suicide, less than 20 percent of adolescent suicide attempters were actually asked about suicidal behavior by physicians at a medical clinic (Slap et al., 1992). A survey of pediatricians and family physicians in Maryland found that only 23 percent either frequently or always screened adolescents for suicide risk factors such as alcohol use or abuse, depression, physical or sexual abuse, or prior attempts (Frankenfield et al., 2000). The American Academy of Pediatrics recommends that pediatricians ask all adolescents about depression, suicidal thoughts, and other suicide risk factors during routine medical history (AAP, 2000). The American Medical Association also recommends annual screening of adolescents to identify those at risk for suicide (US Preventive Services Task Force, 1996).

Ethnic Groups

The general barriers to mental health care for racial and ethnic minorities are similar to those operating for whites—cost, fragmentation and availability of services, and stigma. Added to these barriers are several that are more unique to the minority experience in the US: fear and mistrust of treatment, which stems from the legacy of racism and discrimination, as well as miscommunication for non-English speakers. All of these barriers can act alone or together to deter minorities from accessing and utilizing mental health care. Their access is also lower than whites because of lower socioeconomic status and lower rates of health insurance (Brown et al., 2000). When they utilize care, minorities are more likely than whites to be misdiagnosed or receive inferior quality of care. These disparities between minorities and whites—lower access, lower utilization, and poorer quality of care—are documented in recent reports of the US Surgeon General and the Institute of Medicine (IOM, 2002; US DHHS, 2001). The Surgeon General’s report also documents the similar overall prevalence of mental illness across distinct ethnic groups, including whites. Similar overall prevalence, combined with lower access, utilization, and quality, led to the conclusion that minorities suffer a greater burden of unmet mental health needs (US DHHS, 2001). Whether or not these general barriers expressly apply to detection and treatment of suicide in minority groups in community settings has not been empirically documented but can be assumed by extension.

Barriers to the detection and treatment of suicidality in American Indians and Alaska Natives require special focus because rates of suicide are 72 percent higher than those of the general United States population (see Chapter 2). The risk is greatest among young males under 40 years of age. The vast majority of suicides (69 percent) involve alcohol, although the rate varies depending on cultural group.

Of all ethnic groups in the United States, prevalence information is



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