operating officer of Zero Overdose, noted that suicide is the second leading cause of death among youth (10-24) in the U.S. “When we think about the percentage of high school students that will actually attempt suicide — not just think about suicide, but actually have an attempt – it’s more than a fifth,” said Little. “So I always like to think about it, like 30 kids in a high school classroom, how many kids that is in each classroom, how many classrooms in a hallway, and how many hallways in the average school. You start to think about the extent of how many kids are actually affected by suicide and suicidal thoughts.”

The Crucial Role of Primary Care Providers in Assessing Suicide Risk

Little states that research shows patients dying by suicide visit primary care physicians (PCPs) more than twice as often as mental health professionals. Nearly half (45%) will have seen their PCP in the month before their death, while only 20% will have seen a mental health professional. Those percentages only increase upon a longer look-back: 77% of patients will have seen their PCP in the year before their death, while only 32% will have seen a mental health professional. Even patients who resurfaced after having been lost to care — whether that be primary care, mental health, or even dental service — had an average of two visits with their PCP during the month of their death. “Increased patient portal usage the month of death is very common, so much so it’s actually being considered a flag in many organizations,” said Little. “So we have a unique opportunity in PCP settings to be able to identify and care for people at risk for suicide.”

 Tips for Primary Care Providers

  1. Enable EHR to capture relevant data

Screening for suicide risk at the primary care level begins with enabling the electronic health record (EHR) to capture the relevant data. Adding applicable ICD-10 codes to the problem list lets you capture structured data and know how many people are at risk in your organization. It’s also a quality issue, Little notes. “If I’m covering for you and I see that someone has suicide risk on the problem list, then I may ask different questions or make different decisions.” 

 2. “With such a short appointment, I don’t have time to ask or address suicide risk.”

Little states it’s critical to address suicide risk even in a 15-minute appointment, noting that PCPs are experts at pivoting, “If somebody comes in and their blood pressure is really elevated, we’re going to pay attention to the blood pressure, and that’s going to be the focus of the visit,” she said.  “So, if someone comes in and they say yes to suicide [risk], then that’s going to be the focus of the visit.”

3. “I don’t know how to assess or intervene.”

For providers who feel they are not equipped to discuss suicide risk, Little suggests they simply think about their ability to listen, care, and give people hope. She recommends having two to three “storage statements” prepared beforehand.

  • To show you hear them: “Thank you for telling me you’re thinking about suicide.”
  • To show you care about them: “Your life is very important to me. We care about you here at the center.”
  • To show you have hope for them: “You’ve been through a lot. I see that strength.” or “It took a lot of strength to tell me you are thinking about suicide. I have hope for you.”4. Gather additional information.

Once a patient has self-identified as a suicide risk:

  • Screen for depression, but note that many people who die by suicide don’t have depression; anxiety, however, is a considerable risk factor.
  • Realize that social determinants play a role (housing, finances, relationships), as well as substance and alcohol use.
  • Understand that transitions are a time of suicide risk (getting out of the hospital, substance abuse treatment, foster care, physical rehab, a geographic move, etc).

4. Ask patients directly what you want to know.

To assist in asking further follow-up questions when a patient self-identifies as being at risk for suicide, two evidence-based questionnaires are available: the Columbia Suicide Severity Rating Scale (C-SSRS) and the Ask Suicide-Screening Questions (ASQ) suicide risk screening tool. Little prefers the ASQ for use with children and adolescents as she feels it’s easier to use. It provides a script for nursing staff and a parent/guardian flyer. Per the National Institute of Mental Health, asking kids questions about suicide is safe and is very important for suicide prevention. Research has shown that asking kids about thoughts of suicide is not harmful and does not put thoughts or ideas into their heads.

5. Make follow-up a priority

Have protocols in place for newly identified and follow-up patients. Institute a system to ensure that anyone interacting with a returning patient will know the history and inquire how things are going. Little notes that without the ICD-10 on the problem list, “no one asks if they are safe, no one asks if they are connected to care because the system wasn’t in place and it wasn’t on the problem list.”

6. Understanding Risk

“Our job in primary care is to make sure that people get the right level of care,” Little said. To ensure the right level of care is provided, it’s essential to understand what suicidal risk – and what it isn’t. Little gave the example that a patient may think about suicide and may even know how they would die by suicide but has no current intention to do so. “That’s the key here,” Little said, “is the intent.”

Little suggests thinking of intent as a teeter-totter balanced out with reasons for living. Some protective factors people give for not wanting to die by suicide are family (kids/spouse/parents), pets (“If I gave up my pet, they would be euthanized”), religion, and career (particularly health care).

7. Safety Planning

If the case can be handled at the primary care level, provide the patient with a prioritized list of coping strategies and resources — the written safety plan.

  • Have them enter the following contacts into their phone before leaving your office:
     The Suicide Prevention Lifeline (988) and the Crisis Text Line (text the word “HOME” to 741741).
  • Discuss lethal means restriction. Ask them where they might have access to lethal means. Their preferred method is essential to know and document. If it’s medication, ask where they would get them. If it’s firearms, discuss with the client how they can be kept out of reach during this time. “This doesn’t mean they can’t go hunting in the fall,” said Little.
  • Print out the “Emotional Fire Safety Plan” from NowMattersNow.org for the patient to take home.
  • Give them a calming activity to do. The activity must be available to them immediately, 365 days a year, at all times of the day. Little notes, “Walmart is listed on a lot of safety plans because it’s in many communities and it’s accessible by public transportation.” A less helpful suggestion would be to go outside because “maybe I can’t go outside when I’m at work,” Little said.
  • Provide resources for family members, too: SuicideIsDifferent.Org offers suicide caregivers interactive tools and support.

Additional tips for providing suicide-safer care to Indigenous populations

Zuffante cautions sometimes it’s not going to be a 15-minute fix during a patient visit. “We have a lot of non-native relatives that work in our primary care setting. It’s important to create that connection … so maybe build in a little more time and take the time to listen and watch people’s behavior and how they respond to you,” she said. “We teach our [staff] that just because our people are not looking at you in the eye, doesn’t mean they’re not listening to you. So, I think those are some things that you don’t always see in Western medicine but are very important to us.”

Stiffarm concurred on the need to be respectful of cultural differences. “Things like making sure you understand your policies around smudging and letting patients and families have a way to access their cultural strengths or their practices when they’re in your facility,” she said. “One last thing I would say, another great thing up in Canada that’s happening similar to the hotline that [Dr. Little] mentioned. They have one where Indigent youth call, and they have access to elders. I think that’s something we can think about doing differently … finding ways to embrace and faciltite utilizing the strengths within Indigenous cultures.” 

Resources

Association of Clinicians for the Underserved: Learn more about suicide-safer care for primary care providers working with youth and other populations.

Zero Suicide: Provides organizational support and toolkits for suicide-safer care working with Native American and Alaska Native populations.