Southwest Hub for American Indian Youth Suicide Prevention Research

The overall goal of the research component of the National Institute of Mental Health funded
Southwest Hub for American Indian Youth Suicide Prevention Research is to identify effective,
feasible and sustainable interventions to prevent suicide and promote resilience among
American Indian (AI) youth. The proposed study will build on 20+ years of behavioral and
mental health research and partnerships undertaken by the Center for American Indian Health
(CAIH) at Johns Hopkins with the White Mountain Apache Tribe (WMAT).

The investigators primary research aim, to be undertaken with the White Mountain Apache,
includes: 1) identification and voluntary enrollment of youth 10-24 years old using the WMAT
established surveillance and case-management (CM) system who recently had a validated suicide
attempt, ideation, or binge substance use episode with recent suicidal ideation; and 2)
implementation of a Sequential Multiple Assignment Randomized Trial (SMART) to inform how to
combine and tailor two brief interventions delivered by paraprofessional community mental
health workers (CMHWs), with promising pilot data, to prevent further suicidal thoughts and
behavior and promote resilience; and 3) evaluate what are the cost savings per study
participant with the implementation of the Southwest Hub interventions: NH, ER, NH and ER. A
secondary aim will be to evaluate the acceptability, feasibility and sustainability of the
two brief interventions with other Southwest Hub partners, including the Navajo, San Carlos
Apache, Hualapai, and Cherokee nations, who will have support from the Administrative Core of
the Southwest Hub to implement their own local tribal suicide surveillance systems for
community-based identification of at-risk youth.

The investigators will employ a SMART design to evaluate the effectiveness of New Hope (NH),
Elders' Resilience intervention (ER), Case Management (CM) and the combination of these
approaches on reducing suicidal thoughts and promoting resilience among AI youth ages 10-24
who are confirmed by surveillance case managers to have experienced suicide ideation, attempt
or a binge substance use and recent ideation in the past 30 days. Youth who assent will
complete the baseline (case management visit 1 and will be referred to mental health care—the
standard protocol for the Apache system). During the same visit, youth will be randomized 1:1
to either New Hope (NH) plus Case Management (CM), or CM alone, using a blocked randomized
design, stratifying participants by age and event type. All youth will complete another study
assessment after 30 days. The 30-day time frame will allow ample time to complete the NH
intervention with participants and assess any changes in youth's mental health status for all
study arms. Following another 30-day period, all participants will be re-assessed and
re-randomized, using the same blocking and 1:1 ratio to either the Elders' Resilience (ER)
intervention plus CM, or CM alone. To track long term outcomes, all youth will complete a
final assessment 3 month later (6 months post-enrollment). This study will occur on the White
Mountain Apache Tribe's Fort Apache reservation.

AIM 1

Inclusion Criteria:

- Native American youth ages 10 to 24 years old.

- Reside on or near the Fort Apache Indian Reservation.

- Parent/guardian consent for youth under 18 years old.

- Suicide ideation, binge substance use with recent (i.e. within the last 3 months)
suicide ideation, or suicide attempt in the past 30 days as identified and verified by
the surveillance system.

Terms and Definitions: Definitions for reportable behaviors are modeled on the Columbia
Classification Algorithm for Suicide Assessment (C- CASA).[11] Suicide attempt: intentional
self-injury with intent to die. (Aborted and interrupted suicide attempts are included as
part of this category). Suicidal ideation: thoughts to take one's own life with or without
preparatory action. Binge substance use with recent ideation, defined by Apache
stakeholders, as consuming substances with the intention of modifying consciousness and
resulting in being found unresponsive or requiring ED treatment and answering positively to
a 1-item screening question on the assessment indicating suicide ideation within the past
three months.

Exclusion Criteria:

• Factors identified at baseline that preclude full participation, including: unstable and
severe medical, psychiatric or drug use problem that necessitates inpatient treatment;
acute suicidal or homicidal ideation requiring immediate intervention; recent, severe
stressful life events such as physical or sexual abuse, or violent crime victimization that
requires specific and high intensity interventions or out of home placement. Participants
must speak English and not be severely visually impaired. Foster children will not be
included. Ambiguous cases will be reviewed by one of the co-PIs before being deemed
eligible for recruitment.

AIM 3

Inclusion Criteria:

- Youth over the age of 16 or adults over the age of 18.

- A person with an interest or concern related to youth suicide among AI populations.

Exclusion Criteria:

• Factors identified at baseline that preclude full participation including: being under
the influence of a substance; active psychosis or mania; any other condition that makes an
individual lack capacity to give consent. Foster children will not be included.
Participants must speak English and not be severely visually impaired. Ambiguous cases will
be reviewed by one of the co-PIs before being deemed eligible for recruitment.