Suicide and Life-Threatening Behavior 45 (2) April 2015 © 2014 The American Association of Suicidology DOI: 10.1111/sltb.12122

141

Changing Rates of Suicide Ideation and Attempts Among Inuit Youth: A Gender-Based Analysis of Risk and Protective Factors SARAH L. FRASER, PHD, DOMINIQUE GEOFFROY, MA, EDUARDO CHACHAMOVICH, MD, PHD, AND LAURENCE J. KIRMAYER, MD

Inuit in Canada currently suffer from one of the highest rates of suicide in the world. The objective of this study was to explore the prevalence of suicide ideations and attempts among 15–24 year olds living in Nunavik, Qu
ebec, and to explore risk and protective factors of suicide attempts as a function of gender. A cross-sectional survey was conducted in 2004 across Nunavik. Univariate and multivariate logistic regressions were conducted. A total of 22% of young males and 39% of females adults reported past suicidal attempts. Gender differences were observed in relation to associated risk and protective factors as well as degree of exposure to risk factors. Suicide prevention must include alcohol and drug prevention programs and rehabilitation services, interventions to reduce physical and sexual violence and their long-term impacts on Inuit youth, as well as exposure to culturally meaningful activities.

Inuit, the indigenous people of the arctic in Canada, currently suffer from one of the highest rates of suicide in the world (Bjerregaard, Young, Dewailly, & Ebbesson, 2004; Boothroyd, Kirmayer, Spreng, Malus, & Hodgins, 2001; Hicks & Bjerregaard, 2006; Navaneelan, 2012; World Health Organization [WHO] 2011). Youth are especially at risk of suicide. Between 1994 and 2008, rates of suicide were 30 times SARAH L. FRASER, Psycho
education, Universit
e de Montr
eal, Montreal, QC, Canada; DOMINIQUE GEOFFROY, Culture and Mental Health Research Unit, Montreal Jewish General Hospital, Montreal, QC, Canada; EDUARDO CHACHAMOVICH , Psychiatry, McGill University, Montreal, QC, Canada; LAURENCE J. KIRMAYER, Social and Transcultural Psychiatry, McGill University, Montreal, QC, Canada. Address correspondence to Sarah L.
Fraser, Ecole de psycho
education, Universit
e de Montreal, Pavillon Marie-Victorin C.P 6128 succursale Centre-ville Montreal (Qu
ebec) H3C 3J7Canada; E-mail: [email protected]

higher among Inuit youth under 18 compared with youth of the general population (Oliver, Peters, & Kohen, 2012). These high rates of suicide among Inuit throughout the arctic region are a relatively new phenomenon. Indeed, rates of suicide were as low as 5.2 per 100,000 in the 1950s and 1960s (Health-Canada, 1994; Thorslund, 1990), but steadily increased from the 1970s and 1980s until the turn of the century (Hicks, 2007; Hicks & Bjerregaard, 2006; Thorslund, 1990). Suicide ideation and attempts are part of a continuum of suicidal behaviors and are among the strongest predictors of death by suicide (Beck, Steer, Kovacs, & Garrison, 1985; Brent, Perper, Kolko, & Zelenak, 1988). In 1992, Kirmayer, Malus, and Boothroyd (1996) conducted a survey of 100 Inuit youth (14–25 years of age) living in a community in Nunavik that had just witnessed a cluster of suicides. In this sample, 43% had suicide ideation at least once

142 in their lifetime, and 34% had attempted suicide. In the same year, Sant
e Qu
ebec surveyed 203 youth (15–24 years of age) living in one of the 14 communities of Nunavik. Their data suggested that 38% of youth had suicide ideation and 22% had attempted suicide at least once in their lifetime (Kirmayer, Boothroyd, & Hodgins, 1998). The respective percentages from the general Canadian population are 15% (ideation) and 4% (attempts) (Public Health Agency of Canada, 2006). Many authors have linked suicidality among indigenous youth to the transgenerational effects of rapid culture change, including sedentarization, economic and political marginalization, and forced assimilation through residential schools, which have posed profound dilemmas for youth, families, and communities (Bombay, Matheson, & Anisman, 2011; Elias et al., 2012; EvansCampbell, Walters, Pearson, & Campbell, 2012; Gray, 1998; Hicks, 2006; Kirmayer et al., 1998; Leineweber & Arensman, 2003). Other more contemporary social, economic, and political contexts such as geographic isolation and lack of personal and career opportunities have also been linked to the high incidence of suicide ideation and attempts (Lessard, Bergeron, Fournier, & Bruneau, 2008). Chandler and colleagues underlined the impact of social, political, and cultural environments on individual well-being among people living in indigenous communities (Chandler & Lalonde, 2008; Hallett, Chandler, & Lalonde, 2007). Gender differences in psychosocial risk factors have also been documented among Inuit and other indigenous peoples (Centers for Disease Control, 2008). In an epidemiological study in Nunavik, Quebec, psychiatric morbidity, alcohol misuse, and drug use were the strongest predictors of suicide attempt among Inuit female youth, whereas among male youth, using solvents and number of life events lived in the past year were the most significant predictors (Kirmayer et al., 1998). Similar risk factors have been identified among youth from other indigenous groups, including Maori

SUICIDE AMONG INUIT YOUTH (Clark et al., 2011), Alaskan Natives (Borowsky, Resnick, Ireland, & Blum, 1999), Navajo (Grossman, Milligan, & Deyo, 1991), and Zuni (Howard-Pitney, LaFromboise, Basil, September, & Johnson, 1992). Other psychosocial factors commonly associated with suicide attempt include depression and anxiety; exposure to violence including family violence, peer violence, and sexual abuse; alcohol and drug use (Borowsky et al., 1999; Howard-Pitney et al., 1992; Kirmayer et al., 1998; LeMaster, Beals, Novins, & Manson, 2004; Yoder, Whitbeck, Hoyt, & LaFromboise, 2006), with potential gender differences in both the rates of exposure to these risk factors (Clark et al., 2011; Kirmayer et al., 1998, 1996); and their correlation with suicide attempts (Borowsky et al., 1999; Kirmayer et al., 1996). These psychosocial factors have been identified as important risk factors for suicide behaviors among the general population (Centers for Disease Control, 2008); however, they are generally more prevalent in indigenous communities due to a variety of social, geographic, and economic disparities as well as to the long-term impact of historical trauma and oppression experienced by communities (Kirmayer, Fletcher, & Watt, 2009; Kirmayer, Fraser, Fauras, & Whitley, 2009). Although most epidemiological studies have focused on risk factors associated with suicidal behaviors, a few quantitative studies have also explored potential protective factors among indigenous youth. A survey conducted in Nunavik found that church attendance, high level of academic achievement, and a family history of having received treatment for a psychiatric problem were associated with reduced risk of suicide attempt among Inuit youth (Kirmayer et al., 1996). Howard-Pitney et al. (1992) reported a significant protective effect of liking school, high social support, and interpersonal skills. Similarly, Borowsky et al. (1999) observed a significant protective effect of discussing difficulties with friends and family, positive emotional health, and connectedness to family.

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Among the potential protective factors frequently discussed in qualitative research on suicide prevention in indigenous health are participation in traditional activities, and the cultural relevance of prevention programs and services (Advisory Group on Suicide Prevention, 2003; Henderson, Mellin, & Patel, 2005; Kirmayer, Fraser, et al., 2009; Middlebrook, LeMaster, Beals, Novins, & Manson, 2001; Smye & Mussell, 2001). Indeed, most reports on suicide prevention among indigenous youth have argued for the need to incorporate traditional activities, language, traditional foods, and intergenerational dialogue in suicide prevention programs. In an epidemiological survey of the Cree, a neighboring First Nations people in Quebec, Kirmayer, Boothroyd, Tanner, Adelson, and Robinson (2000) found that time spent on the land was associated with positive mental health. Garroutte, Goldberg, Beals, Herrell, and Manson (2003) observed a significant protective effect of reported commitment to cultural spirituality on suicide attempts among indigenous youth of Northern Plains. HowardPitney and colleagues (1992) explored the potential protective effect of considering oneself to be a traditional Zuni Indian, but found the indicator was not significantly associated with suicide attempts. Yoder et al.’s (2006) study found a significant association between enculturation, as defined by involvement and identification with American Indian culture, and reduced risk of suicide attempts among American Indians in the midwestern United States. In a study performed among Ojibwa youth, however, participation in traditional activities was weakly associated with an increased risk of suicide ideations (LaFromboise, Medoff, Lee, & Harris, 2007). Reconnecting youth to culture and traditions is prominent in many suicide prevention programs for indigenous youth, but further research is needed to clarify the associations between participation in traditional activities or enculturation and suicide behaviors. The primary objective of this study was to assess the prevalence of suicide

143 ideation and attempts among Inuit youth from Nunavik, 10 years after the two previous studies performed in this population. A secondary objective was to explore potential risk and protective factors for suicide attempts as a function of gender.

METHOD

Setting and Sample This study is part the 2004 Qanuippitaa survey organized by the Quebec Public Health Institute (INSPQ) and the Nunavik Board of Health and Social Services (Rochette, Blanchet, Dupont, Papineau, & Anctil, 2007). Data collection took place aboard the Amundsen, a Canadian Coast Guard icebreaker renovated for research purposes that navigated around the Ungava and Hudson coasts of Quebec to assess the health status of a representative sample of Inuit residents from all 14 communities in Nunavik (Rochette et al., 2007). The target population of the survey was permanent residents of Nunavik excluding residents of collective dwellings and households in which there were no Inuit aged 18 years and over. The survey used a two-stage stratified random sampling procedure. During the first stage, households were randomly selected within each community. Interviewers presented themselves to the selected household and asked the mother of the household whether they would participate in the survey. For the second stage, all individuals above the age of 15 and living within the selected household were invited to participate in the survey on a voluntary basis. Participants went aboard the Amundsen icebreaker where they completed survey interviews and confidential self-administered questionnaires. Survey questionnaires completed in this study were similar to those used for the 1992 Sant
e Qu
ebec Inuit Health Survey. All questionnaires were available in English, French, or Inuktitut. More details about the sampling procedure and data collection are available

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SUICIDE AMONG INUIT YOUTH

(Rochette et al., 2007), as well as information on the mental health and well-being component from which the data for this study were drawn (Kirmayer, Paul, Rochette, Dupont, Papineau, & Anctil, 2007). Measures Sociodemographic Characteristics. Gender, age, marital status, and village of residence were documented in the household identification chart and the individual questionnaire. Substance Use. With regard to alcohol consumption, individuals were asked their frequency of consumption and the average quantity consumed per occasion in the preceding 12 months. The CAGE, a 4-item screening tool, was included in the survey to assess alcohol abuse and dependency (Fiellin, Reid, & O’Connor, 2000). A score of two or higher on the CAGE is a commonly used indicator of alcohol misuse. Five categories of drug consumption over the past 12 months were assessed: sniffing glue, gasoline, or other solvents; pot, marijuana, or hashish; cocaine; hallucinogens; and injection drugs. In this study, two variables were used: (1) consumption of marijuana and (2) consumption of any other type of drug in the past 12 months. Psychological Attributes. Psychological distress was assessed using the K-6 (Kessler et al., 2003), a 6-item self-report questionnaire that asks respondents how often they have felt nervous, hopeless, restless, depressed, worthless, and as if everything was an effort over the last 30 days. In survey development workshops with Inuit consultants, the K-6 corresponded well to common modes of expressing distress in Nunavik. The K-6 has been widely used in surveys and studies with the general population in countries including Canada, United States, and Australia (Croft, Mokdad, Power, Greenlund, & Giles, 2009; Dube et al., 2009; Gadalla, 2009; Kim, 2008; Langlois & Garner, 2013; Schmitz, Lesage, & Wang, 2009) as well as in many different cultures around the world (Carra et al., 2011; Mitchell & Beals, 2011).

A recent study validated the use of the K-6 as a screening tool in two American Indian populations (Mitchell & Beals, 2011). Moreover, in a study conducted among Inuit of Canada, a Rasch analysis indicated that the K-6 items did not show differential item functioning across genders, supporting its suitability for comparisons of psychological distress between genders (Chachamovich, 2014). The K-6 items are scored from 0 to 4 and summed to yield a total score between 0 and 24. The Cronbach’s alpha for this scale was .74, suggesting good internal reliability. A dichotomous variable indicating the presence of significant psychological distress was created based on the cut-off score (≥13) proposed by Kessler et al. (2003). Self-esteem was measured using 7 of 10 items of the Rosenberg Self-Esteem Scale (Rosenberg, 1965). Three items were removed to shorten and simplify the questionnaire (“I feel that I am a person of worth, at least on an equal plane with others”; “All in all, I am inclined to feel that I am a failure”; and “I am able to do things as well as most other people”). The seven remaining items were scored on a 4-point Likert scale (usually, sometimes, rarely, never). The initial Cronbach’s alpha was .51; removal of one item with a low item-total correlation (“I wish I could have more respect for myself”) improved the internal reliability with alpha = .60. Two additional questions asked about feelings of boredom and anger, both of which have been associated with suicide attempts in previous studies: (1) “I am easily bored” and (2) “I get angry quickly.” Responses were rated on frequency (usually, sometimes, rarely, never) without any specific time frame. Exposure to Interpersonal Violence. Individuals 18 years and older were asked to complete questionnaires related to sexual abuse during childhood and lifetime physical abuse. Respondents who replied “yes” to any of the following four questions were scored as having a probable history of sexual abuse: “While growing up (1) were

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you ever touched in a sexual way or had to touch someone? (2) were you threatened unless you did something sexual to someone? (3) did you have to do sexual things or watch sexual things? and (4) do you believe you were sexually abused?” The definition of physical violence used in this survey was adapted from the Conflict Tactics Scale (Straus, 1979; Straus, Hamby, Boney-McCoy, & Sugarman, 1996). The questions are asked from the victim’s perspective only and cover violence that could have been committed by anyone, including a series of acts potentially causing injury or bodily harm and violent threats. Participants who responded “yes” to any of the following questions were scored as having a history of interpersonal violence: “Have you as an adult ever been subjected to one or more of the following forms of violence: (1) pushed, shaken or struck lightly? (2) kicked, struck with a fist or object? (3) thrown against furniture, into walls, down stairs or similar acts? (4) subjected to strangulation, assault with a knife or firearm? and (5) other form(s) of violence? Sociocultural Protective Factors. Perceived community cohesion was assessed with a single question: “How strong is the feeling of togetherness or closeness in your village?” with response categories: very close, somewhat close, neither distant nor close, or very distant. Participation in traditional activities was assessed with four questions used to document hunting, fishing, berry picking, and preparing animals. Respondents indicated how often they took part in each activity each season using a 5-point Likert scale: never, less than once a month, 1–3 days per month, 1–3 days per week, and 4 or more days per week. Each of the four indicators was then dichotomized into participates/ does not participate. Two additional potential protective factors were assessed with single items: Cultural Pride (“I am proud to be Inuk”) and Emotional Support (“How often do you have someone to talk to if you feel troubled or for some reason need emotional sup-

145 port?”). Each item was rated on a 5-point Likert scale: all of the time (4), most of the time (3), sometimes (2), rarely (1), and never (2). Suicide Ideation and Attempts. The confidential questionnaire also included four questions related to suicide ideation and attempts, both lifetime and in the last year: (1) “Have you ever thought seriously about committing suicide (taking your life)? (2) In the past 12 months, have you thought seriously about committing suicide? (3) Have you ever attempted suicide (tried to take your life)? (4) In the past 12 months, have you attempted suicide (tried to take your life)?” Data Analysis A series of t tests were performed to identify any potential differences between respondents and participants with missing data on the various independent variables. Next, t tests were performed to compare gender and age groups on both dependent and independent variables. Bivariate logistic regression was used to explore risk factors associated with suicide attempts in the past 12 months. In cases where more than one variable per conceptual category (sociodemographic, psychological attributes, substance use, sociocultural protective factors) was significantly associated with suicide attempts in bivariate analyses (p < .05), these variables were entered into models specific to the conceptual category. The variables that remained significant within these models were then entered into a final model that included all conceptual categories to determine which variables were most strongly associated with past 12-month suicide attempts. Again, statistical significance was set at p < .05. These analyses were conducted separately for males and females. In the survey, violence and sexual abuse were only documented for individuals 18 years and older. Accordingly, a separate model was developed for youth from 18 to 24 including both males and females and

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SUICIDE AMONG INUIT YOUTH

controlling for gender and the other associated risk factors. Statistical analyses were performed with STATA/SE 12.0.

RESULTS

A total of 305 Inuit between the ages of 15 and 24 completed the survey in 2004. Of these, 14 individuals (4.6%) did not answer the question about suicide attempts in the past 12 months and therefore were excluded from the regression analyses. This latter group differed significantly from the respondents, with a higher proportion presenting low self-esteem, alcohol misuse, and boredom. The characteristics of respondents as well as gender differences on these variables are presented in Table 1. The average age of the respondents was 19. A greater proportion of respondents were from the Hudson Coast (59%) compared with the Ungava Bay, and 56% were living in a relatively larger community (i.e., with greater than 1,000 inhabitants) at the time of the survey. Nearly 30% of respondents were married or living with a partner; significantly more females reported being in conjugal relationship than males. Regarding occupational status, 83% reported either working or studying. Compared with males, a greater proportion of females reported psychological distress as assessed by the K-6 scale (score ≥ 13). There were no significant differences in frequency of alcohol consumption as a function of gender. However, a greater proportion of females compared with males reported having problems related to alcohol consumption as assessed by the CAGE. Concerning drug use, significantly more men reported using marijuana in the 12 months prior to the survey. However, there was no gender difference in rates of use of other drugs. Significantly more females reported having experienced sexual abuse and a greater proportion of females reported having experienced physical violence during adulthood. Women were also

more likely to report getting angry quickly. There were also significant gender differences in participation in traditional activities. Indeed, significantly more males reported hunting, fishing, and preparing animals, whereas more females reported berry picking. Comparisons of the 15- to 17- and 18- to 24-year-old respondents revealed that both males and females in the older group were significantly more likely to be married. Compared with the 15–17 age group, a greater proportion of 18- to 24year-old women lived on the Hudson coast and reported having no occupation. Alcohol consumption was also significantly different as a function of age for males; significantly more 18- to 24-year-olds reported drinking once a week and having alcohol-related problems (as indicated by the CAGE). Significantly more of the older females used drugs other than cannabis as compared to the 15- to 17-year-old females. Significantly more males 18 to 24 years of age compared with their younger counterparts reported feeling proud to be Inuk. A total of 133 (45%) respondents reported having had suicide thoughts in their lifetime with significantly more females (57%) reporting suicide thoughts than men (32%) (OR 2.79, p > |z| < .001). Almost one-fourth of respondents (24%) had thought seriously about suicide in the 12 months preceding the survey. Regarding suicide attempts, 31% reported at least one attempt in their lifetime and 15% reported a suicide attempt in the past 12 months. All rates were significantly higher for females as compared to males (Table 2). There were no significant differences in rates of suicide ideation or attempts as a function of age for either males or females. Bivariate Analyses Males. Three variables assessed were significantly associated with suicide attempts in the past 12 months among males (Table 3a): psychological distress; alcohol misuse as assessed by the CAGE; and expe-

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TABLE 1

Sociodemographic and Psychosocial Characteristics of Respondents Aged 15–24 years (Nunavik, Quebec, 2004) All

Age (mean) Married No occupation Region: Hudson Town size 1,000+ Substance use Alcohol consumption (at least once per week) Binge drinking (at least once per week) Alcohol misuse (CAGE) Marijuana use Use of other drugs Psychological attributes Psychological distress (K-6) Self-esteem Easily bored (usually) Anger quickly (usually) Interpersonal violence Lifetime sexual abusea Adult physical violence Potential protective factors Proud to be Inuk Goes hunting Goes fishing Goes berry picking Prepares animals Closeness of community (very) Someone for emotional support

Male

Female

n

%

n

%

n

%

305 294 285 305 305

19.0  2.8 28.9 16.8 58.7 55.7

138 131 128 138 138

18.9  2.8 22.1* 14.1 58.7 52.2

167 163 157 167 167

19.2  2.8 34.4 19.1 58.7 58.7

289

28.0

134

26.9

153

28.8

289

19.4

134

20.1

155

19.0

291 302 303

36.8 73.8 23.4

134 138 135

32.1 84.1* 23.7

157 164 165

40.8 65.2 20.5

288 281 293 291

8.7  4.4 12.4  3.3 18.8 12.0

131 129 133 131

7.7  4.1* 12.9  3.2 15.8 3.1*

157 152 160 160

9.5  4.5 11.9  3.4 21.3 19.4

189 191

46.6 59.2

82 82

20.7* 48.8*

107 109

50.5 67.0

291 302 300 303 305 278 299

77.7 58.7 44.6 50.2 68.9 27.0 16.1

134 136 138 137 138 126 131

78.4 78.7* 52.2* 35.0* 81.2* 31.0 9.9

157 166 162 166 167 141 154

77.1 43.4 39.5 63.3 58.7 33.5 21.4

*p < .05. a Among participants aged 18–24. TABLE 2

Prevalence of Suicide Thoughts and Attempts, Lifetime and Past 12-Month Occurrences Among Inuit Aged 15–24 Years Old in Nunavik All

Lifetime thoughts Past 12-month thoughts Lifetime attempts Past 12-month attempts *p < .05.

Male

Female

n

%

n

%

n

%

Differential Pr(|T| > |t|)

133 69 91 44

45.2 23.6 31.3 15.1

31 16 22 10

31.9 16.3 22.2 10.4

90 47 61 30

56.6 29.9 39.1 19.2

.00* .01* .00* .04*

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SUICIDE AMONG INUIT YOUTH

riencing physical violence during adulthood. No potential protective factors were associated with suicide attempts. Females. Eight variables were related to suicide attempts in the previous 12 months among females: two alcohol and drug use variables (marijuana use, use of other drugs); three psychological variables (psychological distress, low self-esteem, feeling angry), the two indicators of interpersonal violence (physical abuse and sexual abuse); and one sociocultural protective factor (participating in hunting activities). Multivariate Analyses Males. Since no more than one variable per conceptual category was significantly associated with suicide attempts at the bivariate level, no multivariate models within conceptual categories were necessary. The two risk factors identified at the bivariate level were directly entered into a multivariate analysis. Only psychological distress remained significant in the multivariate model. Together, alcohol misuse and psychological distress explained 15% of the variance. Females. In the multivariate model for substance use, only marijuana use remained statistically significant. In the multivariate model for psychological attributes, only psychological distress was significantly associated with suicide attempts in the past 12 months. In the final multivariate model marijuana use, psychological distress and participating in hunting activities were entered. All three remained statistically significant, and together they explained 22% of the variance in suicide attempts. Males and Females. A multivariate model including both male and female participants was conducted to assess the association between exposure to violence and suicide attempts. The analysis suggests that after controlling for gender, psychological distress, alcohol misuse, and marijuana use, both physical violence and sexual abuse are significantly associated with suicide attempts in the past year (Table 4).

DISCUSSION

In this study we examined the prevalence of suicide ideation and attempts as well as the correlates of suicide attempts among Inuit aged 15 to 24 living in Nunavik in 2004. Rates of lifetime suicide attempts among males (22%) were similar to those documented in the 1992 Sant
e Quebec study (27%; Jett
e, 1995) and lower than those documented in a 1992 community study (43%; Kirmayer et al., 1996). Rates of suicide ideation and attempt observed among females in the current study are alarming, with more than half of young girls reporting having seriously thought of committing suicide and a quarter having attempted suicide in their lifetime. Moreover, the observed rate of suicide thoughts was more than twice the rate documented in 1992 (Jett
e, 1994). The rate of suicide attempts was approximately 1.5 times higher than those documented in both the Sant
e Qu
ebec survey (25%) and a previous survey (Kirmayer et al., 1996) of a single community (26%). These results suggest an important increase in suicide ideation and attempts among females over a 10-year span. The rates observed in this study for both males and females are at the high end of the rates reported for other indigenous populations (Borowsky et al., 1999; Clark et al., 2011), where reported lifetime suicide rates generally vary between 8% and 20% (LaFromboise et al., 2007; LeMaster et al., 2004; Silviken & Kvernmo, 2007). Moreover, rates of lifetime suicide ideation in this study are approximately three times higher than those documented in the same age group of the general Canadian population (Public Health Agency of Canada, 2006). Lifetime suicide attempts were reported 10 times more often among Inuit males of Nunavik as compared to males throughout Canada, and six times as often among Inuit females as compared to their counterpart in the general population (Public Health Agency of Canada, 2006). The observed difference in rates of suicide attempts among males and females

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149

TABLE 3

(a) Bivariate Analyses of Potential Risk Factors Associated with Past 12-Month Suicide Attempt Among Inuit Males Aged 15–24 Years Old in Nunavik (2004); (b) Bivariate Analyses of Potential Risk Factors Associated with Past 12-Month Suicide Attempt Among Inuit Females Aged 15–24 Years Old in Nunavik (2004)

(a) Married No occupation Region: Hudson Town size 1,000+ Substance use Alcohol consumption (at least once per week) Binge drinking (at least once per week) Alcohol misuse (CAGE) Marijuana use Use of other drugs Psychological attributes Psychological distress score (K-6, mean/coeff.) Self-esteem Easily bored Usually Sometimes Rarely Never Anger quickly Usually Sometimes Rarely Never Interpersonal violence Lifetime sexual abusea Adult physical violencea Potential protective factors Proud to be Inuk (always) Goes hunting Goes fishing Goes berry picking Prepares animals Closeness of community (very) Someone for emotional support

Nonattempter (n = 121) % or Mean  SD

Attempter (n = 14) % or Mean  SD

Exp (B)

p > |z|

21.1 14.0 58.7 52.9

35.7 16.7 64.3 50.0

2.08 1.23 1.27 0.89

.22 .81 .69 .84

0.64–6.80 0.25–6.11 0.40–4.01 0.30–2.69

26.9

21.4

0.74

.66

0.20–2.83

21.0

7.1

0.88

.52

0.59–1.31

28.6 83.5 22.3

57.1 85.7 35.7

3.33 1.19 1.93

.04* .83 .27

1.08–10.33 0.25–5.72 0.60–6.26

7.2  4.0

11.8  2.8

0.75

.00*

0.64–0.89

11.8  2.9

10.6  3.6

0.991

.27

0.78–1.07

13.6 38.1 28.8 19.5

35.7 21.4 14.3 28.6

0.83

.51

0.48–1.46

3.4 27.6 36.2 32.8

0 50.0 35.7 14.3

0.63

.17

0.325–1.21

20.5 44.6

50.0 87.5

3.87 8.70

.08 .05*

0.87–17.29 1.02–74.28

78.2 77.3 52.1 32.5 80.2 29.5

85.7 85.7 57.1 57.1 85.7 42.9

0.95 1.76 1.23 2.80 1.49 0.72

.90 .48 .72 .08 .62 .29

0.41–2.19 0.37–8.37 0.40–3.75 0.90–8.53 0.31–7.08 0.39–1.32

8.5

21.4

0.65

.15

0.41–1.14

Confidence Intervals

(continued)

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SUICIDE AMONG INUIT YOUTH

TABLE 3

(continued)

(b) Married No occupation Region: Hudson Town size ≥1,000 Substance use Alcohol consumption (at least once per week) Binge drinking (at least once per week) Alcohol misuse (CAGE) Marijuana use Use of other drugs Psychological attributes Psychological distress Score (K-6, mean/coeff.) Self-esteem Easily bored Usually Sometimes Rarely Never Anger quickly Usually Sometimes Rarely Never Interpersonal violence Lifetime sexual abusea Adult physical violencea Potential protective factors Proud to be Inuk (always) Goes hunting Goes fishing Goes berry picking Prepares animals Closeness of community (very) Someone for emotional support

Nonattempter (n = 126) % or Mean  SD

Attempter (n = 30) % or Mean  SD

Odds Ratio

p > |z|

Confidence Intervals

35.0 17.8 54.8 55.6

37.9 24.1 70.0 66.7

1.14 1.47 1.93 1.60

.77 .44 .13 .27

0.49–2.62 0.56–3.89 0.82–4.54 0.69–3.69

28.5

30.0

1.08

.87

0.45–2.58

16.3

26.7

1.87

.19

0.73–4.80

39.2 58.1 17.6

43.3 90.0 40.0

1.19 6.50 3.12

.68 .00* .01*

0.53–2.66 1.87–22.57 1.32–7.40

8.7  4.2

13.1  4.3

0.78

.00*

0.70–0.88

11.8  2.9 16.7 38.9 27.0 17.5

10.6  3.6 33.3 30.0 33.3 3.3

0.77 0.65

.00* .05

0.67–0.89 0.42–1.00

15.1 34.9 33.3 16.7

33.3 40.0 13.3 13.3

0.60

.03*

0.39–0.94

59.8 63.4

86.4 87.0

4.27 3.85

.03* .04*

1.17–15.60 1.05–14.03

79.4 48.0 40.7 65.6 57.9 28.4 21.6

67.9 20.0 31.0 60.0 63.3 8.0 20.7

1.30 0.27 0.66 0.79 1.25 1.34 1.06

.25 .01* .34 .57 .59 .15 .75

0.83–2.06 0.10–0.71 0.27–1.16 0.35–1.78 0.55–2.85 0.90–2.00 0.75–1.50

*p < .05 a Among participants aged 18–24.

has been reported in other studies performed in indigenous communities (LaFromboise et al., 2007; LeMaster et al., 2004; May, 1987; Shaughnessy, Do-

shi, & Jones, 2004; Spaulding, 1985; Walls, Chapple, & Johnson, 2007). The literature on suicide ideation and attempts generally finds that females are at substantially

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ET AL.

151

TABLE 4

Multivariate Logistic Regression Models Explaining Suicide Attempts in the Past 12 Months

Males Model 1: Final CAGE score above 2 Psychological distress Females Model 1: Substance use Marijuana use Use of other drugs Model 2: Psychological attributes Psychological distress Low self-esteem Easily angry Model 3: Final Marijuana use Psychological distress Participating in hunting activities Males and females Gender Alcohol misuse Marijuana use Psychological distress Lifetime sexual abuse Adult physical violence

Exp (B)

95% Confidence Interval

p value

R2

4.33 0.74

0.97–19.35 0.60–0.91

.06 .00

.15

5.26 2.00

1.46–18.94 0.81–4.90

.01 .13

.09

0.79 1.90 0.52

0.70–0.89 0.69–5.46 0.51–1.4

.00 .18 .70

.15

0.81 5.48 0.28

0.72–0.92 1.18–25.59 0.09–0.86

.00 .03 .03

.22

0.72 1.44 2.78 0.83 3.49 4.54

0.22–2.32 0.55–3.80 0.71–10.93 0.73–0.94 1.11–11.05 1.15–17.90

.58 .46 .14 .00 .03 .03

.21

greater risk of suicide ideation and attempts than males (Beautrais, 2002; Joe & Marcus, 2003; LeMaster et al., 2004; Yoder et al., 2006), whereas males are at greater risk for completed suicides (Johnson, Krug, & Potter, 2000; Qin, Mortensen, Agerbo, Westergard-Nielsen, & Eriksson, 2000). Between 1994–1998 and 1999–2003, crude suicide rates among females in Nunavik tripled, increasing from 23.3 to 71.2 per 100,000; while for the same period, the rate among males increased about 60% from 161.8 to 252.8 (Statistics Canada, 2012). The important increase in rates among females may be a cohort effect. However, a recent review points to a changing gender-differential trend in completed suicide among the general population of youth and young adults of Canada (Skinner & McFaull, 2012) and Finland (Lahti, R€as€anen, Riala, Ker€anen, & Hakko, 2011). Indeed, while in recent years studies have pointed to a slight decrease in deaths by

suicide among males (Biddle et al., 2012; Skinner & McFaull, 2012; Stark, Stockton, & Henderson, 2008; Steele & Doey, 2007; V€arnik, Wasserman, Dankowicz, & Eklund, 1998), in several countries, rates have been increasing among females (LaFromboise et al., 2007; Lahti et al., 2011; Skinner & McFaull, 2012). Clearly, there is a need for further research on recent cultural changes in gender roles and expectations both locally and globally to better understand these gender-related phenomena (Kirmayer, 2012). The current study also points to important gender differences with regard to exposure to psychosocial risk factors for suicide. A significantly greater percentage of women had experienced sexual abuse and physical violence. Women had significantly lower self-esteem, higher psychological distress, and a greater percentage reported often feeling angry. Finally, women reported lower rates of marijuana use.

152

SUICIDE AMONG INUIT YOUTH

These differences are not surprising as multiple studies have reported similar gender differences. Native women are generally at greater risk than women in the general population for sexual abuse and physical violence (Wahab & Olson, 2004). They also tend to display higher rates of distress and depression, and lower self-esteem. Of interest, however, is the lack of differences in use of alcohol, frequent binge drinking, scores on the CAGE, and use of drugs other than marijuana. Indeed, in the 1990s, significantly fewer women in Nunavik reported drug use, as compared to men, and significantly fewer women reported positive on alcohol misuse indices (Kirmayer et al., 1996). In the present study, these gender differences were not observed, suggesting that by 2004 young Inuit women were engaging in similar substance misuse as men. Also of interest are the changes in frequencies of substance use. Indeed, in the current study, 27% of men and 29% of women reported alcohol consumption at least once a week.1 These rates are five to six times higher than those documented in Nunavik a decade earlier (Kirmayer et al., 1998). Moreover, 74% of youth reported use of marijuana in the 2004 sample as compared to 52% in the 1996 sample (Kirmayer et al., 1996; Skinner & McFaull, 2012). Small gender differences were also observed in the multiple regression models. Looking specifically at risk factors, alcohol misuse (score on the CAGE) and high levels of psychological distress were associated with suicide attempts in the past 12 months among males in bivariate models; however, only psychological distress remained statistically significant in the multivariate model. For females, the strongest risk factors for suicide attempts in the past 12 months were marijuana use and high levels of psychologi1

In Nunavik, during this period, alcohol was either flown-in on special orders or, in a few communities, was available in bars. In the province of Quebec, the legal drinking age is 18.

cal distress. Moreover, physical violence and sexual abuse were significantly associated with suicide attempts among males and females even after controlling for gender, alcohol misuse, marijuana use, and psychological distress. Prompted by clinical experiences in this population, feelings of anger and boredom were assessed as potential risk factors. Anger was significantly associated with suicide attempts among women in bivariate analyses and boredom just barely made significance. Anger was added to the multivariate analyses but did not remain significant. Walls et al. (2007) and Yoder (2006) observed a significant association between anger and suicide behaviors among indigenous youth in bivariate analyses using multidimensional scales to assess anger. In both studies, anger lost significance in multivariate analyses. Walls et al. suggested that depression may account for most of the variation in suicidal behaviors or that depression mediates the effects of anger. The very low level of anger reported by young Inuit males (3%) in this study is surprising given that they live in challenging social conditions with over-crowding and much frustration. This may be due to the fact that anger was measured with a single question and may not adequately capture the ways in which men express anger. In the present study, several indicators assessed potential sociocultural protective factors, including cultural pride; participating in land-based activities of hunting, fishing, berry picking, and preparing animals; perceived community cohesion; and having someone to talk to when needing emotional support. None of these variables were associated with suicide attempts among males. However, participating in hunting activities was a significant protective factor against suicide attempts among women. Hunting was traditionally a male activity, but ongoing social changes in Inuit communities have led to changes in male and female roles (McElroy, 1975). Many women are occupied in the wage-economy

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in villages, which centers on human service activities. Young women have continued to be involved in child care, in continuity with traditional roles, and this may have afforded them some protection from the negative effects experienced by young men with the loss of traditional patterns of subsistence activity (Kirmayer, Fletcher, & Boothroyd, 1997; McElroy, 1975). Participation in hunting by young women may indicate affirmation of Inuit identity and values associated with land-based activities and/or high levels of integration into family structures which provide social support associated with better mental health (Kirmayer, Fletcher, & Watt, 2009; Richmond, 2009). Limitations This study has important limitations. The cross-sectional nature of the survey did not permit clear identification of antecedents and consequences. Respondents may have been reluctant to disclose sensitive issues like exposure to violence or substance abuse. Many potential risk and protective factors were not assessed in the survey due to practical constraints. While the measures have been used in previous studies with Inuit, they have received limited cultural validation.

CONCLUSION

Results from the Qanuippittaa 2004 survey indicate very high rates of suicide ideation and attempts among young Inuit men and women in Nunavik (northern

153 Quebec). Compared with results obtained in the 1992 Sant
e Qu
ebec Inuit Health Survey, the observed rates in the current study were similar among men, but much higher among women. This change may reflect ongoing social changes that are promoting gender equality but eroding some of the social support and resilience young women experienced through participation in traditional activities such as child care (Kirmayer, 2012). Risk factors for suicide attempts included psychological distress, violence, sexual abuse, and substance use, with gender differences in exposure to certain risk factors and correlation with suicide attempts. Recent work on mental health promotion has emphasized traditional modes of helping and healing (Ajunnginiq-Centre, 2006). Many scholars have discussed the importance of cultural activities, cultural continuity, cultural pride, and collective self-esteem on well-being and mental health (Chandler & Lalonde, 2008; Gone, 2013; Hallett et al., 2007; Kirmayer, Simpson, & Cargo, 2003; Kirmayer, Brass, Holton, Simpson, & Tait, 2007). Reinforcing such coping skills, along with feelings of cultural connectedness, may be an important part of preventive strategies. However, in a transitional society that must deal with the intergenerational consequences of historical trauma and ongoing structural problems that result in high levels of exposure to risk factors such as physical abuse, sexual abuse, alcohol misuse, and drug use, mental health services and broader promotion strategies that address these social structural issues are also needed.

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