This document discusses suicide prevention and provides an overview of a presentation on the topic. It begins with background on suicide rates in Ontario and challenges with suicide data collection. It then covers contemporary theories of suicide and the disconnect between what is known and current practices. The presentation aims to describe suicide as a broader issue, discuss quality improvement approaches to prevention, and promote the Project Nøw initiative to improve care for those at risk of suicide. Project Nøw is a collaborative effort between healthcare, education, and community sectors in Peel Region, Ontario to develop a coordinated suicide prevention strategy with the goal of preventing all youth suicide.

1. The Problem of Suicide…
and what to do about it
Ian Dawe, MHSc, MD, FRCP(C)
Associate Professor of Psychiatry, University of Toronto
Program Chief & Medical Director, Mental Health, Trillium Health
Partners
Chair, Suicide Prevention Standards Taskforce,
Ontario Hospital Association

2. 2

3. Dancing With Mississauga Stars 2019
3

4. The Problem of Suicide…
and what to do about it
Ian Dawe, MHSc, MD, FRCP(C)
Associate Professor of Psychiatry, University of Toronto
Program Chief & Medical Director, Mental Health, Trillium Health
Partners
Chair, Suicide Prevention Standards Taskforce,
Ontario Hospital Association

5. Credit Valley Hospital
2200 Eglinton Avenue West, Mississauga
Mississauga Hospital
100 Queensway West, Mississauga
Queensway Health Centre
150 Sherway Drive, Toronto
Faculty/Presenter Disclosure
• Relationships with commercial interests:
– Grants/Research Support: None
– Speakers Bureau/Honoraria: None
– Health System Consulting Fees: JD Associates; South Island Health; Health Innovations Group;
J&E Dawe Associates
– Other: Employee of Trillium Health Partners; Taskforce Chair, Suicide Prevention Standards,
Ontario Hospital Association; Member, Ontario Youth Suicide Prevention Leadership Committee;
Speaker & Committee Member, Mental Health Commission of Canada; Speaker, Bell Let’s Talk

6. Learning Objectives
At the end of this presentation, you will :
1. Knowledgeably describe the problem of suicide in our
clients as an issue beyond just the traditional targets of our
medical interventions,
2. Understand concepts of quality and process improvement
as they relate to implementation of suicide prevention
strategies in hospital and community settings,
3. Become a champion of the Project Nøw approach to improve
care and outcomes for individuals at risk of suicide in
healthcare systems locally, provincially and nationally.

8. Suicide rate per 100,000 population*,
in Ontario, total and by sex, 2001-2011
7.8 7.5
8 7.9 8.3
7.7 8
7.3
8.5 8.3 8.1
3.9
3.4 3.8 3.8 4.1 3.9 3.9 3.6
4.2
4.7 4.3
11.9 11.8
12.6 12.2
12.7
11.8
12.3
11.2
13
12.1 12
0
2
4
6
8
10
12
14
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Male
Female
Total
Data Source: Statistics Canada Table 102-0552. Deaths and mortality rate, by selected grouped
causes and sex, Canada, provinces and territories, annual. CANSIM 9database). *Age-adjusted
Rate per 100,000 people
Calendar Year

9. Data
There are a number of challenges related to the way suicide
data is collected and reported in Ontario.
delay in accessing mortality data,
underreporting of deaths, and
misclassification of deaths

10. The Problem of Suicide
Camus, A (1942) The Myth of Sisyphus

11. Why do People
Die by Suicide?

12. Émile Durkheim

13. Contemporary Theories of Suicide
• Thomas Joiner • David Klonsky
Klonsky’s Three Step Theory (3ST)

14. Integrated Motivational Volitional model of
suicidal behaviour
O’Connor RC, Kirtley OJ. (2018) The integrated motivational-volitional model of suicidal behaviour. Phil. Trans. R. Soc. B 373: 1754 DOI: 10.1098/rstb.2017.0268 http://dx.doi.org/10.1098/rstb.2017.0268

15. The Disconnect
Between What
We Know…
And what we do

16. A path to suicide…
Psychiatric illness, particularly depression, underlies many suicides, but only a
minority of those who have mental health problems take their own life.
Some personality traits and ‘mind-sets’ contribute to the development of
suicidal thoughts, including the desire to be perfect; self-criticism; brooding;
and having no positive thoughts about the future.
These traits can interact with factors such as
• deprivation,
• unemployment,
• social disconnection, and
• triggering events such as relationship breakdown or job loss, to increase
suicide risk.

17. Resiliency and meaninglessness

18. When Suicides Come in Clusters
What can we do to prevent suicide contagion?

19. Emotional
Illiteracy

20. Maladaptive Responses to Stress

21. Problems of
Mid-life

22. Socio-economic Factors
Socio-economic position can
be defined in many ways – by
job, class, education, income,
or housing. Whichever
indicator is used, people at the
bottom are at higher risk of
suicide.

23. Economic Uncertainty

24. Can the news scare
or traumatize us?
Children can come to view the world as a mean
and scary place when they take violence and
other disturbing themes on TV to be accurate
in real life.

25. The Clinical Cases that have
Inspired Me…
A Systems Level Quality Improvement View

26. Seven Step Recommendation for Hospitals
Report from the OHA Task Force on Suicide Prevention (July 2017)
Lead
Create a leadership-driven, safety-oriented hospital culture that is
committed to a zero suicide
Train
Ensure that all clinical and non-clinical employees receive suicide
prevention training
Identify Systematically identify and assess risk among all patients
Engage
Ensure that every patient has a needs-based ‘suicide engagement
care plan’
Treat
Ensure that all patients at suicide risk receive evidence-based
treatment for suicidal thoughts and behaviours in addition to
other mental health concerns
Transition
Provide continuous contact and support for patients and families,
particularly after acute care. Track and manage
using electronic health records, as necessary
Improve
Apply a data-driven quality improvement approach to inform system
changes that lead to improved patient outcomes and better care for
those at risk
1
2
3
4
5
6
7
Root Cause Analysis
Recommendations
96 incidents reviewed (2014-2017)
C site = 31, M site = 59, Q site = 5, Other = 1
3 recommendations on data and information
4 environmental recommendations
4 recommendations on standardization
4 recommendations for education
16 recommendations on model/process of care

27. Root Cause Analysis
Recommendations
96 incidents reviewed (2014-2017)
C site = 31, M site = 59, Q site = 5, Other = 1
3 recommendations on data and information
4 environmental recommendations
4 recommendations on standardization
4 recommendations for education
16 recommendations on model/process of care

28. Suicide Prevention as a Quality Improvement Initiative

29. What if care was perfect?

31. Global Zero Suicide Initiatives
ü Nuremburg Alliance | European Alliance Against Depression
ü The Mindfulness Initiative
ü Mersey Care
ü 113 Zelfmoord Preventie
ü Ireland National Suicide Prevention Strategy 2015-2020ü Henry Ford Health System
ü Centerstone
ü Institute for Family Health
ü Zero Suicide Institute
ü Healthy St. Mary’s Partnership
ü Central Arizona Programmatic Suicide Deterrent System
ü National Suicide Prevention Lifeline
ü US Airforce
OCEANIA
ü LifeSpan –Black Dog Institute
ü Roots of Hope (MHCC)
ü Together to Live
ü St. Josephs Healthcare
ü Help For Life (Quebec)
U.S.A.
CANADA
EUROPE
In thinking about how we could work together to make a collective impact, a high-level jurisdictional scan was done to
better understand what work was being done using a Zero Suicide approach.
Several collaborative examples were identified across the globe:
• (2018) World Health Statistics Data Visualizations Dashboard.
• (2014) Preventing suicide: a global imperative, WHO 31

32. Research Data
At the System Level

33. 10 ways
to improve
safety
Safer wards
Guidance on
depression
Family involvement
in ‘learning lessons’
Personalised risk
management
Outreach
teams
24-hour
crisis teams
Low staff
turnover
No out-of-area
admissions
Reducing alcohol
and drug misuse
Early follow-up
on discharge
NCISH:
National Confidential Inquiry into
Suicide & Safety in Mental Health
www.manchester.ac.uk/ncish
Based on over 20
years of data
collected from
studies of UK
mental health
services, primary
care and accident
and emergency
departments, the
NCISH group has
developed a list
of 10 key
elements for
safer care for
patients (i.e.
reducing suicide
deaths)

34. Treating Suicidal Behaviours
Directly
Zero Suicide Step #5

35. Evidence-Based Psychological Treatments for Suicide
• Dialectical Behavior
Therapy (DBT)
• Cognitive Behavior
Therapy (CBT): Suicide
Prevention (CT-SP) and
Brief CBT
• Collaborative Assessment
and Management of
Suicidality (CAMS)

36. Ian Dawe, MHSc, MD FRCP(C)
Program Chief & Medical Director, Mental Health
Trillium Health Partners
Associate Professor, Psychiatry
University of Toronto
Youth Suicide in Mississauga
What would it take to prevent every single suicide in our region?

37. Youth Trends in ED Visits
Sources:
*Peel Regional Police, Trend Analysis of Suicide Occurrences, 2016
**National Ambulatory Care Reporting Systems (NACRS), 2017
*** Region of Peel – Public Health. The Changing Landscape of Health in Peel. A Comprehensive Health Status Report. 2019
37
Among Peel students in grades 7 to 12, 33% felt like they “did not know who to turn to” when they wanted to
discuss mental health or emotional health issues***.
• Female students (44%) more commonly reported feeling like this compared to male students (24%), a proportion which has
increased over time between 2013 (34.2%) and 2017 (43.9%)***.
ED visits for mental health disorders among children and youth have increased over time***.
• In 2016-17, more than 2,400 youth visited Trillium Health Partners’ Emergency Department for mental health supports – a
number that is predicted to increase**.
• Between 2003 and 2016, ED visits for mood and anxiety disorders have more than doubled among individuals ages 0-14 years,
and among individuals ages 15 -24 years over the same period of time***.
• Females have higher rates of ED visits for anxiety, mood, personality and eating disorders, while males have higher rates of ED
visits for substance-related and schizophrenia/psychotic disorders***.

38. Our Why – Suicide Statistics in the Region of Peel
In 2017, leaders in the healthcare, education, and community sectors began having initial discussions about the suicide
rate of children and youth in the Region of Peel.
Statistics in the Region of Peel were alarming:
• In 2016, 10 youth died by suicide and 157 youth attempted suicide in Peel Region, an increase of 52% from 2012*.
• In 2017, 14% of Peel students in grades 7 to 12 seriously considered attempting suicide, and 4% attempted suicide in the past 12
months***.
• The prevalence of suicidal thoughts is twice as high among female students (20%) as compared to male students (9%)***.
• In 2016, there were 448 ED visits due to deliberate self-harm and suicide among ages 0-24 years in Peel (41 ED visits among 0-14
years; 407 ED visits among 15-24 years)***.
• In 2016, there were 119 Hospitalizations due to deliberate self-harm and suicide among ages 0-24 years in Peel (20 Hospitalizations
by 0-14 years; and 99 Hospitalizations by 15-24 years)***.
There was a recognition that we needed to think and connect differently if we wanted to ensure that no child or
youth dies by suicide in our community.
Sources:
*Peel Regional Police, Trend Analysis of Suicide Occurrences, 2016
**National Ambulatory Care Reporting Systems (NACRS), 2017
*** Region of Peel – Public Health. The Changing Landscape of Health in Peel. A Comprehensive Health Status Report. 2019
38

39. A Unique Opportunity in Peel
While many global Zero Suicide initiatives are based on a
collaborative approach, typically they were largely health
sector focused.
In our culturally diverse and growing community, there is a
need to learn from each other, broaden our scope, and
build on the work being done by our community, education,
and health sector partners.
A unique opportunity was identified in the City of
Mississauga and Region of Peel to bring together a fully
coordinated, community-wide initiative that included a
unique partnership between the healthcare, education, and
community sectors.HOSPITALS (THP)
COMMUNITY (PCC)
EDUCATION (PDSB)
PUBLIC HEALTH (PPH)
39

40. 40

41. Project Nøw
Launch
41

42. We have a credible and willing coalition
of partners who are working together to
identify how we can make improvements
in the system.
Partners have experience and success in
change management and working across
sectors to break down barriers towards a
common goal.
Project Nøw partners have pledged that
together, we will create a safe, non-
stigmatized, and positive environment
for our children and youth to flourish
and thrive, and when vulnerable, find
safe supports that they can understand
and trust within their community.
Project Nøw Partners
Moving Forward
“This type of collaboration has not been seen in Canada.”
Louise Bradley, President and CEO of the Mental Health Commission of Canada 42

43. 43

44. Co-Design
for Change
1
DEFINE NEED
Use research, population health,
and data to identify community
needs. Engage with YaFL to
understand the needs of those
with lived experience.
Work with children, youth,
and families to measure
outcomes and success to
iterate and evolve solutions.
Apply research, data evidence,
and current state analysis.
Validate and inform evidence
from lived experience
engagement.
Co-design, build, and
implement solutions through
engagement with children,
youth, and families.
2
APPLY
EVIDENCE
4
LEARN
3
BUILD,
IMPLEMENT,
ACTION.
Embed the voice of lived experience
through the Youth and Family League
ADVISE ON DIRECTION
Provide wisdom, advice,
guidance, and feedback on
direction from the perspective of
lived experience.
SUPPORT THE PROCESS
Support engagement process
as appropriate.
INFORM SOLUTIONS
Provide input to inform work streams
and actively participate in co-design.
EVOLVE ITERATIONS
In an advisory capacity, participate
in the iteration and evolution of
solutions
18
Project Nøw Process Map

46. Initiative Selection – Prevention Level vs. Risk Profile
46
LOW RISK
RISKNG RISK
HIGH RISK
(PRIMARY PREVENTION)
(80%)
(SECONDARY PREVENTION)
(15%)
(TERTIARY PREVENTION)
(5%)
PREVENTION LEVEL FOR % OF POPULATION
SUICIDERISKPROFILE
PREVENTION LEVEL VS. SUICIDE RISK PROFILE
SCREENING AND HELP SEEKING
• Rising risk for suicide
• Efforts to further enhance resiliency by helping
students support friends and build an
understanding around mental health in schools
• Efforts to identify those with a rising risk and
provide a help seeking pathway
• Further investigation and scoping required in the
areas of:
• Mental health resiliency training
(YES4MH)
• Youth to youth training
• Standardized screening tool
DIRECT CLINICAL INTERVENTIONS
• Highest risk for suicide
• History of previous attempts, suicidal ideologies
etc.)
• Efforts to decrease ED visits and facilitate keeping
the child at home, in school, and in regular
outpatient treatment
• Predicted to have the highest measurable impact
on reducing suicide in immediate future
• Stepped Care Pilot (SCP) to provide
intensive treatment to children who
require a higher level of care that is not
currently available in Mississauga
BUILDING RESILIENCY
• Low risk for suicide
• Efforts to build a community of awareness
and support around our children
• Further investigation and scoping required in the
areas of:
• Early years self-regulation training for
professionals/families
• Children before entry into school (ages 0-3)
• Cultural competency training specific to
mental health
SCHOOL BOARDHOME/FAMILY PCC HOSPITALPUBLIC HEALTH
LEGEND

47. What Does All This Mean?
Suicide is a health AND a social inequality issue.
1. Take on the challenge of tackling the gender and socio-economic inequalities in
suicide risk.
2. Suicide prevention policy and practice must (also) take account of men’s beliefs,
concerns and context – in particular their views of what it is to ‘be a man’.
3. Recognize that for people in mid-life, loneliness is a very significant cause of their high
risk of suicide, and enable people to strengthen their social relationships.
4. There must be explicit links between alcohol reduction and suicide prevention
strategies; both must address the relationships between alcohol consumption,
masculinity, deprivation and suicide.
5. Support our systems to recognize signs of distress, and make sure that people have
access to a range of evidence-based support, not just medication alone.
6. Provide leadership and accountability at every level, so there is action to prevent
suicide.

48. This is NOT Rocket Science
Now, you are able to:
ü Knowledgeably describe the problem of
suicide in our clients as an issue beyond just
the traditional targets of our medical
interventions,
ü Understand concepts of quality and process
improvement as they relate to
implementation of suicide prevention
strategies in hospital and community
settings,
ü Become a champion of the Project Nøw
approach to improve care and outcomes for
individuals at risk of suicide in healthcare
systems locally, provincially and nationally.

49. Follow me on Twitter
@DrIanDawe