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-Typically, there are many social and cultural factors that contribute to death by suicide. These particular complexities can be especially apparent in some Indigenous communities

-colonalism (impacts)
-The eradication of culture and loss of language, erosion of traditional values, and the disintegration of traditional family structure are all long-term results of these policies.
-this created a psychological and social breakdown in many communities, causing feelings of marginalization, isolation, and hopelessness.

-the arrival of the European explorers coupled with the institutionalized racism inherent in the Canadian government’s policies

-(48%) of all Indigenous people in Canada today are under 24 years of age

-suicidal contagion occurs on some Indigenous reserves because of the closeness of the residents and their shared social predicaments

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-safe drinking water in First Nations is one of the greatest violations of the UN-recognized human rights to water and sanitation.

-Trudeau government committed to ending these water advisories by 2021, but very little progress has been made and the needed funding has not been committed to end this crisis.

-This is even more urgent as COVID-19 continues to spread globally.

-Neskantaga has been living under a boil-water advisory for 26 years.

-Boiling is effective for removing bacteria, viruses and parasites, but not for removing toxic metals, for example.

-Excessive water boiling leads to mould that deteriorates housing, causing overcrowding. Overcrowding and lack of running water contribute to the contraction of methicillin-resistant

-Buying water because what’s coming from the tap isn’t fit to drink or wash with costs money that might have otherwise been used for food

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-Almost half of First Nations adults and children live on reserve. The average number of First Nations family members living in a house is 3.7, compared with the Canadian average of 2.5.

-43% of First Nations houses on reserve are in need of major repairs, compared to 7% of Canadian houses.

-prevalence of infectious diseases such as tuberculosis, bronchitis and influenza; increased social challenges associated with having less success at school; as well as increased vulnerability to injury or death resulting from an unsafe home environment, such as from fires

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July 27, 2016

(Kuujjuaq, Quebec) Inuit Tapiriit Kanatami (ITK) released the National Inuit Suicide Prevention Strategy (NISPS) today, which sets out a series of actions and interventions to address the high number of deaths by suicide among Inuit. The Strategy promotes a shared understanding of the context and underlying risk factors for suicide in Inuit communities and guides policy at the regional and national levels on evidence-based approaches to suicide prevention.

To support implementation of the Strategy, Health Canada announced $9 million for Inuit-specific approaches to improving mental wellness. This funding includes dedicated resources for enhancing mental health services; providing support and training resources for early childhood development programs; supporting a fund for Inuit-led suicide prevention projects, programs, and initiatives administered jointly by Inuit and Health Canada; and supporting Inuit-led coordination, outreach, and education for suicide prevention.

"Suicide among Inuit is a symptom of wider social challenges in our population that have emerged in just the last several decades," said ITK President Natan Obed. "Many these challenges are tied to colonial policies that placed intense stress on our entire population in a context where people have faced limited access to critical resources and supports that are available in most other parts of Canada. The NISPS is a tool for assisting community service providers, policymakers, and governments in working together to reduce the rate of suicide among Inuit to a rate that is equal to or below the rate for Canada as a whole."

"I would like to commend Inuit Tapiriit Kanatami for its efforts to raise awareness about suicide in Inuit communities and we are supportive of the work that they are doing," said the Honourable Jane Philpott, Minister of Health. "We are committed to working directly with Inuit leaders on issues that are important to them, including turning the tide of suicide that is having a devastating impact on Inuit youth, families and communities."

The NISPS, released during a gathering of about 60 people in Kuujjuaq, the largest community in Nunavik (Northern Quebec), focuses on what can be done to reduce suicide risk in Inuit communities while strengthening protective factors that can help buffer individuals and families from risk. The specific objectives and actions ITK will take to prevent suicide among Inuit fall within six priority areas that include creating social equity; nurturing healthy Inuit children from birth; and ensuring access to a continuum of mental wellness services for Inuit. ITK will evaluate its progress in achieving Strategy objectives in two-year increments.

ITK and Health Canada are committed to working together and with other Inuit leaders and provincial and territorial governments to provide effective, sustainable, and culturally appropriate health programs and services to improve the health of Inuit.

"Our ancestors had relatively low rates of suicide. They persevered through hardship, which is why we are here today," said Obed. "We must work together to support the people in our society who are struggling so that they can be strong and resilient throughout their lives once again."

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National Strategy Advocates Inuit-led Approach to Suicide Prevention - Inuit Tapiriit Kanatami

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July 27, 2016 (Kuujjuaq, Quebec) Inuit Tapiriit Kanatami (ITK) released the National Inuit Suicide Prevention Strategy (NISPS) today, which sets out a series of actions and interventions to address the high number of deaths by suicide among Inuit.

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In 2018 and 2019, there was a continual increase in suicides amongst Indigenous Peoples, specifically in Australia. Why is this happening at such an alarming rate? What is the cause of these deaths, especially among the youth?

Globally, suicide is the second highest contributor to adolescent deaths. Studies from high-income countries including Australia, New Zealand, the United States, Canada, and Arctic nations consistently find elevated suicide rates among Indigenous populations, with substantial rate disparities compared to non-Indigenous populations. According to the World Health Organization, low- and middle-income countries and high-income countries have similar annual standardized suicide rates. However, low- and middle-income countries account for 75 percent of suicide deaths worldwide, and there is often a disproportionate burden amongst specific subgroups within countries, such as Indigenous Peoples.

In Canada, the highest suicide rates have been reported among First Nations Peoples. According to Canada's Centre for Suicide Prevention, suicide and self-inflicted injuries are the leading causes of death for First Nations youths and adults up to age 44. The suicide rate for First Nations male youths ages 15-24 is 126 per 100,000, compared to 24 per 100,000 for non-Indigenous male youth. For First Nations females, the suicide rate is 35 per 100,000 compared to 5 per 100,000 for non-Indigenous females. Suicide rates for Inuit youth are among the highest in the world, at 11 times the national average.

In Australia, Aboriginal and Torres Strait Islanders between the ages of 15-24 are almost 4 times more likely to commit suicide than non-Indigenous people in the same age bracket. The Australian Bureau of Statistics reported that suicide is the leading cause of death for Indigenous children ages 5-17. From 2014-2018, Aboriginal and Torres Strait Islander children accounted for close to 25 percent of all child suicide deaths.

To better understand the issue of suicide among Indigenous Peoples, Cultural Survival Indigenous Rights Radio Producer, Shaldon Ferris (KhoiSan), recently spoke to Pat Dudgeon (Bardi), director of the Centre of Best Practice in Aboriginal and Torres Strait Islander on Suicide Prevention at the University of Western Australia (UWA). She is a psychologist, professor, Fellow of the Australian Psychological Society, and Poche Research Fellow at the School of Indigenous Studies at UWA in Perth.

Cultural Survival: Is the spike in the Indigenous suicide rate a recent trend, or has it been on the rise for some time?
Pat Dudgeon: Indigenous suicides have always been a big issue. It's probably gained a lot more national media attention in recent times, but it has been a growing concern in the last 40 years. Our Indigenous suicide rate is twice that of the general population, so it's become a big, big issue.

CS: What are some of the leading reasons for Indigenous suicides?
PD: For any suicide there is a whole matrix of different issues and problems. We believe that it's the history of colonization that Indigenous people have lived through. The country was taken over, there was genocide, people were removed from their countries and moved into missions and reserves. We went through a period we call the Stolen Generations, where people were forcibly taken from their families and put into institutions. In contemporary times, as well as having intergenerational trauma that's been passed down, there are a whole lot of social determinants that impact Indigenous people. We have higher rates of poverty and incarceration, and racism is ongoing, so those are factors that contribute to suicide and bad mental health. It's not a simple or clear answer. There's a lot of grief and loss in the community, substance abuse issues, sexual abuse, and so on, but for Indigenous people, having that history of colonization and ongoing racism is certainly a big part of the story.

CS: Is a loss of identity due to the impacts of colonialism a factor?
PD: Absolutely. We've gone out and done workshops and roundtables with community people, and we've done empowerment programs. What amazes me is how people implicitly know that what the mainstream has done-what the State has done to them-is wrong. They've seen their mothers and grandmothers subject to racist acts and treatments. To have it explicitly taught to them, to say, 'yes, this legislation happened and this was the impact,' validates their experience, and people are very conscious to hold on and to strengthen their cultural identity. I think we're in a process of remaking and restrengthening our cultural identity. Lucky for us, colonization has been a relatively short history compared to other countries. It could've been much more damaging. With Stolen Generations, some of those people were moved far away from home, and we have had some big initiatives called Bringing Them Home, which were about helping people come back to rediscover who their family or language group were, and to reconnect. Archie Roach (a local Indigenous singer) has written about the children coming home. That's important for us, to ensure that we strengthen our identity and people build faith so they know who they are and their role in the future.

CS: Are there patterns of similar occurrences happening in other Indigenous communities around the world?
PD: Yes, it's a very similar story. In November 2018, we held the second World Indigenous Suicide Prevention Conference. We ran it in a certain way where we privileged Indigenous presence and voices. When we formed our committees to plan the conference, we ensured there were youth representatives on there, elders, members of our LGBTQIA+ groups. Having the World Indigenous Suicide Prevention Conference was very important because we had people from Canada, New Zealand, the U.S., and so on, present. We looked at the global Indigenous suicide rates; they are very similar, it's a similar story. So I think all Indigenous societies are in a greater or lesser state of recovery from colonization, and one of the markers is a very high suicide rate, much higher than the rest of the population. That was important to us, to come together as world Indigenous people and to share our stories and to share what the solutions could be. We are seeing a global movement happening, and that's very important. I think we join up with our Indigenous brothers and sisters from other countries to talk, to learn from each other, and to share our knowledge and go forward. And, while we claim the right to have leadership in the discussion, there are certainly great nonIndigenous supporters and governments that support us as well.

CS: Do you think we should be talking to our respective governments about solutions, or should this issue be solved by us as Indigenous Peoples?
PD: Definitely from the people. The State has a very important role, and that is to give the resources to the people. It's very important to ensure that resources are sent into the community. Our position is for Aboriginal people themselves. Unless they're in charge of identifying the problem, the issues, and then implementing the solutions, we're going to have very limited effective suicide prevention or any kind of programs. We know that culture, self- determination, and cultural reclamation is important. Both were assumptions on the work done by Professor Michael J. Chandler in Canada, where they did some research with First Nations people and showed that communities with little self-determination and little cultural reclamation had higher suicide rates. We also used the work of the Harvard Project on American Indian Economic Development in the United States, where they've shown that Indigenous communities that are much happier and have higher health rates are ones that are also exercising their self-determination. That's very important for any group of human beings: they need to be there at the table, making decisions, being part of deciding what happens, how, when, and where.

CS: Is enough being done to reduce the Indigenous suicide rate? Do you think there's hope?
PD: I'm optimistic. I think Australia is alarmed at what's happening in its country. I think the government does want change to happen. I think the communities themselves want change to happen, because we had an elders group at our World Indigenous Suicide Prevention conference who were very vocal in what they wanted. They wanted a royal commission to look at the issue, and they were very vocal in what they thought the government should do. I think that all supporters of our society, whether it's governments, whether it's people on the ground, certainly the communities themselves, they want accountability and they want to be part of the discussion. So, I think things will change. I don't think it'll be an overnight solution, because it's taken us years to get to this point. For some sections it might take time to turn this around, but it will be turned around.

CS: What message can we give the Indigenous person who is in a remote area somewhere, contemplating suicide?
PD: Firstly, don't do it. Do not do it. Things will get better, but go and get help. It would be great if we could have a telephone crisis center that's culturally appropriate and knows our values and our issues and can give immediate help. Counselors too, they need to be trained to be more culturally knowledgeable. But there will be people in your family and in your community who can help. In every family and every community there is usually one strong person, or more, who will help the others. We need to nurture those people. They're the people we go to, and we've all got one or two in our lives, so go to those people, talk to them, get help from them.

Top photo: Pat Dudgeon speaks at the 2nd World Indigenous Suicide Prevention Conference. Photo courtesy of Pat Dudgeon.

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Combatting Suicide Amongst Indigenous Peoples: An Interview with Pat Dudgeon

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In 2018 and 2019, there was a continual increase in suicides amongst Indigenous Peoples, specifically in Australia. Why is this happening at such an alarming rate? What is the cause of these deaths, especially among the youth? Globally, suicide is the second highest contributor to adolescent deaths.

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Among Inuit youth, the suicide rate is about 24 times higher than for non-Indigenous youth. Suicide and self-inflicted injuries are the leading causes of death for First Nations. There were 1,845 total deaths by suicide of the Indigenous population in Canada from May 10, 2011, through Dec. 31, 2016. These are only some of the shocking statistics that best describe what the indigenous people go through on a daily basis. When I say suicide, you think of mental illness, substance abuse, hopelessness, or the loss of someone close to you. At least that’s what I thought. But for this community, it goes way deeper than that. Let me explain. Colonization occurred when a new group of people migrated to North America, took over, and began to control Indigenous People. That being said, they suffered from the eradication of the culture of the language. They lost countless amounts of values and traditions, all because of this new group who seized the land and started to control everything they came across. These factors led to a psychological and social breakdown in their community which came with isolation and hopelessness. In these circumstances, suicide is their only way of escaping reality and that's why their statistics are so high. How sad is that? How sad is the fact that people out there are giving up their lives because they feel someone else already took it? Now, help wise, this community is very poor. The idea is, to provide them with support and training resources, creating social equity and the continuum of mental wellness for all. Health Canada already associated with a group of Inuit and contributed 9 million dollars to help. But the help doesn't end there. There could be a telephone crisis line offered to them, connecting them to people who have lived through the same kind of thing, because that's what they need. To know that they are loved and not alone in what they're going through. A lot of the time, it's up to doctors whether someone lives or dies. It's not in our hands, not our fault. But in this case, it was our ancestors who were the main cause of someone's loss of hope. I think we owe them that much, to help them in whatever way they need. Thank you, and let's take action together.

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make sure to open in new window !

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Robert Olson, Librarian, BA, MLIS, Centre for Suicide Prevention

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Canada’s Indigenous Communities and Suicide - Centre for Suicide Prevention

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Why do some Indigenous communities have higher suicide rates than others? This editorial examines factors that put Indigenous communities at risk.

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Research article

Open Access

Published:

BMC Medicine 16, Article number: 145 (2018) Cite this article

14k Accesses

30 Citations

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Metrics

Abstract

Background

Suicide is the second leading cause of death among adolescents worldwide, and is a major driver of health inequity among Indigenous people in high-income countries. However, little is known about the burden of suicide among Indigenous populations in low- and middle-income nations, and no synthesis of the global data is currently available. Our objective was to examine the global incidence of suicide among Indigenous peoples and assess disparities through comparisons with non-Indigenous populations.

Methods

We conducted a systematic review of suicide rates among Indigenous peoples worldwide and assessed disparities between Indigenous and non-Indigenous populations. We performed text word and Medical Subject Headings searches in PubMed, MEDLINE, Embase, Cumulative Index of Nursing and Allied Health (CINAHL), PsycINFO, Latin American and Caribbean Health Sciences Literature (LILACS), and Scientific Electronic Library Online (SciELO) for observational studies in any language, indexed from database inception until June 1, 2017. Eligible studies examined crude or standardized suicide rates in Indigenous populations at national, regional, or local levels, and examined rate ratios for comparisons to non-Indigenous populations.

Results

The search identified 13,736 papers and we included 99. Eligible studies examined suicide rates among Indigenous peoples in 30 countries and territories, though the majority focused on populations in high-income nations. Results showed that suicide rates are elevated in many Indigenous populations worldwide, though rate variation is common, and suicide incidence ranges from 0 to 187.5 suicide deaths per 100,000 population. We found evidence of suicide rate parity between Indigenous and non-Indigenous populations in some contexts, while elsewhere rates were more than 20 times higher among Indigenous peoples.

Conclusions

This review showed that suicide rates in Indigenous populations vary globally, and that suicide rate disparities between Indigenous and non-Indigenous populations are substantial in some settings but not universal. Including Indigenous identifiers and disaggregating national suicide mortality data by geography and ethnicity will improve the quality and relevance of evidence that informs community, clinical, and public health practice in Indigenous suicide prevention.

Peer Review reports

Background

Globally, suicide accounts for approximately 800,000 deaths annually [ 1] and is the second leading cause of mortality among adolescents [ 2]. According to the World Health Organization (WHO), low- and middle-income countries and high-income countries have similar annual age-standardized suicide rates at 11.2 and 12.7 per 100,000 respectively; however, low- and middle-income countries account for 75% of suicide deaths worldwide [ 1]. National suicide rates range from less than one to 44 per 100,000 population, though there is often a disproportionate burden among specific subgroups within countries, such as Indigenous peoples [ 1]. Studies from high-income countries including Australia [ 3, 4], New Zealand [ 5], the USA [ 6, 7], Canada [ 8, 9, 10], and other Arctic nations [ 11, 12, 13, 14] consistently find elevated suicide rates among Indigenous populations, with substantial rate disparities compared to non-Indigenous populations. Several studies have shown that regional suicide rates vary greatly among Indigenous peoples, and that some Indigenous populations have low rates or no incidence of suicide [ 15, 16].

Indigenous peoples and nations differ vastly in culture, language, political autonomy, and relative wealth, yet many face similar social disadvantages and health disparities as a result of colonization [ 17, 18, 19]. Colonial governments have used discriminatory legislation and policies to deny rights and economic opportunities, and have attempted to acculturate Indigenous people into non-Indigenous societies [ 17, 19, 20]. Structural violence meted out by governments has taken many forms including dispossessing Indigenous peoples from traditional and sovereign lands, forced settlement and relocation, and outlawing cultural practices and languages [ 17, 18, 19, 20, 21]. This violence is grossly evident in the twentieth century assimilationist policies of former British colonies such as Canada and Australia. Indigenous children were systematically removed from their communities and placed in non-Indigenous institutions or families with the policy mandate to "weaken family ties and cultural linkages, and to indoctrinate children into a new culture" ([ 20], p. v). The contemporary legacy of this type of social engineering manifests in differential exposures to health threats and in inequitable outcomes that show up across generations [ 20, 22]. Intergenerational trauma from institutionalized abuse and racism experienced by Indigenous peoples has been linked to persistent social and mental health problems in some communities [ 19, 20, 23].

Although evidence has shown a disproportionate burden of suicide among Indigenous populations in national and regional studies, a global and systematic investigation of this topic has not been undertaken to date. Previous reviews of suicide epidemiology among Indigenous populations have tended to be less comprehensive or not systematic, and have often focused on subpopulations such as youth [ 24, 25], high-income countries [ 9, 26], or regions such as Oceania [ 27] or the Arctic [ 24, 28]. Given that approximately 80% of the world's more than 300 million Indigenous people live in Asia, Latin America, and Africa [ 17, 18], a comprehensive study of global suicide rates that includes low- and middle-income countries is needed. Our aim was to examine the published findings on the incidence of suicide among Indigenous peoples worldwide, and to compare rates with non-Indigenous or general populations to assess relative disparities.

Methods

Search strategy

We systematically reviewed findings on the incidence of suicide in Indigenous populations worldwide. We searched for studies that analyzed population-based data on suicide deaths, and included papers that reported crude or standardized mortality rates. Health science librarians were consulted about the design of the search strategy with the aim to capture all peer-reviewed literature. The search combined terms related to three concept areas: population (Indigenous), outcome (suicide mortality rates), and study design (observational). Term selection was based on previous systematic reviews and combined key terms adapted for each database and also Medical Subject Headings (MeSH) as applicable. The study protocol is available in Additional file 1: Supplement 1. Additional details about the methods are reported in Additional file 1: Supplement 2, including citations for previous reviews, a list of included terms, a description of the procedures used for study selection and eligibility criteria, and a complete list of databases and hand-searched review articles.

One author (NJP) performed online text word and MeSH searches for articles indexed in PubMed, MEDLINE, Embase, Cumulative Index of Nursing and Allied Health (CINAHL), PsycINFO, Latin American and Caribbean Health Sciences Literature (LILACS), and Scientific Electronic Library Online (SCiELO). A second author (KN) replicated the search in PubMed and obtained the same number of articles as the first author. We searched for studies in any language, indexed from database inception until June 1, 2017. We conducted a secondary search with a comprehensive list of terms for specific tribal groups, nations, and populations identified in previous reviews. As no additional studies were identified, this approach validated the primary search. We also searched the WHO's regional medical literature indexes, Indigenous-specific online research portals, and journals focused on Indigenous health. We hand-searched the reference lists of included articles and previous reviews to identify other eligible studies. Additional file 1: Supplement 2 includes a list of all databases and hand-searched sources.

One author (NJP) imported the results into a reference management program and removed duplicates. Two authors (NJP and KN) read the abstracts and screened in papers if they (1) reported a population-based crude and/or standardized suicide rate, or count and population data; (2) reported a rate for an Indigenous population; and (3) used an observational design. We excluded articles that did not include an Indigenous population, focused only on a specific age, gender, clinical subgroup, or deaths from a specific cause (for example, firearms), or were not peer-reviewed. Articles were also excluded if they were iterations, program evaluations or experimental studies, not primary studies, from the gray literature, or used identical data sources as prior studies.

Although there is no international consensus on the definition of Indigenous, we used the United Nation's working definition to assess study population eligibility [ 17, 18]. The UN's conceptualization of Indigenous involves self and group identification; a special attachment to and use of traditional land, distinct knowledge, language, and culture; distinct social, economic, and political systems; common ancestry with original territorial occupants; participation in maintenance and reproduction of distinct ethnic identity; and a non-dominant socio-political status [ 17, 18]. A paper was eligible based on this criterion if it reported an outcome for an Indigenous population, tribe, community, nation, or group, including papers that used the geographic proxy method. For the proxy method, census data is used to detect areas where Indigenous people are a majority population [ 29, 30]. We considered an area to be a proxy identifier if 80% or more of the population self-identified as Indigenous.

Two authors reviewed the full text of each paper and assessed eligibility based on inclusion criteria. At this stage, we excluded papers that did not report rates for the majority of the population (aged 15-65 years), did not conduct the primary data analysis, or provided rates in figures only and did not report count and population data. If two eligible articles used the same data source with a period of overlap, we included the article with the longer study period. During screening, full text review, and data extraction, we resolved disagreements through discussion or consultation with a third author. Translators helped assess non-English language articles and assisted with data extraction for four included studies. The following data was independently extracted by two authors (AL and NJP), then compared: citation, study design, country and region/community, Indigenous population, data source, standard population, number of suicide deaths, population count, crude and standardized suicide rates (overall and by gender and age group), comparative rates for a non-Indigenous or general population, and the measure of relative effect (incidence rate ratio).

Data analysis

We summarized all included studies in a table and reported counts, population, crude and standardized suicide mortality rates, and rate ratios. We calculated crude suicide mortality incidence rates for articles that reported only count and population data, and we estimated rate ratios when not otherwise reported by dividing the Indigenous population rate by the comparison population rate. To identify global patterns, we presented rates and rate ratios in tables and figures grouped by WHO region, country, population, and gender; we did not pool the data due to heterogeneity. We also reported on trends in suicide mortality over time and by age group; reported time trends reflect results from included studies, not pooled and recalculated rates. We modified the Newcastle-Ottawa Scale and used it to assess the quality of included articles. Additional file 1: Supplement 2 includes a description of the quality assessment procedures and scoring, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist is provided in Additional file 1: Supplement 4 [ 31].

Results

The search identified 13,736 papers; after removing duplicates, screening abstracts, and full text review, we included 99 in our analysis (Fig. 1). Included studies examined suicide rates in Indigenous populations in 30 countries and territories across six decades (Table 1), though the majority focused on those in high-income countries such as American Indian and Alaska Natives in the USA ( n = 35) and Inuit and First Nations in Canada ( n = 14). Studies in low- and middle-income countries ( n = 22) were mostly from Brazil ( n = 4), China and Taiwan ( n = 6), and Fiji ( n = 5). Coverage included circumpolar Indigenous peoples such as Sámi ( n = 3) and Nenets ( n = 1), and populations from the Western Pacific region including Aboriginal and Torres Strait Islanders in Australia ( n = 6) and Māori and other Pacific peoples ( n = 16). Four studies were transnational comparisons [ 32, 33, 34, 35], though numerous papers included multiple Indigenous groups within a single country. Studies were mostly of moderate quality (mean 2.79 on a 4-point scale) based on our assessment of study characteristics, as reported in Additional file 1: Supplement 3, Tables S1 and S2.

Flow diagram of study selection

Table 1 Overview of included studies

Incidence

We extracted population-based suicide mortality rates from 93 papers (Table 2) and included gender-specific incidence data from six additional studies [ 5, 10, 36, 37, 38, 39]. Overall, suicide rates among Indigenous peoples varied at all levels of aggregation in both high-income and low- and middle-income countries, and spanned from zero to 187.5 deaths per 100,000 person-years (PY; Table 2). In high-income countries, national and provincial suicide rates among Indigenous peoples ranged from 1.7 per 100,000 in Brunei Darussalam [ 40] to 50.4 per 100,000 among Aboriginal and Torres Strait Islanders in Northern Territory, Australia [ 41]. Rates in high-income countries were highest among rural Indigenous populations and in sparsely populated regions such as the Arctic. Among low- and middle-income countries, Palawan communities in the Philippines had the highest crude suicide rates (134 per 100,000) [ 42], while Indigenous peoples in Malaysia [ 43] and some Pacific small island states such as Fiji had crude rates under 7 per 100,000 population. The number of suicide deaths used for rate calculations ranged from zero to 4219 (Table 2).

Table 2 Suicide mortality rates among Indigenous populations by WHO region and country

Measure of relative effect

Incidence rate ratios were reported or calculated for 102 Indigenous populations in 69 studies. The results showed rate disparities in the majority of studies (Fig. 2), though 22 reported rate ratios below one. The rate ratios ranged from 0.04 in China [ 44] to more than 20 in Brazil [ 45] and Canada [ 30] (Additional file 1: Supplement 3, Table S4). Most Indigenous populations had higher suicide rates than comparison groups; disparities were widest in studies with small populations. One study reported a suicide rate of zero for an urban Indigenous population in Brazil compared the general population rate of 4.8 per 100,000 in the same city [ 46].

Global suicide mortality incidence rate ratios among Indigenous and comparison populations. a Western Pacific Region (Oceania and Australia). b Western Pacific Region (East Asia). c European Region. d Region of the Americas (Canada and Brazil). e Region of the Americas (USA, National). f Region of the Americas (USA, Alaska). g Region of the Americas (Lower 48 states and Hawaii). NWT Northwest Territories, IHSA Indian Health Services Area. The dotted line indicates a rate ratio of one (RR = 1). This means that there is rate parity (no difference) between the incidence of suicide in Indigenous and comparative populations. Rate ratios to the left of the dotted line (RR < 1) indicate that rates are comparatively higher in the non-Indigenous population. Conversely, rate ratios to the right of the dotted line (RR > 1) show that the Indigenous population has a comparatively higher rate. Citations for each study are reported in Additional file 1: Supplement 3, Table S4

Time trends

Suicide rates appeared to increase over time, especially in the latter half of the twentieth century, though reports were limited. Among studies with reported time series ( n = 24), most (83%, n = 20) had fewer than 10 data points and covered an average of 19 years. A study in Greenland was the exception; it reported longitudinal data that showed a steady suicide rate increase among Inuit that began with the near absence of suicide in the early part of the twentieth century (2.4 per 100,000) and climbed exponentially to a rate of 110.4 per 100,000 in 2010-2011; the average number of suicides per year changed from less than one to 55 during this period [ 12]. Aboriginal and Torres Strait Islanders in Northern Territory, Australia experienced similar rate accelerations (6.1 per 100,000 in 1981 to 50.4 per 100,000 in 2002) [ 41], while incidence among Alaska Natives was relatively stable, though high, from the 1980s to the early 2000s [ 47, 48]. Indigenous peoples in the Micronesian islands experienced a sixfold increase in suicide rates between the 1960s and the late 1980s (from 4.3 to 25.8 per 100,000) [ 35], and one study reported slight rate declines for both Māori and non-Māori in New Zealand from 1996 to 2002 [ 5]. Annual rates tended to fluctuate in studies with small populations.

Age differences

Age-specific rates were reported in 39 studies; various age categories were used, and rates were often only available for select strata. Youth less than 30 years old, especially those aged 15-24 years old, had the highest suicide rates of any age group in 89% of studies ( n  = 34) that reported age-specific rates. In the larger studies (> 100 total suicides) with age-specific incidence, youth suicide rates ranged from 15.9 to 108 per 100,000 population. Very few studies reported deaths or rate estimates for adults more than 60 years old.

Gender differences

Men accounted for the majority of suicide deaths in all but four studies; only two of these four studies reported a greater number of suicide deaths among women [ 49, 50]. Studies with gender-specific crude and age-standardized rates ( n = 35) ranged from zero to 75.5 per 100,000 among Indigenous women (Additional file 1: Supplement 3, Table S3). Suicide rates were higher among Indigenous men compared to Indigenous women, though rate differences were marginal among some Pacific populations [ 33, 51]. Suicide rates were also higher among Indigenous men than for men in comparison populations in all countries except Israel and Fiji. Outside of the relatively low rates among Indigenous men in these countries, estimates ranged from 19.5 among Sámi [ 13] to 248.7 per 100,000 among Inuit [ 30].

Discussion

This study showed that the rate of suicide is elevated in many Indigenous populations globally, but that rate variation is common (Fig. 1). The evidence of substantial rate disparities for Indigenous peoples in Australia, Brazil, Taiwan, and circumpolar countries is notable. Equally important, we found that disparities were marginal or non-existent in some US territories and Pacific nations; we also identified 21 studies in which Indigenous populations had lower suicide rates than non-Indigenous populations. These results demonstrate that the high incidence of suicide and large rate disparities are not universal among Indigenous peoples. This confirms and extends findings from prior research that reported variation in localized estimates in the USA [ 52] and Canada [ 16].

Worldwide variation in the incidence of suicide among Indigenous peoples has complex and place-based social origins. These origins are traceable to regional differences in the impact of colonization, which is widely recognized as a major determinant of Indigenous health [ 17, 18, 19, 53]. Colonial governments have historically threatened the well-being of Indigenous peoples through chronic and often state-sanctioned discrimination and human rights abuses, and continue to do so in many countries [ 18, 20, 23]. Until 2016, several high-income countries had not ratified the United Nations Declaration on the Rights of Indigenous Peoples, and therefore legislative reforms to recognize Indigenous self-determination lagged. As a result, many Indigenous nations have yet to attain political sovereignty over lands and natural resources, education, or health care.

Globally, Indigenous peoples commonly experience social and economic marginalization and, as a consequence, some of the most disparate health outcomes [ 17, 18, 53]. In this context, the extent and the persistence of high suicide rates and rate disparities reveal a striking deficit in the global effort to prevent suicide and achieve social and health equity. This is further challenged by overlapping barriers to accessing health care and community supports, especially in rural areas and low- and middle-income countries. Barriers include fragmented care networks, lack of access to services due to geography, discriminatory attitudes from health care providers, and services that are not culturally safe or provided in the necessary language [ 18, 54, 55]. In resource-limited and conflict settings in particular, mental health services are inadequate in scope and quality, chronically under-funded, and in some places non-existent [ 18, 54].

Challenges in accessing mental health care are compounded by the limited relevance and generalizability of some "best practice" interventions in Indigenous contexts [ 56, 57]. Recent clinical trials with gatekeeper training [ 57], hospital-based interventions [ 58], and mobile self-help applications [ 59] reported adverse and limited effects on suicide-related outcomes for Indigenous peoples. Overall, intervention studies with Indigenous populations are rare, and community-based programs are often not evaluated or have weak study designs [ 60, 61, 62, 63]. These challenges point to a need to expand efforts to generate Indigenous-specific evidence [ 23, 56, 60]. Indeed, many communities have developed contextualized and complex approaches to suicide prevention that respond to local priorities. There is emergent evidence that such programs increase protective factors and reduce suicide-related behavior [ 63, 64, 65]. However, knowledge about programs' effectiveness, implementation, and capacity to scale up is limited, and many programs are not sustainably funded [ 56, 60, 61, 62].

Indigenous organizations and governments in New Zealand, Canada, and several Arctic states have moved beyond programmatic approaches and designed Indigenous-specific suicide prevention strategies [ 23, 55, 66]. These strategies integrate evidence-based public health and clinical interventions with Indigenous knowledge about the consequences of colonization, institutionalized violence and racism, and the value of culture. They also recognize that social conditions have an important role in shaping mental health, especially during the early years of life, and that improving these conditions can have a positive impact on population mental health and suicide-related outcomes. The path to lowering the incidence of suicide among Indigenous peoples and achieving health equity requires broader social transformation both within states and globally. This transformation must be collaborative, with Indigenous organizations and communities as leaders and rights-holders in knowledge production and decision-making [ 23, 29, 53, 56, 66, 67]. Public health systems can also enhance capacity for Indigenous suicide prevention with efforts to increase the visibility of community-level differences in health status and by accurately tracking changes in suicide mortality over time.

Limitations

This study is a comprehensive synthesis of the published evidence on the global epidemiology of suicide among Indigenous peoples. Although it is the first review of this scale, our study has several important limitations. First, included studies varied their methods of identifying Indigenous populations. Self-identification is the gold standard in administrative and registry data [ 67]. However, this is a recent benchmark. Its uptake has varied internationally, and some countries do not identify Indigenous populations in health data at all [ 53, 67]. The majority of included studies relied on linkages with census or registry data, geographic proxies, or observer-determined assessments. These procedures are useful approximations, but they use varied definitions and tend to under-count Indigenous people, especially groups without legal recognition [ 29, 53, 67]. This can lead to ascertainment bias and underestimation of inequities [ 53, 67]. A second and related limitation is the under-representation of studies from low- and middle-income countries. In our review, we may have missed studies, particularly from the Global South, due to the conceptualization of Indigenous and the search terms used, which do not necessarily apply in all contexts. We attempted to limit this bias by searching databases focused on low- and middle-income countries and including non-English language papers.

The third limitation was that it was difficult to compare suicide rates between countries. Included studies were heterogeneous in population size, number of cases, aggregation, data source and outcome assessment, method of identifying Indigenous peoples, and coverage period. Many papers provided crude estimates only and did not report numerator and denominator data by age group, gender, or ethnicity. For studies with adjusted rates, different standard populations were used, and confidence intervals were rarely reported. Differences in analytic and reporting practices made it challenging to directly and reliably compare suicide rates across studies. To address this, we examined rate ratios to assess relative differences between Indigenous and non-Indigenous/general populations. This allowed us to estimate rate disparities, which were compared globally.

The fourth limitation was that studies reporting low suicide rates may be under-represented, which is a potential publication bias. It is unclear whether the lack of low incidence populations is related to the common finding of elevated rates of suicide among Indigenous peoples compared to non-Indigenous populations or, as we suspect is more likely, to the possibility that suicide rates are rarely studied when they are low. Additional low incidence reports may exist outside of peer-reviewed studies; however, these were not identified because we did not search the gray literature. The primary reason for excluding gray literature reports was the extensive volume of sources with variable quality and also the risk of over-including data from high-income nations where public reporting of mortality data is common and vital statistics infrastructure is of high quality. Nonetheless, we identified 23 papers that reported rate parity or had a rate ratio below one, but these tended to use older data. A related problem is that case studies tended to examine suicide clusters in small populations [ 42, 68]. The advantage of using localized data is the ability to contextualize a complex health issue. The disadvantage is that the potential to compare health status between multiple groups, across regions, and over time is reduced.

Strengthening surveillance in Indigenous suicide prevention

Our results substantiate previous work [ 16, 52] to demonstrate that elevated suicide rates are not universal among Indigenous people and debunk notions that Indigeneity increases risk for suicide. Our results also point to several gaps in knowledge about the epidemiology of suicide in Indigenous populations globally. The lack of published suicide data on Indigenous populations in low- and middle-income countries is a glaring absence. Previous studies noted a scarcity of Indigenous-specific data in the Global South overall [ 18, 53]. Poor infrastructure for death registration is a key limitation [ 1]. In the context of suicide, this is especially problematic, because countries in Asia, Africa, and Latin and South America are the homelands for the majority of the world's Indigenous populations [ 18] and, at a national level, account for more than three quarters of all suicide deaths [ 1]. Suicide data in high-income countries tends to be of better quality than that in low- and middle-income countries; however, many governments do not include Indigenous or other ethnic identifiers in administrative health data, and do not routinely link census or Indigenous registries with national health datasets such as vital statistics. In Canada for example, the federal government does not know how many Indigenous people die by suicide in a given year. Globally, there is a critical need to strengthen capacity for surveillance in Indigenous suicide prevention.

National governments can take several steps to improve suicide surveillance in Indigenous populations. Actions should include efforts to enhance suicide data quality and standardized classification by improving vital registration infrastructure, especially in low- and middle-income countries, and integrating mortality data with monitoring of suicide attempts [ 1]. Countries should adopt an equity-based approach to data collection that includes Indigenous identifiers derived from self-reported sources and linked to registries or census data to address gaps in identification, and align Indigenous identification procedures with recommendations from the International Group for Indigenous Health Measurement, adapted for each national context [ 1, 53, 56, 67, 69]. Building inclusive, Indigenous-centered models of data governance in suicide prevention will be a critical element of strengthened surveillance. To achieve this will require national statistical agencies to not only consult Indigenous communities, organizations, and leaders about priorities, but to respect Indigenous rights to determine the parameters of data ownership, custodianship, access, and use [ 29, 32, 67].

Future research and global suicide surveillance efforts will be further strengthened with longitudinal and up-to-date national and state-level datasets that allow disaggregation and comparisons of outcomes in small areas and subpopulations by ethnicity [ 1, 17, 53, 56]. Overall, these actions will help maintain robust public health surveillance systems in order to monitor health status, increase knowledge about the social determinants of suicide, target interventions, and evaluate strategies aimed at reducing the incidence of suicide among Indigenous peoples worldwide [ 1, 56]. Increasing the visibility of populations that bear the greatest burden from suicide can help drive efforts to achieve the WHO and Sustainable Development Goals of reducing national suicide rates by up to 30% [ 1, 69].

Conclusions

Suicide among Indigenous peoples is not a universal or intractable problem. Our study showed substantial global rate variation, with striking disparities in some countries. Efforts to understand these differences and to continue to build the knowledge base for effective interventions will require sustained political and financial investments in Indigenous communities, health systems, and governments. Across sectors and countries, Indigenous peoples have called for suicide prevention strategies that are community-led, strengths-based, and trauma-informed, and that redress intersecting forms of structural discrimination, social inequity, and their downstream consequences. Global efforts to reduce suicide rates among Indigenous peoples must include actions focused on communities that experience the most profound disparities, while also seeking to promote population mental health and improve health equity.

Abbreviations

CI:

Confidence interval

CSIR:

Crude suicide incidence rate

FSM:

Federated States of Micronesia

IHSA:

Indian Health Services Area (USA)

NWT:

Northwest Territories (Canada)

SSIR:

Standardized suicide incidence rate

UN:

United Nations

USA:

United States of America

WHO:

World Health Organization

Acknowledgements

Work on this study was conducted while the authors resided in communities in Newfoundland and Labrador, Canada situated on the homelands of the Innu, Inuit, Mi'kmaq, and Beothuk peoples, and in communities in Ontario, Canada situated on the traditional and unceded territory of the Algonquin Nation. We respectfully acknowledge their ancestral and continued ties to the lands and waters.

We wish to thank the health science librarians who contributed their expertise to the design of this study: Janice Linton, University of Manitoba; Lindsay Alcock, Memorial University; and Lindsey Sikora, University of Ottawa. Thank you as well to our colleagues who assisted with translation, data extraction, and article access, and provided feedback on previous versions of this manuscript: Dr. Marina Sokolova, University of Ottawa; Dr. Albert Formanek, Laval University; Dr. Joseph Murray, University of Pelotas; Dr. Peter Bjerregaard, University of Southern Denmark; Dr. Yanqing Yi, Memorial University; Christopher Penney, Indigenous and Northern Affairs Canada, Government of Canada; Dr. Joyce Law, Labrador-Grenfell Health; Michele Wood, Department of Health and Social Development, Nunatsiavut Government; and Morgon Mills, Labrador Institute, Memorial University. We also recognize and are grateful for ongoing partnerships and research collaborations with the Nunatsiavut Government, Innu Nation, NunatuKavut Community Council, and Labrador-Grenfell Regional Health Authority, and for administrative support from the Labrador Institute and Faculty of Medicine at Memorial University, and the University of Ottawa.

Funding

NJP was supported by doctoral scholarships from the Canadian Institutes of Health Research and is a research associate at the Labrador Institute of Memorial University with salary funding from the Government of Canada's Atlantic Canada Opportunities Agency. KN was supported by a studentship from the Ontario Mental Health Foundation. IC is an associate professor at the University of Ottawa and received salary support through the Canada Research Chairs program. SM is a professor in the Faculty of Medicine at Memorial University. There was no direct funding source for this study. All authors had full access to all the data in the study, take responsibility for the integrity and accuracy of the data, and had the final responsibility for the decision to submit for publication.

Availability of data and materials

All data relevant to this study has been reported in the manuscript or included in the additional file.

Author information

Affiliations

1. Division of Community Health and Humanities, Faculty of Medicine, Memorial University, Prince Philip Drive, St. John's, Newfoundland and Labrador, A1B 3V6, Canada

Nathaniel J. Pollock & Shree Mulay

2. Labrador Institute of Memorial University, P.O. Box 490, Stn. B, 219 Hamilton River Road, Happy Valley-Goose Bay, ,Newfoundland and Labrador, A0P 1E0, Canada

Nathaniel J. Pollock

3. School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, 600 Peter Morand Cr, Room 308C, Ottawa, ON, K1G 5Z3, Canada

Kiyuri Naicker, Alex Loro & Ian Colman

Contributions

NJP, KN, AL, SM, and IC met the International Committee of Medical Journal Editors criteria for authorship, and no individual who met these criteria was excluded. NJP, IC, KN, SM, and AL conceived and designed the review; NJP and KN conducted the searches and screened titles and abstracts; NJP, IC, KN, and SM reviewed full text articles; AL, NJP, and KN extracted and cleaned the data; NP and IC analyzed the data; and NJP and IC planned and drafted the manuscript. All authors interpreted the results, revised the manuscript, and approved the final version of the article. NJP is the guarantor.

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Correspondence to Nathaniel J. Pollock.

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Pollock, N.J., Naicker, K., Loro, A. et al. Global incidence of suicide among Indigenous peoples: a systematic review. BMC Med 16, 145 (2018). https://doi.org/10.1186/s12916-018-1115-6
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Keywords

Indigenous

First peoples

Inuit

Health disparities

Suicide

Mortality

Surveillance

Epidemiology

# data[].attributes.attachment_link.title
Global incidence of suicide among Indigenous peoples: a systematic review

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Background Suicide is the second leading cause of death among adolescents worldwide, and is a major driver of health inequity among Indigenous people in high-income countries. However, little is known about the burden of suicide among Indigenous populations in low- and middle-income nations, and no synthesis of the global data is currently available.