1965; Garro, 1988; Jarvis and Boldt, 1982; Spaulding, 1985–1986). Hanging is the second most common cause of suicidal death among Indians and Alaska Natives in most studies in most areas of the continent (Kraus, 1974; Wallace et al., 1996; Wissow, 2000). The range is great, with hanging accounting for an unusually low 7 percent in one study to a more usual 26–40 percent in others (Butler, 1965; Garro, 1988; Spaulding, 1985–1986; VanWinkle and May, 1993). In a state like New Mexico, suicide by firearms and hanging combined account for over 90 percent of all American Indian suicides (VanWinkle and May, 1993).

Social and familial disruption, cultural conflict, and social disorganization are often cited as major influences on American Indian suicide rates. Suicide rates among American Indians vary with the degree of social and cultural change and acculturation pressure (Garro, 1988; Levy, 1965; VanWinkle and May, 1986; 1993). The high suicide rates among youth in Indian families and communities have been attributed to acute acculturation stress (Levy, 1965; May and Dizmang, 1974; Spaulding, 1985–1986; Travis, 1984; VanWinkle and May, 1986; 1993), cultural conflict (Kahn, 1982; Kettl and Bixler, 1991; Opler, 1969; Patterson, 1969) and social disorganization (EchoHawk, 1997; Expert Working Group, 1994; Joe, 2001; Resnik and Dizmang, 1971). While American Indian and Alaska Native adolescents face the same turmoil as mainstream youth, they are also challenged by self-identity and actualization in their minority status and complex choices as to whether to adhere to mainstream or traditional, native culture (Bechtold, 1994; Howard-Pitney et al., 1992; Sack et al., 1994; U.S. Congress, 1990). The stress of these dilemmas can increase the risk of alcohol or drug abuse, depression or other psychopathology, and parasuicidal and suicidal behavior (Beauvais, 1998; Elliot et al., 1990; Kettl and Bixler, 1993; Manson et al., 1989; May, 1982; Norton et al., 1995; Prince, 1988; Sack et al., 1994).

Immigrants and Refugees

Between 1980 and 1991 the United States immigrant population tripled; almost 20 million immigrants resided in the United States in 1990. Suicide in immigrants is a public health concern because this population is subject to many sociocultural risk factors. Immigration also provides opportunities to study the impact of culture and environment on prevalence of mental illness and suicide. In general, suicide rates tend to reflect that of the country of origin, with convergence toward that of the host country over time (Singh and Siahpush, 2001).

A careful review of the data on immigrants reveals some interesting patterns, which may differ across nations. Higher suicide rates have been reported for immigrants to some countries. For example, Finnish immi-



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