From the Editor
Suicide is often discussed, but what do we know about the overall rate of completions? We hear that there are more suicides in the United States over the past few years – but was does the Canadian data say?
In the first selection, we consider a new paper by Mélanie Varin (of Indigenous Services Canada) and her co-authors. Drawing on a Canadian database, they consider suicide mortality. The good news: the suicide rate in Canada decreased by 24.0% between 1981 and 2017. But, in recent years, there hasn’t been a further decline.So – is the glass half full or half empty?
In the second selection, we look further at suicide, considering a new podcast discussing suicide and suicide prevention. I talk with Dr. Juveria Zaheer (of the University of Toronto) about COVID-19, the literature, and, yes, her suggestions for clinical interviews. “If you have a room of one hundred people, one hundred people in that room have been affected by suicide.”
Dr. Rebecca Lawrence is a UK psychiatrist and we can assume that she has done many suicide risk assessments. In a Guardian essay – our third selection – she tells her story: as a person who struggled with mental illness, then made the decision to become a psychiatrist. “If my story helps anyone unsure of their capacity to take on the job, or worried about the ‘dark secret’ of their own psychological troubles, then I think it’s worth telling.”
Selection 1: “Trends in Suicide Mortality in Canada by Sex and Age Group, 1981 to 2017: A Population-Based Time Series Analysis”
Mélanie Varin, Heather M. Orpana, Elia Palladino, Nathaniel J. Pollock, Melissa M. Baker
The Canadian Journal of Psychiatry, 14 July 2020 Online First
Suicide prevention is a key public health priority for communities, governments, and international organizations. In 2014, the World Health Organization (WHO) called on all member states to develop national suicide prevention strategies. This was an effort to encourage investment in coordinated and evidence-based approaches to prevention and to achieve the goal of reducing the incidence of suicide by 10% by 2020. Furthermore, the United Nations includes preventing suicide in its health-related Sustainable Development Goals (SDGs) through a goal to reduce premature mortality by one-third, as measured by suicide mortality rates (SDG indicator 3.4.2). According to their projections, if current trends continue, Canada will not meet the SDG of reducing suicide mortality by 33.0% by 2030.
A recent analysis from the Global Burden of Disease Study reported that the global age-standardized mortality rate (ASMR) from suicide decreased by 32.7% between 1990 and 2016. This decline was driven by decreases in 63 countries, including China and India, which accounted for 44.2% of all suicide deaths globally.
So begins a paper by Varin et al.
Here’s what they did:
- They drew data from the Canadian Vital Statistics Death Database, “a national administrative database derived from death certificates for all deaths registered in each province and territory.”
- They analyzed a 37-year period, 1981 to 2017.
- They calculated annual age-standardized, gender-specific, and age group-specific suicide mortality rates, and used Joinpoint Regression for time trend analysis.
Here’s what they found:
- “From 1981 to 2017, there were a total of 138,548 deaths by suicide across Canada for individuals aged 10 years old and over.”
- “More than three-quarters of all suicide deaths (n= 106,764) were among males; 23.0% were among females (n = 31,784).”
- From 1981 to 2017, the age-standardized suicide mortality rate in Canada decreased by 24.0%.
- “From 1981 to 2007, there was a significant annual average decrease in the suicide rate by 1.1%… followed by no significant change between 2007 and 2017.”
- Gender and age. “From 1981 to 2017 and from 1990 to 2017, females aged 10 to 24 and 45 to 64 years old, respectively, had a significant increase in suicide mortality rates. However, males had the highest suicide mortality rates in all years in the study; the average male-to-female ratio was 3.4:1.”
“Overall, we found that the suicide rate in Canada decreased by 24.0% over nearly 4 decades, from 1981 to 2017. The rate decline occurred primarily during the period of 1981 to 2007; the suicide rate was relatively stable between 2008 and 2017. Similar trends have been observed in other high-income European countries, including Germany, Spain, Italy, and Denmark.”
A few thoughts:
- This is a good study.
- The authors add Canadian data to the discussion of suicide.
- What could explain the plateauing since 2008? The authors forward an explanation: the close connection between unemployment and suicide, and the economic woes of 2008-9. “The flattening of the suicide rate may be due, in part, to the 2008 to 2009 economic crisis.”
- That’s a reasonable explanation – though the reasons for suicide are obviously more complicated. While unemployment is tied to suicide, joblessness has been down in recent years. Since June 2009, unemployment in Canada dropped, from almost 9% to under 5% by December 2017.
The full paper can be found here:
Selection 2: “What all physicians need to know about suicide and suicide prevention”
David Gratzer and Juveria Zaheer
Quick Takes, September 2020
How to think about suicide and suicide prevention?
In a Quick Takes podcast, I interview Dr. Juveria Zaheer, a psychiatrist and clinician scientist at CAMH.
I highlight some of her comments:
“People have linked COVID and suicide in their minds, and the answer might be more complicated. Traditionally, we think about economic hardship. We think also about social isolation, decrease access to care, trauma as being risk factors for suicide, all of which we can see during the COVID-19 pandemic. It’s important to remember, though, that the situation is completely unprecedented in our lifetimes and it’s very difficult to know what to expect. And we know that in the past, when we had increased social cohesion during the World Wars, for example, when people have a feeling that we’re all in it together, suicide rates can actually come down. And the early data suggests that in some nations like Japan, the rates have actually come down in the short term.”
On the evolving literature
“For a long time, suicide prevention research was more about treating underlying mental illness. So how do we reduce suicidal ideation and depression and how do we reduce suicidal ideation and schizophrenia?…
“Now research is thinking about the narrative. And to understand a story, we need to look at it from the top and the bottom. So, from the top: understanding data. And we can think about AI and population-based data to understand how risk and different populations look different. And then the bottom: understanding people’s stories.”
On a practical approach to suicide risk assessments
“It’s really important for a clinician to think about suicidal ideation every time you see a patient.
“There are very practical tools like the Columbia screener or the PHQ-9, which has suicidal ideation as the last item.”
On developing a safety plan…
“One of the things that’s so great about a safety plan is every time you use it, it’s reinforcing. So every time I use a safety plan and I can keep myself safe, I’m reminded of the fact that I have these skills. So it’s a really wonderful tool and it’s a really great tool to get to know the patient, to get to know what’s meaningful for them and what’s important for them.”
And making sure it’s accessible
“I see in the department that people always have their phone with them and I always have my phone with me. And so, taking a picture of it means it’s always going to be with you. I always ask people to print off a copy for their care team or for their family members. If you find that your suicidal thoughts are worse before bed, have a copy by your bed. If you find that it’s the worst when you’re getting out of your car and you’re driving to work, have a copy in your in your glove compartment. So thinking about ways that you can personalize it and make it be the most useful for you.”
The full interview runs just over 17 minutes, and can be found here:
Selection 3: “I thought mental illness meant I’d never be a doctor. Now I’m a consultant psychiatrist”
The Guardian, 16 September 2020
I’m a consultant psychiatrist. I have a job I love, in the specialty I love, and it probably all looks like I’ve been living the dream. But it isn’t as straightforward as it might look. My career in psychiatry actually started on the other side, as a psychiatric inpatient going through multiple admissions, medications and courses of electroconvulsive therapy (ECT). When I was first admitted to a psychiatric hospital, I stepped from one world into quite another – even though I was in the same long, grey building where I had been a medical student.
I was 26, training to be a GP, and I didn’t think I would ever work as a doctor again. I wanted to become a psychiatrist, but felt certain that was now closed to me. I experienced burning envy of psychiatrists I met as a patient. They wore their roles easily, carelessly, as I believed I never would.
I was given a diagnosis of psychotic depression and later bipolar disorder, the trigger having probably been my first pregnancy. I felt terrible shame, and also fear that people saw me as attention-seeking and personality-disordered.
So begins an essay by Dr. Lawrence.
She describes her personal experience: “I could not relate my chaotic and tortured feelings to the textbook descriptions of depression at all, so doubted that anyone else believed my diagnosis… I became convinced they also spoke like this of me.”
She discusses the decision to go into psychiatry:
“I made the decision – unpopular with my family – that I would, after all, apply for psychiatry. I asked one of my previous treating doctors for his opinion; he listened patiently, but said he thought it would be too stressful for me. It was almost a relief to realise that expectations of me were so low, and I proceeded to ignore his advice.”
And she describes her job interviews and the decision to disclose her history: “At my interviews I confessed my psychiatric history and the first hospital offered me a shorter contract than usual, to see if I would cope. At the other one the staff were entirely unfazed and welcoming, and offered me a normal contract. I took it and I worked there for two years.”
And she talks about landing her dream job:
“But despite my anxieties, I experienced little stigma or discrimination, and ultimately gained the consultant job that I wanted most, in my home city – in the very hospital where I had been a patient. Even now I have a love/hate relationship with this hospital: it contains some of my worst memories but it has also given me a great deal back. I have been ill again, over the years, but am lucky enough to usually be well in between. I have also had huge support from colleagues, all of whom know about my illness.”
Dr. Lawrence notes that she has been helped by ECT and lithium. She notes her journey and comments:
“I have been asked if being a patient has made me a better psychiatrist. It has undoubtedly influenced the way I work and think. I often see patients for whom the medicine we give provides limited, if any, benefit but I believe passionately that we must still listen to them and hear their stories. Kindness can bring solace when medication can’t. I also know what it’s like to take a wide variety of psychiatric drugs, and to experience their side-effects, and I know that lots of people stop them without daring to tell their psychiatrist. I’ve done it.”
A few thoughts:
- This is a great essay.
- I’ll comment again – as I have before – about the courage it takes to disclose mental health problems. In the essay, Dr. Lawrence mentions her decision to speak out: “So every few months I give a short talk about my illness, how I got through, what helped me. After the first time I did it, I thought I could never do it again, it felt so exposing. But the feedback was good, and I haven’t looked back.”
- Lucky us.
The full essay can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.