OVERALL PROJECT SUMMARY Suicide is the second leading cause of death for American Indian and Alaska Natives (AI/AN) ages 10-34, and is up to 6 times higher than for their White counterparts. Native youth also suffer a disproportionate burden of suicide risk factors, including mental health disorders, traumatic life events, and substance abuse. These findings derive largely from research in rural, reservation settings. Yet we know the “invisible tribe” in our cities faces enormous challenges stemming from lack of connection with traditional family and cultural environments. These challenges contribute to the notably greater risk of urban AI/AN youth and young adults (YYAs) compared to their non-AI/AN counterparts for attempted suicide (21% vs. 7%), as well as for depression, substance abuse, gang activity, teen pregnancy, and abuse. Yet calls for thoughtful, pragmatic research to inform suicide prevention among urban AI/AN YYAs have not been answered until now. Our response to RFA-MH-17-350, which seeks to establish collaborative hubs to reduce the burden of suicide among AI/AN YYAs, promises to redress the imbalance between urban and rural emphases in suicide prevention research. The central study, “Suicide Prevention for Urban Native Kids and Youth (SPUNKY),” builds on Screening, Brief Intervention and Referral to Treatment (SBIRT) carried out through primary care setting, to detect and manage suicide risk. This approach is multilevel, targeting both the healthcare system and the individual, and links screening to existing mobile phone technologies shown to promote resilience and to tap the protective benefits of social connectedness. This Collaborative Hub will: 1) evaluate existing SBIRT programs to identify and address factors that affect implementation and prevention of suicide among AI/AN YYA patients served by the Seattle Indian Health Board and First Nations Community Healthsource, the country's largest urban Indian health organizations; 2) conduct a randomized control trial that compares the effectiveness of enhancing these SBIRT programs by sending caring text messages to reduce suicidal ideation, attempts, and hospitalizations, and to increase engagement, social connectedness, and resilience, and 3) perform a systematic economic evaluation of SBIRT and its enhancements to determine their relative effects on the use of healthcare resources and quality of life. Our long-term goal is to disseminate and translate the lessons learned into practical policy, organizational changes, and preventive innovations that optimize patient- centered health outcomes and ultimately reduce or eliminate the dramatic and tragic suicide- related health disparities among urban AI/AN YYAs.

PROJECT NARRATIVE Suicide and related risks are common among American Indians and Alaska Natives, especially youth and young adults. The consequences are devastating, resulting in emotional upheaval, social disruption, and enormous costs to individuals, families, and communities. Over 70% of Native people live in our cities; yet we know little about these circumstances among urban AI/AN youth and young adults. This effort will reduce their risk of suicide by reaching out to them through primary care settings, identifying those at greatest risk of suicide, referring as appropriate, and employing caring text messages to engage and support them.