Skip to content
SOCI - Standing Committee

Social Affairs, Science and Technology


Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology

Issue 6 - Evidence - April 21, 2004

OTTAWA, Wednesday, April 21, 2004

The Standing Senate Committee on Social Affairs, Science and Technology, met this day at 4:05 p.m. to study issues arising from, and developments since, the tabling of its final report on the state of the health care system in Canada in October 2002. In particular, the committee shall be authorized to examine issues concerning mental health and mental illness.

Senator Marjory LeBreton (Deputy Chairman) in the Chair.


The Deputy Chairman: Honourable senators, we should begin because there is a vote scheduled for 5:30 today and the bells will start to ring at 5:15. We will be unable to sit past the ringing of the bells. We will have to finish by 5:15. Normally we would continue after the vote, but there is another committee meeting scheduled to sit in this room at six o'clock tonight.

Today, honourable senators, our witnesses are from the Institute of Neurosciences, Mental Health and Addiction, Douglas Hospital and the Centre for Suicide Prevention. Dr. Isaac Sakinosky was scheduled to appear today but developed a medical condition and had to cancel. We are hoping to hear from him as a witness at a later date.

Please proceed.


Dr. Richard Brière, Assistant Director, Institute of Neurosciences, Mental Health and Addiction: I want to thank the committee for asking me to speak about suicide. I am interested in this subject, not just in my capacity of Assistant Director of the Institute of Neurosciences, Mental Health and Addiction, but also because when I was still doing research at the Department of Psychiatry of the University of Montreal, I was fascinated by the neurobiology of suicide.

In my presentation, I will highlight the need to develop a national agenda on research related to suicide and the measures taken by the Institute in this area.

In February 2003, the Institute of Neurosciences, Mental Health and Addiction, Strategic Initiative on Intentional and Unintentional Injury and Health Canada organized a workshop in Montreal on suicide-related research in Canada in conjunction with six other Canadian Institutes of Health Research. The number of institutes that took part in this workshop is proof of the interest of CIHRs in the subject of suicide. The purpose of the workshop was to develop an agenda on research related to suicide in Canada.

Some fifty researchers, stakeholders, NGOs and representatives of Aboriginal communities gathered to review the spectrum of suicide-related research in Canada and internationally, to identify and establish themes to guide suicide- related research over the next ten years and to support multidisciplinary collaboration in research and knowledge translation.

Over a two-day period, six research themes were identified: firstly, evidence-based practices; secondly, mental health promotion; thirdly, multidimensional models for understanding suicide-related behaviours; fourthly, spectrum of suicide behaviours; fifthly, suicide in social and cultural contexts; and sixthly, data systems.

As I see it, these research themes will assist in the process of formulating a national suicide prevention policy. I will speak to you briefly about each system. Evidence based practices include the evaluation of suicide prevention programs. Strategies need to be identified, along with programs that genuinely mitigate suicidal behaviours.

We do not know for certain if current practices in the field are truly effective in terms of reducing the number of deaths by suicide or injuries related to suicidal behaviours. A study of existing programs provides an opportunity to evaluate current practices and their impact on suicidal behaviours. Once such an evaluation has been done, researchers will be able to improve upon intervention methods. Once prevention and intervention strategies are deemed effective, it will be important to inform stakeholders of evidence-based practices and to promote their use.

Knowledge translation is one theme very dear to the CIHRs. While it is important to expand knowledge, it is equally important to promote knowledge translation. Mental health promotion implies the development and dissemination of appropriate culturally and community-appropriate information. Research topics include protective factors, risk factors and resiliency over the life span and address issues related to discrimination, care for the caregiver, social competence, shame, stigma and the perception of mental illness.

The focus must be put on devising a problem-solving approach that is based on efficacy and excellence and that acknowledges the need for growth and fulfillment of human potential. If the public is more attuned to the problem of suicide, this will lead to stronger prevention measures.

It is important to disseminate information about suicide-related risk factors, to underscore the fact that suicidal behaviour is avoidable and to minimize the stigma felt by individuals who have suicidal thoughts and often feel that they cannot get help.

What is important is getting the right message across to the right target group, in the proper format and in a timely manner. To achieve this goal, researchers and stakeholders have to know how to design public information campaigns with a view to maximizing their impact.

Information campaigns must be evaluated to determine if they affect in any significant way the public's understanding of suicidal behaviours. Evaluation outcomes will make it possible to refine the messages that are being conveyed and to enhance their impact.

With respect to multidimensional models, according to psychological autopsies, 90 per cent of the people who commit suicide suffer from mental health problems. Persons with mental health problems, specifically depression and personality disorders, as well as persons with drug and alcohol problems, run a higher risk of committing suicide.

What is the link between mental health and suicide? Why do some persons with mental health problems commit suicide while others do not? While individual mental health problems can greatly contribute to suicidal behaviour, they are not the sole contributing factor to suicide.

Numerous other factors combine to increase the risk of suicidal behaviour. These factors include stressful life events, such as the loss of a loved one or unemployment and life problems such as spousal violence, physical illness or social isolation.

It is not clear how these factors interact and affect the risk of suicide. Moreover, aside from stress and social isolation, alcohol abuse and the use of other mind-altering substances, as well as a tendency to behave impulsively, also greatly increase the risk of suicidal behaviour in people. As in the case of life events and interpersonal problems, it is not clear how addictions and impulsive behaviours increase the risk of suicide.

Designing a multidimensional model, one that takes into account biological, clinical and social determinants, would be a positive step in the process of developing effective intervention methods based on a more dynamic knowledge of risk and resiliency factors and their interaction.

Consideration must also be given to suicide in social and cultural contexts. The incidence of suicide in Canada varies dramatically as a function of regional, social and cultural contexts. Significant variations exist among provinces. While the suicide rate is relatively low in Newfoundland and Ontario, it is especially high in Alberta and Quebec.

In 1996, 37 per cent of all suicides in Canada were committed in Quebec. Between 1960 and 1991, the suicide rate in Quebec tripled, the biggest increase of any province. Moreover, the suicide rate among Canadian Aboriginals is often more than twice that recorded for the general population.

Many factors aside from people's mental health can affect suicide rates. These include social determinants such as social structures, values embraced by the community and , accessibility of assistance for persons in need. Since we do not know for certain how these factors affect suicidal behaviours, it is difficult to develop effective prevention strategies. Researchers, stakeholders and public health agencies need this information in order to formulate better strategies.

Consideration must also be given to the full spectrum of suicidal behaviours, such as aborted suicides, attempted suicides, assisted suicides, attempted suicides disguised as accidents, deliberate self-mutilation, euthanasia, dangerous behaviour that could result in premature death, predisposition to self-mutilation, suicidal actions and the idealization of suicide. Also included in this list are attempts that did not result in death, unmotivated attempts and premature death as a result of risky behaviour.

As part of the process of developing a national suicide prevention strategy, it will be important to take into account the full spectrum of suicidal behaviours. Finally, access to accurate, reliable data on suicidal behaviours will be critical in order to take follow-up action and assess the effectiveness of any measures taken.

Virtually all of the data currently available pertains to deaths. It would be useful to have access to better data on suicidal behaviours, particularly on the level of hospitalization and ambulatory care dispensed following suicide attempts. It is estimated that for every suicide death, nearly 20 persons end up in hospital emergency wards as a result of an attempted suicide. Suicides and attempted suicides entail medical, economic and social costs, especially trauma for the victims' loved ones. Little research has been done into the financial and other costs associated with suicidal behaviours in Canada.

Data of this nature would prove useful in justifying to the public the need for enhanced prevention strategies and in better assessing the effectiveness of prevention programs.

Summing up, a national suicide prevention strategy must be based on evidence-based practices, on mental health promotion programs and on a multidimensional model encompassing biological, clinical and psychosocial aspects; it must take into consideration social and cultural contexts and cover the full spectrum of suicidal behaviours; and finally, it must provide access to reliable, comprehensive data.

Following the February 2003 workshop, the Institute of Aboriginal Peoples' Health, working in cooperation with the Institute of Neurosciences, Mental Health and Addiction, launched a suicide prevention program targeting Aboriginal peoples in December of 2003. The INMHA plans to collaborate on the strategic initiative on intentional and unintentional injuries and to initiate a national research program on suicide using the research methods proposed at the Montreal workshop.


The Deputy Chairman: Thank you, Mr. Brière, for an excellent paper and presentation.

I will now turn to Dr. Turecki.

Dr. Gustavo Turecki, Director, McGill Group for Suicide Studies, McGill University, Douglas Hospital: Madam Chairman, thank you for the invitation to appear before this important committee.

I have brought with me some slides. I invite you to follow with me through the presentation with the slides, which illustrate some of the points I am trying to make.

I am both a clinician working on suicide as well as a researcher doing clinical research and biomedical research on suicide. When I was thinking about what to say today, I ended up deciding to talk about something that you would be certainly less likely to hear from others, namely, about the suicide diathesis, or the biological predisposition and overall predisposition to suicide.

Looking at the epidemiology of suicide, we realize that suicide is an important problem from a public health perspective. It ranks among the 10 top causes of death for individuals of all ages. It is the leading cause of death for young males, in particular those younger than 40 years of age.

On the second page, you will see the distribution of rates by suicide in different provinces. At this point in time, suicide rates in Quebec are the highest among all the provinces, with the exception of the territories. In an average year, we have about 1,500 suicide cases in Quebec. That accounts roughly for about one third of all suicide cases in Canada.

Why is it that people commit suicide? This is a difficult question. Suicide is most probably a result of a number of different causes. It is multicausal and multifactorial. What is clear is that people do not commit suicide just because of unbearable stress. People who commit suicide do so also because they have a given biological predisposition to do so.

The next slide concerns the relationship between biological factors and suicide, which is complex. It is mediated and modified by a number of different factors. Among these factors we have early negative life stressors, personality variance and demographic variables. We also have life events and psychopathology.

Over the last few decades, studies have found that psychopathology or mental health problems are probably the single most important factor of suicide.

When we look at the distribution of psychopathology and suicide completers on the next line, we see that the most important problem that suicide completers have is major depression, as well as drug and alcohol related problems and, to a lesser extent, psychotic problems such as schizophrenia. This information comes from studies we have done in the Montreal area.

As Mr. Brière mentioned, although most suicide completers have a history of psychopathology, studies show that approximately 90 per cent meet criteria for one of these conditions. That figure is probably closer to 100 per cent. The reason it is not stated as 100 per cent is that the studies we do are not sensitive enough to detect that. However, most of the people who have these conditions do not die by suicide. In the studies we are conducting, the most important question is to define among those people who have what look to be the same condition why only some end up dying by suicide.

We have been doing studies that look at, for instance, subjects who have died by suicide in the context of an episode of major depression. We have compared them with people who have the same condition, major depression, but who did not have a history of suicidal behaviour and who have never attempted suicide during such an episode.

Clearly, beyond psychopathology, a number of factors may explain why some may commit suicide. Among these factors are personality variants, such as levels of impulsivity and aggression. Among these personality disorders — in other words, conditions that are characterized by pervasive problems related to these traits — there are borderline personality disorders, antisocial personality disorders and co-morbidity with alcohol and drug-related problems. We see those factors more frequently among those who have had a major depression and who died by suicide as compared to those patients with major depression who did not have a history of suicidal behaviour.

The findings also suggest that high levels of impulsive and impulsive aggressive behaviours combined with behaviour facilitated by a substance abuse disorder may mediate suicide, for instance, in major depression. We are now conducting studies into other conditions as well.

Beyond those factors, we also find that frequently these people report a family history of suicidal behaviour. Whether this is suicidal completion or suicide attempts, it seems to be more frequent in their families. Approximately 35 to 37 per cent of suicide completers have a positive family history of suicide, which has been reported in the literature. For instance, what you see in these slides are two pedigrees from a study of the Amish population. The Amish are a close-knit community that has good social support and does not have problems related to substance and alcohol consumption. They do not have many suicide cases. Over the last 100 years, there have been 26 cases. What was interesting, though, was that these 26 cases were concentrated in only four pedigrees, which marked the first time researchers realized that suicide might be familial. Since then, many studies have been done. We have been doing other family studies that may suggest that suicidal behaviour aggregates or clusters in families.

Some of this clustering may be related to genes. We have been conducting a number of molecular studies trying to better understand and characterize the molecular factors that may explain this genetic predisposition to suicide.

We have been doing expression studies in suicide. That is to say, we take RNA or tissue from the brain of suicide completers and compare it with brain tissue from people who have died from other causes. We then use "microarrays," which are chips that contain all the genes in the genome, to try to identify specific patterns. What we end up with are snapshots of what was going on in the brains of these people before they died. As you can see in the graph on the right, we are able to separate people who have died by suicide as compared to controls based on those —

Senator Morin: There is an error on the left slide. One of the lines is not there.

Dr. Turecki: Sorry for that.

With the new technology, we are better able to understand the genetics of suicide. Nevertheless, I must stress that the relationship between genes and the outcome of suicide is complex and must be understood in the context of a number of different factors: social, clinical, environmental and general.

What is needed? First, we need to promote Canadian research on suicide. If we compare ourselves to other countries that have similar problems related to suicide, we see that Canada lags behind. We need to promote research focusing on suicide completers as well because they represent probably the most extreme and less heterogeneous phenotype. We need to identify risk factors taking into account the multifactorial nature of suicide. In order to do so, we need to do large-scale studies; to do large-scale studies, we need funds.

The Deputy Chairman: We will now turn to Ms. Yackel, who has travelled to Ottawa from Calgary to make this presentation.

Ms. Diane Yackel, Executive Director, Centre for Suicide Prevention: Honourable senators, thank you for the opportunity to speak with you today.

The Centre for Suicide Prevention is a program of the Canadian Mental Health Association. It focuses specifically on providing information services, research and suicide prevention training programs, while CMHA colleagues across the country carry out the more direct counselling and support services.

The Centre for Suicide Prevention houses a specialized resource library with over 32,000 documents on site. It is the largest English language collection of information in the world on suicide and suicide information.

When our centre received the invitation to appear here today, to support the work of this standing committee, we set about becoming aware of what information honourable senators had already received. Consequently, we took the liberty to create this English document, summarizing the suicide-specific evidence presented by the previous witnesses. Hopefully, it will serve as a handy reference tool for you.

At the back of the document, we have appended some new information and a small number of our own reference bulletins to supplement one or two specific content areas. It is obvious that this committee has already received excellent evidence on suicide in the course of its examination of mental health and mental illness issues.

The second document that we prepared is a compilation of the national, state and provincial suicide prevention strategies housed within our library. As you will see from the contents, and as you have heard from past witnesses, many countries have opted to develop specific initiatives directed to the reduction of suicide as a preventable problem. The countries that we have listed have published plans supported by that country's national government. Some countries, notably Australia and the United States, have also encouraged the initiation of secondary level provincial, state, territorial or county strategies.

There may be other international strategies of which we are unaware, or that are not published in English, but we will be posting this document on our Web site and will be adding new information as it becomes available.

The second document, the summary of national, state and provincial suicide prevention strategies, underscores the central message I wish to convey today. I refer to the urgent need for a national strategy specific to suicide prevention in Canada.

Canada possesses neither a specific national suicide prevention strategy, nor a more broadly-based national mental health framework. On a provincial level, only Quebec and New Brunswick have finalized some form of suicide prevention plan.

An analogy for suicide in Canada has been made to that of a jumbo jet crashing every month. If that were to occur month after month — every 30 days, another 340 souls going down on a large aircraft carrier somewhere in Canada — would not reasonable people eventually say, "What is going on here?" Would it not make more sense to put energy into stopping the crashes versus tolerating the aftermath? Suicide is a stoppable problem. It is an action, not an illness.

In my view, it is appalling that Canada lacks a specific federal direction to reduce the incidence and prevalence of suicide and suicidal behaviours that we experience in this country. Moreover, attempted suicides, where the individual's actions have been non-fatal, are like the submerged, unseen base of an iceberg; they engender untold suffering to individuals and families and they also consume enormous health care resources.

In the year 2000, a report jointly published by Health Canada, Alberta Wellness, the Alberta Centre for Injury Control and the Centre for Suicide Prevention calculated a ratio that for every suicide death in Alberta, there were nearly seven hospitalizations due to suicide attempts and over 17 emergency room visits for self-inflicted injury. If that Alberta ratio were to be applied to all of Canada, it would represent approximately 28,000 hospitalizations and 68,000 emergency room visits per 4,000 suicide deaths every year. This is costly to Canadians.

A 1996 New Brunswick study outlined the direct and indirect financial impacts of suicide with a mean total cost estimate at nearly $850,000 per suicide death. For attempted suicides, other sources estimate the cost in the range of $33,000 to just over $300,000 per individual.

On a positive note, the Canadian Association for Suicide Prevention has led recent impressive efforts to guide the development of a blueprint for a pan-Canadian strategy to reduce suicide and its impacts. On Monday of this week, they released the first public draft of the blueprint, which may be found on their Web site,

Some have suggested that if Canada were to have a well-formulated mental health strategy, there would be no need for a suicide specific initiative. I was encouraged that out of the handful of health care issues that the standing committee felt needed greater in-depth study, the honourable senators of this committee unanimously agreed to examine the area of mental health and mental illnesses as your first priority.

There is a need for a pan-Canadian mental health plan. I hold the opinion, however, that not only is a specific national suicide prevention strategy required on its own merit, but that such a strategy holds potential benefits in addressing the greater objective of improved mental health and mental well-being across our society. I suggest that a strong national suicide prevention strategy could serve a catalytic purpose in the development and implementation of a comprehensive national plan for mental health and mental illness.

My closing comments will revolve around the area that I feel has been most under-represented in these hearings to date — the voice of the survivors, those left in the profound aftermath of suicide.

On a personal note, I am not a survivor of suicide. By profession I am a nurse, a psychologist and a certified thanatologist. Prior to joining the Centre for Suicide Prevention, I was in a private counselling practice specializing in grief therapy, a role I continue on a selective basis.

While I could never adequately represent the devastation suicide causes in personal relationships, I believe I can convey some of the messages the survivors I have known would want to communicate to you were they able to be here today to do so in person. I can relay an endless number of tragic stories, but I think of four mothers in particular.

The first was a woman who had had two husbands. Both had died by suicide. She came to see me at the point in time when her son, her only child, had hung himself. Several weeks after her son's death, she was released from her work responsibilities because "she no longer was a productive employee."

Then there was the incapacitated mother. She was frozen in time. She was unable to sleep anywhere but on her chesterfield near the front door of her home. This was the chesterfield from which she last saw her son and from where she heard the gun shot. Perhaps, just perhaps, if she stayed there long enough, he might come back through that front door again and she would have a second chance to stop him from going into his bedroom and shooting himself.

There was an Aboriginal mother whose 19-year-old daughter lay down on the railway tracks when life became too difficult for her to go on.

There is yet another mother, herself a widow, who discovered and had to cut down the body of her 14-year-old daughter hanging in their house. I am not a parent, but I cannot help but feel adamant that no parent, let alone that of a 14 year old, should ever have that kind of experience.

It is truly impossible to convey the profound anguish that survivors suffer. It is beyond our ability to truly comprehend. The greatest anguish is that, in most instances, suicide deaths can be prevented. To a person, every survivor that I have ever known would say to you that something desperately and urgently needs to be done to stop this needless, unspeakable pain.

To be truthful, I now seldom tell survivors that there are 32,000 documents on suicide in our library at the centre. There is nothing in our library that justifies the preventable death of their loved one.

While it is discomforting to ask, the question needs to be raised: What will it take to move a national suicide prevention strategy forward? What more do we need to know before we will act? Will it be 33,000 documents, 40,000? Is it 75,000? How much more information will be enough before we start?

Yesterday, there were more than 10 families somewhere in our great nation whose lives were unalterably changed because a father, a son, a sister or some family member with some degree of "intentionality" chose to die by suicide. Today, there have been at least 10 more families who have received news from a police officer or a physician or, most catastrophically, opened a door to a gruesome discovery that will now change their family forever. Tomorrow, there will be another 10 families and the day after that 10 more unless we do something differently.

In the United States, the movement to adopt a national strategy has been strongly driven by a volunteer survivor organization. There is no such organization or structure within Canada. The public survivor voice here is faint and fragmented without organization, but it is here. We hear this voice every day in our CMHA offices across Canada.

I plead with you. Unashamedly, I beg you to use your influence in calling for the urgent and immediate development of a national suicide prevention strategy for Canada that would, in turn, be a catalyst for the development of provincial and appropriate community strategies.

Honourable senators, we need your leadership.

The Deputy Chairman: Thank you very much for your moving and compelling testimony, and thank you, as well, for this document.

Senator Morin: I know you quoted some very important people in this document, especially Senator Cook. She is very proud of this.

I have two questions.


Dr. Brière, my question pertains to suicide prevention.

Obviously, this condition cannot be treated. What evidence do we have that the various programs in place are truly effective in terms of preventing suicide?

This is an important question because if we want to develop a suicide prevention strategy and invest the necessary resources, we need some assurances first of all that the programs will be effective. People turn to programs such as Suicide Secours, but would a placebo of some kind be just as effective? Do you understand the gist of my question?

Dr. Brière: I certainly do. Many prevention programs are in place and few have been evaluated. There is no way of knowing if these measures really have any kind of impact. Obviously, some actions are effective and can be taken.

During the 1970s, Sweden had a program in place where general practitioners were trained to diagnose depression and prescribe anti-depressants. As a result of this nation-wide program, the suicide rate in the country dropped.

Senator Morin: Did the suicide rate among youths decline? It is a fact that suicide rates tend to rise when anti- depressants are prescribed to young people.

Dr. Brière: That is a controversial finding. I do not know whether youths were included in that study or not. An initiative such as this which does not target suicide specifically, but rather depression in general, can prove successful in lowering the suicide rate. That is what my colleagues found.

If we found a way to treat mental health problems and depression more successfully, we would lower the suicide rate and in the process, address drug and alcohol addiction problems, which are also major risk factors. The important thing is for programs to be properly evaluated to ensure that they produce positive results.

Senator Morin: You maintain that before steps are taken to devise a national suicide prevention strategy, it would be a good idea to evaluate the various programs to see which ones work, and which ones do not.


My second question is for Dr. Turecki, the question of cultural factors in suicide. Health Canada published a paper this week. It says that immigrants in Canada have a much lower rate of suicide, but their children have the same rate as the rest of Canadians.

In addition, our very competent and very expert researchers from the Library of Parliament prepared a chart of selected countries covering the years 1998 to 2000, and Canada is surprisingly low on that list. For example, Sweden, which we referred to as having this program of prevention, is fairly high on the list and Finland is among the highest. The United States is even lower than Canada, and the U.K. is lower than everyone. France is quite high, which might have something to do with the fact that the suicide rate is high in Quebec and low in other parts of the country.

This, of course, would have nothing to do with the genetic buildup because the children of immigrants in one generation have not changed their genetic pattern. What are your comments on the cultural factors here?

Dr. Turecki: That is a pertinent point. One thing we know now is that there is a predisposition. However, the relationship between the predisposition and the outcome of suicide is mediated by different factors, such as cultural factors, psychological upbringing and life stressors.

That said, diathesis relates not only to genes. A number of different factors are involved, such as behavioural traits, personality profile, et cetera. They more or less predispose people to suicide, but the variation in the rates is clearly environmental.

We are not to think, for instance, that the rate changes in one province from year to year have to do with changes in the genetic makeup of the population. Quite the contrary. The population is the same. What changes is the level of the stressors, but not everyone responds to them in the same way.

With respect to immigrants, the rates might be low, but there are still people who commit suicide. It is this relationship we have to better understand. When I talk about diathesis, I think the important issue is that it is important to better understand who is at risk of suicide.

It is important to create programs for suicide prevention — absolutely. However, these programs will be more effective in certain people as compared to everyone in general. In that sense, we have to better understand exactly who is more at risk of committing suicide when exposed to certain situations.

We still lack a lot of that knowledge. We know very little about exactly what are the determinants of suicide. That was the primary point I was trying to make. We have to understand that to better grasp the complexities behind the person who commits suicide.

As a clinician, I am often at the emergency room, and many people come there having attempted suicide. Am I supposed to keep everyone inside against his or her will? Of course not. Many people who attempt suicide will not end up committing suicide. A suicide attempt is a complex phenomenon. A lot of people attempt suicide because they want to communicate, because they want other things beyond actually dying.

We have to better understand who exactly is at risk. In that sense, genes can provide part of that story — not the whole picture — and we have to better understand how the genes relate to other factors, which is why we have to conduct large-scale studies.

Senator Callbeck: Thank you for your compelling presentations this afternoon.

I have a chart of the suicide rates in Canada for the last 50 years. As you say, we have no national suicide prevention strategy. Only two provinces have one, yet the rate has varied tremendously. It went up sharply from the 1950s to the 1980s and peaked in 1983. It was more or less stable and then there was a slight decrease between 1995 and 1998, the latest year for which we have statistics. In your opinion, what caused that? Was it the flower generation? Was it the drugs?

Mr. Turecki: That is the $10 million question. We do not really understand exactly. If we could, we could prevent it from happening.

Certainly there are a number of changes in society that could have facilitated the changes in rates. As well, there are changes in the way we have reported suicide, the way we have looked at suicide over the years. Many years ago people were more reluctant to indicate that a death was a suicide, and so society evolved at a number of levels.

For example, I remember discussions that I had with coroners in Ontario, who would identify a death as being a consequence of suicide based on a different set of factors than a coroner in Quebec. They used different systems. Part of that difference between provinces may be due to how coroners look at suicide.

Again, it is a complex situation. A number of social factors have changed over the years. There are also cohort factors, such as how generations regard suicide and how generations have faced problems over the years that have changed. These factors may explain some of these changes. This is a question that all of us would like to better grasp and understand.

Ms. Yackel: I am glad that you answered the question. It is a very difficult thing to try to analyze and understand. I have nothing further to add to what Dr. Turecki has said.

Senator Callbeck: Ms. Yackel, you mentioned that Quebec and New Brunswick are the only two provinces that have prevention programs. Can you comment on their effectiveness? Are there things that we can learn from the successes or failures in those two provinces?

Ms. Yackel: I am not certain whether Quebec, which has the more comprehensive of the two programs, has done specific evaluations. I rather suspect, because of the leadership that comes out of CRISE and Dr. Brian Mishara, that more work has likely been done in that regard.

Overall, in terms of measurements, the questions that we receive most commonly relate to what you have just done, that is, explain the rates. What does this mean? Whatever the rate is, can we reduce it? If we are comparing apples to apples, the difficulty of comparing one province to another, comparing one country to another, is that often we are not using the same set of standards. However, what have we done that has changed? I do not have data that would suggest whether the rates in New Brunswick or Quebec have been reduced in relationship to their programs.

Looking at the issue from a more global perspective, when Dr. Links was here, he referred to the Finland experience, which is the longest. In the course of the first 10 years, they did manage to reduce their overall rate by 20 per cent, and it has now levelled out at 10 per cent.

The early indications out of England are that there seems to be the beginnings of a dip. They would not in any way label it as a trend because it is only within their first year. However, this is what we look for, ultimately.

Senator Fairbairn: This is a difficult and upsetting issue. I do not know about my colleagues, but I have had friends who have had this actually occur in their families.

I would like to ask a question about the degree to which one can get information on which to draw the statistics. To what degree today in Canada are suicides hidden so that they will not turn up in the statistics?

Mr. Turecki: That is an interesting question. As I mentioned before, there are different systems of how suicide is actually seen by the coroner. To my knowledge, no studies have looked at how the different ways of understanding suicide may modify the rates. That was one of the suggestions we made at the workshop that was mentioned before. There should be studies looking at the process coroners undertake to consider a death as suicide. A number of suicides are considered as undetermined deaths. Whether that would have a major impact on suicide rates is an interesting question, but to my knowledge, we do not know that precisely.

Senator Fairbairn: There is an issue of the stigma on families. In my youthful years I was a journalist, and there was an accepted protocol that if a death occurred by suicide, it was never spoken of and never reported, which I think has changed in recent years.

I ask the question because with our young people, especially those in the Aboriginal community, the suicide rate is meant to be seen. However, with others, it may be meant to be unseen. In the end, it may be a difficult issue to quantify.

Concerning a strategy for prevention or even a strategy for generating national statistics, I am sure you are all aware of the difficulty in our glorious country of being able to share information between provincial jurisdictions. In your studies, have you been given a sense that it would be possible to cross over those jurisdictional lines on an issue such as this because of the degree to which the sharing of this knowledge would be helpful in establishing the kind of national prevention programs that I think we all desire? Have you had any sense from the provinces that this sharing and openness would be difficult to attain or whether the issue itself commands consensus?

Ms. Yackel: There is a will to do something about this issue. Whether that will translate into what you are addressing in terms of practical difficulties concerning privacy of information, those difficulties would certainly have to be addressed in the early stages of consultation, discussion and development.

Other countries have information that we do not even possess on a national basis. I would use again the example of England, where they have targeted five groupings. One of those groupings is high-risk occupations, and they have set a specific target of three top occupational subgroups: agricultural workers, nurses and physicians. For our death statistics, we do not collect information on occupations at risk.

For your information, the other four groupings that the researchers look at are, first, people who have been in contact with the health care system, the mental health care system, currently or very recently; second, people who have attended some type of self-injurious or self-harm behaviour within the past year; third, young men; and fourth, prisoners. The fifth grouping that I mentioned are people who are have an occupational risk.

Within each of those groupings, the researchers have a target of reducing the rate, which I believe stands around 9.2 compared to, say, Canada's rate of 13. Their target is to take that 9.2 and reduce it by 20 per cent over 10 years. Therefore, out of the 1,200 deaths that relate to people who are currently in contact with the mental health system, we want to reduce that number by 20 per cent; we want to reduce the 1,180 in the self-injurious death category by 20 per cent; we want to reduce the 1,300 deaths in the young men category by 20 per cent; and we want to reduce the 85 deaths in the prisoner category by 20 per cent. In a sense, the researchers are able to set micro goals because they know their groupings.

Dr. Turecki: Problems with regard to jurisdiction might appear if we were to do such a study. However, that could easily be overcome in the sense that suicide is usually seen as a priority everywhere.

We took the initiative of conducting a study based on the Finnish experience and looking at all suicide cases over a period of one year in the province of New Brunswick. We wanted to do something similar in Quebec, but it always comes down to a problem of lack of funds. That is the major problem we would have to face were we to do such an important study.

Over a period of one year, case managers in Finland, the people who actually work with the population on a daily basis, studied all suicides. They interviewed all of the families of suicide completers, which helped them to better understand the underpinnings and problems of suicide and helped them to identify issues such as major depression, which at the time was not well understood as a major problem. Therefore, prescriptions for antidepressants decreased dramatically and suicide rates were reduced by 20 per cent over the following years.

Studies of that sort help the country as a whole understand who is at risk. If we were to do such a study, the problems we would face would be minimal compared to the potential benefits of such an initiative.

Senator Fairbairn: There is a problem that has been growing within my own province of Alberta. Would you care to comment on whether the availability of gambling opportunities to all of society has increased the concerns about suicide?

Ms. Yackel: I can only respond, somewhat subjectively, that I believe so. I would really be happy to determine if we have any studies related to the association of gambling and suicide. I know that is an area of interest. I do not recall off hand what we have done in that area, but I would be happy to get back to you.

The Deputy Chairman: Does gambling not fall within the ambit of addiction?

Dr. Turecki: Yes, that is correct.

The Deputy Chairman: Therefore, would it not be natural to assume that it would be a contributing factor?

Dr. Turecki: Pathological gambling is classified as part of the impulse control disorders, which brings us back to the importance of impulsivity in relation to suicide. We look at the association between pathological gambling and suicide as part of the same spectrum of problems that lead to suicide as a risk factor.

Senator Keon: My question is directed to Ms. Yackel, but I would like you all to comment on it. You are pleading for a national strategy for suicide prevention. You told us that 90 per cent of people who commit suicide have mental illness. Other people have told us that as well. Other people are pleading for a national strategy to deal with mental health, mental illness, addictions, substance abuse, criminality, and so on, all of which are associated with mental illness.

Last night we heard witnesses from Australia. They were able to develop a national strategy for mental illness about 14 years ago. Obviously, some good things have happened out of that initiative.

Could you develop a national strategy for suicide prevention within the structural framework of a national strategy for mental health? What would you do with the 10 per cent of people who do not fit into that category? Would it be better to have a national strategy for suicide prevention allied to a national strategy for mental health? Have you thought about that?

Ms. Yackel: I tend to think in pictures. Let me give you a very simple one.

I look at the mental health and mental illness continuum like a big long freight train with many components and box cars. At the front, I would place the engine of a national mental health action plan, something to pull everything else. At the end of this long train, this continuum, is a caboose, not such a small one, but a caboose of suicide. In my analogy, a suicide prevention strategy would be like hooking up a second engine at the back of that train to give it the push it needs because the challenges of a broad mental health plan are so immense. The time that it will take to overcome that whole inertia, to make a commitment, to consult, to engage in development and to then implement the plan and determine whether there is an actual impact on the system gives me concern. That takes so much time.

I would hook up the suicide prevention engine at the back of the train for an extra boost. We are both on the same track; we will not derail. It is important that establish an integrated plan. Both England and Scotland have had suicide prevention strategies that have emerged out of their broad-based thinking on mental health.

On the other hand, we can look at Australia and New Zealand, where they started with a narrow focus; that is, a suicide prevention strategy for young people. Over time, they have had to draw back and make it more comprehensive. In view of the figures and what I perceive to be an urgency, that is my analogy.

Dr. Turecki: I have a slightly different opinion on that issue. I think that, yes, the strategy could be fully integrated. The way I see suicide is that it is a consequence of mental illness. I think that is 90 per cent of what we see. It is a methodological artifact. The way we study this issue is by doing retrospective interviews with family members. It often happens that people who commit suicide are isolated, so we do not necessarily have access to the information. These people probably make up the 10 per cent figure. We have done studies on this 10 per cent of people and have found that they also exhibit evidence of mental illness. However, we are unable to diagnose it.

Suicide is intertwined, intermingled, with mental health problems. If we were able to address mental health problems more fully, we would at the same time address the problems of suicide.

At the same time, we need to better understand the predisposition to suicide or better identifying who is at risk. Therefore, there must be an independent initiative, which could be within the mandate of an initiative on mental health, to address suicide separately from the rest of the mental disorders. The way I see it, suicide is a consequence of mental illness.

Senator Keon: How would you deal with the 10 per cent of people who are considered not to have mental illness? For example, physicians who commit suicide are never considered in my opinion, or usually not considered, to have any sort of mental illness. How would you deal with that segment of the population?

Dr. Turecki: It is a question of promoting programs. For instance, we know very well that out of the people who die by suicide only a small percentage of them had access to a health caregiver. If we look at the previous year before people commit suicide, studies show that only about 50 per cent had contact with a GP or with a health provider. Only 30 per cent had contact with a psychiatrist. If we look at the last month prior to death, the rates are even more amazing. Only one fifth or perhaps one eighth of them had contact with a psychiatrist and only 30 per cent with a GP. We do not have access to the people who are actually dying by suicide. We need treatment programs and awareness programs that disseminate information about available resources for those who are at risk of suicide.

Mr. Brière: Perhaps I could make a last comment on the stigma attached to suicide but also on mental illness in general.

People who need help often do not seek help because they are ashamed of what happens to them. If we can do something about the stigma attached to mental illness, you will have people bragging about it the way they do about heart disease, saying, "Well, I had a bypass." People will tell their friends about that, but many people will not talk about their mental illness problem. If we can do something about the stigma, it will help people talk about their mental health and it could help us assist people with suicide. A stigma is still attached.

Also, there is the issue of access to health services. It takes months to see a psychiatrist in Montreal, so access to health care for mental illness is also a problem. It could be better.

The Deputy Chairman: On behalf of all senators, I wish to thank the witnesses for being here today. For those who have been reading the testimony we have heard, the problem of stigma is front and centre in terms of getting to the centre of this horrific situation.

The committee adjourned.

Back to top