Suicide-Related Research in Canada: A Descriptive Overview

C. Author's Commentary

The views included in this next section are those of the author. By definition, the commentary that follows is partial and situated. It is recognized that individual readings of this work will inevitably lead to different interpretations and questions and that participants at the February Workshop will bring their own perspectives to the text. The comments that follow are offered in the spirit of a "conversation-opener."

Suicide Research in Canada

Many of the findings generated from suicide-related research conducted in or about Canada have made an important contribution to the national and international evidence base. Furthermore, there are clear signs that a commitment to undertaking high-quality, collaborative, multi-disciplinary research about suicide is driving some important new research initiatives in many parts of this country.

Key questions to be considered include:

• Where are suicide researchers in Canada devoting most of their attention?
• Which research traditions and disciplines are making the largest contribution to the current knowledge base?
• How do Canada's research efforts relate to other international research endeavours?
• What are the strengths on which we can build, and where are the obvious gaps?
• What do Canadian research activities reveal about how the problem of suicide in Canada is being constructed and what are the potential consequences of this?

Canadian investigations have frequently focused on identifying specific risk factors, antecedent conditions, and potential pathways to suicide. Studies have commonly taken the form of large scale mortality reviews or psychological autopsy studies, whereby retrospective analyses of coroners' records and medical examiners' reports are analyzed for themes and patterns, and sometimes augmented with interviews with key informants. These studies have helped to identify statistical risk factors for suicide, and to corroborate international and regional studies. For example, empirically validated risk factors for completed suicide are well established and include: mental disorder, previous suicidal behaviour, family history of suicidal behaviour, impulsivity, and social isolation. Specific populations have also been determined to be at elevated risk for suicide including: individuals with mental disorders, males, youth, elderly, gays/lesbians, Aboriginal individuals, and incarcerated persons.

Interest in the problem of suicide from a clinical or treatment perspective has also been considerable during the period under review. Most of the published Canadian studies undertaken in this area have been devoted to describing the characteristics of clinical populations at risk for suicide rather than to evaluating the specific efficacy and effectiveness of various treatment approaches. Several studies currently underway at the Arthur Sommer Rotenberg Chair in Suicide Studies are specifically concerned with investigating the effects of various psycho-educational, therapeutic, and pharmacological interventions on emotional distress and suicidal behaviours within specific clinical populations, e.g., those diagnosed with borderline personality disorder.

Dominant Research Traditions and Disciplines

Suicide research is firmly rooted in the traditional scientific paradigm where a concern with prediction, control, and understanding is placed in the foreground. Research about suicide is commonly undertaken by researchers located within academic institutions, with the following disciplines furnishing the bulk of studies: psychiatry, psychology, public health, and sociology. Research designs are typically quantitative in nature; in keeping with contemporary trends to articulate and promote evidence-based approaches, the "strongest" studies are considered to be those that employ some form of randomized experimental design. Even though few studies investigating the problem of suicide are able to consistently employ randomized controlled trial designs (due to ethical constraints, the multi-causal nature of suicide, and the challenges associated with studying a low-base rate phenomenon), the RCT is still considered the "gold standard" for advancing knowledge claims.

Suicide is an individual outcome that takes place in a social context and as a result has given rise to two distinct approaches to studying the phenomenon. Individually-focused researchers, such as those conducting biomedical investigations and those examining specific psychological dimensions of suicide, are generally interested in specifying more precisely the intrapersonal and/or individual genetic contributions to suicide. These studies have fairly direct clinical implications for the way we work with suicidal individuals.

At the more macro-level, sociologists, community and social psychologists, and those who work in the area of cultural psychiatry are particularly concerned with the socially situated nature of suicide, and these researchers have turned their attention to the historically and culturally-embedded risks for suicide. These types of investigations raise important questions about the way we construct the problem of suicide, as well as the way in which we plan broad-based prevention programs.

Considerations

Canadian research has provided an important empirical foundation for designing prevention and intervention programs as they have helped to draw our attention to the groups at statistically highest risk to die by suicide. However, given the retrospective character of many of these large-scale mortality reviews, many of these studies have an inherent bias built into them, i.e., since the outcome of suicide is known from the outset, it may serve to over-sensitize researchers to the presence of mental health problems and psychopathology.

Many current investigations into suicide are part of an overall program of research, and several individual projects are being pursued within the context of a larger, specialized research unit, three of which are located in Québec. For example, studies emerging from the Arthur Sommer Rotenberg Chair in Suicide Studies have a distinctly clinical focus, as well as an emphasis on health services research. Meanwhile, researchers working as part of CRISE are bringing a pragmatic focus to their research by collaborating with existing service providers in both the design and execution of their studies. Their studies are explicitly grounded in an ecological tradition that recognizes the multiple, macro-level influences on suicide and suicidal behaviour. Studies like those being led by Gustavo Turecki at Douglas Hospital, McGill University are focused on understanding biomedical and genetic aspects of suicide. Finally, the scholarly work emerging from the Centre de recherche Fernand-Seguin, Hopital Louis H –Lafontaine, brings together a focus on bereavement, health services, and clinical research.

Current Capacities and Gaps

The individual strengths and collective talents of Canadian researchers studying suicide are extraordinary and far too numerous to enumerate in detail. A few noteworthy contributions will be highlighted briefly below for the purposes of identifying some of the unique contributions being made by Canadian researchers to the overall suicide knowledge base.

Resources and Strengths

Canadian researchers are leaders in advancing our understanding of the genetic and biomedical contributions to suicide (Hrdina, 1996; Turecki et al., 1999; 2001). The work of Mishara and others (2000) has also been at the forefront of the field in terms of evaluating telephone-based crisis intervention services. Epidemiological studies on suicide and parasuicide undertaken by Bland and colleagues (Bland et al.,1994) have been widely quoted in the international literature. The contributions made by clinical researchers in Canada (e.g., Links, 2002; Paris, 1990; Sakinofsky et al., 1990) have also been substantial, particularly in terms of increasing our knowledge base about working with suicidal patients with borderline personality disorders and repeat attempters. Adam's scholarly contributions (Adam et al., 1996) regarding the role of attachment and suicidal behaviour have also received international attention. Leenaars' (1999) extensive series of empirical investigations of suicide notes has provided us with unique insights into the suicidal mind. The establishment of the Laboratory for the Study of Suicide and Bereavement in Montréal by Alain Lesage and Monique Séguin highlights the explicit emphasis that will be placed on studying the unique aspects of suicide bereavement, which will fill an important gap in the international literature on suicide. The work of Breton and others (2002) in promoting a more theoretically coherent approach to program evaluation in the suicide prevention field is both timely and important. Research investigating Aboriginal and Inuit suicide in Canada from a developmental, cultural anthropological, and social historical perspective is highly prized here in Canada and elsewhere (e.g., Chandler and Lalonde, 1998; Kirmayer, et al., 1998; and Kral, et al., 2000). The broad psychosocial risk factors and demographic influences on suicide at the population level have been well articulated by researchers in Alberta (e.g., Bagley, et al., 1995; Trovato, 1992), Ontario (e.g., Leenaars, 1995) and Québec (de Man, et al. 1993). Finally, for providing ongoing leadership to the suicide prevention community in Canada and for their role in enthusiastically nurturing the idea for a national research strategy in Canada, it is worth mentioning the special and important contributions of Ron Dyck, Richard Ramsay, and Bryan Tanney from Alberta, and Antoon Leenaars and Isaac Sakinofsky from Ontario.

Gaps

Community action research, participatory research, large-scale multi-site studies, longitudinal research, policy research, knowledge generation and dissemination research, and program evaluation studies rarely appear in Canadian published literature on suicide. Educational research and investigations about suicide from a nursing or social work perspective are also rare, despite the relevance of suicide prevention to these professions. Suicide bereavement and effective clinical responses for those bereaved by suicide has not received a lot of attention by Canadian researchers. Despite the call for more research into prevention programs almost 20 years ago (Health and Welfare Canada, 1987), knowledge in this area continues to be limited. Studies designed to evaluate the effects of specific treatment modalities for suicidal individuals, e.g., cognitive behavioural therapy or dialectical behavioural therapy, are less common in Canada than in other parts of the world.

Few of the published suicide-related studies in Canada are authored by women, racial minorities, or Aboriginal people.

To close this section, it is worth noting that there might be some additional ends that could be accomplished through conducting suicide-related research that could add an important dimension to the traditional focus on "prediction and control." For example, writing from the perspective of health promotion research, Buchanan (2000) suggests that there are at least five other purposes that theory and research can serve, including: making assumptions explicit, understanding, sense-making, sensitization, and critique.

Research as Product and Process

Beyond providing a sound knowledge base upon which to make program planning and intervention decisions, formal research also serves an important agenda-setting function by selectively orienting our attention to key concepts and opportunities for action. In other words, where we focus often determines where we will go, and the focus of Canadian investigations about suicide has, at least to date, tended to place the following issues in the foreground:

• Identification of psychopathology among those who are suicidal
• Recognition of suicide trends at the provincial and national levels
• Determination of specific risk factors among particular high-risk groups (especially youth, elderly, Aboriginal, incarcerated, and individuals with mental disorders), and
• Highlighting of social and demographic influences on suicide.

Findings from these types of studies often get converted into "lists of risk factors for suicide," ranging from broad social influences to individual traits, which are then offered up to clinicians and program planners as helpful guides to suicide prevention practice. While certainly helpful, these types of studies may also have the unintended effect of restricting the focus of practitioners and clinicians to risks, deficits, and psychopathology.

Increasing attention is being paid to protective factors and the creation of "competence-enhancing environments" (Weissberg, Caplan, and Harwood, 1991), as key ingredients in suicide prevention and it is encouraging to note that Canadian program planners and researchers alike (e.g., Greenfield; Manion) are helping to shift our attention toward the promotion of resilience and the building of capacities as important elements in the prevention of suicide.

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