The research component of the Southwest Hub will identify effective, feasible and sustainable interventions to prevent suicide and promote resilience among American Indian (AI) youth building on 20+ years of partnership between the Johns Hopkins Center for American Indian Health (CAIH), the White Mountain Apache Tribe (WMAT) and Navajo Nation (NN). The foundation of these partnerships is tribally-mandated surveillance for early identification, and follow-up and case management to connect at-risk youth to treatment after a recent suicide attempt, ideation or binge substance use episode. In addition, we have been designing and piloting brief interventions informed by local tribal data. Two such interventions were selected to be evaluated in sequence by our Suicide Prevention Study. Both employ Native paraprofessionals as a means of task-shifting much-needed psychoeducation and promoting continuity of care in under-resourced communities. The first intervention, New Hope (NH), is an evidence-based first-stage strategy delivered by paraprofessional community mental health workers (CMHWs) focused on reducing immediate suicide risk through safety planning, emotion regulation skills, and facilitated care connections. The second, the Elder?s Resilience (ER) intervention, is a longer-term strategy delivered by Elders with support from CMHWs to promote resilience by increasing youth?s connectedness, self-esteem and cultural identity and values. Our Primary Aim is: to use a Sequential Multiple Assignment Randomized Trial (SMART) design to evaluate which of four sequences of New Hope (NH), Elders Resilience (ER) and Case Management (CM) has the greater effect on immediate and longer-term suicidal ideation (primary outcome) and resilience (secondary outcome) among AI adolescents ages 10-24 identified at risk for suicide. We hypothesize that: a) New Hope vs. Case Management alone will significantly reduce participant suicidal ideation; b) Elders Resilience vs. Case Management alone will significantly improve participant resilience; c) New Hope followed by Elders Resilience will have the strongest effects on suicidal ideation and resilience; and d) Case Management alone will have the weakest effects of all combinations. Our Secondary Aims are: 1) to examine mediators and moderators of treatment effectiveness and sequencing in order to determine which types and sequence of interventions is best suited for which youth; and 2) to assess the acceptability, feasibility and capacity for sustainability of the Hub?s key intervention components with core and satellite partners, the Navajo, San Carlos Apache, Hualapai, and Cherokee nations. Due to heterogeneity of suicide risk factors generally and among AIAN youth, not all youth require the same type of interventions. Generating evidence for what works, when it works and for whom is even more paramount to AI suicide prevention efforts, where rates are currently high and resources are limited.
