THE STANDING SENATE COMMITTEE ON SOCIAL AFFAIRS, SCIENCE AND TECHNOLOGY
EVIDENCE
OTTAWA, Wednesday, October 5, 2022
The Standing Senate Committee on Social Affairs, Science and Technology met with videoconference this day at 4:05 p.m. [ET] to study the Federal Framework for Suicide Prevention.
Senator Ratna Omidvar (Chair) in the chair.
[English]
The Chair: My name is Ratna Omidvar. I am a senator from Ontario and chair of this committee. Welcome, members.
Before we welcome our witnesses, I would like to provide a content warning. Today, our committee continues its study of the Federal Framework for Suicide Prevention. We will be discussing topics related to suicide and mental health. This may be a trigger for both people in the room with us, as well as those watching and listening at home. Phone numbers for crisis lines will be broadcast during this meeting. Senators and parliamentary employees are also reminded that the Senate’s employee assistance program is available to them and offers short-term counselling for both personal and work-related concerns, as well as crisis counselling.
On our first panel, joining by video conference, we welcome Dr. Tyler Black, Clinical Assistant Professor, Department of Psychiatry, University of British Columbia; and Dr. David Klonsky, Professor, Department of Psychology, University of British Columbia. Thank you for joining us today.
Before I invite you to deliver your openings, I want to remind our witnesses and our committee members that the focus of this study is on evaluating the Federal Framework for Suicide Prevention, which was published in 2012, and not about suicide prevention in general. I ask you to please keep your comments to the framework and, colleagues, your questions, as far as possible, focused on the framework. This is, of course, true for all of us. To the witnesses, I invite you to deliver your opening remarks. I remind you that you have five minutes allocated for opening statements, followed by questions from the members of the committee. Thank you very much.
Dr. Tyler Black, Clinical Assistant Professor, Department of Psychiatry, University of British Columbia, as an individual: I’m thankful to the Standing Senate Committee Social Affairs, Science and Technology for the opportunity to share my perspectives on the Federal Framework for Suicide Prevention as it stands, as well as what is necessary to add a solid evidence base to federal efforts.
By way of introduction, I’m a child and adolescent psychiatrist who practises almost exclusively in crisis and emergency psychiatry at B.C. Children’s Hospital in Vancouver, situated on Coast Salish Musqueam and Tsleil-Waututh lands. I’m a suicidologist and emergency medicine researcher for the University of British Columbia.
Though I’m proud of my employers, these views represent my own and I have solely prepared my own testimony. In regard to suicide prevention and specifically youth suicide, I bring not only the expertise of my research and studies but also the interaction and consultation of over 10,000 children, adolescents and families in crisis in my career.
First, I want to describe the current state of affairs before and after the 2012 passage of the Federal Framework for Suicide Prevention. I will be referring to the first five visuals in my evidence submission, which you should have.
In visual 1, 12 years of pre-framework suicide rates for all Canadians is plotted over time. We can see that there was a small but significant declining trend. To quickly orient you, suicide rate is often expressed as the number of suicides per 100,000 people per year, and 11 suicides per 100,000 equates to approximately 4,300 Canadian suicides per year, using 2020 demography.
Visual 2 shows the baseline 2012 year and the seven years following. We can see that the general decrease has halted. In fact, if it were not for an outlier year in 2016, the trend is upward at a rate higher than the previous 12.
Now that the pandemic has occurred, our ability to abstract data for 2020 is challenging, though I would submit visual 3 to clearly show that the pandemic, contrary to moral panic about suicide in the age of COVID, is associated with a sharp 17% decrease in Canadian suicide rates.
The situation is worse, not better, for young Canadians under the age of 24, a key demographic identified by the federal framework. For example, in visual 4, I am able to demonstrate the generally rising rates of suicide in Canadian girls and young women occurring within the time frame of the post-federal framework era.
For Indigenous people, suicide rates are horrific, starkly represented by visual 5, where we see severe over-representation in the First Nations people and Inuit, with young Inuit men and women dying at rates of suicide 24 times that of the non-indigenous population. Note I use the phrase “over-representation” instead of saying “increased risk,” as the risk is not inherent to Indigenous people, but a reflection of the traumas inflicted by colonization and systemic discrimination.
I’ve submitted other demographic breakdowns for the committee’s consideration, but the sum of the data is clear. We have no evidence that the federal framework has improved the situation for suicide rates in Canada for the general population or specific areas of concern.
I found the framework to have failed the strongest in sections 2(a), 3 and 4 of the framework, which refers to statistics about suicide and collaborative knowledge exchange. We’re still heavily reliant on provincial data releases and extremely lagged and limited Statistics Canada releases. It is imperative that we have a national database of information on suicide measures, demographic information on the people involved and support for rapid and comprehensive investigations to establish the present and missing factors involved in a death by suicide. If we as a nation purport to care about suicide in the 2SLGBTQI+ populations, why do we have virtually no information on suicide deaths, attempts or hospitalizations regarding them?
The framework also tasks the Government of Canada with defining evidence-based practices in prevention and promoting research to establish these, but our efforts have fallen short. This is compounded by the dearth of high-quality research in suicide prevention. It is clear that if Canada wants high-quality evidence, Canada will have to do the research to produce high quality, reliable results. This research must not just be statistically or strictly related to mental health. Though I’m a psychiatrist, part of a pilot program involving ketamine and I love my research, my research requires a suicidal child. There are so many interventions worth investigating that can prevent a child from becoming suicidal.
The Framework for Suicide Prevention cannot be aspirational or ephemeral; it has to be involved up with tangible and reportable outcomes like fewer deaths, hospitalizations or fewer attempts. For people who experience suicidality and for families who survive suicides, we do not need documents containing platitudes or kind words, but government action that creates tangible and measurable benefits. Thank you.
E. David Klonsky, Professor, Department of Psychology, University of British Columbia, as an individual: I am grateful for the work that you are doing and for your interest in my area of expertise. My name is David Klonsky, and I’m a professor of clinical psychology at the University of British Columbia. I have more than 100 publications on suicide, self-injury and related topics. Beyond my research, I served as lead editor for self-injury diagnosis for DSM-5, which is the psychiatric diagnostic manual that is most widely used worldwide. I have experience working with various Canadian and U.S. government organizations on suicide and self-injury prevention.
A Federal Framework for Suicide Prevention will only work if three conditions are met. It specifies actions, not just ideas; it chooses actions that are likely to work; and it ensures resources are available so the actions can be carried out. In that context, I would like to share my thoughts on the current framework, starting with its strong points.
One strong point is that it decouples suicide from mental illness and includes a public health approach. Suicide, in brief, is motivated by extremes of pain and hopelessness. Mental illness is one context in which these extremes occur, but human experience contains many other events, conditions and contexts that can cause extreme pain and hopelessness and motivate suicide. It is appropriate and essential that both public health and mental health perspectives are utilized.
A second strong point is the emphasis on quality data. As Dr. Black noted, we cannot know what is happening in Canada and we cannot know the impact of anything that we do without high-quality data about suicide and related outcomes.
A third strength is the framework’s emphasis on enhancing knowledge exchange between researchers and practitioners. In my subjective experience, there is often a 20-year lag between the state-of-the-art knowledge that we have and its implementation.
I would like to focus the rest of my comments on some aspects of the framework that are perhaps not so good and could be improved.
First, the framework puts a large emphasis on increasing awareness. I’m concerned that this conflates awareness with knowledge and destigmatization. Awareness without knowledge can be scary and even paralyzing. The emphasis needs to be on knowledge and people’s comfort in using that knowledge.
Second, the framework’s vision centres hope and resilience, which is great, but I might suggest including meaning and connectedness. I think it would be equally well received, but more grounded in the evidence.
Third and importantly, the framework relegates means restriction or means safety, the restriction of the availability of lethal means, as more of a detail under intervention. From my perspective, this is the only truly evidence-based intervention at the population level, so it should, therefore, be featured. In other words, the first step of a government plan for suicide prevention should be to feature what is known to work, and the framework in its current form does not quite do this.
Fourth, the framework relegates the effort to define best practices for suicide prevention to more of a detail than a central aim. If our first priority is to feature what works, our second is to identify evidence-informed options that experts think might work and study their effectiveness in limited context. That way, we can identify the ones that should be rolled out more widely or even nationally. Examples of this can include school-based education programs with promising data for reducing suicide attempts, targeted changes to how emergency and hospital personnel and everyday physicians identify and respond to those at risk, identification of a small set of warning signs for suicidal crises that could potentially change the way that the public understands and responds to suicide crises, and the effectiveness of suicide crisis lines.
Fifth, I think something perhaps missing from the framework is a strong emphasis on the need to develop clinical treatments designed specifically for suicide risk. The vast majority of psychological and psychiatric treatments that are around are for a diagnosis. Some diagnoses are more associated with suicide risk than others, but very few treatments are designed specifically to reduce suicide risk. Those that do exist have limited evidence for their effectiveness and were designed more than ten years ago and are not informed by the latest knowledge about suicide.
Finally, to make any of these ideas happen, from my perspective there needs to be a streamlined team to determine a finite number of priority actions, because we can’t do everything. Teams with large numbers of members and expert consultants, while having some obvious advantages, have the disadvantage that they tend to produce documents that include everything that anyone feels is important and the result is something that is cumbersome and not actionable. In my subjective experience, after five years on the Canadian Research Advisory Committee on Suicide and its Prevention, this is what happened. We produced a document that had 28 themes and priority populations and priority settings with 69 opportunities for action, but we cannot prioritize 28 ideas with 69 actions. Making a national suicide prevention plan actionable likely requires a streamlined effort from a relatively small number of committed individuals.
Thank you very much for your time. I look forward to any discussion or questions.
The Chair: Thank you very much.
We now go to questions from senators. We will start with Senator Bovey from Manitoba, who is the deputy chair of the committee.
Senator Bovey: I would like to thank both of our speakers. This is a very compelling topic.
I do not know whether you would agree with me, but I often feel that frameworks for important societal issues are often likened to building foundations for buildings. If our foundations are not solid, the building won’t be. If I can use your words, there needs to be focus.
My question is around research. If we are looking to develop or update the federal framework from 2012, you both talked about the need for research. You have talked about the need for tangible outcomes. You have talked of the need for knowledge exchange. I was stunned that you feel there is often a 20-year lag between knowing the knowledge and implementing it. Tell me, what can we do to strengthen that framework so that the desired outcomes are focused and we know what the framework is supposed to be building? This is to both of our witnesses, if I may.
Mr. Klonsky: Dr. Black has kindly messaged me that he has yielded to me for this particular moment, which is kind of him.
It is a very hard question because it gets complicated very quickly. Not all research is equal in terms of its applicability to applied settings. Not all research is equally valid. The result of an uncontrolled study is not the same thing as a meta analysis of 20 very well-controlled studies. There can be a lot of reasons, many of them sociological, why the knowledge does not translate quicker. Some of that is beyond my expertise. There are people with specific expertise in dissemination and implementation. That is a growing field. I don’t know that that was recognized as a subfield 20 years ago. We need to make use of that and include those folks with that expertise in these conversations and in plans for suicide prevention.
I would say in general, though, that another barrier is that researchers do not all agree on what the most important knowledge is on how to best understand suicide and respond to it. At some point — and this is very difficult and I don’t envy the decision — the government needs to choose a couple of researchers who they have decided have the right approach and allow them to identify those priorities. Without doing that, you just have a mess of hundreds of studies out there and people saying this should be disseminated. You cannot disseminate everything. It is overwhelming to do it, even if you could, and it would be overwhelming to receive. It has to be the right information in the right kind of chunks to the right people.
Again, I would come back to I think at some point there needs to be a streamlined team with the right expertise. That would include expertise in suicide and expertise in dissemination and implementation, which is a different expertise. Then make some decisions with the help of public health experts and other government experts on what should be disseminated to which folks out there in the applied setting. That includes not only the health settings but schools and other kinds of settings that are in powerful positions to reduce suicide risk.
Senator Bovey: The research, if we are going to have a solid framework, has to be evidence-based research rather than anecdotal research. Is that correct?
Mr. Klonsky: 100%.
Senator Bovey: Dr. Black, do have anything to add?
Dr. Black: I’m in total sync with what Dr. Klonsky was saying.
My addition to this would be the knowledge that the public health lens is different than the clinical approach lens. When you are working in clinical approach — honestly, I teach suicide risk assessment to students all around the world, and it is individualized: what is going on for them, reducing the risk factors and finding them housing. It is a whole bunch of things. The public health point from the large national point is a different lens.
When Dr. Klonsky was talking about means restriction, with what we know about the relationship between poverty and suicide, all health disorders and suicide and large population groups that are over-represented like Indigenous communities in Canada, it gives us targets to focus large strategies on. Sometimes we use our research for the clinical and try to plan it with public health. Deploying CBT to the masses probably is not as helpful as we want it to be.
Senator Patterson: Thank you both.
Dr. Black, you have presented terribly heartbreaking evidence of 25 times the national average in suicide deaths amongst Inuit and equally alarming statistics about First Nations. I would like to ask you both, given these shocking figures which are very burdensome to those of us who live in these regions, should there be more of a focus on this issue in our Federal Framework for Suicide Prevention?
Dr. Black: Absolutely. From my point of view, if we want to see the largest effect sizes in suicide reduction, we have to go to the populations and the groups that are over-represented the most in suicide rates. For example, the types of studies necessary to prove that suicides are reduced in a group that is very unlikely to die by suicide or less likely to die by suicide requires more people, but you could do interventions to targeted groups. When the rates are as high as they are, you could see effects. I do think that research and focus has to be on Indigenous people in Canada. It is crucial to me.
Senator Patterson: If I have more time, I would like to defer to Dr. Kutcher, Senator Kutcher.
The Chair: Senator Kutcher, you are rich. You have five minutes of your own time and 3.2 minutes of Senator Patterson’s time.
Senator Kutcher: Senator Patterson asked the fundamental question, and we heard from Dr. Black. I wonder if we could hear from Dr. Klonsky for his thought on that. Dr. Klonsky, you mentioned setting priorities. To me, with these abysmal numbers and its tragic impact, shouldn’t this be one of the priorities that is set?
Mr. Klonsky: That should definitely be one of the priorities. I certainly echo everything that Dr. Black has said.
It does not have to be either/or. We can have some universal principles that guide our suicide prevention that then can be applied to very different contexts in ways that are ideographic and appreciate the differences between communities, for example. Even in the Indigenous context, not all Indigenous communities have the same suicide rate. Some actually have rates below the national average, and some are way higher. Even at that level, what we do needs to be tailored.
At the same time, though, I would argue that knowledge is now at a point where we can boil down the pathways to suicide to that the near-universal motivation is overwhelming pain and hopelessness that things can get better. What can keep people alive even in that context is a sense of connectedness or meaning that makes life worth living despite the pain. Even if people are at a point of suicidal desire because of pain and hopelessness and perhaps lower connectedness, they need the capability to attempt suicide, which involves some version of the courage to do something scary and the practical means to do it. Those are four pathways — pain, hopelessness, connection and capability — that I think can be applied universally.
If we were to pick a particular Indigenous community to focus on, we would want to focus on the causes of pain in that community, what causes people to feel less hopeful? What are the barriers to feeling connected, whether it’s to one’s family and friends, community or to a larger country? What makes capability higher? And what kinds of lethal means are more prevalent? There will be universal principles that can help us to determine very personalized ways, so to speak, of intervening and where we could very much collaborate with leaders in that community. It very much should be a priority, but I think there are ways we can do it.
Senator Kutcher: Great. Thank you very much for that.
For both of you, the minister and her bureaucrats, when they were here, talked about the importance of having an evidence base to work from. She said suicide is too serious an issue to be funding ideas at the expense of evidence-based programs. Both of you have actually touched on that.
One of the issues that has come from your very useful critique of the framework is that, while it talks about some public health measures — such as means restriction — it doesn’t focus on them, but it also doesn’t talk about clinical interventions. There are some clinical interventions that might be helpful. What are your thoughts on a framework that could blend both types of interventions?
Dr. Black: The importance of the clinical aspect comes from our knowledge that people who do have mental illness or other forms of health suffering can interact with professionals, and those professionals, given knowledge and training and support, can actually be part of suicide prevention. I would love to say that we have fantastic evidence, but we have good, pointing evidence that it’s worth looking at gatekeeper training, for example, for family physicians — maybe not as well evidenced for those in the community but certainly for some physicians.
Whenever professionals are involved, we want professionals to be comfortable in doing this. That’s where training programs really step up. Unfortunately, when we evaluate those training programs, we typically evaluate them on the basis of asking whether the people felt they benefitted from the program or did they answer a test well after the program. That’s not the outcomes that we’re looking for. We’re looking for outcomes of reduced suicides; we’re looking for outcomes of fewer presentations to hospital or less suicidal thinking, even on a survey. It’s a lot less important what the administrators of a program feel about their skills and more the impact of their skills.
The evidence needs to really be stepped up if we’re going to use it seriously, but we have these key ideas that are worth pursuing. We need to actually do the research ourselves. We can’t just keep meta-analyzing the same 18 studies.
Mr. Klonsky: I would agree. We absolutely have to get the science right. There is a history in general, but there’s also a history in suicidology of well-meaning people with credentials having ideas, creating group treatments and doing things at a community level that turn out not to be helpful or even sometimes to be harmful in terms of increasing people’s suicide risk. The only way we know which of these nice sounding ideas work is by doing the research and through good science. That’s absolutely essential, and we have to do that.
In terms of the question about clinical interventions, my read of the literature is that the science so far is saying they’re not that effective. They’re better than nothing but not a whole lot better than nothing. I’m referring specifically to the ones created for suicide risk, not other kinds of diagnoses associated with suicide risk. They’re better than nothing, so we should keep using them as a nice complement to the public health approaches. I suggest we also need an emphasis on developing new ones using the latest knowledge that hasn’t yet been incorporated into existing treatments.
Senator Kutcher: Thank you very much for that. One of the useful things in having a framework is that it can help correct us if we’re going off the rails, by monitoring what we’re doing and seeing what impact we’re having on designated outcomes.
You’ve both talked about — and so did the minister — the importance of key outcomes being decreased rates of suicide or decreased hospitalizations for suicide attempts or decreased emergency room visits for suicide attempts, as key criteria. The framework lacks an evaluation framework; it has no evaluation built into it. If you were going to advise the government on how to create a framework, how would you deal with this issue of ongoing evaluation so that it could be used to learn from it and to give direction midstream?
Dr. Black: It’s really challenging to do this, but it requires federal support, likely, to create real-time or near-real-time monitoring. With suicide data, it takes time to investigate a suicide. I appreciate all of the coroners’ efforts, but we end up waiting months and months to get just simple numbers on suicide before we can even go into it. When we’re trying our hardest to get the data that we need, it needs to be national. It needs to be shared. It needs to be relatively real time. Hopefully, with enough parameters and depth, we can start taking a look at targets to aim for.
I have given the evaluation in my evidence, and I would say that the evaluation of the federal framework is rather poor. If it were not for the pandemic and likely economic supports and the pull-together effect and other things, I don’t think we would have seen a 17% decrease in suicides in 2020. The rates were increasing since the framework’s been passed.
Senator Brazeau: Good afternoon to both of you. Thank you for being here. Obviously, we’re dealing with a subject matter that’s not necessarily everyone’s cup of tea or anyone’s priority, but, unfortunately, we have to have these discussions, and this issue is very personal to me.
In 2019, my office conducted some research. Essentially, we asked every provincial government to forward the types of programs they had in terms of suicide prevention. To make a long story short — and the numbers are quite in your face — it demonstrated that 75% of suicides are committed by men. When you look at the available programming for women and men throughout the country, there’s a huge disparity in terms of what exists in programming for men. I want to say this is not an issue of gender, of men versus women, but if 75% of people who commit suicide are men, and if we have an over-representation of Indigenous people in this country in terms of suicide, what specifically would you recommend that we put in this report so that we actually tackle these issues head on for once? Thank you.
Dr. Black: It’s a great question. When we think about targeted populations, we definitely need to think about men. We need to think about young people, in particular. In Indigenous communities, there’s an extremely alarming rate per 100,000 in the group that are under 40.
Programs need to be targeted specifically at groups. I really like what Dr. Klonsky was saying about having these principles to guide them. For example, what causes men in Canada pain and lack of connection and things like that might be different than the things that affect women in Canada or, for some women, the causes might be the same. We need to target things, but we need to have principles to guide those targets. If all we’re doing is sort of playing whack-a-mole with the highest suicide rate, it will never end. What we have to do is target a principled approach to suicide risk and then possibly use the deploying of those principles to targets of high concern as the sort of framework for that.
Mr. Klonsky: I also appreciate the question. We do need to target the higher priority populations, but anything we do needs to be based on an understanding of why. The answer to why is going to be different in different populations, and the examples you raised are wonderful exemplars of that because as much as I do think we can understand suicide in terms of pain, hopelessness, connection and capability to attempt suicide, when we apply that to different subgroups, we will come up with different answers.
For example, with men, there is a consistent finding that rates of feeling suicidal and even attempting suicide are not higher in men. Rates of dying by suicide are higher in men. As far as we can tell, that’s because of the lethal means that are available to them and that they choose. Firearms are one example of that. If we were to apply these principles of pain, hopelessness and connection and capability for suicide to a particular Indigenous community, we might find a very different kind of answer. We might find there that it is something about the pain people are experiencing or the sense of hopelessness or disconnection. Perhaps it does involve capability.
We would need to focus on those populations, as you suggest, but we would need to focus on them in a way where we can figure out the “why,” which would be a different answer for different populations. Then we could intervene accordingly.
Senator Cordy: This whole issue is so very important. I want to thank Senator Kutcher, who suggested that the committee study this. Thank you all for being with us today.
Today is National Teachers’ Day, and I used to be a teacher, so I would like to ask questions related to information that teachers are given. Sometimes, a teacher would ask the question, and it would be going back to your point earlier about needing to streamline data. If you give people a 3.5-inch-thick document to read, saying that after reading it that they’d be an expert, that’s not going to work. It has to be specific. It’s been a while since I’ve been teaching. Listening to you and from the reading I’ve been doing, I’m not sure things have changed that much.
What information is given to teachers about what works and what doesn’t work? Who do teachers turn to for help when there is what they think may be a concern? When I was a teacher, I remember a student writing something that concerned me. I phoned the school counsellor and was told they were busy and could I please handle it and talk to the student. I did, but I was on my own. I was praying to God that I would not say or do the wrong thing. How do we talk to front-line people like teachers who see students interacting with one another — or not interacting with one another — and see things that students write? How do we do that?
Dr. Black: That’s a great question.
We have to create urgency within school administrations and schools that this is actually something important to schools. I published a piece in Scientific American using 7.9 billion years of child life over 21 years showing that there is a 60% increase in suicides during the school year compared to the non-school year in America. That is not different in Canada; we see the same in our emergency departments. Schools are a child’s full-time job. They have co-workers, bosses, supervisors and overtime with homework. There are conflicts and bullying situations. It’s a full-time job, and it requires lots of supports. Of course, if an organization doesn’t prioritize the mental well-being of its employees, the mental well-being of its employees suffers. In the same way, if schools and administrators don’t prioritize that — it doesn’t become a thing — then it becomes almost like a side-of-the-desk thing where you’re kind of running from emergency to emergency without a plan.
I often find that teachers are very surprised when I explain that link, and then I talk a lot about the things that schools could do that we could investigate almost immediately to reduce the pressure on kids. There are things like later starts to the day, no homework — things that sound radical but are very well supported by the science. But we need administrators on board. I always feel like teachers are the ones we think of, and they’re definitely on the front line, but they need the support of their administration and the overall direction of a framework, guidance or principle.
Mr. Klonsky: Just because we understand suicide, which is a challenge in and of itself, doesn’t mean we know how to implement that knowledge in different settings. You raised a setting that is incredibly complicated. There is expertise that comes along with that. There are people who have that expertise who are doing good work implementing suicide prevention guidelines. There is a signs of suicide program that seems to have good evidence where they can take a holistic approach as to how you handle the school system. We need that expertise, because school systems bring up a lot of things that are very complicated.
One of the things that was apparent in your example is those complications. For example, it is not uncommon for a student to feel suicidal and the expression of suicidal feelings is not an emergency. If we mobilize as an emergency when it’s not, that can feel terrible to the kid who then might not want to ever share their feelings again. At the same time, we don’t want to be wrong. Also, we don’t want to be wrong legally, which is sort of a whole other consideration. Sometimes there is a misalignment between what’s best for the kid and what we’re supposed to do legally. It’s very complicated.
Fortunately, there are people doing that work. I think there are existing programs we could borrow from that already have some promising evidence and that could help us address the challenges you raised.
Senator McPhedran: Thank you to our expert witnesses who are with us, and thank you to Senator Kutcher for initiating this very important study.
This week, there have been a number of headlines. I’m just going to quote one of them and then ask my question. I’m an independent senator from Manitoba, and this was a headline coming out of Manitoba: “Winnipeg woman who chose to die with medical assistance said struggle for home care help led to the decision.” This is just one of numerous headlines that we have been facing since the more recent legislation on medical assistance in dying. Prior to that term, I think we probably knew the process more as assisted suicide. There is attention at this point about these kinds of medical-assisted deaths where we have evidence that choices are being made by people with disabilities to access medical assistance to die when they also state that it has a great deal to do with the fact that they have not been able to access adequate resources from our society to live with dignity. Is there a category emerging for that kind of suicide? I’m wondering what you could tell us about that.
Dr. Black: I’ll pass off to Dr. Klonsky quickly, as he likely has more to say on the theoretical end of this.
There is a stark difference between the types of suicides that occur based on a few parameters. The first is how impulsive it is versus how planned and fatalistic it is. If someone is facing an uphill battle that will never get better, it is not just, “Hey, you need a support line.” We actually need to substantially help that problem to help that person get better. Fatalistic suicidal motivation is the more common pathway in medical assistance in dying where it is a calculated, thought-out, “I can’t beat this problem, so I want to die with dignity,” whereas an anomic suicide, which is the impulsive type, is very much “I got dumped” or “I got fired” and it’s a reaction or overreaction. There are different motivations.
It’s really important for us not to conflate medical assistance in dying with suicide generally. I don’t perceive the tension. I would think in the medical assistance in dying space — and I have submitted to the Senate committee on exploring MAID — one of the principles is that no one should select MAID because of a service they could not receive from the government. That should be one of our principles. However, if the person chooses, knowing all of the risks and benefits of whatever is available to them, to die with dignity, we also can’t take away the rights of people who have mental health disabilities as compared to other types of disabilities. It will require a thoughtful assessment by trained professionals, and I think that’s possible.
Mr. Klonsky: It’s an incredibly important question.
I do think we can understand people’s decisions to choose MAID and to choose suicide using the same principles. People choose MAID when they’re suffering, in pain day to day and they feel hopeless about getting better. In that case, it’s because there’s a real reason to think that. The illness prognosis is that it’s not going to get better. Eventually, you get to a point where the pain is so great you can’t appreciate or engage in the connections that are required for living.
A big difference is similar to what Dr. Black said in that in most suicides, when those peaks of pain and hopelessness occur, it is not the case that it is the reality that will happen forever. It’s someone being overwhelmed in a moment. We know that they would not make the same choice because in studies of people who choose methods that usually end in death but happen to survive, over 90% do not go on to die by suicide. For the same person in a suicidal crisis, their future self is likely to be happy that they’ve been saved. However, with MAID, theoretically the person’s future self would make the same decision.
What is striking and heartbreaking about the example you raise is that it does not sound like it was the person’s organic condition. It was, as Dr. Black noted, that a service was being denied that could have eased that person’s pain and could have given them hope for a more functional future but they were denied that. Clearly, that’s not right and it requires our attention, our outrage and our doing something different.
Senator Martin: Thank you to our witnesses who are giving us their expert testimony on a very difficult topic.
I’m looking at the visuals, the charts, and there isn’t a significant trend. The numbers are similar even after the federal framework, which tells us that we need to do better. There are ways to improve the current framework.
I know there are best practices in Canada. Going beyond Canada, how does Canada compare with other jurisdictions in terms of our best practices for suicide prevention? Are there elements missing in our framework that could be adopted to strengthen the current framework? Maybe I can start with Dr. Klonsky.
Mr. Klonsky: There is a really good chance Dr. Black has better command of the epidemiological data since that’s been one of his many areas of focus — not necessarily in his job description, just something he does over and above.
It’s hard to compare Canada with other countries in part because different countries have very different considerations. In the United States, it is overwhelmingly clear that firearms are probably the first point of intervention. It’s also a great illustration that suicide is about more than mental illness because households that own firearms in the United States have suicide rates that are three to five times higher than everyone else, although there is no evidence that rates of mental illness are higher. It’s a great example of why this is a public health issue. Canada can’t take the same lessons from that as the United States because firearm ownership is an issue. It should be an area of attention, but it’s not as widespread.
Another difficulty in answering that question is when you look at the trends of suicide rates over time, you get very different answers depending on how far you pan out. There is a period of time where the suicide rate was going up for 12 consecutive years in the United States but going down for 12 consecutive years in Canada. However, if you pan out to a 30- or 40-year perspective, rates in Canada are roughly the same now as they were in the 1970s. You could roughly say the same thing for the United States.
It’s definitely worth seeing if countries are doing things that we are not doing. At the same time, in the end, we’ll have to come up with something that fits the Canadian context because we are different enough that there are limits to what we can learn from comparisons to other countries. Dr. Black may have something more useful to say.
Dr. Black: That’s a great point. For example, if we look at Italian rates of suicide, they’re rated extremely low, three to four per 100,000 per year. I just simply don’t believe that number. I think we’re measuring different things. We’ve known from some research that even the religiosity of coroners can influence the call of suicide or non-suicide. Using national statistics is fraught with some challenges.
In general, Canada has performed much like its Commonwealth colleagues. The United States often leads our media and political discussion because they are our extremely large and populous neighbour to the South dominating the media, but their rates of suicide have done things that our rates of suicide haven’t. Dr. Klonsky talked about that very well. I would point to one big difference. The United States had a very meager COVID benefit for people during the pandemic, and their rate of suicide changed by about 3.6% less. Canada, however, had a rather ample COVID benefit, and our rate deceased by 17%. I don’t think that’s a coincidence. I think we would find that countries that invest in their population during times of hardship significantly and financially see extreme benefits. This is borne out in employment research, where times of hardship and economic hardship, which are usually associated with suicide rates, is obliterated when governments invest in their population financially during times of austerity as opposed to cutting back on programs during austerity. There are large things that we can learn from governmental responses to crises. I think the pandemic actually opens us up to a really interesting phenomenon where we probably had the strongest rate drop in suicides in 2020 compared to our colleagues.
The Chair: Dr. Black, since you raised the issue of guns and suicide, does the framework take into account the co-relationship in Canada between gun control and suicides? The Coalition for Gun Control of Canada has found that most firearm deaths, in fact, are suicides. Do we take that evidence? Are we gathering that evidence? What can you infer from this?
Dr. Black: Firearm death remains a top cause of suicide. Hanging and suffocation — sorry for the graphic language — often is number one in Canada. Obviously, if we went out to more rural areas, we would see firearm ownership and firearm deaths by suicide start to take over. If we look at the difference between men and women, we see more firearms even in Canada. There is definitely a role for firearm regulations in suicide prevention. This is well established. This is not controversial. Gun regulation laws that are sensible, that prevent suicidal people from acquiring guns or that reduce the accessibility to guns or make it harder to impulsively use a gun are very well related to reductions in suicide.
Senator Ravalia: Thank you very much to our witnesses.
I’ve just been thinking about what you said earlier, Dr. Klonsky, in terms of not overwhelming the framework with huge amounts of data. We have a significant number of communities that are vulnerable, and one size may not fit all. In your experience with issues such as cultural diversity, the rural/remote/urban divide, immigrant and refugee populations and the impact of social media, how do these factor into us constructing a framework that’s more pliable than kind of rigid and fixed?
Mr. Klonsky: Thank you for the question.
That goes to the point that I was trying to make earlier. I think there are universal principles of suicide that are incredibly flexible and would lead to different understandings of what’s happening in different communities. I really do believe that, to pick a number, 98 or 99% of suicides are motivated by overwhelming pain and hopelessness that things will get better. Connectedness can give people a purpose for living that makes even the pain worthwhile and, in the end, desire for suicide does not translate to a death by suicide unless there is the capability to make that attempt. I think those are four universal principles that can be applied everywhere. However, when you apply them to different communities or to an immigrant group or to a different school, the stories of pain, hopelessness, barriers to connection and capability will be very different. That will allow for a personalized understanding of what is happening in that context. On the one hand, we do want national kinds of rollouts; on the other hand, these principles can be rolled out in ways that empower communities or individual groups to help themselves.
To give one heartbreaking example, some years back, a high school in the United States started having number of suicides within that community. They tended to be by railroad. Students were jumping in front of a train, to be straightforward. But they did not have the understanding of these principles. Although there were data at the time showing that rates of feeling suicidal in that school were about the same as the national average, that was not different. What was different was the number of people transitioning from suicidal thoughts to actions. What was likely happening is that all those people who felt suicidal but could not imagine acting on it now had examples of peers just like them who died by suicide in a particular method that was available to them. In other words, their capability, that fourth pathway, is what was different. This even came across in interviews. This particular school didn’t have this information. They hired more guidance counsellors and tried to make things less stressful, but they were intervening at the wrong part. Where they should have been intervening was in capability — block the railroads, security guards at the railroads, signs at railroads, lighting at railroads. That was step number one and an example of how universal principles can be applied to a specific community.
I agree with you that we want universal principles that can be flexibly implemented so that we’re not shoving communities with unique needs into something that does not fit, and I think that we can do that.
The Chair: This brings us to the end of this panel. Dr. Black and Dr. Klonsky, thank you so much for your time. You have been very useful witnesses. We thank you for sharing your expertise with us.
For our second panel, we welcome, by video conference, Dr. Johanna Henderson, Director, Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health, and Senior Scientist, Child, Youth and Emerging Adult Program, Centre for Addiction and Mental Health; Dr. Allison Crawford, Chief Medical Officer, Talk Suicide Canada, Centre for Addiction and Mental Health; and Ms. Mara Grunau, Executive Director, Centre for Suicide Prevention.
I now invite each of you to provide opening remarks. I remind you that you have five minutes each for your opening statements, which will be followed by questions from committee members.
Dr. Johanna Henderson, Director, Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health; Senior Scientist, Child, Youth and Emerging Adult Program, Centre for Addiction and Mental Health: Thank you very much, members of the Standing Senate Committee on Social Affairs, Science and Technology, for the opportunity to speak with you today about the Federal Framework for Suicide Prevention. To situate myself, I’m a clinical psychologist focused on children, youth and families, and a clinical and health services researcher at the Centre for Addiction and Mental Health. I’m also the executive director of Youth Wellness Hubs Ontario, a province-wide youth system transformation initiative.
In my view, the framework needs to be strengthened by increasing its emphasis on clinical intervention, evidence-based practices and outcome data. Moreover, greater emphasis on early intervention with youth is essential to strengthening the framework. I will be discussing system intervention opportunities for addressing youth suicide risk through leveraging Canada’s emerging integrated youth services, learning health systems and through enhancing evidence and data.
Youth are unique in that they are navigating a rapid series of developmental stages, tasks and milestones on their journey from childhood to full adulthood. Key risks for suicide-related concerns include family and social factors like exposure to abuse and bullying, mental health-related concerns like depression, and substance-related concerns like harms from substance use and acute intoxication.
Despite the benefits of specialized treatment for trauma, mental health and substance use concerns, a majority of youth who could benefit from these services do not receive them. Youth who are connected to services face long wait-lists and an emphasis on assessment over treatment and a fragmented system that does not respond holistically to youth needs. The opportunity to reduce the risk for suicide is missed.
In the past seven years, integrated youth services, also known as IYS, have been co-created with youth, family members, service providers and researchers to address the significant gaps that have existed in services for youth. IYS bring together mental health, primary health care, substance use, education, employment, cultural, housing and other community and social supports into a one-stop-shop model of service delivery emphasizing timely and easy access to developmentally tailored clinical interventions for youth aged 12-25. Services are available on a walk-in basis on evenings and weekends when other services are often not available. Access to services right now is critical for meeting the needs of youth experiencing intense psychological distress, a common precursor to intentional self-harm, suicide-related thoughts and suicide attempts.
At this time, the majority of provinces and territories have committed to implementing provincial integrated youth services initiatives, and approximately 50 IYS youth hubs are operating in communities throughout Canada, including in some First Nations and Inuit communities. Another 60 hubs are in development.
Two of the most well-established provincial IYS initiatives, Foundry in B.C. and Youth Wellness Hubs Ontario, have provided services to thousands of youths both virtually and in person over the course of the pandemic, with approximately 40% of youth reporting that they would not have known where to go or would have not gone anywhere if not for IYS. Youth who identify as 2SLGBTQ+ and who as a group are disproportionately impacted by suicide-related concerns, have, in particular, had high rates of IYS utilization, demonstrating the capacity of IYS to address a long-standing gap in our mental health and substance use treatment systems.
IYS initiatives like Youth Wellness Hubs Ontario and Foundry also integrate measurement-based care through a common data platform, allowing youth progress and individual outcomes to be actively monitored over time, and also facilitating ongoing improvements in services at the local and provincial levels. Importantly, by working as a learning health system, emerging youth needs and effective service innovations can be easily identified and either addressed or scaled as appropriate.
Our next step is to facilitate development of a pan-Canadian learning health system, IYS-Net, that will allow youth, families, community leaders, service providers and researchers throughout Canada to work together to answer questions that we have not been able to answer separately. By working together, we will have opportunities to more efficiently and effectively understand what works for whom in early identification of suicide-related risk and early intervention. Together with youth, we can support youth to build lives worth living.
Thank you.
Dr. Allison Crawford, Chief Medical Officer, Talk Suicide Canada: Good evening, members of the Standing Senate Committee on Social Affairs, Science and Technology. Thank you for the invitation to appear as an expert witness in your study on the Federal Framework for Suicide Prevention.
I am a psychiatrist and clinician scientist at the Centre for Addiction and Mental Health in Toronto and an Associate Professor in the Department of Psychiatry at the University of Toronto. I have two roles that are directly related to the standing committee’s focus on suicide prevention, particularly at the public health level. I’m the chief medical officer for Talk Suicide Canada, which is the national crisis line funded by the Public Health Agency of Canada. CAMH is a founding partner in Talk Suicide and has been selected to lead the implementation of 988, the three-digit number just approved by the CRTC.
I’m also the medical director of virtual care and psychiatry outreach to rural and underserved areas and oversee psychiatry services to Nunavut. I have been very involved with Inuit Tapiriit Kanatami and was the lead consultant in the development of the National Inuit Suicide Prevention Strategy. Additionally, I’m a scientific adviser to the Sustainable Development Working Group of the Arctic Council with a focus on youth and community engagement in suicide prevention.
I wanted to briefly outline how our work at Talk Suicide Canada and 988 fits within the Federal Framework for Suicide Prevention and highlight areas for necessary growth that I think also apply to the federal framework.
Talk Suicide Canada provides crisis support to people living in Canada by trained responders in both English and French and is available 365 days a year, 24/7. Our service priorities include building a community-based network of crisis centres, training crisis responders across Canada in suicide prevention, enhancing the equity of crisis services — in other words, ensuring that we’re reaching a diverse range of communities — bringing an evidence-based approach to crisis response and suicide prevention and challenging the stigma around suicide by promoting open conversations about suicide. We believe that 988 will provide easy access to life-saving support for people across the country who are experiencing suicide-related crises. This work is in line with the Federal Framework for Suicide Prevention strategic objectives.
There are some areas where immediate growth is necessary. I have tailored these remarks to relate to crisis services but they also apply to the framework more broadly. The first area is equity. We need to ensure crisis services are culturally safe and meaningful for everyone who needs them. A particular priority is crisis services provided by and for First Nations, Inuit and Métis communities.
The second area is in implementation. This definitely applies to the federal framework. We know that 988 must be delivered with a community-based approach, but getting implementation right will also allow us to make recommendations about how to better integrate crisis services into the health system.
The third area, and it’s been talked about quite a bit today, is measuring impact. Implementing 988 will allow a more rigorous approach to evaluation. Looking at outcomes is essential to ensure a strong return on investment and to inform future strategic direction. In order to look at outcomes across sectors, however, we need better standardization of health utilization and coroner’s data.
There are many positive aspects to the Federal Framework for Suicide Prevention. It has brought diverse partners together to take stock of suicide prevention in Canada, and the Public Health Agency has made investments in Talk Suicide Canada and other essential services. However, there are areas of suicide prevention that remain unaddressed by the federal framework. I continue to believe, as I outlined in an article in the Canadian Medical Association Journal back in 2015, that Canada needs a national suicide prevention strategy. Canada is one of the few high-resource countries that does not have one, yet we know that national strategies are an effective approach. National strategies differ in important ways from the federal framework. I know that the federal framework is currently advancing an accompanying action plan, but I do not believe that it meets the criteria for a national suicide prevention strategy.
Finally, and most importantly, we need to think about suicide prevention across the lifespan and to invest in early childhood intervention. This is a bold but essential step. Children exposed to early childhood adversity, including abuse and trauma, are at much higher risk for suicide throughout life. We should not wait until people are calling crisis lines. This was a key focus of the National Inuit Suicide Prevention Strategy, but these efforts are needed across Canada in order to truly move the dial on suicide prevention.
Thank you again for inviting me to speak to you today.
Mara Grunau, Executive Director, Centre for Suicide Prevention: Good afternoon. I’m joining you today from Treaty 7 territory, ancestral land of the Blackfoot Confederacy, the Stoney Nakoda and Tsuut’ina Nations and the Métis nation of Alberta, Region 3.
Thank you, senators, for inviting me to your Standing Senate Committee Social Affairs, Science and Technology meeting today. I am the Executive Director of the Centre for Suicide Prevention, an office of the Canadian Mental Health Association.
As we have all heard from much of the amazing testimony today, suicide is complex because people are complex. Each person who considers suicide does so for reasons unique to them. There are many precipitating factors that can lead someone to consider suicide, some based in mental illness, others based in social determinants. For most people, it is the interaction of these factors that brings them to the point of suicidality. The people who think about and attempt suicide do not want to die. They want a way out of their intense psychological pain or their deep sense of burdensomeness. That is why this work is important.
I echo other witnesses when I say that to reduce suicide, we need both a mental health approach focused on individuals and a public health approach focused on populations. I will identify four areas of current work under the framework that can be amplified.
Again, as previous witnesses have already stressed, I would like to highlight the importance of data. As everyone here knows, some groups of people or priority populations experience suicide more than the general population. While this is reported by communities and revealed in research studies, we lack a systematic way of collecting this data routinely.
The Public Health Agency of Canada is convening provincial and territorial coroners and medical examiners to explore standardization of practice. The opportunity to expand and standardize death certificates, for instance, also exists. Collecting information such as indigeneity, ethnicity, occupation and gender identity would help contribute to our understanding of what is happening in various populations, which can lead us to direct our evidence-based efforts more specifically.
Crisis lines play an integral role in accessing mental health care. The federal government’s investment in and commitment to Talk Suicide and the implementation of 988 will provide more people with low-barrier access to care. Judging by the experience in the United States, we can expect call volumes to increase dramatically with the advent of 988. Therefore, we also need to expand the realm of crisis support so that crisis line responders have places to refer callers for further care.
Developing the national standards for mental health and substance use services in Canada is another example of federal leadership. It is the first step to help formalize high-quality, timely and culturally appropriate mental health and substance use services, and it is what Canadians can expect in the timeliness and quality of services in Canada.
Finally, as we move forward, as others have all said, we need to develop a companion evaluation framework so that we can assess the work as it is implemented. We need to be measuring what works, where and why so that we can support as many people as possible. We have much work to do.
Thank you.
The Chair: Thank you very much, witnesses, for your very thoughtful presentations.
We will go on to questions. I would like to remind my colleagues you have five minutes both for your question and for your answer. We will start with Senator Bovey, deputy chair of the committee, from Manitoba.
Senator Bovey: I want to thank you all of you. The complexity of this issue makes a quick question and answer complex too.
In the earlier panel, which I am sure you saw, we did hear about the need to focus this update of the national framework. Yet, I am getting the sense, having heard from five of you today, that the needs for the framework are expanding. I appreciate that, in the 2012 framework, there was a need for the government to report after the four-year point and two years thereafter.
If we’re going to have a robust framework that is going to be evidence-based and have solid positive outcomes, we hope, what would be the top three issues that you think the framework needs to address to fix the gaps in the current one? We have heard far more than three today, and my head needs you to help me focus on what you think the most important three issues are to be included. This is an open question to each of you.
Dr. Henderson: Okay. Maybe I will hop in.
First, from my perspective, it is critical that we focus on action, of course — really thinking about what actions are practical for us to take in the short term and then with a long-term vision as well. Second, it is essential that the framework and action plan articulate specific evidence-based interventions but also contain the opportunity for evidence-generating interventions. We really need to move the field forward. Third, it has to be evaluated. Without an evaluation plan, the framework would fall short. Those would be my three top contenders.
Dr. Crawford: I definitely echo all of those, and now I get to add three more.
I have to add data again. We need standardization of the data that is available to surveil suicide on a national level. It needs to be more timely so that we can see trends as they develop. It has to be standardized across provinces — what they collect when someone dies by suicide. We don’t know what we’re measuring right now, so it is very hard to evaluate things effectively.
Again, I would make a pitch that this action plan is not a national suicide prevention strategy, because a national suicide prevention strategy would take on the complexities across different pillars — public health approaches, clinical approaches. It would bring multiple sectors together. Right now, we don’t know who is accountable for what or if it would be adequately resourced. Creating a national suicide prevention strategy with good data would be — I will stick with two.
Ms. Grunau: It is great to go last, because I can just add on.
One area we need to look at that and that we tend to shy away from is the relationship between the federal government and the provincial and territorial partners. A national strategy, as Dr. Crawford is asserting, is an opportunity to really focus on what the federal government can do. What are those standardization practices that we can put in place that can drive levers at the provincial and territorial levels? Don’t worry so much about the health service delivery level but look from a systems approach first.
Senator Bovey: Do those include the cultural needs that we have and that have been clearly demonstrated in different cultural communities of Canada?
Dr. Crawford: We are all nodding.
The Chair: I see all of you nodding your heads, but Dr. Crawford, please go ahead.
Dr. Crawford: Yes. We all agree on that. Some of those comments that were made about principled approaches apply locally. Leadership from within communities is so important. There are all kinds of people working on suicide prevention in communities that have higher risk and higher rates and who are well positioned to do that work with adequate supports.
Senator Bovey: Thank you.
The Chair: Senator Bovey, I will borrow your minute quickly to ask Dr. Crawford a question of clarification. Did I hear you say that the 988 line would be available in English and French only?
Dr. Crawford: At this point, that is the mandate, because the go-live date is November 2023. It is quite a tight timeline. I think everyone is aware that language is so important to equity and access.
The Chair: Yes. I should point out that, in a previous panel, we talked about the stigma associated with suicide in certain cultural communities. If they cannot access culturally — let’s forget “culturally appropriate.” If they cannot access advice in their mother tongue, then I think that is a problem. My colleagues can explore that further in their questions.
Senator Patterson: Thank you, panellists.
Dr. Crawford, I was most interested to hear that you have been involved in the creation of the National Inuit Suicide Prevention Strategy that has been developed by Inuit and has received some financial support for implementation. We’re here to study the federal framework. I hope this is not a difficult question: How does the National Inuit Suicide Prevention Strategy inform the improvement of our framework? What can we learn from the strategy that was developed by Inuit leaders so as to strengthen the national framework?
Dr. Crawford: I know the federal framework references the National Inuit Suicide Prevention Strategy as a gold standard example. It has certainly been picked up around the world, especially in circumpolar contexts. It does a very good job of marrying health care evidence and also Inuit knowledge in its approaches. It is a very good example of how general principles derived from evidence can also be applied locally effectively, through Inuit leadership in that case. It also takes a lifespan approach in quite a systematic way, and it has evaluation built into it. It exemplifies some of the things that a national suicide prevention strategy could do.
Senator Patterson: Thank you.
We have heard from a number of witnesses today that we do not have adequate data about suicide. We have been relying too much on provinces, and there isn’t information relating to minority populations, including Indigenous populations. What can we recommend, as we study this framework, to improve that apparent deficiency? Is it a responsibility of Statistics Canada to step up and gather that data? I would appreciate any comments from any of the panellists to help me understand this issue.
Dr. Henderson: I would be happy to offer some initial comments.
We need significantly more investment in boundary-spanning integrated data platform infrastructures that allow us to work across all sources of data. Instead of thinking along particular streams of data, we really need to think about how we integrate data, from research contexts, administrative health data contexts and service delivery contexts so that we’re able to really bring all of that together. To examine, for example, predictors of experiencing unbearable psychological pain, we need to understand more about what that looks like in all of those contexts and have the robust power that comes with very large data sets. To do that, we need a commitment and a vision articulated by the federal government that provincial and territorial governments can get behind, but we also need investment to really both build and sustain that kind of approach.
Senator Patterson: Do I have any time remaining?
The Chair: You have 40 seconds.
Senator Patterson: Dr. Henderson, very quickly, you said that you are responsible for providing psychiatric services to Nunavut. We do not have any Inuit psychiatrists, and we have no resident psychiatrists. We hear that healing should be Inuit-led and trauma-informed. What can we do to provide these kinds of services within our communities rather than relying on the best intentions of southern-based psychiatrists?
Dr. Henderson: I will turn that over to Dr. Crawford.
Dr. Crawford: Thank you, Dr. Henderson.
The more that people are trained within Inuit communities and can do that work within Inuit communities, whether that’s in Western health care or in Inuit-specific approaches — and both are needed — that will really change things, including the involvement and engagement of people to whom the services apply.
Senator Patterson: Thank you.
Senator Kutcher: Before I ask a question, could I ask the witnesses to, in writing, please, send to the committee what you think should be included in our report relating to what data is needed, when and how — very specifically detailed. You brought it up, and Dr. Black and Dr. Klonsky brought it up. We could use that detail. It’s pretty clear that’s missing from the framework. Maybe we could ask Dr. Klonsky and Dr. Black to do the same thing so that we know exactly what you would suggest. I’ve been going around the circle with StatCan and the Ministry of Health on data for four years now, and I really would like to get some clarity.
My question to you all is about the framework. We’ve been told it does not focus on public health measures that we know are effective, particularly means restriction, and there is little or no mention of access to clinical services or improvements in clinical care. Two of you have discussed the importance of robust clinical services and access to services and crisis services. In your opinion, should the framework include aspects of clinical care and clinical services in addition to some of the public health measures?
The Chair: I see them all nodding their heads, but at least one of you needs to go on the record.
Dr. Henderson: From my perspective, absolutely. The role of a framework is to provide direction and guidance. That’s clearly articulated as part of its aims. If we don’t think along the continuum of opportunity to intervene and change the course of young people across their lifespan, across people’s life course, then we miss an opportunity. I know we’re short on time and I know the others have something to say as well.
Ms. Grunau: Thank you for the question, Senator Kutcher. I couldn’t agree more that we need to be looking at people as individuals, and we need to be servicing their needs where they’re at. At the same time, the government has a role to play at a public health level. When we’re looking at population health, we need to be putting those efforts in as well. When we are working from both ends, we will see a real change in society overall.
Senator Kutcher: I would like to hear from Dr. Crawford, who has some expertise in this area.
Dr. Crawford: I agree with the other comments. There is the usual tension between the federal and provincial scopes, but a national strategy that tasked provinces with doing certain things would get more into the clinical realm. We would be able to implement programs, like the one Dr. Henderson oversees, the youth hubs, things that are evidence-based, and we could attach those to the kind of federal public health areas of focus. Partnerships are really critical to doing this work, and it should be at both the public health level and the clinical level.
Senator Kutcher: There have been some very good reviews and meta-analyses of suicide prevention interventions published or provided over the last few years. One of the issues around them is that there are not many with really robust evidence behind them. I’d like your opinion about how to ensure that the ones that do have robust evidence behind them are included in the framework. For the ones that look promising, how might the framework identify those so that further research on their impact and effectiveness could happen?
Dr. Henderson: In part, you have provided the solution. We can’t limit ourselves to existing evidence. We know that the way we do research has led to biases in our existing evidence and gaps in evidence. As you pointed out, the impacts are not as robust as we would like them to be. At the same time, we need to focus our attention on how to support new evidence generation and innovation in this space so that we can actually achieve better outcomes and also broaden our approach to research so that the kind of evidence we generate is more inclusive and takes into consideration culture and identity and intersectionality more robustly than we have in the past.
Senator Brazeau: Welcome to all of you here this afternoon. I feel very honoured and privileged and lucky to be able to ask you the following questions as a survivor of attempted suicide.
When we talk about suicide, no pun intended but in many Indigenous communities, suicide was foreign. It didn’t occur all that often. Unfortunately, as with many other social issues, we still have Indigenous over-representation in terms of suicides. My question is, what can we include in the framework in terms of directives to tackle head on this issue of over-representation in suicide?
Ms. Grunau: Thank you, Senator Brazeau, for your question, and thank you for sharing some of your experience with us today. Thank you for trusting us with that.
There’s not much I can add compared to what Dr. Klonsky has already offered us in terms of understanding different communities and understanding the identity of the communities. What is driving the pain in the various communities needs to then lead to how we’re going to help instill hope. It’s going back to what we were talking about before. We recognize the intergenerational trauma and the effects of it in many of the Indigenous communities in Canada, but we can’t treat them all the same. It’s coming back to the people and really appreciating what’s happening specifically there.
Dr. Crawford: Just to pick up on that, involving people who have living experience is so critical because we can’t presume to know. That is why your sharing is especially helpful. We incorporate that into all of our programs, including at the policy level.
I just lost my train of thought. I apologize. I will turn it over to Dr. Henderson, and maybe it will come back to me.
The Chair: That happens to senior citizens like me, and I’m glad it happens to you as well.
Dr. Henderson: As I go back to my previous comments about our existing evidence, one of our precautions about looking only to our existing evidence is it does reflect a colonizing approach to knowledge. Part of the solution going forward will really be to work in collaboration with the community and have community leadership based in culture. That allows us to expand our definition of knowledge and evidence, and that will bring us to new kinds of approaches that will translate into outcomes.
Dr. Crawford: I found my thought; I channelled through Dr. Henderson. I also think that this is a very important reminder. We’ve talked so much about suicide at an individual level — and I know Dr. Black addressed this in his comments — but it reminds us about the social and historical context. Unless we address some of those issues around basic equity and ensure that people have livelihoods and homes, then we are going to continue to have problems around suicide.
The Chair: Thank you. Senator Brazeau, you have a minute left. Would you like to ask another question?
Senator Brazeau: I’m good for now. Thank you.
[Translation]
Senator Mégie: Thank you for being with us. My questions are for Dr. Crawford. I have four questions, but I hope the answers will be very short. First question: How long has virtual care in psychiatry been around?
[English]
Dr. Crawford: Thank you for the question. Since the 1950s, there were experimental uses of it, but really mainstream for about the last 10 years. Of course, over the pandemic, our rates went up about 500% in terms of the use of virtual care. It has really accelerated over the last two and a half years.
[Translation]
Senator Mégie: Thank you. Who is virtual care offered to? Is it for a specific clientele or is it for everyone?
[English]
Dr. Crawford: It is open to everyone. There used to be lots of restrictions and suggestions that certain kinds of people would not benefit from virtual care or might be harmed, but it’s now recognized that most people can benefit from or use virtual care. We have to make sure that people can consent to the use of virtual care and that the clinician seeing them deems that to be an appropriate way to assess or connect.
[Translation]
Senator Mégie: In all this time, do you have any reports that provide data on the impact of virtual care on the overall suicide rate?
[English]
Dr. Crawford: I haven’t seen anything linking virtual care and suicide rates, but at different points throughout the pandemic I’ve been engaged in more describing the global landscape around virtual care. We saw increases pretty much everywhere in the use of virtual care. It was one of the areas we really had to develop. What are the clinical parameters to doing that safely if someone is experiencing suicidality? People have come up with those standards locally. That’s another area where Canada needs standards around virtual care.
[Translation]
Senator Mégie: Thank you. May I ask my last question? Who are the professionals providing this virtual care? Are they psychiatrists, psychiatric nurses or other professionals?
[English]
Dr. Crawford: Again, we’ve seen huge shifts over the last few years. It’s pervaded all specialties and disciplines. As we move into the future, I think funding those services is a key issue. Right now, it’s physicians who mainly have access to specialized funding for virtual care. Something that needs to be looked at is stable funding models to ensure virtual care and,I have to add, to ensure virtual care is culturally safe and doesn’t erode local programs.
[Translation]
Senator Mégie: Thank you.
Senator Brazeau, could you table your study? I don’t know if you have already; I’m talking about the study you did on suicide.
[English]
The Chair: Senator Mégie, thank you. We’re asking questions of our witnesses. We can get back to questions to our colleagues at a later time.
Senator McPhedran: I don’t want to assume, but I think that all of you, as our current expert witnesses, heard the question that I raised with the previous experts, so I won’t repeat that. You know that the focus was on people living with disabilities and difficult choices and situations that are part of their reality.
I’m aware of the fact that each of you, in your own way, has spoken to the need for intersectionality in the gathering of data. You’ve spoken to the high value of figuring out ways to capture qualitative as well as quantitative data. My question is fairly general. Can you help us understand better how each of you approach the design and the gathering of data that is related to the realities of people living with disabilities in our country, and in particular, poor people living with disabilities in our country?
Dr. Crawford: Thank you for that critical question.
One of the areas in Talk Suicide Canada that we’re moving towards is understanding the use of services by sociodemographic and, in particular, income, race and ethnicity. We don’t have that data now. I think it’s very hard to provide equitable services without that data. It is a priority.
Regarding some of the approaches we use, we’re working with public safety personnel right now and we’re trying to understand their use of crisis services. Quantitative data is important, but qualitative data that allows you to richly understand people’s perspectives before you know what to measure at a population health level or just using numbers, that qualitative step, is also very important.
Ms. Grunau: Our organization does some work in knowledge translation and secondary research. Some of what we would do when we’re looking at social determinants of health and how they impact priority populations is synthesize the existing knowledge and existing research. Then, as part of the process of developing a knowledge translation brief or other publication, we invite people of those populations to meet with us, either in a focus group setting or one-on-one interviews, just to have validation from them around the knowledge translation before we would put it out publicly, as well as having it vetted by caregivers to those populations.
Dr. Henderson: We work from a co-creation model for our primary research, secondary research, knowledge mobilization and service delivery. We work together with youth with lived and living experience and expertise of all different intersectionalities, including neurodiversity, for example. We do that because one of the long-standing issues has been the long delays in the implementation of research and evidence that has been generated in the past, which in part could be explained by its lack of relevance or applicability to real-world settings. By working with youth, family members and service providers together with researchers, we are finding that we can ask more relevant questions. We can create more inclusive research processes so that our samples that are included in research are more representative of the populations we hope to impact and that the actual interventions that we create reflect the needs of young people more closely than by other models that might exclude those folks from participation.
Senator Cordy: Thank you very much for all the comments that you’ve made. Your comments have been very forthright. It’s very much appreciated.
Our earlier panel has said that we needed data but that the data has to be actionable and that it shouldn’t be cumbersome. We should know what works and what doesn’t work. We all agree that the data has to be standardized. How do we ensure that the data we collect isn’t cumbersome but, rather, is actionable, so that it’s not so cumbersome that it takes so long to wade through it that it isn’t actually effective? We also have to know what we should be measuring so that we can determine what we should be collecting and what would be effective. Dr. Henderson, it has to be not cumbersome but actionable, but I thought your comment was also very relevant that we can’t limit it to the biases that we hold and that we have to focus and also look at new evidence. How do we balance taking what we know works but also not limiting new information that is coming in so that we don’t have so much data that it becomes cumbersome and that it becomes useful and actionable?
Dr. Henderson: We have to start with where we’re at. From that perspective, we need to leverage what we already have in place. Where we have existing common data platforms and minimum data sets, we need to take advantage of those, and we need to continually ask the question, “Are these measures and approaches capturing what we need them to capture?” We have to do both in parallel. We can’t wait until we have better measures because then it will take us a long time to get where we need to go.
Dr. Crawford: I agree, and going back to Dr. Klonsky’s point about setting priorities, once you set priorities, then if you have evaluation built into your strategy, you can follow through and find the most useful metrics to ensure that that priority has been met. Right now we have lots of priorities, lots of different data, and after the fact we’re trying to match them up with very delayed data. I think that all needs to be tightened to be effective.
Ms. Grunau: I’ll add that once we have the priorities, then we’ll know what questions we’re trying to ask and then we’ll see if we have the data that is helping to support these answers, and if not, it will help us form the questions about what we need to investigate.
Senator Ravalia: Thank you very much to our witnesses.
My question is for Dr. Crawford. How do we ensure that our framework remains flexible and responsive to our ever-changing demographic? I was particularly struck by two points you made about equity and lifespan screening. The populations that are recently coming into Canada are coming from areas where individuals have suffered significant emotional and physical trauma. How do we adapt our framework to ensure that we can be responsive to the vulnerability of this type of demographic?
Dr. Crawford: I think it is knowing the priorities that you’re advancing through a framework and then applying those priorities with people, with the groups where there are issues that need to be addressed. I think there are some common principles that are the same. Frequent evaluation — we often call it iterative evaluation or quick evaluation — is very important. It can’t wait until the end of something. We have to be able to see those gaps as they emerge.
That’s the other reason that suicide prevention needs to be very community-based. It can’t be like a call centre, to use that analogy, in the middle of a big city. There are people across this country who want to be involved in suicide prevention, and it’s happening everywhere. That needs to be harnessed so that we know what local needs are as they emerge.
The Chair: Thank you very much.
We’re at the end of this committee meeting. I would like to thank all our witnesses. This has been an outstanding panel. Thank you very much. We also appreciate your response to Senator Kutcher’s proposal to send us your thoughts, collectively or individually, on the data collection strategy or principles.
I want to again remind everyone that the content of the study may have been difficult for many. Once again, senators and parliamentary employees can access the Senate’s employee and family assistance program for counselling services.
Honourable senators, our next meeting is tomorrow at 11:30 a.m. We will continue our study on the Federal Framework for Suicide Prevention and our study on the role of gender-based analysis in the policy process.
(The committee adjourned.)