Can a community reach zero youth suicide?
That’s the lofty goal of a new initiative in southwestern Ontario.
Creating the right system of trained teachers, social workers, doctors and peers; making it easier for hospitals and schools to communicate; giving the best care to the most high-risk patients: With all these elements in place, Ian Dawe, program chief and medical director of mental health at Trillium Health Partners, believes his region of 1.4 million can begin to eliminate youth suicide.
The idea that a system should be designed with the objective of preventing every suicide – with the aim, essentially, of working perfectly – is still controversial, even among mental health experts. Skeptics say it creates an unrealistic standard that puts too much pressure on health care workers, and adds to their guilt when a suicide happens.
But zero-suicide proponents argue that the aspirational goal is needed to change the way suicide has been seen as inevitable, or impossible to predict. They point to research that continues to better ways to identify those most at risk – as well as pinpoint the nature and timing of the care that could save them.
Too often, young people don’t get help in time, or their families are left to co-ordinate that help on their own. “Leaving people who are most in distress to manage their own care can’t be the way it continues to happen,” Dr. Dawe says. “That is unconscionable.”
By the time a young person turns up in the emergency department, the chance to be pro-active – to use services most cost-effectively and prevent a crisis – has already passed. “All our resources are scrambling to meet the need when it has exploded,” Dr. Dawe said. “How can we bend the curve by getting in early?”
Still in the planning stages, the new program – called Project Now – has received $3-million from the Ontario government. Dr. Dawe envisions a collaborative system that will include mental health education in middle school to build resiliency and help identify struggling youth early, as well as a clear standard of care for every young person who attempts suicide.
Such a system would include better access to dialetic behavioural therapy, or DBT, an intensive form of talk therapy that teaches people how to manage their emotions. It is one of the few kinds of psychotherapy that has been found effective in clinical research at reducing suicidal behaviour. But wait lists to receive publicly funded DBT can extend more than a year in Ontario, and, even for families who can afford to pay privately, there is a shortage of therapists trained to deliver it.
One goal of the program is to ensure that every young person who attempts suicide receives follow-up care – check-in calls, for instance, and assistance in making appointments – since the weeks and months after a visit to the ED or hospitalization are the highest risk for a second attempt.
For the most intense treatment, “we’ll stay laser-focused on our target population,” says Zoe Dawe, the director of clinical leadership and excellence at EveryMind Mental Health Services in Mississauga.
One small step that can make a big difference, Ms. Dawe says, includes making sure that any missed appointments are followed up on. A “no-show” can lead to someone being scratched off a wait list, even though teenagers are often resistant to getting treatment, and those most severely ill have the hardest time keeping appointments.
Shannon Mackie, 20, who has volunteered to be one of the youth advisers for the program, visited an emergency room in Oakville, Ont., last summer with her mom – an experience that has helped inform her suggestions for a better system. Privacy was one issue – when she had to explain to the receptionist in the public waiting room why she was there, she said she had had a panic attack; only later, in the private exam room, did she admit to a nurse that she was feeling suicidal, a fact that she had to explain several times to different staff members. She suggests a written safety plan from the hospital when she was discharged – a standard of care for suicide prevention – would have given her reassurance while waiting for an appointment with the psychiatrist a week later. “It was chaotic, and I didn’t really know what was going on,” she says. “It can be hard to tell your story once, let alone two or three times.”
Zero suicide grew out of a similar zero-accident approach developed by the aviation and construction industries to shift from a workplace culture of trying to avoid more accidents to one that aims to have no accidents at all.
“It’s not saying we will never have a suicide,” says Dr. Dawe. But if one happens, the system should look for reasons why, and ways to improve, rather than laying blame or assuming there was nothing to be done.
Project Now is one of the first attempts to adapt a zero-suicide strategy to an entire community, and to focus on youth specifically. The strategy, which was pioneered in 2001 by the Henry Ford Health System in Michigan, has been adopted in hospitals across the United States and Europe, as well as at universities in Britain. In Canada, St. Joseph’s Hospital in London, Ont., launched a zero-suicide initiative for outpatients in 2016 that included screening patients for suicide risk, making follow-up calls and training staff in suicide prevention, and expanded the program to urgent care in fall 2019.
In hospital settings, zero-suicide approaches have focused on areas that both mental health experts and patients say have often fallen short in Canada’s mental health care system.
Natasha Tat, another youth advisor for the project, who will study psychology at the University of Guelph this fall, says a community-wide effort also sends a message to young people who may worry about being dismissed for faking or attention-seeking if they seek help: “It says every single person matters. You’re not just a number.”
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