March 23, 1999

To:Board of Health

From:Dr. Sheela Basrur, Medical Officer of Health

Subject:Public Health Education and Preventive Services in Mental Health and Their Role in Suicide Prevention

Purpose:

This report addresses the range of prevention and education programs and services known to be effective in suicide prevention and to identify those needed within the City of Toronto.

Source of Funds:

Not applicable.

Recommendations:

It is recommended that:

(1)the Board of Health support Public Health's continued role in the three major interventions for reducing suicides as outlined in this report: restricting access to the methods of suicide; developing a system of mental health services for Toronto that is adequate to need; and promoting mental health and preventing mental illness among the Toronto population.

(2)the Board of Health advocate to the Ontario Ministry of Health for full funding for mental health services in Toronto as stipulated by the Metropolitan Toronto Mental Health Reform strategy. The Province should immediately release the $21 million for mental health services in Toronto which it announced in December 1998, and allocate an additional $30 million as soon as possible to bring total funding in line with the Mental Health Reform recommendation of $51 million; and

(3)the Board of Health, in concert with the Canadian Mental Health Association and other community mental health agencies, continue to monitor mental health needs and service adequacy in Toronto, advocate for sufficient resources to meet ongoing and emerging needs, and collaborate in mental health promotion and education.

Background:

On March 23-24, 1998, the Urban Environment and Development Committee dealt with various reports and communications regarding the prevention of suicides from the Bloor Street Viaduct. The Committee requested that the Commissioner of Community and Neighbourhood Services, in consultation with the appropriate City officials, submit a report regarding:

(a)improved services which could be implemented in an effort to prevent suicides; and

(b)a public education program which would set out actions that should be taken by members of the public if confronted with a potential suicide situation.

On April 20, 1998, the Urban Environment and Development Committee reviewed the report from the Commissioner of Community and Neighbourhood Services (April 14, 1998) who, through the Medical Officer of Health, stressed that suicide prevention needed to be seen in the context of mental health reform -- reform which requires a financial commitment and timely implementation by the Province.

The Committee subsequently recommended that Council adopt the report with the recommendations that:

(1)City Council urge the Ontario Minister of Health to make a financial commitment to the Mental Health Reform strategy by:

(a)allocating funding immediately to ensure that a comprehensive crisis response system is in place for Toronto;

(b)ensuring that the community services dealing with suicide (i.e. distress centres, phone-in lines) are adequately funded to meet increased demands for these services, and

(c)implementing key components of related community-based services (e.g. case management, housing) as quickly as possible.

(2)The Medical Officer of Health report via the Board of Health on the range of prevention and education services already in place within the City, and in consultation with the Canadian Mental Health Association, identify further educational components needed to better equip the general public in the area of suicide awareness and prevention.

The following report addresses the incidence, prevalence, origin of and at-risk populations for suicide as currently understood from the literature, and documents the range of prevention and education programs and services known to be effective in preventing suicide. The report also touches on the service shortfall in Toronto at the present time and the critical role of public health in suicide prevention and mental health promotion in the city.

Comments:

Incidence and Prevalence of Suicide

Suicide in Canada has been identified as a major public health problem. Rates of suicide have been steadily increasing over the years and have only recently reached a plateau. Statistics for 1996 indicate an age-standardized national rate of 13 per 100,000 population, higher than the U.S. rate of 12 per 100,000. In each of the past 15 years in Canada, an average of over 3,500 suicide deaths has been recorded (1). For every completed suicide, many more are attempted, with four times more men completing the act, and more women attempting it (2). Of those who attempt suicide, one in 25 succeeds, and there are repeat attempts among 6% to 16% of those who survive an attempt.

Canada's native population is particularly vulnerable to suicide. Among this population, death by suicide is almost four times higher than among the rest of the Canadian population, half the suicides being in the 15-24 age group. Of this group, most are young men (3).

For Canadian children under age 14, the suicide rate is very low, rising at ages 14-19 to 11-13 per 100,000 for males and 1-3 for females (4). In the period 1989 to 1991, suicide and motor vehicle accidents were the leading causes of death for Canadians age 15 to 19. The prevalence of suicide among young people, particularly young men, has a tremendous social cost, resulting in one of the highest rates of potential years of life lost in Canada. Higher than average rates of suicide have also been noted among lesbian, gay, bisexual and trans-gender youth. The elderly, too, are vulnerable because they are more likely than the rest of the adult population to experience a constellation of suicide risk factors, including poverty, isolation and bereavement.

In 1996 the age-standardized suicide rate in Ontario was 9.4 per 100,000 population, down from a rate of 9.7 per 100,000 in 1995, ranking Ontario tenth out of 12 provinces and territories in suicide incidence. Prince Edward Island at 8.6 per 100,000 and Newfoundland at 6.6 per 100,000 were lower, while the Northwest Territories at 32.0 and the Yukon at 31.1 ranked highest (5). However, the Ontario Health Survey (1991) revealed that, within the six months prior to the survey, a high percentage of young people age 12-16, representing 5%-10% of boys and 10%-20% of girls, reported thinking about suicide.

According to unpublished raw data prepared for the new City of Toronto, the age-standardized mortality rate for suicides in Metro Toronto has increased from 3.3 per 100,000 population in 1986 to 9.4 per 100,000 population in 1994. Suicide is a significant cause of premature death in the new city, accounting for 9.1% of deaths among persons age 10-19. In 1994, suicide ranked fourth after ischemic heart disease, AIDS and lung cancer in potential years of life lost among Toronto residents (6). In 1995, there were 250 suicide deaths in Metropolitan Toronto according to statistics compiled from the files of the Chief Coroner for the Ontario Ministry of the Solicitor General and Correctional Services. The rate of suicide per 100,000 population was 6.35 in Scarborough, 7.86 in the City of York, 7.74 in Etobicoke, 9.21 in North York, 10.02 in East York, and 18.31 in the former City of Toronto. The average across all six municipalities was 9.92 per 100,000 population, higher than the Ontario suicide rate for the same year. While specific reasons for this difference between the City and the Province have not been identified, some of the realities of the urban environment, such as poverty and homelessness, are also known risk factors for suicide.

Why Do People Commit Suicide?

The World Health Organization (1993) reports that 90% of those who commit suicide are mentally ill at the time of killing themselves and that depression and alcohol are associated with 80%-85% of suicides (6). That noted, it is wise to take the broadest possible view when attributing a suicide outcome to mental illness. Certainly people who attempt suicide are acutely distressed and the vast majority are depressed to some extent. However, while their depression may be the result of a diagnosable mental illness, it may also be an understandable reaction to life's stresses and losses. The difficulty comes in differentiating these two kinds of depression, as their symptoms and effects are similar. People suffering from a mental illness such as schizophrenia or clinical depression do have significantly higher suicide rates than average, but they are still in the minority of people who attempt suicide.

Generally, the factors linked to suicide are those linked to intense personal distress. They embrace a range of significant life changes and losses, as well as abuse, neglect, and homelessness. These factors include personal or family illness, family discord, loss of a close family member or friend, difficulties in personal relationships, financial, employment and self-esteem problems, poverty, isolation and lack of social support. Individuals facing such adverse life events, singly or in combination, may become depressed and turn to the use of alcohol and other substances as a means of coping. By doing so, they are increasing their risk factors for suicide, as indicated in the WHO data cited above.

It is unwise to see suicide as a purely psychological phenomenon requiring therapeutic intervention, and ignore the social stressors that contribute to the act. Throughout the literature, the causes of suicide address both the internal process of the person who attempts suicide and the broader determinants of health such as poverty, income, and social support which act on his or her process. For a full understanding of the kinds of services and programs needed to obviate suicide in Toronto, it is important to acknowledge the fundamental interconnectedness of both types of contributing factors. While the incidence of suicide in Toronto is only slightly higher than in the province as a whole, the high proportion of people living in poverty, the extent of homelessness, the high proportion of elderly people, and the city's diverse ethnoracial composition pose challenges for comprehensive suicide education and prevention. With respect to a public health response, a range of interventions and approaches are indicated. They include specialized mental health services, as well as mental health promotion, particularly through programs targeted to at-risk populations such as young people and the elderly, and continued development of policy that promotes overall population health.

What Can Be Done to Prevent Suicide?

There are three major types of intervention for reducing suicides. First is reducing access to the methods of suicide, including targeting such suicide "hot spots" as the Bloor Street Viaduct and subway lines. Other prevention strategies in this category include policies to detoxify car exhaust gases and restrict the use of medications, as well as legislation that restricts the ability of individuals to use firearms. Because self injury methods chosen by individuals attempting suicide are largely determined by case histories, these methods can be readily identified and blocking of access to the observed means imposed.

The second means of intervention is the development of mental health services to meet the needs of Toronto's large and varied urban community. Such a system is delineated in the Metropolitan Toronto Mental Health Reform strategy, and includes a crisis response system and a service system which encompasses individual support and case management by qualified professionals; housing and community supports; alternative supports such as self-help groups; treatment and rehabilitation through multi-disciplinary teams; and specific mental health promotion and illness prevention among consumer/survivors of the mental health system (7). The strategy places particular emphasis on ethnoracial groups and aboriginal people who have complex special needs, as well as on the homeless population, 25% of whom are aboriginal and 30%-35% of whom are estimated to have serious mental health problems (8). Both are strong risk factors for suicide which are stronger in combination.

Central recommendations of the reform strategy include the establishment of a Mental Health Authority for Toronto as the manager of the overall mental health system, and a reallocation of $51 million from the Ministry of Health budget to achieve an adequate level of mental health services and programs across Toronto. In December, 1998 the Ontario Ministry of Health announced an investment of $21 million in additional supports for community-based mental health, case management and crisis support services in Toronto. Of this figure, $11 million has been allocated to establish 11 community-based multi-disciplinary mental health teams to address the needs of individuals with serious mental health problems. An additional $ 2.5 million has been earmarked for case management services, and $700,000 for habitat services for women, homeless people, hostel users and patients leaving a psychiatric facility. Crisis response services will receive $2.5 million and $5 million will be allocated to forensic services. While the Ministry's announcement does not cover all the services and needs identified in the Mental Health Reform strategy, the new funds will go a long way toward improving community mental health programs. An analysis of these kinds of programs in downtown Toronto conducted by the Department of Psychiatry at the Wellesley/Central Hospital confirmed their ability to decrease the risk of suicide attempts and inpatient admissions (9).

As of February 1999, the Mental Health Branch of the Ministry of Health is proceeding with a request for proposals to provide the additional mental health services specified in the December announcement. The Ministry's request has gone out only to community-based services which the branch currently funds, which precludes Public Health from applying for the new monies.

The third means of intervention is through the promotion of mental health and the prevention of mental illness. The goal of mental health promotion (MHP) is captured in the following definition of mental health:

Mental health is the emotional resilience which enables us to enjoy life and to survive pain, disappointment and sadness. It is a positive sense of well-being and an underlying belief in our own, and others' dignity and worth (10).

Mental health is the cornerstone that secures the ability of individuals, families and communities to cope with life, and hence mental health promotion is integral to all public health activities. Like other forms of health promotion and disease prevention, MHP can occur at various points along the wellness-illness continuum. It relates equally to the optimal psychological, emotional, intellectual and spiritual development of a young child, and to the optimal integration of treatment, rehabilitation, and social supports for an adult consumer/survivor of the mental health system. Within public health it is likely to encompass the broadest range of strategies at the individual and social level that prevent the occurrence of mental illness, as well as the broadest range of strategies for treating mental illness that enhance quality of life.

Mental health is at the heart of all health promotion programs because it is concerned with fundamental processes that produce or maximize health, from individual empowerment to community participation to an optimal social environment and healthy public policy. However, the most effective mental health promotion interventions tend to focus on stressors particular to populations at different developmental stages (for example, infants, school-age children, and older adults), to at-risk or vulnerable populations (for example, isolated new Canadians), or to individuals with a mental health or behavioural problem. For these populations, effective interventions tend to target the factors that promote mental health: coping skills, good family and social relationships, health-promoting environments, and meaningful activities. Such interventions fall within the mandate and activities of public health.

Complementary to mental health promotion for at-risk populations is crisis intervention when an individual is contemplating suicide. In these situations, there need to be adequate, sensitive crisis services readily available, with a system for expediting a prompt response or referral. The latter role is also part of the public health mandate and activities.

Toronto Public Health's Activities in Suicide Prevention and Future Role

Toronto Public Health has participated in all three means of suicide prevention as outlined above. First, we have played an active part in relation to a number of important initiatives to reduce the means of access to the methods of suicide. Since 1994 Toronto Public Health, in partnership with the Council for Suicide Prevention, women assault groups, concerned physicians and others, has taken the lead in successfully mobilizing the public health community to support federal gun control legislation through the Coalition for Gun Control. Through this effort, gun control has moved from an issue of urban crime and policing to one of suicide prevention, based on data indicating that 75% of the 1400 firearms-related deaths occurring on average annually in Canada are suicides. Other notable examples from Toronto Public Health's on-going programs and services include our work in substance abuse, harm containment in the use of alcohol, and the wise use of prescription medications, particularly among the vulnerable elderly.

With respect to the second means of suicide prevention--the development of a system of mental health services for Toronto--Toronto Public Health has been central to determining the shape of mental health reform in the City. One of our directors co-chaired the mental health steering committee of the District Health Council which produced the Metropolitan Toronto Mental Health Reform System Design and Implementation Recommendations Final Report, while other Public Health staff served on the work groups and advisory groups of the reform process. Recommendations of the reform have been supported in the report from the Commissioner of Community and Neighbourhood Services to the Urban Environment and Development Committee (April 14, 1998) on the prevention of suicides on the Bloor Street Viaduct, which advocated to the Ontario Government for their implementation and adequate resourcing.

The third means of suicide prevention--the promotion of mental health and the prevention of mental illness--is an essential part of a range of prevention and education programs and services implemented by Toronto Public Health. These kinds of programs and services have been identified in the literature as effective in suicide prevention. A number of programs help reduce the stressors that face specific populations at critical points along the life course. These include programs related to healthy parents and healthy children, such as Healthiest Babies Possible and Parents Helping Parents. They also include school-based initiatives, such as school food programs, which promote social and community support as well as good nutrition. Public Health's multi-faceted work with ethnoracial communities provides a notable example of interventions targeted to at-risk populations. The importance of this work will continue to grow over the next two years as racial minorities become 53% of Toronto's population. Other initiatives to at-risk populations are more specific; for example, those targeted to the frail elderly who live in isolation and are vulnerable to mental and physical ill-health.

In addition, Toronto Public Health has a number of mental health nurses who are specialists in responding to the needs of individuals in the community with mental health or behavioural problems. Mental health nurses have played an important role in suicide prevention through case management of suicidal and at-risk clients; educational sessions on suicide prevention for health care workers; and advocacy, community and program development related to suicide prevention. These nurses have also been instrumental in establishing and supporting various community networks comprising social service and health-related organizations and law enforcement personnel working in partnership to prevent suicide.

For many years mental health nurses in the former City of Toronto worked with the front line staff of community agencies to address the mental health needs of their clientele. In 1998, Public Health in the new city conducted a survey to determine the satisfaction levels of the community agencies who were still receiving these services (11). Respondents to the survey included child welfare and youth services, mental health services, drop-in centres, shelters, housing agencies, suicide prevention networks, a mental health alliance, and the police. Their clientele included women and men, children, youth, adults and seniors, singles and families, recent immigrants and refugees, employed persons and people on social assistance.

Results indicated that Public Health's mental health nurses provide services that are unique and indispensable. The survey also established that, with support from our nurses, front line staff in community agencies are able to intervene more effectively with at-risk clients, and that withdrawing the mental health services provided by Toronto Public Health would prove detrimental to the most marginalised and most vulnerable people in the community. Notably, the survey identified that additional Public Health support is required to meet the critical need for community crisis intervention with at-risk and suicidal clients.

All of the agencies surveyed noted the ability of early intervention by our mental health nurses to prevent or reduce full-scale mental health crises which, as noted previously, are a precipitating factor for suicide. This observation reflects the effectiveness of Public Health's orientation to mental health promotion and prevention of mental illness, particularly among citizens who are at risk through poverty, homelessness, aging, disability, isolation, and the changing social and economic realities of the urban environment. In this regard, specialized programs directed to stress management, violence prevention, conflict resolution, effective parenting and coping skills for a range of populations in a range of settings, including community agencies and schools, all promote the mental health of Toronto residents. In addition, Public Health continues to play a significant role in educating workers in community agencies and shelters, as well as families and friends in Toronto schools, regarding the signs of and responses to a threat of suicide. Through these kinds of community settings Public Health also continues to promote crisis services for at-risk individuals, while working to ensure that such services are appropriate, accessible and user-friendly to a range of clients.

In today's larger, city-wide context, the need for mental health services to prevent suicide will continue to grow. Key findings from the literature, together with successful interventions and outcomes noted in the community agency survey, suggest a number of program and policy directions for Toronto and Public Health. First, to reduce suicide among children and youth, the mental health and resiliency of adolescents must continue to be promoted with a variety of programs and services, from gathering places in city recreation centres where young people can meet, share and define themselves, to counselling in teen clinics. Second, to reduce suicide in the adult population, issues of low income and homelessness must continue to be addressed so that the cycle of poverty and despair can be broken. In addition, the determinants of health need to remain central to Public Health's mandate in order to create the healthy environments and living conditions that produce mental health among Toronto residents.

Third, adequate mental health services to meet the needs of Toronto's large and varied urban community need to be implemented as recommended by the Mental Health Reform strategy, with full resourcing of $ 51 million. In particular, there is general consensus among community providers and the Canadian Mental Health Association, Ontario Division, that preventive and educational services within the community require increased funding in order to be able to meet growing demands.

Conclusions:

Studies from the literature suggest that suicidal behaviour should be regarded as part of a complex interaction of life events and conditions, leading to prevention and intervention strategies that focus on the factors that alleviate human distress. Moreover, there is clear evidence that mental health and mental illness need to be viewed both at an individual level and at the level of communities and society, and interventions need to encompass complementary activities at each level.

Toronto Public Health has responded on all levels, applying unique skills to a range of programs and services that are competent in promoting mental health across the population at the individual, family, community and organizational level. These programs, together with our accessibility to the public and connections to other mental health services that are unmatched by any other organization or institution, give Public Health a leadership mandate in suicide prevention. Such leadership needs to be supported with sufficient staffing and resources to maintain programs and services and to anticipate future needs. The expected outcome will be improved population mental health and lower rates of suicide in Toronto in the years ahead.

Contact Name:

Liz Janzen, Regional Director, Toronto Office

Public Health

Tel: 392-7458

Fax: 392-0713

ljanzen@toronto.ca

Dr. Sheela V. Basrur

Medical Officer of Health

ENDNOTES:

(1)SIEC Frequently Asked Questions. http://www.siec.ca/faq.htm.

(2)Ronald J. Dyck, Brian L. Mishara, and Jennifer White, Summary of Suicide in Children, Adolescents and Seniors: Key Findings and Policy Implications. Publication in the National Forum on Health Series, "What Determines Health." http://www.hc-sc.gc.ca/main/nfh/web/publicat/execsumm/dyck.htm.

(3)University of Toronto Faculty of Medicine, Preventing Suicides, an article in Health News. Volume 11, Number 3. June, 1993.

(4)Ibid

(5)Statistics Canada April 16, 1998 release. http://www.statcan.ca/Daily/English/980416/d980416.htm3ART1.

(6)WHO, Guidelines for Primary Prevention of Mental, Neurological and Psychosocial Disorders. No. 4 Geneva: World Health Organization. 1993.

(7)Metropolitan Toronto Mental Health Reform, System Design and Implementation Recommendations: Final Report. Metropolitan Toronto District Health Council. December, 1996.

(8)Ibid.

(9)Comment in the Canadian Journal of Psychiatry, April 1998; 43(3):325.

(10)Health Education Authority, London England, 1996. Quoted in Jennie Naidoo and Jane Wills, Practising Health Promotion: Dilemma and Challenges. London: Baillaire and Tindall. 1998:259.

(11)Angela Loconte and Catherine Turl, Community Agencies' Satisfaction Levels with Mental Health Nursing Services. Toronto Public Health. July, 1998.