The Federal Framework for Suicide Prevention – Progress Report 2020

Table of contents

• Minister's message
• Executive summary

1. Introduction
2. The changing landscape and current environment
   • National Suicide Prevention Action Plan (M-174)
   • COVID-19 pandemic
3. Facts about suicide in Canada
4. Update on federal activities
   • Moving upstream: holistic approaches to suicide prevention
   • Strategic objective 1: Reduce stigma and raise public awareness
   • Strategic objective 2: Connect Canadians, information and resources
   • Strategic objective 3: Accelerate the use of research and innovation in suicide prevention
5. Going forward

• Appendices
• Endnotes and references

Minister's message

I am pleased to share the 2020 Progress Report on the Federal Framework for Suicide Prevention.

Suicide is a leading cause of death in Canada – a serious public health issue that affects people of all ages and backgrounds. Approximately 4,000 people die by suicide in Canada each year. Suicide has a profound impact on individuals, families and entire communities. That is why preventing suicide is an important priority for the Government of Canada. As we respond to the COVID-19 pandemic and its wider consequences, it will be important to track and mitigate the impact of the pandemic on the mental health and wellbeing of Canadians, including suicide risk.

The Federal Framework for Suicide Prevention (the Framework) provides a foundation for aligning federal activities and complementing the important work underway across Canada, within Indigenous communities, among provinces and territories and national organizations working in suicide prevention. It focuses on reducing stigma and raising awareness, connecting people, information, and resources, and advancing knowledge and evidence to better understand suicide and inform prevention, treatment, and recovery. This year's Progress Report focuses on suicide prevention and life promotion activities led by key federal departments and partners from 2018 to 2020.

While we have made progress over the past two years in advancing our federal mental health and suicide prevention initiatives, there is more to do. Going forward we will implement a National Suicide Prevention Action Plan in the areas of suicide-related research and data, responsible reporting, best practices and training, and tailored programs for populations most affected by suicide.

As Minister of Health, I recognize that addressing suicide requires commitment and coordination across a variety of sectors, levels of government and within diverse communities. That is why we will continue to work with our partners and people with lived experiences to research and share the most up-to-date information and resources about suicide prevention.

I am optimistic that through our collective efforts, we will make important progress in preventing suicide and improving the circumstances that empower people in Canada to live their lives with dignity, hope, healing, recovery and resiliency.

The Honourable Patty Hajdu
Minister of Health

Executive summary

The 2020 Progress Report on the Federal Framework for Suicide Prevention provides an update on federal activities related to suicide prevention between 2018 and 2020.

The report highlights the changing context for suicide prevention in Canada. Since the release of the Federal Framework for Suicide Prevention (Framework) in 2016, our understanding of suicide and its prevention, and the broader mental health landscape, has continued to evolve. In particular, two key developments have emerged since the publication of the 2018 Progress Report: Parliament's unanimous adoption of Motion 174 – A National Suicide Prevention Action Plan (Action Plan), and the impact of the COVID-19 pandemic. This report profiles federal initiatives and investments that address the direct and indirect impacts of the pandemic on the mental health of Canadians.

An overview of suicide data is provided in the section “Facts about Suicide in Canada”. In 2018, 3,811 people died by suicide, corresponding to a suicide mortality rate of 10.3 per 100,000 population. While suicide mortality rates have remained stable since 2008, the potential negative impacts of the COVID-19 pandemic and related public health measures on the suicide rate remains unknown.

Aligned with the Framework's strategic objectives, the report highlights federal initiatives in suicide prevention which aim to:

• Promote holistic and strengths-based approaches focused on wellness - such as the National Inuit Suicide Prevention Strategy, The First Nations Mental Wellness Continuum Framework and programs supporting wellness and life promotion;
• Reduce stigma and raise public awareness – through the development of evidence-based resources, including updated media guidelines (Mindset), the adaptation of PHAC's bilingual “Language Matters” resource, and suicide prevention awareness for rail lines;
• Connect Canadians, information and resources – such as support for a pan-Canadian suicide prevention service, Indigenous-led suicide prevention and life promotion efforts, and suicide prevention resources for Veterans, public safety officers, and members of the Canadian Armed Forces; and,
• Accelerate the dissemination of research and innovation in suicide prevention – including the Mental Health Commission of Canada's work on the Roots of Hope Research Demonstration Project which builds upon community expertise to implement suicide prevention interventions that are tailored to the local context; and, PHAC's collaboration with an artificial intelligence (AI) company on a feasibility study that examines the use of AI and machine learning to detect suicide ideation using retrospective Twitter data.

The report concludes by outlining areas for future action, including efforts to strengthen data to improve our understanding of suicide; advance life promotion initiatives with First Nations leadership; and implement the National Suicide Prevention Action Plan, informed by continued research and evidence. This work will form the basis of future progress reports on the Framework.

I. Introduction

The Federal Framework for Suicide Prevention Act (Act) became legislation in 2012, requiring the Government of Canada to work with relevant departments, partners, provinces, and territories on the development of the Federal Framework for Suicide Prevention (Framework). Published in 2016, the Framework sets out the Government of Canada's guiding principles and strategic objectives for suicide prevention.

The Act requires the Government of Canada to report on activities and progress related to the Framework every two years. The Public Health Agency of Canada (PHAC) is responsible for publishing the progress reports on behalf of relevant federal departments and agencies contributing to suicide prevention. The previous progress report highlighted activities from 2016 to 2018.

The Framework is not a strategy nor does it replace existing strategies or frameworks implemented by provinces, territories, communities or Indigenous organizations. The Framework sets out the federal role for aligning suicide prevention efforts, and biennial reporting enables the sharing of information to enhance coordination and collaboration, complementing the important work underway by others in the sector. A summary of the Framework follows in Figure 1.

The present report provides an update on federally funded suicide prevention initiatives, noting that it does not capture all of the suicide prevention and life promotion initiatives taking place in Canada. The report includes distinctions-based approaches to mental wellness and suicide prevention among First Nations, Inuit, and Métis peoples. Distinctions-based programs acknowledge the unique histories, cultures and realities of First Nations, Inuit and Métis communities in order to best meet their respective needs.

Figure 1. The Federal Framework for Suicide Prevention (2016): At a glance

[Figure 1] The Federal Framework for Suicide Prevention (2016): At a Glance

Vision
A Canada where suicide is prevented and everyone lives with hope and resilience
Mission
Prevent suicide in Canada, through partnership, collaboration, and innovation while respecting the diversity of cultures and communities that are touched by this issue
Purpose
To guide the federal government's efforts in suicide prevention through implementation of An Act respecting a Federal Framework for Suicide Prevention (2012)
Strategic objectives
Reduce stigma and raise public awareness.	Connect Canadians, information, and resources.	Accelerate the use of research and innovation in suicide prevention.
Legislated elements (Section 2 of the Act)
1. Provide guidelines to improve public awareness and knowledge of suicide	2. Disseminate information about suicide and its prevention. 3. Make existing statistics about suicide and related risk factors publicly available. 4. Promote collaboration and knowledge exchange across domains, sectors, regions, and jurisdictions.	5. Define best practices for suicide prevention. 6. Promote the use of research and evidence-based practices for suicide prevention.
Guiding principles
Build hope and resiliency. Promote mental health and wellbeing. Complement current initiatives in suicide prevention. Be informed by current research and best available evidence. Apply a public health approach. Leverage partnerships.
Foundation
Changing Directions, Changing Lives: A Mental Health Strategy for Canada

II. The changing landscape and current environment

In 2016, the Federal Framework for Suicide Prevention (Framework) highlighted the complexity of preventing suicide. While there is no single cause that explains or predicts suicide, a combination of factors are associated with suicide, such as mental illness, physical health, personal issues and loss, childhood abuse and neglect, exposure to trauma (e.g., personal, occupational and intergenerational), family history of suicide, prior suicide attempt, misuse of alcohol and other substances, and access to lethal means. As a result, effective suicide prevention requires a multifaceted, comprehensive approach^{Footnote 1} that includes evidence-based strategies at the community and individual level, tailored to respond to the needs and contexts of populations that experience unique risk factors.

Since the release of the Framework, our understanding of suicide and its prevention, as well as the broader mental health landscape, continues to evolve. This year's report reflects the changing landscape by highlighting a broad range of activities that contribute to suicide prevention, including holistic and strengths-based approaches focused on wellness.

Two key developments since the publication of the 2018 Progress Report are Parliament's unanimous adoption of Motion 174 – a National Suicide Prevention Action Plan, and the impact of the COVID-19 pandemic, including wider consequences of related public health measures.

While the landscape and social environments will continue to change, advancing suicide prevention in Canada will remain contingent on continuous coordination and collaboration between federal departments and agencies, with partners, stakeholders and people with lived experiences. Working together, with a concerted focus on a National Suicide Prevention Action Plan, we will continue to advance suicide prevention in key areas for people most affected.

National Suicide Prevention Action Plan (M-174)

On May 8, 2019, Parliamentarians voted unanimously in favour of Motion 174 (M-174), which calls for a national suicide prevention action plan (Action Plan). M-174 is non-binding, and there were no new resources attached to the Action Plan (see Appendix A). The Action Plan is the latest in a series of key suicide prevention policy developments in Canada. A summary of these developments is provided in Appendix B.

The Government of Canada is supporting the development of the Action Plan while emphasizing current federal initiatives in suicide prevention, underlining the importance of Indigenous-led initiatives for addressing suicide in First Nations, Inuit and Métis communities, and acknowledging provincial and territorial jurisdiction in some areas. Through its convening role on the Framework, PHAC will continue to facilitate coordination and collaboration with relevant departments and agencies, and partners to develop the Action Plan.

Many of the items proposed for the Action Plan align with existing federal initiatives under the objectives of the legislated Framework. Figure 2 presents a diagram depicting this alignment.

Figure 2 - Text description

The figure illustrates the alignment between the three strategic objectives of the Federal Framework for Suicide Prevention (FFSP) and the items outlined in the National Suicide Prevention Action Plan (Motion-174). This diagram works from left to right as well as from top to bottom, showing how the FFSP encompasses the actions of the National Suicide Prevention Action Plan.

The first strategic objective is to Reduce Stigma and Raise Public Awareness. PHAC initiatives under this objective are:

• Anti-stigma and safe messaging
• Responsible reporting by federal departments and agencies

National Suicide Prevention Action Plan items that align with this objective are:

• Development and promotion of tools to promote responsible and safe reporting of suicide and its prevention by media

The second strategic objective of the FFSP is to Connect Canadians, Information, and Resources. PHAC initiatives under this objective are:

• Pan-Canadian suicide prevention service (24/7/365 voice, text, chat)
• Tools and resources

National Suicide Prevention Action Plan items that align with this objective are:

• Culturally appropriate community-based programs (Indigenous focus)
• National best practices guidelines
• National training standards
• National online information hub (official and Indigenous languages)

The third strategic objective of the FFSP is to Accelerate the Use of Research and Innovation in Suicide Prevention. PHAC initiatives under this objective are:

• Research priorities agenda
• Suicide-related data, surveillance and analysis

National Suicide Prevention Action Plan items that align with this objective are:

• National monitoring system on suicide (risk and populations)
• Research and knowledge including timely and accurate statistics
• Analyses of risk and protective factors; priority populations; barriers to service, including stigma and best practices

PHAC will report on activities and progress every two years.

COVID-19 pandemic

On March 11, 2019, the World Health Organization (WHO) announced the COVID-19 outbreak as a global pandemic. While necessary public health measures such as physical distancing have been implemented to reduce transmission, there are concerns about their negative impact on the mental health of Canadians and the potential for increased rates of suicide. Wider consequences of the pandemic include impacts at the societal or community level (e.g., economic downturn, barriers to accessing health care, including mental health care) and impacts at the relationship or individual level (e.g. job/financial loss, harmful use of alcohol/substances, family violence, social isolation, and experiences of trauma), all of which are risk factors for suicide^{Footnote 2,Footnote 3,Footnote 4}.

The mental health of Canadians has declined during the COVID-19 pandemic. The percentage of Canadians (aged 15+) who reported that their mental health is very good or excellent was only 54% in the first cycle of the Canadian Perspective Survey Series (CPSS; March 29-April 3, 2020),^{Footnote 5} and continued to decrease to 48%^{Footnote 6} in the second cycle (May 4-10, 2020), compared to 68% in 2018. Furthermore, data from these surveys suggest that the COVID-19 pandemic has had a larger negative impact on the mental health of some socio-demographic groups (e.g., young, women, Indigenous people, etc.)^{Footnote 6,Footnote 7,Footnote 8,Footnote 9,Footnote 10}.

While there are no clear signs of increased suicide deaths during the COVID-19 pandemic, there are some concerning signs of an impact on suicidality, such as through an increase in calls to distress centres. For example, the Canada Suicide Prevention Service has experienced a significant increase in calls since the start of the pandemic, with the number of interactions rising from 2,375 in March 2020 to 6,700 in October 2020.

There is a possibility of a delayed effect similar to one that has been documented after disasters. For example, immediately following the earthquake in Japan in 2011, the rate of suicide among men remained low, however, the suicide rate among men increased significantly two years following the earthquake.^{Footnote 14} Evidence suggests that the risks associated with the pandemic may be alleviated through improved access to supports.^{Footnote 15}

This shows the importance of continued monitoring during and following the pandemic. To this end, PHAC and Statistics Canada are partnering to conduct the following surveys:

• The Survey on COVID-19 and Mental Health (SCMH), which includes questions on mental health and thoughts of suicide. The initial findings from this large representative sample will be published in February 2021, and the survey will be repeated from February to April 2021.
• The Survey on Mental Health and Stressful Events, which includes questions regarding suicidal thoughts and general mental health.

Further examples of data collection and research related to the mental health impacts of the COVID-19 pandemic are described in Appendix C.

In addition, The Chief Public Health Officer of Canada's Report on the State of Public Health in Canada 2020 – From Risk to Resilience: An Equity Approach to COVID-19 describes the cumulative impact of COVID-19 and public health measures on Canadian society including on mental health with a particular focus on equity considerations.

Federally-funded resources related to mental health and substance use during the COVID-19 pandemic

As part of its response to the COVID-19 pandemic, the Government of Canada has supported a number of investments to address direct and indirect impacts of the pandemic. Examples of investments related to mental health and substance use include:

Wellness Together Canada portal

The Government of Canada is supporting the Wellness Together Canada portal, which provides Canadians in all provinces and territories with free access to a range of credible resources and supports related to mental health and substance use. The portal complements suicide prevention services by providing access to educational content, self-guided programming, peer-to-peer support, and confidential one-to-one counselling and crisis text lines. The Government is planning an independent evaluation of the portal to examine how it has addressed key objectives, such as increasing access to services and improving client outcomes.

The November 2020 Fall Economic Update announced an additional $43 million to provide further support for the Wellness Together Canada portal and the resources it offers. To date, the Government of Canada has invested $67 million in Wellness Together Canada.

Supporting increased demand for services

The Government of Canada has also invested $7.5 million to support Kids Help Phone (KHP) in providing mental health support for youth during the COVID-19 pandemic. KHP has experienced a significant increase in demand for its services as a result of the mental health impact of the pandemic, with suicide among the top five reasons youth sought support between April and September 2020. By the end of 2020, KHP projects they will reach at least 3 million young people, compared to 1.9 million youth in 2019.

In addition, the November 2020 Fall Economic Update announced a $50 million investment to bolster the capacity of distress centres, which are experiencing a surge in demand during the COVID-19 pandemic.

COVID-19 readiness resource for public safety personnel

The COVID-19 pandemic has underscored the essential role of public safety personnel (PSP)^{Footnote 16} and other frontline workers in serving and protecting all Canadians. As a result, in March 2020, with funds from Public Safety Canada and significant in-kind contributions from Veterans Affairs Canada, the Canadian Institute for Public Safety Research and Treatment designated a COVID-19 Task Force to create an online resource. The COVID-19 Readiness Resource Project (CRRP), supports the mental health and well-being of Canadian first responders, including PSP, working on the frontlines of the pandemic. The CRRP Final Report outlines the resources and content available to all PSP across Canada.

Interim Federal Health Program

Immigration, Refugees and Citizenship Canada (IRCC) recognizes that refugees, asylum claimants, and other vulnerable newcomers, like many Canadians, may experience limited access to some health and mental health-care services, particularly in light of the COVID-19 pandemic. In March 2020, the Interim Federal Health Program began providing coverage for tele-services and virtual appointments to facilitate access to care. These services include virtual psychology and psychotherapy services, as well as coverage for interpretation services during the initial assessment treatment sessions, which align with provincial and territorial health insurance programs.

Other examples of federally-funded resources related to mental health and substance use during the COVID-19 pandemic are described in Appendix C.

COVID-19 funding for mental wellness support in Indigenous communities

The COVID-19 pandemic and related public health measures are also having a significant impact on mental wellness in Indigenous populations, magnifying existing mental health issues and inequities, evoking past trauma, and creating new gaps and needs.^{Footnote 17} In response, the Minister of Indigenous Services Canada (ISC) announced an investment of $82.5 million in mental health wellness supports to help Indigenous communities adapt and expand mental wellness services, improve access and address growing demand during the pandemic.

In addition, there is a wide range of virtual resources available to help Indigenous communities with their mental wellness during and after the COVID 19 pandemic, described in the section of this report on Connecting Canadians, Information, and Resources and in Appendix C.

III. Facts about suicide in Canada

Suicide is a preventable complex public health issue that affects Canadians of all ages, sexes, genders, ethnicities, income levels, and regions. Suicide was the ninth leading cause of death among all Canadians in 2018, and the second leading cause of death among individuals aged 15 to 34, behind unintentional injuries, according to Statistics Canada data.^{Footnote 18}

As part of its role in suicide surveillance, PHAC is documenting how suicide mortality is changing in Canada over time. A recent paper by PHAC researchers Varin et al. (2020) found that Canada's overall suicide rate did not significantly change from 2008 to 2017.^{Footnote 19}

Deaths by suicide^{Footnote 20}

Suicide mortality: Both sexes

Source: Statistics Canada, Canadian Vital Statistics - Death Database (CVSD), 2018

• In 2018, 3,811 people died by suicide in Canada, corresponding to a suicide mortality rate of 10.3 per 100,000 population.
• More than half of all deaths by suicide were due to suffocation (including hanging and strangulation).

Source: Statistics Canada, Canadian Vital Statistics - Death Database (CVSD), 2018

Comparison: Suicide mortality rate by sex - Text description

Rate by Sex, 2018 per 100,000 population: 15.7 Male, 5.1 Female

• In 2018, the suicide mortality rate was more than three times higher among males compared to females. The rate was 15.7 deaths per 100,000 population for males and 5.1 deaths per 100,000 population for females.
• Varin et al. (2020) found that although rates were consistently higher among males, there were significant rate increases over time among females in specific age groups.^{Footnote 19}

Source: Statistics Canada, Canadian Vital Statistics - Death Database (CVSD), 2018

Comparison: Suicide mortality rate by age group and sex - Text description

Rate by age group & sex, 2018 per 100,000 population:

• 10-19: 4.0 Female, 7.9 Male
• 20-34: 6.5 Female, 17.4 Male
• 35-64: 6.4 Female, 21.0 Male
• 65 and older: 3.7 Female, 16.0 Male

• The difference in the suicide rate between males and females was larger in older age groups than in younger age groups. The suicide rate among males was more than four times higher than the suicide rate among females aged 65 and older, and around two times higher among males than the rate among females aged 10-19.

Source: Statistics Canada, Canadian Vital Statistics - Death Database (CVSD), 2018

Suicide mortality: Males - Text description

• Overall rate, 2018: 15.7 per 100,000 population
• Number of deaths by suicide, 2018: 2880

Rate by age group, 2018, per 100,000 population

• 10-19: 7.9
• 20-34: 17.4
• 35-64: 21.0
• 65 and older: 16.0

Number of deaths by age group, 2018:

• 10-19: 166 (5.8%)
• 20-34: 676 (23.5%)
• 35-64: 1571 (54.6%)
• 65 and older: 465 (16.2%)

• In 2018, 54% of all suicide deaths among males were due to suffocation (including hanging and strangulation), followed by firearms (18%), and poisoning (14%).

Source: Statistics Canada, Canadian Vital Statistics - Death Database (CVSD), 2018

Suicide mortality: Females - Text description

• Overall rate, 2018: 5.1 per 100,000 population
• Number of deaths by suicide 2018: 931

Rate by age group, 2018, per 100,000 population

• 10-19: 4.0
• 20-34: 6.5
• 35-64: 6.4
• 65 and older: 3.7

Number of deaths by age group, 2018:

• 10-19: 81 (8.7%)
• 20-34: 238 (25.6%)
• 35-64: 486 (52.2%)
• 65 and older: 126 (13.5%)

• In 2018, 52% of all deaths by suicide among females were due to suffocation (including hanging and strangulation), followed by poisoning (31%).

Hospitalizations associated with self-harm injury^{Footnote 21}

Source: Canadian Institute of Health Information (CIHI), Discharge Abstract Database (DAD) and Ontario Mental Health Reporting System (OMHRS), 2018-2019 fiscal year, excluding Quebec hospitals.

Comparison: Hospitalization rate by sex - Text description

Rate by sex, fiscal year 2018-2019, per 100,000 population: 81 female, 46 male

• There was an approximately 80% higher hospitalization rate associated with self-harm injuries among females compared to males.

Source: Canadian Institute of Health Information (CIHI), Discharge Abstract Database (DAD) and Ontario Mental Health Reporting System (OMHRS), 2018-2019 fiscal year, excluding Quebec hospitals.

Comparison: Hospitalization rate by age group and sex - Text description

Rate by age group & sex, fiscal year 2018-2019 per 100,000 population:

• 10-19: 209 female, 54 male
• 20-34: 118 female, 67 male
• 35-64: 59 female, 47 male
• 65 and older: 23 female, 26 male

• The difference in the hospitalization rate associated with self-harm injuries for males and females decreased with age. The rate was approximately four times higher among females by comparison to males aged 10-19 years, and was similar for males and females aged 65 and older.

Other suicide related data

In Statistics Canada's Canadian Community Health Survey (CCHS) 2019,^{Footnote 13} 12% of Canadians reported having thoughts of suicide in their lifetime, and 3% reported having thoughts of suicide in the past twelve months, which are similar to the rates in the CCHS in 2016, the last time thoughts of suicide were measured^{Footnote 22}

According to 2016 CCHS data, 4% of Canadians reported that they had made a plan to seriously attempt suicide in their lifetime.^{Footnote 22} People in the lowest income quintile group were more likely to report that they had made plans to attempt suicide in their lifetime: 7% in the lowest income group compared to 3% in the top income group.

Also in the 2016 CCHS, 3% of Canadians reported having attempted suicide in their lifetime.^{Footnote 22} Suicide attempts were approximately three times higher among people born in Canada than among immigrants to Canada.

Suicide rates among First Nations, Inuit and Métis^{Footnote 23}

In June 2019, Statistics Canada published a report on suicide rates among First Nations people, Inuit and Métis for the 2011-2016 period. The report is the first to examine suicide rates among all three Indigenous peoples, comparing these rates to those among non-Indigenous people in Canada using one single methodology.^{Footnote 24}

The report found that the suicide rate was highest among Inuit (72.3 deaths by suicide per 100,000 persons per year) and, specifically, adolescents and young adults. For First Nations people, the suicide rate was 24.3 deaths by suicide per 100,000 persons per year; the rate among First Nations people living on reserve was higher than for those living off reserve, and higher among males than females. The suicide rate for Métis was 14.7 deaths by suicide per 100,000 persons per year.

Of particular concern is the high rate of suicide among Indigenous children under the age of 15. For example, nationally, the suicide rate among First Nations boys was four times higher than among non-Indigenous boys. It was ten times higher among First Nations boys living on reserve.

There is considerable variability across communities. For example, about 60% of First Nations bands and 11 of 50 Inuit communities have a suicide rate of zero.

The report also found that the combination of geographic (i.e., living on and off reserve or urban/rural area) and socioeconomic factors (i.e., household income, labour force status, level of education, and marital status) accounted for increased risk of suicide among First Nations people (78% of increased risk), Inuit (40%) and Métis (37%), by comparison to non-Indigenous adults.

IV. Update on federal activities

This section of the report begins with a description of holistic approaches to suicide prevention, followed by federal actions contributing to suicide prevention in Canada from November 2018 to November 2020 under the Framework's three strategic objectives:

1. Reduce stigma and raise public awareness
2. Connect Canadians, information and resources
3. Accelerate the use of research and innovation in suicide prevention.

Over the life course, many factors, including social, economic and physical environments, also known as the social determinants of health, influence individuals' mental health.^{Footnote 25} While no single cause explains or predicts suicide, the likelihood that someone will think about, attempt, or die by suicide may increase or decrease due to a complex interplay of suicide risk and protective^{Footnote 26} factors, which may include individual, biological, psychological, relational, spiritual, socioeconomic and/or cultural factors.^{Footnote 27,Footnote 28}

Recognizing the complex interplay of risk and protective factors, this segment of the report introduces holistic^{Footnote 29} approaches to suicide prevention and life promotion that focus on building strengths and consider the role of population health, such as how interventions at the community, policy, and systems-level impact suicide, highlighting Indigenous-led initiatives. Evidence in this area is emerging, as suicide prevention research has typically focussed on evaluating the effectiveness of a single intervention at a time. Evaluating and attributing outcomes from a comprehensive suicide prevention strategy is challenging, but a priority area for research.

In particular, preventing suicide in Indigenous communities needs a holistic, Indigenous-specific, strength-based, distinctions-based, community-driven approach which supports people, families, and communities. Such an approach also needs to address the legacy of residential and day schools, the Sixties' Scoop, and other devastating impacts of colonization as well as focus on current racism, discrimination, and inequities in determinants of health such as basic needs (e.g. clean water, food security, housing, healthy early child development), culture, language, health care, self-determination, education, and employment.

The National Inuit Suicide Prevention Strategy (NISPS) and the First Nations Mental Wellness Continuum Framework both outline a holistic approach to mental wellness and suicide prevention grounded in culture and Indigenous-specific determinants of health and aims to create systems change.

National Inuit Suicide Prevention Strategy

Inuit Tapiriit Kanatami's (ITK's) National Inuit Suicide Prevention Strategy (NISPS) “envisions suicide prevention as a shared national, regional, and community-wide effort that engages individuals, families, and communities. It provides a unified approach to suicide prevention in Inuit Nunangat that […] [promotes] a shared understanding of the context and underlying risk factors for suicide among Inuit, by providing policy guidance at the regional and national levels on evidence-based approaches to suicide prevention, and by identifying stakeholders and their specific roles in preventing suicide. The NISPS outlines how different stakeholders can effectively coordinate with each other to implement a more holistic approach to suicide prevention.”^{Footnote 30}

The NISPS articulates six priority areas that reflect a broad approach to suicide prevention among Inuit in Nunangat:

1. Creating social equity,
2. Creating cultural continuity,
3. Nurturing healthy Inuit children from birth,
4. Ensuring access to a continuum of mental wellness services for Inuit,
5. Healing unresolved trauma and grief, and
6. Mobilizing Inuit knowledge for resilience and suicide prevention.

First Nations Mental Wellness Continuum Framework

The First Nations Mental Wellness Continuum Framework states: “Mental wellness is a balance of the mental, physical, spiritual, and emotional. This balance is enriched as individuals have: purpose in their daily lives whether it is through education, employment, care-giving activities, or cultural ways of being and doing; hope for their future and those of their families that is grounded in a sense of identity, unique Indigenous values, and having a belief in spirit; a sense of belonging and connectedness within their families, to community, and to culture; and finally, a sense of meaning and an understanding of how their lives and those of their families and communities are part of creation and a rich history.”^{Footnote 31} It also emphasizes that “cultural knowledge about mental wellness does not narrowly focus on ‘deficits.' Rather, it is grounded in strengths and resilience.”^{Footnote 32}

The concept of life promotion is reflected in the First Nations Mental Wellness Continuum Framework, which describes mental wellness as “a broader term that can be defined as a state of well-being in which the individual realizes his or her own potential, can cope with the normal stresses of life, and is able to make a contribution to her or his own community.”^{Footnote 33}

Life promotion and mental wellness

The Promoting Life Together Collaborative with the Canadian Foundation for Healthcare Improvement described Life Promotion as “an Indigenous paradigm shift that encompasses both suicide prevention and life promotion to reduce premature unnatural death.”^{Footnote 34} It includes building hope and resiliency, giving meaning to life, promoting mental wellness, offering skills and tools to deal with stress, and providing a strong foundation of culture. The Collaborative recognized “the need to take a broader and more encompassing approach to the issue of suicide, to consider all aspects of one's life and community wellness.”^{Footnote 34}

Examples of programs supporting wellness and life promotion that are contributing to suicide prevention in Indigenous communities are described in the section of this report on Connecting Canadians, Information, and Resources.

Examples of PHAC mental health promotion programs acting at individual, family, community and systems levels to address health inequities and act on risk and protective factors for mental health are described in Appendix D.

The stigma associated with mental illness and with suicide-related thoughts and behaviours is a significant barrier to suicide prevention, particularly as it may discourage people from seeking help when most needed. There is some evidence that suggests that public awareness plays an important role as part of a multi-faceted approach to suicide prevention, particularly if informed by people with lived experience and when it shares information on where to seek help and support.^{Footnote 35} Activities that have taken place since 2018 related to reducing stigma and raising public awareness follow.

Reducing stigma and raising awareness

Promoting safe messaging and responsible reporting

The Government of Canada continues to support a number of initiatives that connect Canadians, information, and resources on suicide and suicide prevention, including improving access to mental health services and supports.

Connecting Canadians to suicide crisis supports

Connecting Indigenous communities to Indigenous mental wellness and suicide prevention resources and information

Preventing suicide in Indigenous communities is a key priority for Indigenous leaders, organizations, communities, and youth, and Indigenous Services Canada (ISC).

ISC is guided by the First Nations Mental Wellness Continuum Framework (FNMWCF) and the National Inuit Suicide Prevention Strategy (NISPS), two key documents previously mentioned in this report.

Examples of First Nations mental wellness and suicide prevention initiatives

Connecting military members and veterans to resources and information

Connecting public safety personnel to resources and information

Connecting people in federal correctional services to resources and information

In its ongoing efforts to address the mental health needs of federally incarcerated individuals, the Correctional Service of Canada launched a Suicide Prevention and Intervention Strategy in April 2019. The strategy is aligned with the Federal Framework for Suicide Prevention and provides a national structure for suicide prevention, intervention, and postvention activities and informs policy, research, and staff learning initiatives. 

A key component of the strategy has been the development of a Clinical Framework for Identification, Management, and Intervention for Individuals with Suicide and Self-Injury Vulnerabilities, which is a coordinated, evidence-based approach to suicide, self-injury assessment and intervention. The Clinical Framework will assist Correctional Service Canada's health care professionals in identifying individuals with suicide/self-injury behaviours early so that proactive treatment plans for managing these needs are developed, with the goal of preventing suicide/self-injury. Together, Correctional Service Canada's Suicide Prevention and Intervention Strategy and Clinical Framework emphasize the importance of interdisciplinary teamwork by connecting individuals with cultural/spiritual resources, encouraging meaningful activity, promoting health and wellness, and facilitating access to mental health care.

Connecting Canadians to information about our shared federal, provincial, and territorial health priorities

In August 2017, all provinces and territories agreed to a Common Statement of Principles on Shared Health Priorities. Following the agreement, the federal government negotiated and signed bilateral agreements with each province and territory that set out details of how each jurisdiction is using federal funding to improve access to home and community care and mental health and addiction services. To support provinces and territories in improving access to these services, the federal government is providing them with $5 billion.

The following provinces/territories have included federally-funded suicide prevention activities in their agreements:

• British Columbia: will leverage existing provincial investments to increase access to culturally safer, trauma-informed and culturally appropriate healing and treatment services and mental health and substance use care. This includes a focused approach to suicide and crisis intervention and response and land-based healing opportunities in certain Indigenous communities.
• Saskatchewan: will expand the capacity to deliver child and youth mental health and addiction treatment along the service continuum, including programs and services that promote better emotional health for children and youth in schools and other places where they spend time. This includes supporting community developed strategies aimed at preventing suicide in targeted communities.
• New Brunswick: will support the implementation of the “Enhanced Action Plan on Addictions and Mental Health”, with one of its priority areas focused on increasing prevention efforts for people at risk of suicide.
• Newfoundland and Labrador: will support the implementation of “Towards Recovery: The Mental Health and Addictions Action Plan for Newfoundland and Labrador”, with one of its guiding pillars focusing on promotion, prevention and early intervention including a focus area on suicide prevention.
• Northwest Territories (NWT): will develop and implement a Territorial Suicide Prevention and Crisis Support Network to support communities in proactive suicide prevention activities as well as provide expert and timely intervention in times of crisis. The large and diverse Indigenous population in NWT highlights the importance of enhancing culturally-appropriate approaches to mental health supports, including the prevention of suicide-related crises and improving the response to community and family needs when a crisis does occur.

Connecting suicide stakeholders and healthcare professionals to information and resources

Connecting Canadians to data

The Government of Canada continues to support and perform research on effective interventions and best practices to advance the field of suicide prevention based on the best available evidence for research and practice, while also addressing gaps in data to better guide suicide prevention efforts.

Developing a Shared Canadian Research and Knowledge Translation Agenda on Suicide and its Prevention

PHAC continues to collaborate with MHCC on the development of a national suicide prevention research and knowledge translation agenda that will address the lack of alignment in research across the country. Following the literature review and stakeholder consultations in the first phase, PHAC and MHCC are engaging with community-based organizations, universities and researchers with expertise and perspectives related to populations with higher rates of risk of suicide, including: LGBTQ2, men and boys, older adults, rural and remote populations, and youth. This will inform the final report on research priorities in suicide and its prevention.

Supporting Roots of Hope: A community suicide prevention project

Aiming to reduce the impacts of suicide within communities across Canada, MHCC has continued its work on the Roots of Hope Research Demonstration Project. Multi-site and community-led, the project builds upon community expertise to implement suicide prevention interventions that are tailored to the local context. There are currently eight communities participating in the project: Burin Peninsula in Newfoundland and Labrador, Madawaska/Victoria in New Brunswick, La Ronge, Meadow Lake and Buffalo Narrows in Saskatchewan, Edmonton in Alberta, Iqaluit in Nunavut, and Waterloo/Wellington in Ontario. Officially launched on September 5, 2019, the Roots of Hope project will lead to the development of an evidence base, including best practices and suicide prevention guidelines and tools, to support the scale up and implementation of this “made-in-Canada” model across the country.

Strengthening suicide data

Understanding factors associated with suicide in Canadian Veterans

VAC examined suicide mortality trends over a 39-year period, which demonstrated that Veterans had a consistently higher rate of suicide death than the Canadian general population, with young male Veterans at the highest rate. The 2019 Veteran Suicide Mortality Study was released in June 2020.^{Footnote 46}

The following two articles were published in July 2019:

• Group identity, difficult adjustment to civilian life, and suicidal ideation in Canadian Armed Forces Veterans: Life After Service Studies;^{Footnote 47} and
• The Life Course Well-Being Framework for Suicide Prevention in Canadian Armed Forces Veterans.^{Footnote 48}

In 2018 and 2019, 43 projects were approved through the Veteran and Family Well-Being Fund, which encourages innovation and research related to issues Veterans and their families are facing as part of the transition experience to civilian life.

Strengthening Indigenous data

Supporting research innovation in Indigenous communities

Piloting innovation: using AI to detect suicide ideation

PHAC is collaborating with an artificial intelligence (AI) company on a feasibility study that examines the use of AI and machine learning to detect suicide ideation using retrospective Twitter data. Traditional data on suicide mortality and hospitalizations are often delayed or only capture individuals who receive medical care. Social media can provide timely information, and provides an opportunity to improve public health surveillance. Initial results suggest that these types of data tools could be a complementary data source for suicide surveillance. In addition, the development of an accompanying visualization tool as part of this feasibility study has the potential to aid public health surveillance. Risk factor analyses demonstrated that feelings and/or symptoms of depression were the largest factor of suicide ideation. This type of content was mentioned in more than 40% of the tweets where suicide ideation was expressed. Results also showed that tweets containing feelings and/or symptoms of depression were more prevalent during evenings and overnight, and on Mondays, Sundays, and Saturdays. PHAC is exploring potential ways to expand on this initial feasibility study.

Understanding suicide through modeling

The University of Saskatchewan, in collaboration with PHAC, has developed a dynamic model of suicide in Canada, which also applies machine learning, and can be used to simulate suicide deaths as well as the projected impact of several suicide prevention interventions. This model was presented at the International Association for Suicide Research Summit in October 2019 and an article will be submitted to a peer-reviewed journal in the winter of 2021. This model is currently being adapted to simulate suicide deaths during the COVID-19 outbreak. PHAC is also leading a systematic review on universal suicide prevention interventions in high-income Organisation for Economic Co-operation and Development (OECD) countries to inform future suicide modeling. The systematic review was submitted to a peer-reviewed journal and should be published in the first half of 2021.

Undertaking analyses on risk factors

Supporting research to improve mental health services and care

CIHR, in partnership with the Graham Boeckh Foundation, continues to support ACCESS Open Minds, a national project that transforms the way youth (aged 11 to 25) access mental health care by evaluating evidence-informed approaches. For example, Ulukhaktok, a remote community in the Northwest Territories with limited accessibility to professional service providers is testing a model where lay health workers are trained to provide support to youth in distress.

In 2019, CIHR announced the results of the Transitions in Care Evaluation Grant funding opportunity, supporting several research teams focused on evaluating the current supports available for continuity of care for youth with mental health and/or addictions concerns.

V. Going forward

The Framework, and the suicide prevention initiatives under its strategic objectives that have taken place over the last two years, continue to lay a foundation for collaboration across departments and with diverse partners. Our understanding of suicide and its prevention continues to evolve, and the Government of Canada will be focusing on a number of key activities in the years ahead. In particular, we have identified key areas and opportunities to address suicide and its prevention in Canada in the future: increased focus on data to inform our actions; advancing life promotion initiatives with Indigenous leadership, informed by Indigenous knowledge; and implementing the National Suicide Prevention Action Plan for Suicide Prevention.

Improving data

To improve our understanding of suicide, PHAC will explore working with Statistics Canada and other partners to enhance our suicide surveillance system, and address key gaps in suicide data. For example, PHAC will work towards expanding data sources for younger youth (12-15 years of age) to estimate thoughts of suicide and suicide attempts. PHAC will also explore linking various data sources in an effort to decrease data gaps (e.g., linking Canadian Vital Statistics [mortality] data with the census data to examine how various occupations may differ in suicide mortality). Finally, PHAC will examine data sources that can provide real-time data on suicide related outcomes and could act as an early warning system for self-harm and suicide mortality (e.g., crisis line and social media data). Improving this data would help to inform suicide prevention approaches that are tailored for populations with the greatest need, including populations that may experience high rates of suicide or suicide attempts.

In addition, CIHI will continue its work in developing and reporting on pan-Canadian indicators measuring access to mental health and addictions services, which will help identify barriers to care.

Advancing life promotion / suicide prevention strategy for First Nations peoples

The Assembly of First Nations plans to develop a Life Promotion / Suicide Prevention strategy and is currently gathering information with help from its partners, Thunderbird Partnership Foundation and First Peoples Wellness Circle, about the types of strategies that are being implemented in regions. Whereas many suicide prevention strategies focus on youth, a lifespan approach recognizes that there are children and adults who have tragically died by suicide. The Life Promotion / Suicide Prevention strategy will align with the First Nations Mental Wellness Continuum Framework, with a holistic approach guiding the work.

Implementing a National Suicide Prevention Action Plan

To support the development of the Action Plan, PHAC will engage with the Federal Coordinating Committee for Suicide Prevention, as well as outreach to experts, partners and people with lived experiences. Where some of the Action Plan items pertain to the access and provision of services and training standards (for assessment, treatment, recovery and bereavement), PHAC will work with the MHCC, CIHR, and other partners to adapt best and promising practices and resources based on emerging evidence and implementation science. These actions will require further engagement and development between departments, different sectors and stakeholders (e.g., health care, workplaces and media), jurisdictions (e.g. provinces, territories and communities), as well as people with lived experiences.

The Action Plan will also focus on suicide prevention approaches tailored for priority populations with a focus on measuring the impact of these interventions. This will be supported by the development of an evaluation framework that is informed by suicide experts and leaders in Canada. In particular, we have identified the following populations as priorities in the context of suicide:

• Men and boys
• LGBTQ2+ populations
• Racialized communities
• Occupations that may have increased risk of suicide, for example:
  • First responders and health professionals (in the context of COVID-19 pandemic)
  • Construction, trade and agricultural workers.

With respect to the Action Plan elements concerning the needs of First Nations, Inuit and Métis, we acknowledge that these require an Indigenous-led approach that is strengths-based, culturally-safe and relevant, and based on evidence. Some Indigenous-led initiatives are taking a life-promotion approach and focusing on action across the lifespan. Historical trauma and the impacts of colonization, including racism and discrimination, underlie many of the mental wellness challenges Indigenous communities face today. Approaches need to be trauma-informed, support healing of unresolved trauma, and address present day issues. The Government of Canada's response honours commitments to reconciliation and continues to be guided by the Truth and Reconciliation Commission's Calls to Actions, and the Calls for Justice from the National Inquiry into Missing and Murdered Indigenous Women and Girls.

PHAC is working with the National Collaborative for Suicide Prevention, including members who endorsed the development of the Action Plan, such as the Canadian Association for Suicide Prevention (CASP) and Inuit Tapiriit Kanatami (ITK), to prioritize and mobilize actions.

Future reporting

These suicide prevention and life promotion activities will continue to evolve as new and emerging evidence becomes available. We will report on key milestones under the objectives of the Federal Framework for Suicide Prevention in the next progress report in 2022.

Appendices

Appendix A: Motion 174 National Suicide Prevention Action Plan – text

On May 8, 2019, parliamentarians voted unanimously in favour of a national suicide prevention action plan. The Motion M-174 calls on the Government of Canada to:

1. establish a national suicide prevention action plan, including among its provisions:
   1. commitment to the actions and resources required to establish culturally appropriate community-based suicide prevention programs as articulated by representative organizations of the Inuit, First Nations, and Métis peoples;
   2. establishment of national guidelines for best practices in suicide prevention based on evidence of effectiveness in a Canadian context;
   3. the creation of a national public health monitoring program for the prevention of suicide and identification of groups at elevated risk;
   4. creation of programs to identify, and to attempt to fill, gaps in knowledge relating to suicide and its prevention, including timely and accurate statistical data;
   5. development of tools to promote responsible and safe reporting of suicide and its prevention by media;
   6. establishment of national standards for the training of persons engaged in suicide prevention, whose contact with potentially vulnerable populations provides an opportunity to identify at-risk individuals and direct them to appropriate assessment and treatment;
   7. creation of a national online hub providing essential information and guides to accessing services, in English, French, selected Indigenous languages, and other languages spoken widely in Canada for suicidal individuals, their families and friends, people bereaved by a loved one's suicide, workplaces and other stakeholders concerned with suicide prevention;
   8. conducting within 18 months comprehensive analyses of high-risk groups of people, and the risk factors specific to each such group, the degree to which child sexual abuse and other forms of childhood abuse and neglect have an impact on suicidal behaviour, the barriers to Canadians accessing appropriate and adequate health, wellness and recovery services, including substance use, addiction and bereavement services, the funding arrangements required to provide the treatment, education, professional training and other supports required to prevent suicide and assist those bereaved by a loved one's suicide, the use of culturally appropriate suicide prevention activities and best practices, the role that social media plays with respect to suicide and suicide prevention, means to reduce stigma associated with being a consumer of mental health, bereavement and other associated services, and ways in which society can reduce access to means and methods for people to harm themselves; and,
2. report to Parliament annually on preparations for and implementation of the national action plan for suicide prevention, including data on progress over the previous year, and a comprehensive statistical overview of suicide in Canada for the same year.

Appendix B: Key suicide prevention policy developments in Canada, 2006 – 2019

Figure 3 - Text description

The diagram is a series of circles on a line representing a timeline that starts on the left, moving to the right.

2006: Senate Standing Committee (SOCI) recommends federal government support efforts of the Canadian Association for Suicide Prevention to develop a national suicide prevention strategy.

2009: CASP Blueprint for a Canadian National Suicide Prevention Strategy (2004 1st release; 2nd edition 2009).

2012: Federal Framework for Suicide Prevention Act legislated a framework with key action areas and reporting requirement every two years.
Mental Health Commission of Canada releases Mental Health Strategy for Canada: Changing Directions Changing Lives with six strategic directions including suicide prevention.

2016: Government of Canada releases Federal Framework for Suicide Prevention (FFSP) outlining strategic objectives, guidelines and actions.
Amendments to the Criminal Code of Canada replace ‘commit’ suicide with ‘die by suicide’.

2017: Federal Coordinating Committee for Suicide Prevention established.

2019: Parliamentarians voted unanimously in favour of establishing a national suicide prevention action plan (Motion 174)

International: WHO Member States committed to working towards global target of reducing the suicide rate in countries by 10% by 2020 (WHO Mental Health Action Plan 2013-2020).

Appendix C: Additional items related to mental health in the context of the COVID-19 pandemic

Data collection

Evidence review on interventions for alcohol-related suicide

PHAC is supporting an evidence review on interventions that can address alcohol-related suicide, focusing on applying this to the COVID-19 context. This review will summarize original research over the past 30 years. It will also result in a narrative review of policies and programs to reduce alcohol-related suicide, including how these interventions may be applied in the context of the global pandemic.

Additional examples of federally-funded resources related to mental health and substance use during the COVID-19 pandemic

• The Canadian Centre on Substance Use and Addiction has developed resources focused on mental health / mental wellness and substance use during the COVID-19 pandemic on:
• How to identify stress and anxiety and suggestions for positive methods of coping for Canadians and healthcare professionals
• Tips for positive coping and mental wellness during the COVID-19 pandemic
• Promoting the importance of seeking help during the pandemic for people who may be experiencing mental health or substance use issues: infographic. This resource emphasizes virtual services and supports that are available during this time.
• In addition, the following resource describes how the Government of Canada is Helping people who use substances during the COVID-19 pandemic.
• Mental Wellness Support in Indigenous Communities during and after the COVID 19 pandemic, include:
• Hope for Wellness Help Line by phone and chat
• Kids Help Phone, supporting Indigenous youth through text, phone and linking with youth programs
• Non-Insured Health Benefits program's mental health counselling for First Nations and Inuit, delivered via telehealth platforms
• Community-based supports that are being delivered while respecting public health measures and/or that have shifted to telehealth and virtual platforms
• Regional and community-based supports and resources that have been developed to meet community-specific needs and priorities.
• The Government of Canada also provides a list of resources to help Canadians take care of their physical and mental health during the COVID-19 pandemic
• The Mental Health Commission of Canada (MHCC) developed a policy brief to inform policy makers and those in the health sector of the potential impact of COVID-19 on suicide rates in Canada, available at: https://www.mentalhealthcommission.ca/English/media/4403.

Appendix D: PHAC programs supporting mental health promotion among specific groups

PHAC mental health promotion programs act at individual, family, community and systems levels to address health inequities, reduce risk factors, and increase protective factors for mental health. These programs are helping to build knowledge and evidence about the effectiveness of metal health promotion interventions, how they work, for whom, and in what context. While there is evidence that mental health promotion interventions can improve protective factors such as resilience, additional research is necessary to understand the role of these types of upstream actions on suicide prevention.

Mental Health Promotion Innovation Fund

The Mental Health Promotion Innovation Fund (MHP-IF) is a national program designed to test interventions and build evidence on results related to mental health outcomes. It funds population health interventions that promote protective factors and address the underlying determinants of mental health and health equity for children, youth, young adults and their caregivers. The MHP-IF projects' focus is on the design, development, delivery and testing of promising and innovative mental health promotion interventions. Projects operate across multiple sites and jurisdictions to engage participants from a variety of communities including First Nations, Inuit, Métis, newcomer and immigrant, and LGBTQ2 groups.

In particular, the MHP-IF project Qaujigiartiit Health Research Centre: Inuusirvik Community Wellness Hub – Pilot of a holistic, community-centred wellness program model for Inuit families in Nunavut, builds on the existing pathways to wellness to improve mental health by coordinating existing programs into an integrated community-led mental health and wellness service delivery model. This includes land-based programs, literacy programs, early childhood education programs, Inuit counselling services, suicide prevention, and maternal-child health programs. While the project has just begun, progress and results will be shared through the MHP-IF Knowledge Development and Exchange (KDE) Hub, an interactive web-based platform to share lessons learned, connect with various stakeholders and apply new knowledge to a broader policy and system change agenda.

Promoting health equity: Mental Health of Black Canadians initiative

In September 2020, PHAC released a knowledge product titled “Social determinants and inequities in health for Black Canadians: A Snapshot”, which highlights how anti-Black racism and systemic discrimination are key drivers of health inequalities faced by diverse Black communities in Canada.

Projects funded by PHAC's Promoting Health Equity: Mental Health of Black Canadians initiative, launched in October 2018, address mental health promotion and the social determinants of mental health, such as anti-Black racism (internalized, interpersonal, institutional / systemic), education, policing and criminal justice systems, poverty, social exclusion, and/or stigma and discrimination.

Endnotes and References