The Culturally Infused Curricular Framework (CICF) for Suicide Prevention Trainings.

Although suicide prevention trainings (SPT) have been a standard approach for suicide prevention for years, researchers have noted a need for more clarity in the definition of core competencies for SPTs, particularly in the areas of diversity and culture. Recent research has identified key theoretically- and empirically-based cultural considerations for suicide prevention, but translation is needed to infuse these standards for culture-related competencies into SPTs. This study performed a systematic literature review with a thematic synthesis analytic approach to establish a set of curricular guidelines for infusion of cultural considerations into SPTs. The study also examined the extent to which existing community trainings already incorporate cultural components. Based on the thematic synthesis of 39 SPT studies from 2010 to 2020 and seminal reviews of the cultural and suicide literature, results identified three overarching categories of cultural curricular competencies (suicide knowledge and awareness, suicide intervention skills, and curriculum delivery) and 14 core cultural curricular subthemes for community trainings (e.g., culturally informed risk factors and warning signs, systemic inequities, etc.). These three categories with 14 core cultural curricular competencies comprise the Culturally Infused Curricular Framework (CICF) for Suicide Prevention Trainings. The majority of trainings (62%) included five or less out of 14 total possible core cultural competencies in their training curricula, pointing to insufficient integration of cultural components in existing community trainings. This study's research-based guideline establishes a culture-inclusive framework to strengthen content and approach of community trainings and suicide prevention across cultural groups.

Erratum: Improved accuracy of cerebral blood flow quantification in the presence of systemic physiology cross-talk using multi-layer Monte Carlo modeling.

[This corrects the article DOI: 10.1117/1.NPh.8.1.015001.].

Ethnic variations in suicide method and location: An analysis of decedent data.

This study analyzed ethnic variations in suicide method and suicide location for 1,145 suicide deaths in a diverse California county. Hanging was the most common method of suicide death. Latino/a/x and Asian and Pacific Islander (API) decedents were more likely to suicide-by-hanging; White and African American decedents were more likely to suicide-by-firearms. API and African American decedents were less likely than White decedents to die-by-suicide at home. Suicide location can be predicted by the co-occurring influence of ethnicity and suicide method. Implications focus on culturally-informed suicide prevention research, assessment, and risk management.

Community-based participatory research with police: Development of a tech-enhanced structured suicide risk assessment and communication smartphone application.

OBJECTIVE: Police officers initiate psychiatric holds following determination of suicide risk. Such referrals constitute direct decriminalization of mental illness at the single most efficient criminal justice system diversion point. However, system-level problems with this process highlight a need to further understand and improve this service connection juncture. The goal of the present study was to inform the development of a smartphone application designed to enhance police referrals of individuals experiencing suicide crises into treatment via culturally responsive structured professional judgment. HYPOTHESES: Given the developmental and qualitative nature of this study, there were no formal hypotheses tested. Research questions included the following: Would police officers broadly endorse concerns about the care referral process? Would officers support the use of technology to assist with those concerns? And would officers raise concerns about the demands on time and expertise that would be placed on them to conduct thorough risk assessments? METHOD: Researchers used community-based participatory research (CBPR) methods to obtain police stakeholder-driven data through four focus groups with 47 police officers (76.6% male, 59.6% White, with a mean of 10.7 years of police employment) sampled from patrol and hostage negotiation units. Participants shared information about specific problems arising in the process through which police refer people to medical care, and they gave feedback on the beta version of a culturally responsive mobile app designed to streamline officers' evidence-based and culturally informed determinations of suicide risk. RESULTS: Results, qualitatively coded using grounded theory methodology, yielded key considerations for police use of culturally responsive apps to divert individuals in suicidal crisis into treatment, including the need to maintain a balance between risk assessment and communication, allow for variance in time constraints, allow for flexibility in response and report options, account for inaccurate reports of suicide risk factors, maximize utility of the app's risk report output, incorporate sensitivity around cultural questions, and consider officers' safety in their use of the app in the field. CONCLUSIONS: The results illustrate a theoretically based (CBPR) approach to cross-disciplinary technology development to facilitate evidence-based assessments by law enforcement. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Improved accuracy of cerebral blood flow quantification in the presence of systemic physiology cross-talk using multi-layer Monte Carlo modeling.

Significance: Contamination of diffuse correlation spectroscopy (DCS) measurements of cerebral blood flow (CBF) due to systemic physiology remains a significant challenge in the clinical translation of DCS for neuromonitoring. Tunable, multi-layer Monte Carlo-based (MC) light transport models have the potential to remove extracerebral flow cross-talk in cerebral blood flow index ( CBF i ) estimates. Aim: We explore the effectiveness of MC DCS models in recovering accurate CBF i changes in the presence of strong systemic physiology variations during a hypercapnia maneuver. Approach: Multi-layer slab and head-like realistic (curved) geometries were used to run MC simulations of photon propagation through the head. The simulation data were post-processed into models with variable extracerebral thicknesses and used to fit DCS multi-distance intensity autocorrelation measurements to estimate CBF i timecourses. The results of the MC CBF i values from a set of human subject hypercapnia sessions were compared with CBF i values estimated using a semi-infinite analytical model, as commonly used in the field. Results: Group averages indicate a gradual systemic increase in blood flow following a different temporal profile versus the expected rapid CBF response. Optimized MC models, guided by several intrinsic criteria and a pressure modulation maneuver, were able to more effectively separate CBF i changes from scalp blood flow influence than the analytical fitting, which assumed a homogeneous medium. Three-layer models performed better than two-layer ones; slab and curved models achieved largely similar results, though curved geometries were closer to physiological layer thicknesses. Conclusion: Three-layer, adjustable MC models can be useful in separating distinct changes in scalp and brain blood flow. Pressure modulation, along with reasonable estimates of physiological parameters, can help direct the choice of appropriate layer thicknesses in MC models.

Reducing mental health disparities by increasing the personal relevance of interventions.

One of the most persistent health disparities is the underutilization of mental health services by people of color. Neither evidence-based treatments (universal focus) nor culturally adapted treatments (group focus) have reduced these disparities. We propose the personal relevance of psychotherapy (PROP) model, which integrates universal, group, and individual dimensions to determine the personal relevance of interventions. A cultural example of personal relevance among people of East Asian ancestry involves "face" (i.e., one's prestige and position in society), which may moderate treatment outcomes. Pragmatic intervention approaches focused on helping individuals cope with specific external problems, compared to managing a "personal" disease, can effectively "restore" face. Thus, social problem-solving interventions may be more personally relevant to many people of East Asian ancestry than are approaches that are internally focused. In addition, we posit that social neuroscience can offer unique opportunities above and beyond self-report measures when assessing the impact of PROP and the personal relevance of interventions for diverse populations. Our preliminary evidence upon testing this hypothesis indicated that among Asian Americans, exposure to problem-solving therapy content elicited significantly greater neural activity in brain areas associated with personal relevance compared to exposure to cognitive-behavioral therapy content. Identifying personally relevant interventions has the potential to reduce mental health disparities by increasing engagement with mental health services for diverse groups. The increased client engagement produced by personally relevant interventions also has the potential to make mental health services more effective for diverse groups. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Cultural pathways for suicidal ideation and behaviors.

OBJECTIVE: Goals were to empirically examine cultural suicide pathways initially theorized by the cultural theory and model of suicide, by examining relationships between cultural (family conflict, minority stress, cultural suicide sanctions), general distress (depression, hopelessness), and cultural idioms of distress factors as predictors of suicidal ideation and attempts. METHOD: Path analysis examined a moderated mediation model with a community sample of 1,077 ethnic minority and/or LGBTQ adults (average age of 24.32 (SD = 10.23) ranging from 18 to 88, 299 LGBTQ, 447 Asian American, 196 Latino/a, 60 Black or African American, 8 Hawaiian or Pacific Islander, 6 Arab American, 2 Native American, 187 mixed race). RESULTS: Multiple pathways of statistical significance emerged. First, cultural life events (family conflict and minority stress) showed direct paths to ideation and attempts and indirect paths through general (depression and hopelessness) and cultural idioms of distress to ideation and attempts. The path from minority stress to ideation was entirely explained by general/cultural distress. Second, cultural suicide sanctions moderated the relationship between family conflict and ideation. Third, cultural idioms of distress was an important component of overall distress, alongside depression and hopelessness, predicting attempts and ideation. CONCLUSIONS: Findings elucidated pathways involving both general distress and cultural factors, and pathways from cultural life events to suicide constructs independent of mental illness-related factors. Findings question utilizing mental illness as a primary suicide driver, make theoretical contributions in refining the cultural theory and model of suicide, and advance understandings of roles of cultural factors in suicide research and practice. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Perceived Utility of the Internet-Based Safety Plan in a Sample of Internet Users Screening Positive for Suicidality.

Background: The Internet may offer resources for individuals who struggle with suicidality but have no access to other resources or fail to use them. Aims: To develop an automated, self-guided Internet-based safety plan (IBSP), and to evaluate its use and perceived utility among individuals who report suicidality online. Method: Participants (N = 150) were recruited from a depression/suicide screening website. Participants developed personalized safety plans and reported their perceived utility. Results: Participants reported moderate utility of the IBSP. Participants' demographic and clinical characteristics were not related to any metrics reflecting the perceived utility of the IBSP, suggesting that the ISBP does not appeal more or less to any particular group. Similarly, participant characteristics were largely unrelated to IBSP completion rates. The sole exception was gender, with males completing fewer steps (p < .001). Interestingly, participants were more likely to believe that IBSP could be helpful for others than for themselves (p < .001). Limitations: Quality and use of IBSPs were not assessed; poststudy assessments were limited to those completing the study; participants uninterested in reducing suicidality are not represented. Conclusion: The IBSP may eventually be an acceptable tool for Internet users at risk for suicide.

Cultural versus classic risk and protective factors for suicide.

The current study examined the predictive value of cultural versus classic risk and protective factors for suicide in a community sample of 322 ethnic, sexual, and gender minority adults. Cultural factors played a significant and substantial role in predicting suicide attempts (explained 8% of variance in attempts and correctly classified 8.5% of attempters) over and above the classic factors of hopelessness, depression, and reason for living (which explained 17% of variance in attempts and correctly classified 14.1% of attempters). Findings suggest that cultural factors are important to include in standard suicide practice.

A Prototype of Mathematical Treatment of Pen Pressure Data for Signature Verification.

A prototype using simple mathematical treatment of the pen pressure data recorded by a digital pen movement recording device was derived. In this study, a total of 48 sets of signature and initial specimens were collected. Pearson's correlation coefficient was used to compare the data of the pen pressure patterns. From the 820 pair comparisons of the 48 sets of genuine signatures, a high degree of matching was found in which 95.4% (782 pairs) and 80% (656 pairs) had rPA > 0.7 and rPA > 0.8, respectively. In the comparison of the 23 forged signatures with their corresponding control signatures, 20 of them (89.2% of pairs) had rPA values < 0.6, showing a lower degree of matching when compared with the results of the genuine signatures. The prototype could be used as a complementary technique to improve the objectivity of signature examination and also has a good potential to be developed as a tool for automated signature identification.

A Shortened Screener Version of the Cultural Assessment of Risk for Suicide.

The current study aimed to establish a shortened version of the Cultural Assessment of Risk for Suicide (CARS) measure that can be more widely utilized under time constraints in clinical and applied settings. Based on a sample of 485 adults, confirmatory factor analysis, bivariate correlations, and Receiver-Operating Characteristic analyses were employed to determine the most psychometrically valid shortened version. The 14-item, 8-factor CARS screener (CARS-S) evidenced high reliability, high correlation with the original full version of the CARS questionnaire, and high convergent validity with measures of other suicide-related constructs of depression, hopelessness, suicidal ideation, and lifetime suicide attempts. The suggested clinical cut-off is 38.5. The shortened CARS-S offers a time-efficient assessment of cultural suicide risk factors.

Violating Clan and Kinship Roles as Risk Factors for Suicide and Stigma among Lao Refugees: An Application of the Cultural Model of Suicide and "What Matters Most" Frameworks.

BACKGROUND: While Asian groups have immigrated worldwide, suicide risk models have neglected to integrate cultural components. This study incorporates how stigma associated with failure to uphold clan/kinship roles can increase suicide risk in highly-marginalized Lao-Americans. METHODS: One focus group with five Lao participants and 21 individual semi-structured interviews with community family members were conducted. Transcripts were coded via directed content analysis using the "What Matters Most" and Cultural Theory of Suicide frameworks. RESULTS: Violating role-expectations associated with youth, adults and older adults appears to be associated with risk for suicide. This suggests that the failure of adults to fulfill their roles might potentially threaten loss of "full personhood" and trigger stigma, thus potentially evoking greater suicide risk. CONCLUSION: Interventions would benefit from cultural considerations of fulfilling role-expectations and "personhood" to combat suicide and stigma within cultural communities.

An Empirical Model and Ethnic Differences in Cultural Meanings Via Motives for Suicide.

OBJECTIVE: The importance of cultural meanings via motives for suicide - what is considered acceptable to motivate suicide - has been advocated as a key step in understanding and preventing development of suicidal behaviors. There have been limited systematic empirical attempts to establish different cultural motives ascribed to suicide across ethnic groups. METHOD: We used a mixed methods approach and grounded theory methodology to guide the analysis of qualitative data querying for meanings via motives for suicide among 232 Caucasians, Asian Americans, and Latino/a Americans with a history of suicide attempts, ideation, intent, or plan. We used subsequent logistic regression analyses to examine ethnic differences in suicide motive themes. RESULTS: This inductive approach of generating theory from data yielded an empirical model of 6 cultural meanings via motives for suicide themes: intrapersonal perceptions, intrapersonal emotions, intrapersonal behavior, interpersonal, mental health/medical, and external environment. Logistic regressions showed ethnic differences in intrapersonal perceptions (low endorsement by Latino/a Americans) and external environment (high endorsement by Latino/a Americans) categories. CONCLUSION: Results advance suicide research and practice by establishing 6 empirically based cultural motives for suicide themes that may represent a key intermediary step in the pathway toward suicidal behaviors. Clinicians can use these suicide meanings via motives to guide their assessment and determination of suicide risk. Emphasis on environmental stressors rather than negative perceptions like hopelessness should be considered with Latino/a clients.

Advancement in the maturing science of cultural adaptations of evidence-based interventions.

OBJECTIVE: Concerns about the maturing science of cultural adaptation of evidence-based interventions (EBIs) have encompassed deficient standardization of theoretical frameworks and inefficiencies adapting multiple EBIs for multiple ethnic groups. Others argue that original EBIs applied with fidelity address universal processes applicable across ethnicity without adaptation. Study goals were to (1) establish a unifying data-driven framework for culturally adapting mental health EBIs for ethnic minorities, and (2) provide information for the fidelity debate by examining the extent to which fidelity to core EBI components is achieved in the cultural adaptation process. METHOD: A systematic review of primary research was conducted utilizing an inductive approach via thematic synthesis to code 20 years of cultural EBI adaptation studies for mental health problems in ethnic minorities. Studies were coded for adapted EBI components and extent of EBI modification. RESULTS: Results yielded the Cultural Treatment Adaptation Framework (CTAF), an overarching data-driven framework providing common concepts and language for adapted treatment components that unifies cultural adaption science. Findings also demonstrated patterns of adapted components. All adapted EBIs (100%) yielded changes in peripheral (engagement and treatment delivery) components. In contrast, only 11.11% of culturally adapted EBIs yielded core therapeutic component modifications. Instead, 60.0% required core additions that address sociocultural, cultural skill, and psychoeducation needs. CONCLUSION: Fidelity to core components is largely preserved in cultural adaptation, but core component addendums, delivery, and contextualization are substantially changed. The CTAF and its patterns represent a key step in advancement of a maturing cultural adaptation science. (PsycINFO Database Record

Ethnic variations in suicidal ideation and behaviors: a prominent subtype marked by nonpsychiatric factors among asian americans.

OBJECTIVE: Main objectives were to utilize multivariate rather than traditional regression approaches to capture the heterogeneity of subtypes of suicidal ideation and behaviors within ethnic minority groups. Mental illness is associated with suicidal ideation and behaviors in a vast majority of the general population, making psychopathology a common identifier of suicide risk. Yet recent studies suggest a need to better characterize suicidal ideation and behaviors among ethnic minorities and Asian Americans who do not exhibit the most commonly assessed risk factors. METHOD: The present study examined adults 18 years of age or older from the National Latino and Asian American Study and utilized latent class analysis to classify 191 Asian Americans with a history of serious suicidal ideation or attempts from a community sample into subtypes. RESULTS: Two main subtypes resulted, including 48% in a "psychiatric" and 52% in a "nonpsychiatric" subtype of suicidal ideation and behaviors. The nonpsychiatric subtype was predominantly characterized by sociocultural factors (discrimination, family conflict, and low acculturation), medical problems, and limited functioning. The nonpsychiatric was less likely than the psychiatric subtype to seek help for mental health but was no different in access to a medical doctor, highlighting possible points of outreach. CONCLUSIONS: Findings advance the culture and suicide literature by highlighting how current research and practice that characterize suicidal ideation and behaviors as a mental health phenomenon may not comprehensively identify suicidality among an ethnic minority group.

A tool for the culturally competent assessment of suicide: the Cultural Assessment of Risk for Suicide (CARS) measure.

Despite important differences in suicide presentation and risk among ethnic and sexual minority groups, cultural variations have typically been left out of systematic risk assessment paradigms. A new self-report instrument for the culturally competent assessment of suicide, the Cultural Assessment of Risk for Suicide (CARS) measure, was administered to a diverse sample of 950 adults from the general population. Exploratory factor analysis yielded a 39-item, 8-factor structure subsumed under and consistent with the Cultural Theory and Model of Suicide (Chu, Goldblum, Floyd, & Bongar, 2010), which characterizes the vast majority of cultural variation in suicide risk among ethnic and sexual minority groups. Psychometric properties showed that the CARS total and subscale scores demonstrated good internal consistency, convergent validity with scores on other suicide-related measures (the Suicide Ideation Scale, the Beck Depression Inventory suicide item, and the Beck Hopelessness Scale), and an ability to discriminate between participants with versus without history of suicide attempts. Regression analyses indicated that the CARS measure can be used with a general population, providing information predictive of suicidal behavior beyond that of minority status alone. Minorities, however, reported experiencing the CARS cultural risk factors to a greater extent than nonminorities, though effect sizes were small. Overall, results show that the CARS items are reliable, and the instrument identifies cultural suicide risk factors not previously attended to in suicide assessment. The CARS is the first to operationalize a systematic model that accounts for cultural competency across multiple cultural identities in suicide risk assessment efforts.

Asian American mental health: a call to action.

The U.S. Surgeon General's report Mental Health: Culture, Race, and Ethnicity--A Supplement to Mental Health: A Report of the Surgeon General (U.S. Department of Health and Human Services, 2001) was arguably the best single scholarly contribution on the mental health of ethnic minority groups in the United States. Over 10 years have now elapsed since its publication in 2001. This article highlights advances and illuminates gaps in the knowledge gained about the mental health and psychotherapeutic treatment of Asian Americans in the past decade. Though larger epidemiological surveys point to lower prevalence rates of mental illness in Asian Americans, further advances are needed in culturally valid assessment and quantification of cultural biases in symptom reporting in order to draw definitive conclusions about the state of Asian American mental health. A focus on prevalence in Asian Americans as a whole also shrouds important subgroup elevations such as heightened suicide risk in Asian elderly women or greater posttraumatic stress disorder in Southeast Asian refugees. Despite important developments in our knowledge about mental health prevalence, help-seeking behaviors, and culturally competent treatments for Asian Americans, it appears that troublingly low rates of service utilization still remain even when one accounts for the seemingly low prevalence rates among Asian Americans. Some progress has been made in the cultural adaptations of psychotherapy treatments for Asian Americans. In order to reduce mental health care disparities, greater efforts are needed to provide outreach at the community level and to bridge the gap between mental health and other medical or alternative health facilities. We call for innovation and provide recommendations to address these issues in the next decade.

Cultural adaptation of evidence-based practice utilizing an iterative stakeholder process and theoretical framework: problem solving therapy for Chinese older adults.

OBJECTIVES: Main objectives were to familiarize the reader with a theoretical framework for modifying evidence-based interventions for cultural groups, and to provide an example of one method, Formative Method for Adapting Psychotherapies (FMAP), in the adaptation of an evidence-based intervention for a cultural group notorious for refusing mental health treatment. METHODS: Provider and client stakeholder input combined with an iterative testing process within the FMAP framework was utilized to create the Problem Solving Therapy--Chinese Older Adult (PST-COA) manual for depression. Data from pilot-testing the intervention with a clinically depressed Chinese elderly woman are reported. RESULTS: PST-COA is categorized as a 'culturally-adapted' treatment, where core mediating mechanisms of PST were preserved, but cultural themes of measurement methodology, stigma, hierarchical provider-client relationship expectations, and acculturation enhanced core components to make PST more understandable and relevant for Chinese elderly. Modifications also encompassed therapeutic framework and peripheral elements affecting engagement and retention. PST-COA applied with a depressed Chinese older adult indicated remission of clinical depression and improvement in mood. Fidelity with and acceptability of the treatment was sufficient as the client completed and reported high satisfaction with PST-COA. CONCLUSIONS: PST, as a non-emotion-focused, evidence-based intervention, is a good fit for depressed Chinese elderly. Through an iterative stakeholder process of cultural adaptation, several culturally-specific modifications were applied to PST to create the PST-COA manual. PST-COA preserves core therapeutic PST elements but includes cultural adaptations in therapeutic framework and key administration and content areas that ensure greater applicability and effectiveness for the Chinese elderly community.

Recruitment of African Americans and Asian Americans with late-life depression and mild cognitive impairment.

OBJECTIVE: The purpose of this study was to compare the relative effectiveness of several different strategies for recruiting elderly Asians, African Americans, and whites to participate in mental health research. PARTICIPANTS: A total of 35 African American, 24 Asian American, and 215 white participants were phone screened for potential enrollment into a University of California, San Francisco, Department of Psychiatry treatment outcome study for older adults (aged 60 years and older) with major depression and mild cognitive impairment. DESIGN: The methods by which participants were recruited were recorded, coded into composite categories, and statistically analyzed to determine whether certain recruitment strategies were disproportionately effective for recruiting participants from the three racial groups. RESULTS: Fisher's exact test analyses revealed that Asians and African Americans were significantly less likely than whites to be recruited through mental health-based methods, and African Americans were significantly more likely than whites and Asians to be recruited through referrals rather than solicitations. Logistic regression, which controlled for potential confounds, largely supported these findings. CONCLUSIONS: Findings suggest that the recruitment of elderly African or Asian Americans into mental health treatment outcome research can be facilitated by a flexible consumer-oriented strategy that integrates multiple recruitment methods. Establishing study credibility through nonmental health media and professional referral sources may be especially effective in engaging the participation of elderly Asian Americans; and cultivating ongoing relationships with key gatekeepers, who can observe benefits to the community, may be particularly effective in recruiting elderly African Americans.

Depression and emotional reactivity: variation among Asian Americans of East Asian descent and European Americans.

Studies of Western samples (e.g., European Americans [EAs]) suggest that depressed individuals tend to show diminished emotional reactivity (J. G. Gehricke & A. J. Fridlund, 2002; G. E. Schwartz, P. L. Fair, P. Salt, M. R. Mandel, & G. L. Klerman, 1976a, 1976b). Do these findings generalize to individuals oriented to other cultures (e.g., East Asian cultures)? The authors compared the emotional reactions (i.e., reports of emotional experience, facial behavior, and physiological reactivity) of depressed and nondepressed EAs and Asian Americans of East Asian descent (AAs) to sad and amusing films. Their results were consistent with previous findings: Depressed EAs showed a pattern of diminished reactivity to the sad film (less crying, less intense reports of sadness) compared with nondepressed participants. In contrast, depressed AAs showed a pattern of heightened emotional reactivity (greater crying) compared with nondepressed participants. Across cultural groups, depressed and nondepressed participants did not differ in their reports of amusement or facial behavior during the amusing film. Physiological reactivity to the film clips did not differ between depressed and control participants for either cultural group. Thus, although depression may influence particular aspects of emotional reactivity across cultures (e.g., crying), the specific direction of this influence may depend on prevailing cultural norms regarding emotional expression.