A National Suicide Prevention Strategy for Canadians—From Research to Policy and Practice

The 4 articles in this issue, by Bennett et al,¹ Langille et al,² Chachamovich et al,³ and Chartrand et al,⁴ draw attention to the significant public health problem of suicide, and suicidal behaviour, in the Canadian context. In 2011, 3728 people in Canada died by suicide—about 10 people per day.⁵ The rate of death by suicide, nation-wide, was 10.8 per 100 000 population,⁶ and suicide was the second leading cause of death for youth under 24 years.⁷ Each of the 4 studies in this issue highlights areas for further attention or intervention, areas that could be systematically addressed and prioritized in a suicide prevention strategy; and yet Canada is one of the few countries in the industrialized world that does not have a national strategy for suicide prevention.

The systematic review of reviews of suicide prevention strategies relevant to youth, by Bennett and her large cross-national team of researchers,¹ most explicitly calls for a national approach, including a national research-to-practice network to facilitate the incorporation of evidence into policy and practice. Overall, they comment on the limited randomized control trials that address youth suicide prevention. They focus their review on 2 areas: school-based prevention programs; and the prevention of repeat suicide attempts. Their review results in 6 consensus-based recommendations, which encourage decision makers to adopt both school-oriented strategies (including suicide awareness curriculum, skills training, and gatekeeper training, and screening as a targeted prevention measure) and strategies that enhance the skills of trained professionals in health care settings where youth seek care. Bennett et al¹ point to the lack of gender- and (or) sex-based analysis in intervention studies, and the lack of studies that address suicide prevention among First Nations, Inuit, and Métis youth.

Adding to the literature on the importance of the school setting for youth, Langille et al² examine the protective nature of school connectedness in high school on suicidal ideation, in both males and females, and on suicide attempts in females. The protective effect of school connectedness on suicide attempt was not significant for males when depression was added as a variable in the model of suicide attempt, despite similar levels in ratings of school connectedness for males and females. School connectedness was measured using a rating scale that asked students to rate the degree to which they feel close to people in school; are happy to be in school; and, feel safe in their school. Future inquiry into other dimensions of how students experience connectedness in school, including their cognitions, and behavioural indices, such as attendance and extracurricular participation, may further explicate these associations, and gender differences. Nevertheless, their study makes a strong case that “increasing school connectedness should be considered as a universal adolescent mental health strategy,”2, p 258 and underlines the importance of interpersonal and ecological factors in youth suicide.

Working within the tertiary health care setting, Chartrand et al’s investigation⁴ of the correlates of NSSI contributes to ongoing investigation into the relation of NSSI to suicidal behaviour, including SA. As with Langille et al’s study,² the importance of including gender analysis in studies of suicide is underscored. Both NSSI and SA were associated with being female, childhood abuse, anxiety and depressive disorders, aggression and impulsivity, age under 45, and substance use disorders. SA was differentiated only by recent life stressors, active suicidal ideation, higher rates of depressive disorder, and previous psychiatric care or SA. These findings have clinical and health policy implications, suggesting that NSSI has considerable overlap with suicidal behaviour, and is associated with significant mental health problems and early childhood adversity.

The psychological autopsy study reported on by Chachamovich et al³ marks a significant contribution to the global suicide literature, as the first study of its kind in an Indigenous population. It is particularly important in the Canadian context because it employs a rigorous methodology to examine risk factors for suicide among Inuit, a population for which little data were previously available, despite the high rate of suicide by Inuit since the 1980s. Suicide rates in Nunavut are about 10 times the national average, with young males at particular risk.⁸ The average age of the 120 people in this study who died by suicide was 23.4 years, in contrast to Canada as a whole, where suicide tends to be most prevalent in the 45 to 55–year age group.⁴ The study reveals that completed suicide is associated with higher rates of MDD, alcohol dependence, and cannabis dependence, in the 6 months prior to the act of suicide, and these individuals were more likely to meet criteria for a cluster B personality disorder, and to have increased impulsivity and aggression. They also tended to have a higher loading of familial risk, including MDD, alcohol and drug use disorders, and suicide completion. This higher burden of psychiatric illness signifies the importance of clinical risk factors that are relevant to suicide globally. In other words, the high rates of suicide in Nunavut can be understood in terms of general models of suicidal behaviour, such as the one advanced by Hawton et al.⁹ This is a contribution to the debate around whether suicide in Indigenous contexts is qualitatively different that suicide in non-Indigenous populations, with implications for the consequent role of mental health interventions.

Chachamovich and team³ limit their investigation to individual risk factors for suicide, yet one of the most striking aspects of their findings are the high rates of risk factors in the control group. Among control subjects, 22.4% had a previous suicide attempt, and both groups had similar rates of attempts among family members (27.3% of subjects and 24.6% of control subjects). This is consistent with results from the recent IHS, in which lifetime suicidal ideation was 48%, with 29% of respondents reporting a prior suicide attempt.¹⁰

Childhood adversity was also highly prevalent among the group of people who died by suicide, and strongly suggestive of the importance of early developmental impacts, particularly child abuse. Among people who died by suicide, 47.5% experienced childhood abuse, including sexual abuse in 15.8% (compared with 27.5% and 6.6% in control subjects, respectively). Similarly, childhood abuse was highly prevalent in the IHS, with 41% of respondents reporting a history of severe sexual abuse in childhood (52% of women and 22% of men).¹¹ In comparison, a recent national survey, which did not include Nunavut, showed a prevalence rate of 32% for any type of childhood abuse, and 5.8% and 14.4% sexual abuse for males and females, respectively.¹²

While Chachamovich et al³ are careful to apply a case–matched control methodology to “ensure that the environmental conditions and historical context during subjects’ upbringing were comparable across groups,”^{p 273} their results point to historical and contemporary factors not captured by the study. This leaves an urgent gap unfilled, both in the literature and in providing direction for suicide prevention efforts in this context.

Social and health inequities must also be accounted for. Suicide is the most tragic expression of wider social distress in Nunavut communities. While individual risk factors for suicide have clearly been demonstrated to be of importance, it is unlikely that larger social factors will be resolved without a concomitant focus on families and communities, and without engaging and collaborating with Inuit in these collective efforts.

Taken together, all 4 of these studies^1–4 provide further guidance for people engaged in suicide prevention and intervention—at community, clinical, and policy levels. In particular, they remind us of the importance of primary prevention in childhood, an area that remains understudied in the field of suicide prevention, despite these and many studies linking early developmental adversity to later self-harm and suicidal behaviour.

The strength of this research by our Canadian colleagues also reminds us of the role that Canada can take in furthering suicide prevention. Suicide prevention strategies have been shown to be capable of reducing rates of suicide.¹³ In Canada, Quebec’s multilevel suicide prevention strategy¹⁴ is credited for the more than 50% reduction in suicide among youth (aged 15 to 19 years) in that province since the strategy was implemented.¹⁵ However, the Quebec strategy did not include an Indigenous-specific component, nor impact the rates of suicide among Inuit in Northern Quebec, which outpace even the high rates in Nunavut.⁸ Inuit Tapiriit Kanatami, the national Inuit organization, is developing a National Inuit Suicide Prevention Strategy that will be based on evidence and best practices. Suicide prevention strategies for use in First Nations, Inuit, and Métis contexts can benefit from evidence around individual risk and resilience factors, but will also need to consider community-level factors and social determinants of health. Such efforts, and public health for all Canadians, would be bolstered by a commitment to create a Canadian national suicide prevention strategy. An Act Respecting a Federal Framework for Suicide Prevention¹⁶ received Royal Assent by parliament in December 2012; implementation will demonstrate whether it has the resources, intersectoral collaboration, and monitoring of outcomes to ensure success.

Abbreviations

IHS

Inuit Health Survey

MDD

major depressive disorder

NSSI

nonsuicidal self-injury

SA

suicide attempt