Dr. Perez-Rodriguez is clinical researcher in the Department of Psychiatry at Ramón y Cajal University Hospital in Madrid, Spain. Dr. Baca-Garcia is adjunct assistant professor, Dr. Oquendo is professor of clinical psychiatry, and Dr. Blanco is associate professor of clinical psychiatry at Columbia College of Physicians and Surgeons in New York City.

Disclosure: Drs. Perez-Rodriguez, Baca-Garcia, and Oquendo report no affiliation with or financial interest in any organization that may pose a conflict of interest. Dr. Blanco receives grant support from the American Foundation for Suicide Prevention, the National Institutes of Health, and the New York State Psychiatric Institute.

Acknowledgments: The authors thank Elizabeth M. Langer for contributing to the literature search and article drafting.

Please direct all correspondence to: Carlos Blanco, MD, PhD, Department of Psychiatry, Columbia University, 1051 Riverside Dr, Box 69, New York, NY 10032; Tel: 212-543-6533; Fax: 212-543-6515; E-mail: cb255@columbia.edu.

Abstract

Suicide is one of the leading causes of death, and suicidal ideation and attempts are a major public health concern. However, little is known about the relationship between ethnicity and suicidal behaviors. This article provides an update on the relationship between ethnicity and suicidal ideation and attempts. It reviews the rates of suicidal ideation/attempts across ethnic groups in the United States as well as the risk factors associated with suicide attempts in each ethnic group. The results of published studies have been inconsistent. Some studies have suggested that non-Hispanic Whites have significantly higher suicide attempt risk than other ethnic groups, while two studies using national data did not find any significant relationship between race/ethnicity and suicidal ideation or attempts. From the epidemiologic point of view, these findings underscore the need to conduct large studies in general population samples that include enough individuals from all ethnic groups and that are large enough to detect significant effects among those groups. From the clinical point of view, mental health professionals should focus on factors consistently found to be strongly associated with suicide attempts across different populations, including major depressive disorder and other psychiatric disorders, female gender, and young age.

Introduction

In the United States, suicide is the 11th cause of death for all ages, the third cause of death in individuals 10–24 years of age, and the second in those 25–34 years of age.¹ Every year, >300,000 individuals (112–145 per 100,000 population) are treated for suicide attempts in emergency departments in the US.¹ Suicidal ideation strongly increases the risk for suicide attempts.²

Studies have consistently documented that women^2-5 and young adults^2,5-7 are at increased risk for suicidal behavior. In contrast, much less is known about the relationship between ethnicity and suicidal ideation and attempts. Some studies have suggested that non-Hispanic Whites have significantly higher risk for suicide attempts than other ethnic groups,⁴ such as Blacks² and Hispanics,⁸ although some⁹ but not all¹⁰ studies have suggested that different subgroups among Hispanics have divergent rates of suicide attempts. In contrast, two studies using national data did not find any significant relationship between race/ethnicity and suicidal ideation or attempts.^2,6 It is debatable whether these inconsistencies are due to the fact that ethnic groups as usually conceptualized are rather heterogeneous. There are also some questions as to whether risk factors for suicidal ideation and attempts among the general population may not apply to specific ethnic groups such as African Americans, American Indians, or Hispanics.¹¹

This article provides an update on the relationship between race/ethnicity and suicidal ideation/attempts. The article reviews the rate of suicidal ideation and attempts across races and ethnic groups in the US as well as the specific risk factors associated with suicide attempts in each race and ethnic group. Rates of suicidal ideation and attempts across ethno-racial groups are presented in Table 1.^2,4-10,12-18 Risk factors for suicide attempts across races and ethnic groups are presented in Table 2.^{8-10,13,15-35}

This article uses the five racial classifications used by the US Census Bureau to collect and present federal data on race and ethnicity. These classifications include American Indian and Alaska Native; Asian; Black or African American; Native Hawaiian and Other Pacific Islander; and White.³⁶ There are also two categories for ethnicity, namely, Hispanic or Latino and Non-Hispanic/non-Latino (Hispanics and Latinos may be of any race).³⁶ Rates and risk factors for suicidal ideation and attempts in each of these groups are presented in alphabetical order.

Rates and Risk Factors for Suicidal Ideation and Attempts Among American Indians and Alaska Natives (Native Americans)

The broader term, “Native Americans,” potentially includes American Indians, Alaska Natives, Native Hawaiians, and all indigenous people of Canada, Mexico, and Central and South America. In contrast with the common view that Native Americans are a homogeneous group, according to Census reports there are >561 tribes speaking over 220 indigenous languages with various dialects living in the US.³⁷ Relatively little is known about suicidal ideation and attempts among Native Americans, with most of the studies being based on student populations.^13,38-40

In 1977, the National Congress of American Indians and National Tribal Chairman’s Association issued a joint resolution that preferred the term “American Indian” over “Native American” for the indigenous population of the “lower 48.” The term “Alaska Native” was reserved for the indigenous population of Alaska. Native Hawaiians were not included in either of these groups.¹³ A more recent survey by the US Department of Labor⁴¹ indicated that approximately 50% of the Indians sampled preferred the term “American Indian” over “Native American.” Therefore, the more specific term “American Indian” will be used throughout this article.

According to the US Census, 4.1 million American Indians/Alaska Natives live in the US, comprising approximately 1.5% of the US population.⁴² Studies have reported a high prevalence of suicidal ideation and attempts among American Indians, particularly among females, adolescents, and young adults.¹³ Data on adults are scarce but suggest that there is a high prevalence of suicidal ideation and attempts among American Indians.¹³ According to the Alaska Trauma Registry,⁴³ rates of suicide attempts, particularly those using firearms, were significantly higher for Alaska Natives than Alaska Whites between 1994 and 1999. In a study of a sample of urban Native Americans ≥50 years old, 31% of those who had been physically abused and 12% of those who had not been abused reported a history of depression or suicide attempts. The authors failed to provide rates for history of suicide attempts only, making it difficult to compare their results with those of other studies.¹⁹

Although the reasons for the high rates of suicidal ideation and attempts among American Indians are unknown, they are likely related to the high prevalence of depression, substance use disorders, including alcohol, and posttraumatic stress disorder in this population.^44,45 Chester and collegues⁴⁵ studied 235 off-reservation Native Americans and found high rates of mental health problems, but low levels of service use. Alcoholism has been described as “epidemic” among Alaska Natives.⁴⁶ Hill and colleagues⁴³ reported that alcohol was involved in 60.8% of intentional injuries involving Alaska Natives, compared to only 27.1% for Alaska Whites. May and colleagues²¹ observed that two-thirds of all self-destructive acts in the Western Athabaskan Tribal Nation reservation were alcohol related and occurred among unemployed individuals. This is particularly relevant given that in some reservations 80% of those ≥16 years of age are unemployed. Moreover, physical abuse may be particularly prevalent in some Native American communities and has been associated with depression and suicide attempts.⁴⁷ The lack of culturally appropriate models of mental health in Native Americans and the barriers to providing effective mental health services to Native Americans may also be related to the high rates of suicidal acts in this population.⁴⁸

Some studies have found that a greater percentage of American Indians had attempted suicide in their lifetime than had reported suicidal ideation or planning. This suggests that in this population suicide attempts may be more impulsive than previously hypothesized.¹³ Alternatively, the wish to die, which has been understudied so far, as opposed to the presence of suicidal ideation, may be a key factor related to the risk for attempting suicide.⁴⁹

Rates and Risk Factors for Suicidal Ideation and Attempts Among Asians

Asian Americans are also an extremely diverse group of people with varying cultures, histories, views of mental illness, and views of suicide, although they comprise slightly >2% of the US population.⁵⁰

Suicide attempts and suicidal ideation among Asian Americans have been understudied to date.⁵⁰ Part of the problem is that most epidemiologic studies examining this topic collapse Asian Americans and American Indians into a single category, precluding the examination of the suicidal behavior in those groups independently.^2,6 Asian Americans and American Indians represent very small percentages of the general population (2.0% and 1.5%, respectively), and some of the outcomes are sufficiently rare that most epidemiologic surveys may not have enough power to detect differences in such small group sizes.⁶ Iribarren and colleagues¹² analyzed rates of hospitalization for suicide attempt in a sample of White, Asian, and African American men and women. Among women, the rate of hospitalization for suicide attempts was highest among Whites, while rates for Asian and African American women were lower (Table 1). Among men, the rate of hospitalization for suicide attempt was highest among Whites, intermediate among African Americans, and lowest among Asians. By contrast, Kennedy and colleagues¹⁴ reported no differences in rates of suicide attempts across Europeans, Chinese, and Indo-Asians. Studies in other Western countries have generally reported significantly lower rates of suicidal behaviors among individuals of Asian origin than among individuals of other ethnic groups.^51-53 Furthermore, some groups of Asian Americans, such as southeast Asian refugees, appear to have increased needs for mental health services compared to the general population.^54-56 Overall, these data suggest that clinicians and researchers should pay more attention to Asian American communities.⁵⁴

Rates and Risk Factors for Suicidal Ideation and Attempts Among Blacks

Two large national epidemiologic studies have suggested that Blacks are at lower risk for suicide attempt than non-Hispanic Whites.^2,4 However, another recent national study indicated that there may have been an increase in the rate of suicide and nonfatal suicidal behaviors among Blacks, particularly among youths.¹⁶ Studies based on Black samples have reported high rates of suicidal ideation and attempts among Blacks, particularly among young individuals.^15,16 Moreover, it has been suggested that suicidal behavior among African Americans is often underreported or misclassified.30 These contradictory findings need to be explored in national studies with large samples that include all other ethnic groups.

Regarding subgroups within the Black community, Joe and colleagues¹⁶ reported that the lifetime prevalence of suicide attempts among Caribbean black men (7.5%) was the highest among the four ethnic-sex groups analyzed (African American and Caribbean American men and women). The authors of this article have not found any other studies comparing suicide attempts in different groups within the African American community.

Blacks share some of the risk factors for suicide attempt identified in the general population, such as life events, female gender, depression and other psychiatric disorders, and hopelessness.^{15,16,26-29,31-34,57} According to data from the National Hospital Ambulatory Medical Care Survey, African Americans had significantly higher rates of psychiatric-related emergency department visits compared with Whites.⁵⁸ There are also some indications that Blacks may also have specific risk factors such as lower ethnic identity, alienation from family, and fragmentation of social support.²⁶ By contrast, other authors have reported that religious well being, but not acculturation, was related to history of suicidal ideation and attempt.⁵⁹ Some studies have found that Blacks report suicidal ideation or depression as a possible precursor to suicide attempts less often than non-Hispanic Whites. Similarly, it has been hypothesized that Black youths may act out and attempt suicide as a defense against feelings of sadness.^60,61

Rates and Risk Factors for Suicidal Ideation and Attempts Among Hispanics

It is estimated that by 2020 Hispanics will be the largest racial/ethnic minority group in the US and that by that time they will represent 17% of the US population.⁶² However, research on suicidal ideation and attempts among Hispanics in the US is limited and rarely analyzes different Hispanic groups separately. In addition, many Hispanic individuals are undocumented workers who are not represented in epidemiologic studies.⁶³

Some studies have suggested that suicide attempts may be less common among Hispanics than in other ethnic groups.⁸ In contrast, two large nationwide surveys did not find any significant relationship between race/ethnicity and suicide ideation or attempts,^2,6 and studies focused on Hispanic samples have reported rates of suicidal ideation and attempts that are similar to those reported in White populations or even higher among some subgroups of Hispanics.^9,10

Studies have also reported that rates of suicidal ideation and attempts are different across Hispanic ethnic subgroups,^9,18 while others have not found any significant differences in rates of suicidal ideation or attempts across Hispanic subgroups after adjusting for demographic, psychiatric, and sociocultural factors.¹⁰ The most consistently reported findings are a higher rate of lifetime suicide attempts among Puerto Ricans and a lower rate among Cuban Americans.^9,10,18,64

This variability in suicide attempt rates across Hispanic subgroups has been attributed to many factors such as the impact of the migration process, socioeconomic status, acculturation, cultural differences in norms and attitudes, and different rates of psychiatric disorders, among others.^9,10 This is supported by the fact that the Hispanic population is heterogeneous in terms of ethnicity, geography, acculturation, migration patterns, education, and socioeconomic status.¹⁰

The variability in suicide attempt rates across Hispanic subgroups is consistent with the differences in the prevalence of major depressive disorder (MDD) observed among Hispanic subgroups. Non-Hispanic Whites and Puerto Ricans have higher rates of MDD compared to other Hispanic ethnic groups.^9,65 Fortuna and colleagues¹⁰ observed that any lifetime Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,⁶⁶ psychiatric diagnoses were associated with an increased risk of lifetime suicidal ideation and suicide attempt among Hispanics.

Acculturation may also be related to suicidal behavior among Hispanics.^10,67 Fortuna and colleagues¹⁰ observed that different aspects of acculturation, such as language spoken as a child, current English proficiency, and parental US nativity may be risk factors for suicidal behaviors. The prevalence of suicidal ideation and attempts appear to be higher among Puerto Ricans and Mexican Americans¹⁷ with higher levels of acculturation than among those with lower levels of acculturation. It has been reported that US-born Hispanics have a higher rate of mental health and substance abuse problems than recent immigrant Hispanic populations.⁶⁸ The mechanism by which acculturation is a potential risk factor for psychiatric disorders and suicidality may be related to culturally influenced coping strategies and cultural values such as moral objections to suicide, which may be less prominent as acculturation progresses.^10,69

Despite the existence of some specific risk factors such as acculturation or family cultural conflict, Hispanics appear to share some of the risk factors for suicidal behavior found in the general population, such as female gender and presence of psychiatric disorders, particularly MDD.^8-10

Limitations

The findings of studies examining suicide attempt and suicidal ideation rates in specific ethnic groups should be viewed with two limitations in mind. First, some of the groups analyzed are heterogeneous in terms of ethnicity, geography, acculturation, education, migration patterns, socioeconomic status, and access to health care.^9,10 The second limitation is that studies have different designs and target populations. For example, the results reported in studies of clinical populations whose data are based on discharge diagnoses rather than self-reports may reflect issues such as access to care, which may vary across ethnic groups and may have excluded suicidal behavior not requiring medical attention.⁹ It has been reported that immigrants may under-use psychiatric services.⁷⁰ A third limitation is that some of the ethnic groups analyzed may be too small (<5% of the general population) for the differences to achieve statistical significance in epidemiologic surveys in the general population.⁶

Conclusion

The published studies indicate that the prevalence of suicidal ideation and attempts vary widely across ethnic groups. However, many of these studies were focused on a single ethnic group or used relatively small or local samples sizes, suggesting caution in their interpretation. Overall, these existing findings underscore the need to conduct large studies in general population samples that include enough individuals from all ethnic groups and that are large enough to detect significant effects among those groups.

This stresses the importance of focusing on factors that have been consistently found to be strongly associated with suicide attempts across different populations, such as MDD and other psychiatric disorders, female gender, and young age.^2-7

Besides examining associations between suicide and risk factors such as demographic variables (eg, female gender, young age), future research should aim at identifying factors that may be modifiable with interventions, including the treatment of psychiatric disorders such as MDD.⁷¹ A better understanding of risk factors may allow the implementation of selective suicide prevention programs that could then be tested empirically.⁶³ These programs are more likely to be effective if they are culturally sensitive. More research is needed to examine which aspects of the prevention programs can be universally applied and which have to be tailored for the specific target groups.

Another key issue is the identification of protective factors that may act upon individuals of different ethnicities and may help explain the lower rates of suicide attempts found among some of them. For example, Oquendo and colleagues⁶⁹ found that several factors protective against suicidal behaviors (those regarding survival and coping beliefs, responsibility to family, and moral objections to suicide) were significantly more common among Hispanics than non-Hispanics. Since this may reflect cultural norms endorsed by Hispanic groups, it would be of interest for further studies to examine the impact of protective factors on suicidal behavior and their relationship to specific cultural constructs.⁶⁹ The protective role of African American culture has been consistently reported.⁷² Culture-based strengths like spiritually based coping, extended social support networks, flexible family roles, strong family ties, and positive ethnic group identity have been suggested as protective factors against suicide risk.^26,72 Female kinship networks have been suggested as a protective factor against suicidal behaviors among African American women.³⁴ In a sample of 1,456 Northern Plains American Indians, Garroutte and colleagues⁷³ observed that high levels of cultural spiritual orientation had a protective effect against suicide attempts. Although most suicide prevention strategies so far have been aimed at decreasing the suicide risk factors, research should also focus on increasing the effects of factors that protect against suicide.

Despite recent progress in the area, the examination of the relationship between ethnicity and suicidal ideation and attempts is still in its infancy. As the ethnic diversity of the US continues to increase, the identification of common and specific risk and protective factors for suicidal ideation and attempts and the development of effective preventive interventions offer important opportunities and challenges for clinicians, researchers, and policy-makers. PP

References

1.    Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System. Available at: www.cdc.gov/ncipc/wisqars. Accessed January 3, 2008.
2.    Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry. 1999;56(7):617-626.
3.    Klerman GL. Clinical epidemiology of suicide. J Clin Psychiatry. 1987;48(suppl):33-38.
4.    Moscicki EK, O’Carroll P, Rae DS, Locke BZ, Roy A, Regier DA. Suicide attempts in the Epidemiologic Catchment Area Study. Yale J Biol Med. 1988;61(3):259-268.
5.    Spicer RS, Miller TR. Suicide acts in 8 states: incidence and case fatality rates by demographics and method. Am J Public Health. 2000;90(12):1885-1891.
6.    Kessler RC, Berglund P, Borges G, Nock M, Wang PS. Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990-1992 to 2001-2003. JAMA. 2005;293(20):2487-2495.
7.    Kuo WH, Gallo JJ, Tien AY. Incidence of suicide ideation and attempts in adults: the 13-year follow-up of a community sample in Baltimore, Maryland. Psychol Med. 2001;31(7):1181-1191.
8.    Sorenson SB, Golding JM. Suicide ideation and attempts in Hispanics and non-Hispanic whites: demographic and psychiatric disorder issues. Suicide Life Threat Behav. 1988;18(3):205-218.
9.    Oquendo MA, Lizardi D, Greenwald S, Weissman MM, Mann JJ. Rates of lifetime suicide attempt and rates of lifetime major depression in different ethnic groups in the United States. Acta Psychiatr Scand. 2004;110(6):446-451.
10.    Fortuna LR, Perez DJ, Canino G, Sribney W, Alegria M. Prevalence and correlates of lifetime suicidal ideation and suicide attempts among Latino subgroups in the United States. J Clin Psychiatry. 2007;68(4):572-581.
11.    Willis LA, Coombs DW, Drentea P, Cockerham WC. Uncovering the mystery: factors of African American suicide. Suicide Life Threat Behav. 2003;33(4):412-429.
 12.    Iribarren C, Sidney S, Jacobs DR Jr, Weisner C. Hospitalization for suicide attempt and completed suicide: epidemiological features in a managed care population. Soc Psychiatry Psychiatr Epidemiol. 2000;35(7):288-296.
13.    LeMaster PL, Beals J, Novins DK, Manson SM, AI-SUPERPFP Team. The prevalence of suicidal behaviors among Northern Plains American Indians. Suicide Life Threat Behav. 2004;34(3):242-254.
14.    Kennedy MA, Parhar KK, Samra J, Gorzalka B. Suicide ideation in different generations of immigrants. Can J Psychiatry. 2005;50(6):353-356.
15.    Ialongo N, McCreary BK, Pearson JL, et al. Suicidal behavior among urban, African American young adults. Suicide Life Threat Behav. 2002;32(3):256-271.
16.    Joe S, Baser RE, Breeden G, et al. Prevalence of and risk factors for lifetime suicide attempts among blacks in the United States. JAMA. 2006;296(17):2112-2123.
17.    Sorenson SB, Golding JM. Prevalence of suicide attempts in a Mexican-American population: prevention implications of immigration and cultural issues. Suicide Life Threat Behav. 1988;18(4):322-333.
18.    Ungemack JA, Guarnaccia PJ. Suicidal ideation and suicide attempts among Mexican Americans, Puerto Ricans and Cuban Americans. Transcult Psychiatry. 1998;35(2):307-327.
19.    Buchwald D, Tomita S, Hartman S, Furman R, Dudden M, Manson SM. Physical abuse of urban Native Americans. J Gen Intern Med. 2000;15(8):562-4.
20.    Kost-Grant BL. Self-inflicted gunshot wounds among Alaska Natives. Public Health Rep. 1983;98(1):72-78.
21.    May PA, Serna P, Hurt L, Debruyn LM. Outcome evaluation of a public health approach to suicide prevention in an American Indian tribal nation. Am J Public Health. 2005;95(7):1238-1244.
22.    Mock CN, Grossman DC, Mulder D, Stewart C, Koepsell TS. Health care utilization as a marker for suicidal behavior on an American Indian Reservation. J Gen Intern Med. 1996;11(9):519-524.
23.    Hurwitz EJ, Gupta J, Liu R, Silverman JG, Raj A. Intimate partner violence associated with poor health outcomes in U.S. South Asian women. J Immigr Minor Health. 2006;8(3):251-261.
24.    Anderson PL, Tiro JA, Price AW, Bender MA, Kaslow NJ. Additive impact of childhood emotional, physical, and sexual abuse on suicide attempts among low-income African American women. Suicide Life Threat Behav. 2002;32(2):131-138.
25.    Bush JA. Similarities and differences in precipitating events between black and anglo suicide attempts. Suicide Life Threat Behav. 1978;8(4):243-249.
26.    Compton MT, Thompson NJ, Kaslow NJ. Social environment factors associated with suicide attempt among low-income African Americans: the protective role of family relationships and social support. Soc Psychiatry Psychiatr Epidemiol. 2005;40(3):175-185.
27.    Joe S, Kaplan MS. Suicide among African American men. Suicide Life Threat Behav. 2001;31(suppl):106-121.
28.    Juon HS, Ensminger ME. Childhood, adolescent, and young adult predictors of suicidal behaviors: a prospective study of African Americans. J Child Psychol Psychiatry. 1997;38(5):553-563.
29.    Kaslow NJ, Thompson MP, Meadows LA, et al. Factors that mediate and moderate the link between partner abuse and suicidal behavior in African American women. J Consult Clin Psychol. 1998 Jun;66(3):533-540.
30.    Kaslow NJ, Thompson MP, Brooks AE, Twomey HB. Ratings of family functioning of suicidal and nonsuicidal African American women. J Fam Psychol. 2000;14(4):585-599.
31.    Kaslow N, Thompson M, Meadows L, et al. Risk factors for suicide attempts among African American women. Depress Anxiety. 2000;12(1):13-20.
32.    Kaslow NJ, Thompson MP, Okun A, et al. Risk and protective factors for suicidal behavior in abused African American women. J Consult Clin Psychol. 2002;70(2):311-319
33.    Kaslow NJ, Price AW, Wyckoff S, et al. Person factors associated with suicidal behavior among African American women and men. Cultur Divers Ethnic Minor Psychol. 2004;10(1):5-22.
34.    Nisbet PA. Protective factors for suicidal black females. Suicide Life Threat Behav. 1996;26(4):325-341.
35.    Thompson MP, Kaslow NJ, Kingree JB. Risk factors for suicide attempts among African American women experiencing recent intimate partner violence. Violence Vict. 2002;17(3):283-295.
36.    U.S. Census Bureau. Racial and Ethnic Classifications Used in Census 2000 and Beyond. Available at: www.census.gov/population/www/socdemo/race/racefactcb.html. Accessed January 3, 2008.
37.    Alcantara C, Gone JP. Reviewing suicide in Native American communities: situating risk and protective factors within a transactional-ecological framework. Death Stud. 2007;31(5):457-477.
38.    Blum RW, Harmon B, Harris L, et al. American Indian--Alaska Native youth health. JAMA. 1992;267(12):1637-1644.
39.    Borowsky IW, Resnick MD, Ireland M, Blum RW. Suicide attempts among American Indian and Alaska Native youth: risk and protective factors. Arch Pediatr Adolesc Med. 1999;153(6):573-580.
40.    Freedenthal S, Stiffman AR. Suicidal behavior in urban American Indian adolescents: a comparison with reservation youth in a southwestern state. Suicide Life Threat Behav. 2004;34(2):160-171.
41.    A Joint Project Between the Bureau of Labor Statistics and the Bureau of the Census. A Test Of Methods For Collecting Racial And Ethnic Information. Available at: www.bls.census.gov/cps/pub/ethnic_0595.htm. Accessed January 3, 2008.
42.    U.S. Census Bureau. The American Indian and Alaska Native Population: 2000. Avaiable at: www.census.gov/prod/2002pubs/c2kbr01-15.pdf. Accessed January 3, 2008.
43.    Hill R, Wells RS, Andon H, Ballew C. Non-fatal injury hospitalizations among Alaska natives, 1994--1999: results from the Alaska Trauma Registry. Alaska Med. 2004;46(2):37-48.
44.    Beals J, Manson SM, Whitesell NR, Spicer P, Novins DK, Mitchell CM. Prevalence of DSM-IV disorders and attendant help-seeking in 2 American Indian reservation populations. Arch Gen Psychiatry. 2005;62(1):99-108.
45.    Chester B, Mahalish P, Davis J. Mental health needs assessment of off-reservation American Indian people in Northern Arizona. Am Indian Alsk Native Ment Health Res. 1999;8(3):25-40.
46.    Seale JP, Shellenberger S, Spence J. Alcohol problems in Alaska Natives: lessons from the Inuit. Am Indian Alsk Native Ment Health Res. 2006;13(1):1-31.
47.    Bohn DK. Lifetime physical and sexual abuse, substance abuse, depression, and suicide attempts among Native American women. Issues Ment Health Nurs. 2003;24(3):333-352.
48.    Johnson JL, Cameron MC. Barriers to providing effective mental health services to American Indians. Ment Health Serv Res. 2001;3(4):215-223.
49.    Brown GK, Steer RA, Henriques GR, Beck AT. The internal struggle between the wish to die and the wish to live: a risk factor for suicide. Am J Psychiatry. 2005;162(10):1977-1979.
50.    Leong FT, Leach MM, Yeh C, Chou E. Suicide among Asian Americans: what do we know? What do we need to know? Death Stud. 2007;31(5):417-434.
51.    Burke AW. Attempted suicide among Asian immigrants in Birmingham. Br J Psychiatry. 1976;128:528-533.
52.    Burvill PW, Armstrong BK, Carlson DJ. Attempted suicide and immigration in Perth, Western Australia, 1969-1978. Acta Psychiatr Scand. 1983;68(2):89-99.
53.    Sundaram V, Qin P, Zøllner L. Suicide risk among persons with foreign background in Denmark. Suicide Life Threat Behav. 2006;36(4):481-489.
54.    Kwon IW, Bae M. Health status of Asian Pacific Americans in Missouri. Mo Med. 1995;92(10):648-652.
55.    Blanchard PD, Yao JD, McAlpine DE, Hurt RD. Isoniazid overdose in the Cambodian population of Olmsted County, Minnesota. JAMA. 1986;256(22):3131-3133.
56.    Nolan CM, Elarth AM, Barr HW. Intentional isoniazid overdosage in young Southeast Asian refugee women. Chest. 1988;93(4):803-806.
57.    Baker FM. Black suicide attempters in 1980: a preventive focus. Gen Hosp Psychiatry. 1984;6(2):131-137.
58.    Hazlett SB, McCarthy ML, Londner MS, Onyike CU. Epidemiology of adult psychiatric visits to US emergency departments. Acad Emerg Med. 2004;11(2):193-195.
59.    Walker RL, Utsey SO, Bolden MA, Williams O. Do sociocultural factors predict suicidality among persons of African descent living in the U.S.? Arch Suicide Res. 2005;9(2):203-217.
60.    Gibbs JT. Conceptual, methodological, and sociocultural issues in black youth suicide: implications for assessment and early intervention. Suicide Life Threat Behav. 1988;18(1):73-89.
61.    Gibbs JT. African-American suicide: a cultural paradox. Suicide Life Threat Behav. 1997;27(1):68-79.
62.    U.S. Census Bureau. Projections of the Resident Population by Race, Hispanic Origin, and Nativity: Middle Series, 2016 to 2020. Available at: www.census.gov/population/projections/nation/summary/np-t5-e.pdf. Accessed January 3, 2008.
63.    American Psychiatric Association. Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. Available at: www.psych.org/psych_pract/treatg/pg/SuicidalBehavior_05-15-06.pdf. Accessed January 3, 2008.
64.    Monk M, Warshauer ME. Completed and attempted suicide in three ethnic groups. Am J Epidemiol. 1974;100(4):333-345.
65.    Oquendo MA, Ellis SP, Greenwald S, Malone KM, Weissman MM, Mann JJ. Ethnic and sex differences in suicide rates relative to major depression in the United States. Am J Psychiatry. 2001;158(10):1652-1658.
66.    Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
67.    Escobar JI, Hoyos Nervi C, Gara MA. Immigration and mental health: Mexican Americans in the United States. Harv Rev Psychiatry. 2000;8(2):64-72.
68.    Alegria M, Canino G, Stinson FS, Grant BF. Nativity and DSM-IV psychiatric disorders among Puerto Ricans, Cuban Americans, and non-Latino Whites in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2006;67(1):56-65.
69.    Oquendo MA, Dragatsi D, Harkavy-Friedman J, et al. Protective factors against suicidal behavior in Latinos. J Nerv Ment Dis. 2005;193(7):438-443.
70.    Perez-Rodriguez MM, Baca-Garcia E, Quintero-Gutierrez FJ, et al. Demand for psychiatric emergency services and immigration. Findings in a Spanish hospital during the year 2003. Eur J Public Health. 2006;16(4):383-387.
71.    Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies: a systematic review. JAMA. 2005;294(16):2064-2074.
72.    Utsey SO, Hook JN, Stanard P. A re-examination of cultural factors that mitigate risk and promote resilience in relation to African American suicide: a review of the literature and recommendations for future research. Death Stud. 2007;31(5):399-416.
73.    Garroutte EM, Goldberg J, Beals J, Herrell R, Manson SM, AI-SUPERPFP Team. Spirituality and attempted suicide among American Indians. Soc Sci Med. 2003;56(7):1571-1579.