By Liza Simon / Ka Wai Ola Loa

At last month's Honolulu conference on suicide, survivors of victims openly shared their grief. Participants in a breakout session adorned paper flowers with stickers and drawings that reflected the qualities of loved ones who took their own lives. Some cried while others laughed as they explained the meaning of the designs on their hand-crafted pua, relating favorite memories of those that were lost to suicide. Moloka'i cultural specialist Lori Higa, a guide for the exercise, intertwined their paper blossoms into one long "memorial lei," calling it a symbol of the safety net that can be created when people come together to shed light on the tragedy of suicide.

The message that suicide is a community problem that is also preventable through community action was the theme of Nov. 18-19 event, sponsored by the Department of Health Injury Prevention and Control program and the Queen's Medical Center. Suicide survivors convened with professional experts in mental health, social work, education, emergency medical services and clinical research to share information about Hawai'i's suicide problem—the leading cause of fatal injury in the state, and to learn more about the latest strategies for prevention.

"We've come a long way from the days when a stigma of shame hung over the experience of suicide and prevented us from even talking about this subject," said Pua Kaninau, a conference organizer whose 18 year-old son died by suicide in 2003. "When Kani passed, there wasn't much help for coping. I found my way to a support group for parents who had lost their children to diseases such as Leukemia, but it wasn't the appropriate place to talk about suicide."

Kaninau said she began reading up on suicide and was shocked to learn that what she didn't know might have saved her son's life. He had gone from being friendly and fun-loving to alone and sullen. She realized too late that his behavior meant that he was suffering from depression—a major risk factor for suicide in all age groups. "I had to ask, why didn't I know this? It should be common knowledge but it isn't. Everyone should be aware of the connection between depression and suicide, because depression can be treated, meaning that suicide can be prevented," said Kaninau.

Kaninau switched careers after her son's death from real estate to social work "in order to be in a position to save families from enduring what I've been through." She is now on staff at Queen Lili'uokalani Children's Center, which partnered in presenting the November conference. Kaninau was among several QLCC social workers at the conference, who expressed concern at seeing many young Native Hawaiian clients exhibiting suicidal tendencies. They said they want to know how this group compares with peers from other ethnic backgrounds, but research so far is inconclusive.

According to DOH research presented at the conference, Hawai'i had the nation's seventh lowest rate of suicide, recording a total of 119 such deaths in the period from 2004 to 2008. A separate analysis of Hawai'i suicide data shows that in the category for 15 to 25 year olds, Native Hawaiians had more deaths attributable to suicide than any other ethnicity in the state. But the actual number of deaths in this category was 45—far below the national average and too small to be considered a statistically significant trend, according to state health officials.

Meanwhile, the conference also highlighted a separate body of data from the school-based Youth Risk Behavioral Surveillance System, indicating that Native Hawaiian youths had the state's highest incidence of all ethnicities for reports of suicidal thoughts, plans for carrying out suicide and actual suicide attempts leading to injury that required medical attention.

"More research is warranted to determine if special interventions need to be tailored to native youths," said Dan Yahata, a conference participant and an education professional, who recently completed a needs assessment under a grant-funded study for Papa Ola Lōkahi on at-risk behavior among Hawaiian youths.

"National studies affirm that high suicide rates for one group impact the entire community in many ways ranging from poor economic outcomes from the lost earning power (of suicide survivors) to widespread psychological costs and spiritual devastation," said Yahata, adding that the problems associated with suicide in Hawai'i have received priority attention from the Department of Health ever since a report from the U.S. Surgeon General in 2000 issued a report calling on all states to support better interventions.

DOH officials at the conference highlighted a new intervention program aimed at reducing suicides and suicide among youths. Funded under a $1.5 million federal grant for mental health services, the Hawai'i Gatekeeper Initiative trains professionals in daily contact with youngsters to identify signs of suicidal risk and to know how to steer those in crises into effective treatment.

"When the warning signs are right in front of us, we have the tendency to skirt the issue," said Pua Kaninau, who recalls that when her son became abnormally withdrawn, she and other adults including school counselors only asked if he had thoughts of hurting himself. "That is a vague question that will won't get an honest answer from someone who is suicidal," said Kaninau, a participant in Gatekeeper training.

The Gatekeeper training will be offered through 2011 to the Peer Education Program and Behavioral Health within the Department of Education and to Emergency Psychological Services within the Honolulu Police Department.

Yahata said that he and other Hawai'i suicide prevention advocates in 2001 visited a remote Alaskan Native community involved in a pilot project similar to Hawai'i's Gatekeeper training initiative. "In this village of only 350 people accessible only by plane, they had lost over one dozen loved ones to suicide, and they were struggling to build better capacity for response." Yahata describes what he observed in Alaska as promising: "With the Gatekeeper approach, you are trained to ask the right questions, beginning with reasons for wanting to die. There is usually this ambivalence, so, as you progress, you find the part of the person that wants to live and you encourage this part."

The Honolulu conference also highlighted possible causes of suicide. According to local autopsy reports, 75 percent of all suicide victims have some form of mental illness. Other possible causative factors vary over the lifespan. The research shows that older victims are likely to have serious medical illnesses, while a majority of younger victims have experienced trauma in intimate relationships.

In conference breakout sessions, some cited reports of higher than average suicide rates in Alaskan and Native American communities and questioned whether native ethnicity should be considered risk factor for suicide. "The mainstream view is that suicide is a permanent solution to a temporary problem, that will vanish once the person finds help. What the native people in Alaska told us is that they are not dealing with a temporary problem but with the permanent loss of culture and identity," said Dan Yahata, referring to his experience in the Alaskan village that implemented intervention efforts. "Particularly for the men, we heard that the grief over loss of subsistence lifestyle worsens over generations, and once there is a suicide in a small community, the possibility that suicide as an option seems tragically amplified over time," Yahata said.

Pua Kaninau said that she never tires of telling the story of her experience with her son's untimely death, as she did at the conference. "As a survivor, this is my kuleana to the community," she said. Her one recommendation as both a professional and parent of a suicide victim is to follow your gut instinct when dealing with a severely troubled person. "Never just walk away and leave someone alone if there is even the slightest indication that suicide might be on a person's mind."

For more information on suicide prevention workshops under the Hawai'i Gatekeeper training initiative, call the Department of Health at (808) 733-9204.