Advancing Public Mental Health in Canada through a National Suicide Prevention Service: Setting an Agenda for Canadian Standards of Excellence

Abstract

The Public Health Agency of Canada is funding a new Canada Suicide Prevention Service (CSPS), timely both in recognition of the need for a public health approach to suicide prevention, and also in the context of the COVID-19 pandemic, which is causing concern about the potential for increases in suicide. This editorial reviews priorities for suicide prevention in Canada, in relation to the evidence for crisis line services, and current international best practices in the implementation of crisis lines; in particular, the CSPS recognizes the importance of being guided by existing evidence as well as the opportunity to contribute to evidence, to lead innovation in suicide prevention, and to involve communities and people with lived experience in suicide prevention efforts.

The Public Health Agency of Canada is providing its largest commitment of funding to suicide prevention, through a Canada Suicide Prevention Service (CSPS); $21,000,000 over 5 years will go toward creating a National network of crisis services, delivered 365/24/7 by phone, text, and chat in both English and French. This service will be led by the Centre for Addiction and Mental Health, in partnership with the Canadian Mental Health Association (CMHA) National, and Crisis Services Canada (CSC).

The CSPS supports appeals for greater investment in public health approaches to mental health and wellness ¹ and for an integrated, national response to suicide prevention. ² Suicide remains one of the top 10 leading causes of death in all age groups, and it is the second leading cause of death among 15- to 24-year-olds in Canada. ³ These needs are even more pressing in the current context of the pandemic caused by COVID-19. Increases in psychological distress have been reported globally. ⁴ A recent survey by the CMHA found that 6% of respondents endorsed thinking about suicide, compared with 2.5% the year prior. ⁵ Those who work in suicide prevention have also predicted an increase in suicide as a result of the pandemic, ⁶ including in Canada. ^7,8 While data to substantiate an increase in the rate of suicide during the pandemic in Canada are not yet available, rates of calls to the national crisis service have increased 185% over the course of the pandemic and are 200% higher than the same time period in 2019. ⁹ Factors cited as potential risks include isolation and decreased social support; economic hardship; and, decreased access to mental health services. ⁶ This increase is not inevitable, however, underscoring calls for improved mental health services, including crisis support.

The CSPS is also a major fulfillment of Bill C-300, An Act Respecting a Federal Framework for Suicide Prevention, adopted by the House of Commons in June 2012, and the subsequent 2016 Federal Framework for Suicide Prevention. ¹⁰ The Federal Framework aligns federal activities in suicide prevention, while complementing suicide prevention initiatives underway in provinces and territories, communities, and nongovernmental organizations across Canada. The Federal Framework recognizes that suicide prevention requires cross-sectoral collaboration and multidimensional approaches along a continuum of care. The Framework’s core objectives include reducing stigma and raising public awareness of suicide; connecting Canadians, resources and information; and accelerating research and evidence in suicide prevention. ¹⁰ The CSPS will contribute to each of these goals.

An environmental scan, conducted through online search and by contacting existing crisis services, identified 146 crisis and distress services across Canada. CSC laid the foundation for this new CSPS, from 2017, bringing four distress centers together into a network, and piloting technology to create a national crisis line. The new CSPS will scale these efforts, building a robust community and network across Canada, and innovating to design evidence-based guidelines and best practices, interventions, and technological solutions.

The CSPS will focus on bringing together community-based crisis and distress services to create a national network of crisis response. The CSPS partners are united in a commitment to sustain existing community crisis and suicide prevention resources, upholding the value that a community-based approach is key to ensuring that people in Canada across the country can participate in suicide prevention within their own communities, and in turn receive services that recognize their local contexts. This is particularly true for underserved, and higher risk groups, such as some First Nations, Métis, and Inuit communities, and LGBTQ2 communities, which have unique strengths and needs. ¹¹

Crisis services are an evidence-based component of a multidimensional approach to suicide prevention. ¹² A recent systematic review demonstrated that crisis line services reduce distress, including suicide-related distress and behavior, immediately, and in the short term, among the high risk population of people who utilize these services. ¹³ Crisis services have also been shown to be cost-effective. ¹⁴ Less evidence exists for the longer-term impact on mental health symptoms, wellness, and suicide-related outcomes. More recent directions support better integration of crisis services into the health system, such as integration of crisis line service with mobile crisis services ¹⁵ ; the use of crisis line services to link callers with mental health supports, or to follow-up with those who are at high risk, such as those who have recently discharged from psychiatric hospitalization. ^16,17

Implementation of crisis line services in other international contexts provides gold standard models, including the National Suicide Prevention Lifeline (NSPL) service in the United States, ¹⁸ and the Samaritans helpline in the United Kingdom. ¹⁹ It is beyond the scope of this editorial to provide a comprehensive review of best practices in the implementation of crisis services globally; however, the framework in the National Guidelines for Behavioural Health Crisis Care, by the Substance Abuse and Mental Health Services Administration (SAMHSA) in the United States, which funds the NSPL, ¹⁵ aligns with the direction of the CSPS. The model proposed by the CSPS partners to advance a vision for a National suicide prevention service is included in Figure 1; it highlights key principles and dimensions necessary for the effective development and implementation of a national suicide prevention service.

Figure 1.

Dimensions of a national suicide prevention service.

In their National Guidelines, SAMHSA outlines the essential principles and core elements for crises services including crisis lines. ¹⁵ Reflecting the National Action Alliance for Suicide Prevention evidence-based actions, known as Zero Suicide or Suicide Safer Care, the National Guidelines emphasize principles of access to crisis services, with a person-centered, “no-wrong door” approach, and a philosophy that removes barriers to accessing care” (p. 26), operating “every moment of every day (24/7/365).” In the United States, the Federal Communications Commission has recently approved a 3-digit number, under the National Suicide Hotline Improvement Act. ⁹ Universal access numbers have been shown to be an essential variable in emergency response. ²⁰ Other principles in the National Guidelines include the provision of trauma-informed care, and making space for a significant role for peers and inclusion of people with lived experience of suicide. The guidelines place significant weight on the importance of implementation, drawing on the implementation approach of the National Action Alliance for Suicide Prevention’s tool kit of evidence-based actions, along with continuous quality improvement, “applying a data-driven quality improvement approach to inform system changes that will lead to improved patient outcomes and better care for those at risk” (p. 30). Training for crisis line staff should follow the standards and guidelines of the NSPL, including clinicians to oversee clinical triage, assessment of risk of suicide, practice of active engagement and collaboration, and use least invasive intervention. Technology should incorporate advances that improve efficiency of the service working toward seamless connections to care in a mental health and substance use crisis system. Finally, the guidelines recognize the importance of a community-based approach in which crisis services are integrated into a continuum of a comprehensive system of care that includes crisis mobile response and crisis receiving and stabilizing facilities, with the goal of providing continuous contact and support, especially after acute care. Of note, particularly given recent crises in the Canadian context, ²¹ this system integration is pivotal to “minimize the existing default to use of law enforcement in mental health crises” (p. 11). ¹⁵

Key priorities for the CSPS that align with the SAMHSA framework are summarized in Table 1, recognizing that the foremost of these priorities is consultation with community partners and stakeholders and involvement of a broader and more diverse group of people with lived and living experience of suicide, and thus priorities and specific actions taken will likely evolve.

Table 1.

Promoting Hope and Preventing Suicide: Key priorities for the Canada Suicide Prevention Service.

Priorities	Specific Actions
Principles Improve access to crisis services Inclusion of people with lived experience Equity and diversity Cultural safety Trauma-informed	Ensure bilingual, 24/7/365 service in phone, text and chat “No wrong door” policy—both human and technological factors should support this ease of access, and the experience of the service user should be safe and seamless Expand the capacity of the service by onboarding new centers and supporting existing centers Explore the feasibility of a universal, three-digit crisis support number available across Canada 9 Involve people with lived experience in co-design of the service, particularly those who represent a diversity of experiences, and from under-served populations. Canadian research has demonstrated that the co-creation of services can result in higher rates of engagement and satisfaction for those who will use the service 22
Implementation and evaluation	An approach grounded in implementation science will support the scalability and ensure fidelity throughout the network The adoption of continuous quality improvement will help to create a learning health system with the goal of targeted, timely quality improvement Identify gaps in knowledge and foster innovation in suicide prevention. While crisis services have proven effective in the immediate and short-term, there is a paucity of evidence for their impact in the long-term. The CSPS will engage in longitudinal evaluation and contribute to gathering this evidence
Best-practices and training	Collaborate across the network to develop Canadian standards and best-practices in crisis intervention Collaborate to share best practices and design standardized training for crisis line volunteers and staff 23 Include training in culturally safe and trauma-informed care, and approaches that also support the wellness of responders 24
Technology and innovation	Foster innovation that will improve technology and system capacity; for example, leveraging machine learning and natural language processing to improve the identification of those callers at greatest risk, and to support responders in real-time with evidence-based guidance 25 Expand the range of interventions to include tools for self-management of suicide related distress, which have had promising results in other contexts 26
Community-based network	In contrast to a centralized model, we have chosen to build upon a community-based model that will engage existing crisis and distress centers across Canada We plan to use a proven virtual telementoring model—Project ECHO 27 —to create a National community of practice that will promote collaboration and build capacity among the network, and to disseminate training. Develop a National Advisory Committee that will create a broader network of diverse perspectives to guide the service Contribute to public awareness and the reduction of stigma. Stigma and secrecy surrounding suicide are associated with greater mental health difficulties, suicide, and grief related to suicide loss 28
System integration	Work toward integration across mental health and community services. We know that many Canadians experience mental health care as difficult to access and fragmented. 29 In addition, delays in access to care can result in worse outcomes, with those who have recently been discharged from emergency departments and hospital admission are at heightened risk of suicide 30 Solutions such as follow-up calls and linking crisis line services with existing mental health supports have proven effective in other jurisdictions and should be considered in Canada 15,16

The investment of the Federal government in a CSPS is an evidence-based approach to suicide prevention, which will also stimulate people living in Canada, volunteers, clinicians, researchers, and communities to strive for increased knowledge creation, dissemination, and implementation of interventions that prevent suicide. As we register the current levels of distress nationally, and affirm the importance of an evidence-based, public health approach to suicide prevention, we are compelled to put evidence in service of preventing suicide and to seek further evidence where none is available. If we work collaboratively, across communities, learning with diverse people with lived and living experience, and from those in Canada who have experienced loss to suicide, we can promote hope and prevent suicide.