How to Manage a Suicide Pact

Recently at a Montreal high school, 62 high school students made a suicide pact. As the story broke last week, the Montreal Gazette revealed that school officials had determined the three people who started the pact, who claimed that it was a prank. The article also quoted a school official as saying that “some of the students did not know what they were signing because only the first sheet indicated that it was a suicide pact”. No doubt school personnel were trying to allay the fears of the public, and more importantly, parents of students at College d’Anjou, a private high school in Montreal’s east end.

I learned about this situation when I was asked to comment and provide advice for Global News. I found the tone of school officials, as characterized by the Montreal Gazette, to be troubling. We know too much in 2017 not to be concerned whenever news of a suicide pact emerges, especially among youth between 15 and 24 years old. During these years, suicide is the second most common cause of death.

Some of the other facts that ought to have engendered more concern are the actual statistics about suicide and suicide attempts in Canada. The Canadian Mental Health Association has found that 34% of youth between the ages of 15 and 24 have contemplated suicide – one third. Also, the actual number of suicide attempts in this population in Canada is 8%. Both the rate of contemplation and the rate of attempts increases when there is a suicide pact. The acceptance implied in a suicide pact reduces a young person’s emotional barriers to suicide and so the risk increases.

What should happen when a school learns of a suicide pact? There are 3 direct steps that might help. The first step consists of education through assemblies. Bring all concerned together, in this case the entire student body along with their parents and other interested family members, e.g. siblings. Have an experienced resource person speak to this group about what to do to reassure themselves that their family member will be okay. This person can direct the assembly to resources for Mental Health First Aid as well as to local crisis and emergency services. There will be lots of questions about both the general subject of suicide and suicide pacts and about the specific situation. The resource person and school personnel should be prepared to address these. The school personnel must be prepared to address concerns openly, without judgment, and compassionately. This is not a time to be defensive. It is a time to make sure you have support moving forward should there be a need for further mental health assistance.

The second step must involve meetings with mental health professionals for each person involved in the pact. The best scenario is that one third of these youth were contemplating suicide and it is important to reach out and find help for these young people.

Finally, it is an important time to remind everyone of these three circumstances that indicate an increased risk of suicide in a young person:
1. Increased use of alcohol and drugs.
2. Giving away one’s belongings.
3. Signs and symptoms of depression or a history of depression.

Doing all of this is a good start to preventing suicide, but suicide and suicide attempts are symptoms of a serious medical illness. People die of serious illnesses. In some cases, such as this, these deaths can be prevented.

If anyone reading this has questions, please ask. The best way to prevent suicide is to talk about it openly and without judgment.

Opioids and Social Capital

Over the weekend, I read the first article about the opioid crisis that made any sense to me. It was published in Scientific American last week and explained why so many of the strategies that we are using to combat the rising rates of opioid overdose have been ineffective in curbing the rate of overdose to any great degree.

The article summarizes the research that suggests that the best ways to address the abuse and dependence on opioids is to help communities strengthen the social ties between people. The author opines that the emotional reasons that we become dependent on any substance are factors that communities should seek to address in to reduce the morbidity and mortality related to opioids.

In one study published in the Journal of Health Economics, researchers looked at the impact of macroeconomic changes on opioid use in specific counties and states in the United States. For the region studied, researchers found that, when the county unemployment rate rose 1%, the opioid death rate per 100,000 rose by 3.6% and the opioid overdose Emergency Department visit rate rose by 7%. These statistics held throughout the state.

The article summarizes the science related to the body’s naturally occurring opioids – endorphins and enkephalins – these help us to moderate both physical and emotional pain. The science is outlined concisely and briefly and reminds the reader of those factors which increase the levels of these naturally occurring opioids. It also reminds us how this hormonal system insulates us from emotional pain in our lives.
I have never prescribed opioid medication myself, and most of the doctors I know are similar in practice to me so I have been bewildered about who all the doctors prescribing them could possibly be. I’ve seen the numbers, however, and I certainly know of physicians who have gotten into difficulties because of the way they prescribe opioids. I understand that physician regulatory bodies have sought to address the increasing rate of opioid abuse and overdose by offering courses on prescribing these medications.

To address this dangerously increasing use of opioids, communities have been distributing naloxone kits, setting up safe injection sites and running health prevention campaigns. I support these measures as urgent action must be taken in the moment to do what we can to prevent harm to those already at risk because of opioid use.
Having said this, it’s time to think about what can be done to address those social capital deficits. The OECD defines social capital as “networks together with shared norms, values and understandings that facilitate co-operation within or among groups”. These networks include such networks as family, friends, groups we belong to, or organizations that support us. According to the research, the loss of social capital is linked to increasing opioid use and all its attendant risks.

I’ve been thinking of social capital lately as I’ve worked to find supports in their communities for youth in my practice, supports such as groups where families might learn to cook or spend time with other families. As I did this research, I realized that some Ottawa communities are better at this work than others. It makes sense from this that communities might consider supporting community development as well as safe injection sites and naloxone kits.

Many reading this will believe that this is all about the social determinants of health but this is a reflection on the need for all of us to consider how we personally build communities. Do we go to groups? Do we initiate support activities? Do we go to community events? All things considered, cities can support communities but they can’t provide them the way they can buy naloxone kits or new services. They can’t make your neighbours neighbourly. That takes individual people getting out of their chairs, turning off the TV or their devices, and talking to people or working with people. While it does build a community to have skype meetings or online chats, this research is telling us that, if we truly want to have communities, then we must have some that we can walk to when we’re caught in a snowstorm or hurricane, or the power goes out. Perhaps if we volunteered at the food bank, it wouldn’t be so hard to go there for food, or even just company, when the need arose. Having community meals or parties or street events, bringing disparate parts of communities together, can help you find out what services you can have or help in your neighbourhood.

Last weekend, the Wellington West Community held an event on Wellington Street. As I walked along running my errands, I stopped off at a few services. I learned that one agency, Ottawa West Community Support, has a range of services to help seniors continue to live in their own homes. They told me that volunteering with them has helped many older people make the transition to using their services. That is social capital. I learned that the library helps anyone learn how to navigate the internet safely, from kids to seniors to newcomers. The library has an English Conversation Group. These are examples of building social capital.

This research and consideration has me thinking about how I could invest in social capital in my hospital practice and so I have been thinking about the kinds of groups that could most help youth in my community. I have a few ideas but would be interested in others’ ideas also. Please tell me. It seems a long way from the opioid crisis to me, but the research suggests that I am wrong. How do you build social capital? How do you think we could help?

(This photo has been in multiple places on the internet. I found it in Lawrence Wall’s twitter feed.)

Just Ask

I consider myself to be a very fortunate doctor because I do not often have to deal with the death of my patients. My patients usually recover from their illnesses and, because they are young, I am often able to see them live out the promise of their lives.
The deaths in my practice, however, always continue to haunt me because they are deaths by suicide and suicide is such an insidious outcome that even those of us who see it most often can forget that suicidal ideation and attempts are serious symptoms of a severe illness. We should know better, but we still forget that this severe illness is very difficult to recognize.

Severe illnesses in youth are so difficult for all of us to comprehend. Depression and suicide are even more difficult because they are symptoms that often occur in young people who can present a cheerful countenance to the world – who have a gift of helping others to feel happy. Have you not heard this? Do you not know of a situation in which this was exactly the case?

On the weekend, I read J. Kelly Nestruck’s article in the Globe and Mail about Jonah McIntosh, a young actor at the Shaw Festival who died by suicide in July. He recorded how the Artistic Director at the Shaw Festival saw Mr. McIntosh: “always smiling and making everyone around him smile”. Mr. Nestruk also documented that a death such as the young actor’s suicide was not one the theatre company had experienced, which seemed surprising to me. There is a suicide every forty seconds in the world and artists and actors have a suicide rate of 24 per 100,000, higher than physicians or teachers or nurses.

The article underlined for me once again that those of us who work in mental health fail to educate the public about how difficult it is to predict the course of depression – we have not communicated how a smiling face cannot be assumed to be an accurate reflection of mood. Many people with depression leave their friends and family, leave their doctors’ offices, with a smiling face even when they are plagued by persistent suicidal thoughts, with plans to act on their troubling symptoms. Most of these people have brought joy to their families and friends, but have never found it for themselves.
At this stage in my career, I no longer think about whether I am asking the question sensitively. I just ask, “Are you thinking of suicide?” “Do you have a plan to kill yourself?” People ask all the time if these questions could cause a person to think of suicide but this is not the case.

Just ask, I tell people. If the person you ask seems shocked, or makes some protest, just say,”I am so worried about you and I do not want to make the mistake of not asking about suicide.” We would not hesitate to ask about the serious symptoms of heart disease. We must begin to do the same for depression and suicide. We can save these wonderful lives if we ask. We can prevent suicide.

(On September 10 at 8 pm I put a candle in my window to show my support for suicide prevention and for those who die by suicide and for those who survive.)

A Public Health Campaign for Legal Marijuana

When I first reviewed the Government of Ontario’s approach to legal marijuana, I was disappointed. I was hoping for an approach with a strong foundation in public health. I feel strongly about this and wrote about my concerns for the Ottawa Citizen.

As I read the views of other health stakeholders in legal marijuana, I could not help but notice that many of these felt that the government had addressed many of their concerns. Both Ontario Public Health and the Canadian Medical Association reported being satisfied with a legal age of 19 for marijuana, even though both had advocated for a higher age. The article I read said these organizations described the government’s approach as “pragmatic”. Why am I not satisfied?

This pragmatic approach focuses on regulations and where marijuana will be sold and the public health relies on regulation to manage the age of use. However, as all clinicians working in youth mental health and addiction, I know that the key to changes in behavior and attitude lie in education, specifically public education through health communication campaigns. In mental health, we are very familiar with how successful these campaigns can be. In the past ten years, vigorous health communication campaigns have  been able to neutralize the stigma that existed for centuries against mental illness and persons with a mental illness. I had hoped that, right from the beginning, the Health Minister would have pledged the funding for a sophisticated health communication campaign to ensure that all citizens understood the health risks of marijuana, especially youth for whom the impact on the developing brain can be significant. There was the promise that such a campaign would be developed, but no firm details were provided as to what steps have been taken to implement the campaign.

The campaign I wanted would include persuasive communications informed by social marketing strategies, with messaging designed for different target groups. The public health messages must be accurate, interesting and stimulating so that different communications might be needed for different groups and especially different age groups. I know that the Ministry of Health and Long Term Care can manage this level of sophistication. In fact, I even found a presentation entitled Developing health communication campaigns on the Public Health Ontario website.

The campaign I wanted would start now so that awareness of the risks of cannabis use and information about safe practices for using legal marijuana would be known by the time legalization comes into effect  in July 2018.

The campaign I wanted for youth would reflect the reality that Canadian young people are already the highest users of marijuana in Canada by age group. It would recognize that rules and regulations cannot be the only tools we use to prevent marijuana overuse and addiction.

Another public health element that I was seeking was the commitment of support for further research to evaluate the impact of legal marijuana. This will help us to understand how the Government’s approach might be improved in the future. It will reassure the public, including mental health professionals, that the Government is prepared to be prudent in ensuring that legal marijuana is introduced safely.

Finally, with the growing demand for mental health services, another element that I had hoped to see was a commitment to improved funding for services for addiction. While I do not believe that the legalization of marijuana will necessarily lead to higher rates of marijuana addiction, we know that the province’s coffers will benefit from increased tax revenues. Many groups were hoping for a commitment to improved services, services that are already much needed.

The legalization of marijuana is an opportunity for the Government of Ontario to demonstrate understanding that addiction is a mental health problem and that those people with an addiction should be assisted and not shunned. The young people that I see with marijuana addiction have higher rates of many psychiatric symptoms including psychosis and suicidal ideation and attempt. Many of the young people I see who are now in recovery would provide great advice on how the public health approach to legal marijuana could engage youth in its safe introduction. I hope the Government will seek the advice of those most at risk – people under 25.

Not Just Any Village

In recent months, I have come to learn more and more about the difficulties indigenous youth have in obtaining mental health services. In part, this is because local, provincial and federal news reports are calling attention to these difficulties but I am also very much aware of the needs of these young people in my own community and practice.

It is especially distressing that, despite the goodwill of governments and their financial investment, all the measures that have been taken seem to have no impact. How can this be?

I have come to understand this only in the context of being a mother myself and it is only using this reference point that I can make sense of why our efforts have been so ineffective. Let me see if this helps you to understand what is missing.

Imagine that your child has serious mental health problems. She is twelve years old and started using substances like cannabis, or alcohol, or solvents. (I have seen indigenous youth who started using substances, especially solvents, as young as seven years old.) School is a struggle and because of this, the child feels hopeless about the future. Perhaps as a parent, you can understand this because you were in the same situation at her age. You are desperate for your child to get help and so you agree that she should travel hundreds of miles away from home to get that help. You agree to this even though you will miss her desperately, and worry about her all day, every day. You know she is anxious and will cry because she misses you and her family, but you know that you cannot travel with her because there are other children to care for, or your job, or even because you yourself do not have the emotional strength to support her. Who cannot relate to the desperation of this situation? Of this parent? Of this child?

The research evidence is overwhelming that children’s health depends on family support. It takes the first year of our life to be able to walk. It takes us until we are two to utter a few words. We begin to have the skills to read, and write, and do math around age five. The evidence says that our enormous brains can take until age 25 to fully develop. We clearly need personal support to grow and develop and every culture relies on families to provide that support. When we are unwell, we need that support even more.

How do we expect these children to heal when we send them away from their families? If we must do this, could we not at least set up those sophisticated telehealth networks and facetime for parents and children and grandparents and brothers and sisters to stay in touch? “It takes a village to raise a child” is an African proverb that recognizes the universal truth that we need our families and kin – our village.

When I am having a hard day, I will often count my blessings and the blessings I remember first are the people of my personal village: my children and husband and family and friends.

Do we really believe that indigenous youth (or any youth) will become stronger mentally away from their families? Have we really learned nothing from the experience of those sent away to residential schools? Are we really not listening?

If those African philosophers will permit, I do have one slight modification to their proverb. I agree that it takes a village to raise a child, but not just any village will do. Each child deserves the support of their own village: their own family, their own friends, their own people.

(Photo credit: Family Ties sculpture by Kevin Barrett)

Bleak Midwinter

The holiday season has officially started. I have begun to make a list of the families in my practice that should receive grocery vouchers so that they can afford food for the holidays. I also make a list for the teenagers who are living on their own. I confirm addresses and watch young people’s faces closely so that I can discern whether they are, in fact, housed. I ask them if their housing is safe, looking them right in the eye. I have a list of numbers on the corner of my desk for families or youth to call if they need housing. I have lists of where free holiday dinners are provided and where one can sign up to receive gifts. I am not trained for any of this. In fact, few doctors are trained for this work, but we all do it.  The hardest part of this work is finding a balance between the fear I have about how precarious my patients’ living situations can be and the realization that I have a responsibility to make that situation more secure.

I know there are many who will say that this is not a doctor’s job, but I cannot escape the knowledge that I have that says otherwise. Every doctor I know works for the best for their patients even when the best has nothing to do with pathology, physiology or medicines. Every doctor I know asks their patients questions about their income and work and family life.

The sharp contrast between the glittery mall displays and the realities of many lives is especially evident at this time of year.  While so many are focused on what they want the holiday to be, others are thinking of what they need so that the holiday is bearable. The impact of this contrast on mental health is significant.

At a time of year when family is glorified, the difficulties in one’s own family become highlighted. The support of family members is known to be a factor in good health, but how many people do you know who dread the “family” events that come with the holidays? How many of those events end much differently than sitcoms would have us think? Many of the youth I see live in care. Some will be preparing for a visit with family of one kind or another. Some will have days or even a week with their family. Helping youth stay realistic about these visits and the holidays is very difficult for those of us who care for these youth.

I am always most concerned about the youth who do not have a family to visit. Most people around them will be planning a visit and excitedly buying and wrapping gifts and planning travel. The youth without a family will be sharing their Christmas lists with a youth worker or social worker. You will receive gifts, often thoughtful gifts of things you want, but you will not have what you really want which is love, true affection from someone who has known you all your life and is happy for just being able to hang out with you. As a psychiatrist, I could point out the link between “hanging out” and endorphins but I think this just serves to distance us from the feelings. If you can understand what a young person with no family is feeling, you know that this feeling is not good for someone’s mental health.

As a physician, I always take some time off in November or early December to prepare emotionally for the holiday season, whose starkness is so evident in psychiatry. Then I come back to work ready to spend the next month social determinants of health.

010

The ER Choice

After a CTV report last week outlining how many adolescents in Ontario have to get care from Emergency Rooms, I decided to evaluate how care is in one outpatient program, the one where I work.

My goal was to try and get an impression of what it was like to be a patient in the Youth Outpatient Program at The Royal, the psychiatric hospital in Ottawa. I am the physician Director of that program. I started at the Admitting Department, proceeded up to the Outpatient waiting room, and then imagined I participated in both the psychological testing and the clinical interview that comprise a first assessment in the program the Outpatient Team has developed. This is the kind of exercise that is recommended as part of a Quality Audit.

It took two and one half hours to complete the exercise. The process was complicated by the fact that I had decided not to tell anyone what I was doing – I felt that this would make the experience more authentic. At the end of the experience, I can say that I am surrounded by helpful and curious people – especially curious. Also, a lot of people know me…a lot.

Here are some of the questions people ask:

In Admitting, “Can we help you, Dr. Beck?”

To find the Youth Program, you follow red butterflies to the third floor. I have to ask, “Which butterfly do you think is red and which maroon?”

When I don’t take my usual route to my office (because I’m following red butterflies), one helpful person says, ”You’re going the wrong way, Dr. Beck.”

While sitting in the waiting room, “Did you forget your keys? Shall I call Security?”

It occurs to me that, if I had to sit in that waiting room for any length of time, I’d be pretty bored. Should we suggest that parents waiting for their adolescent bring a book? Should we see whether it might be possible to get a TV for the waiting room – one that showed educational tapes on mental health or information about services locally. I ask others waiting with me. They like that idea and speak with me about the services they’d like. When I tell them who I am and what I’m doing, the suggestions are even more useful. There is a lot of curiosity about why I’d do this: ”Can’t someone less important do this?” (MY favourite question!) “Do you think You’ll be able to change anything you don’t like?”

At the end of this exercise, my impressions are of a large, complex building with lots of light – The Royal’s new building is a beautiful, light-filled building. It is, however, somewhat difficult to find your way around it. The offices are numbered but it seems as if they are oddly arranged at times – I can never remember if I am in Room 3311 or 3312. I also recall trying to find a colleague in the Geriatric Psychiatry Program and realizing that finding their office would conclusively establish that my executive functioning was still intact.

People are friendly. I started working at The Royal in 2002 after a long period in private practice and I remember how impressed I was by how much many people enjoyed their work and how many of them were kind and devoted. It’s one of the best things about the hospital and it’s still true today despite all the cutbacks we’ve had to work around.

It’s also evident that many patients who’ve been coming to the hospital for a while feel very comfortable there. A young man that I saw five years ago as a teenager is attending St. Nicholas Adult High School close by and picks up his morning coffee at The Royal. He always tells me how his courses are going. Another young woman greets me every morning as she arrives for the Day Hospital. This is very important, that people feel comfortable there. To me, this would help others feel comfortable.

There is a lot more that is good about the youth program than comfort. The team I work with has gotten the wait list down to three months, less than two weeks for urgent patients.  Last week’s news report suggests that there are not enough mental health services in the community for youth and that access to physicians in the system is not adequate.

Having said this, if you have ever known an adolescent experiencing a mental health crisis, you will likely recall that these seldom occur at 9 a.m. They occur in the evening, when you can’t figure out your homework, or your girlfriend dumps you, or your parents are fighting. When we’re worried about a youth, my team and I develop a safety plan with them and their family. During the day and early evening, there are places to go and people to see. These safety plans often include a family doctor and the family doctors are not the inaccessible ones mentioned in the CTV report.

But even family doctors’ offices and psychiatry departments close and, in the wee hours, when things get scary, there is only one place left. “Where will you go?” I ask youth, “Where will you go if you can’t find anyone else?”

“I’ll go to Emergency, Dr. Beck. They know me there.”

That, to me, is the point. The Emergency Room may not seem like the best place if you’re stressed out, but it’s better than the alternative. I wish that the CTV report had ended by reminding youth and their families that Psychiatric Services in Emergency Rooms are still the right choice in a crisis. I wish they’d said, “We wish there were more psychiatric services for youth, but please use the Emergency Services if you have to.”

Sometimes it’s the best choice.