What ER visits for self-harm reveal about Ontario's mental-health system

New research shows that more young people are visiting emergency rooms for incidents of self-harm. Experts say that we’re not giving them the support they need — and that the system needs to change
By Brianna Sharpe - Published on June 26, 2019
Emergency room signage
According to a recent study, rates of self-harm visits in Ontario more than doubled between 2009 and 2017, from 1.8 youths per 1,000 to 4.2 youths per 1,000. (iStock.com/Kameleon007)

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When Gloria Nelson found her stepdaughter’s half-written suicide note, in 2014, she knew it was time to seek professional support.

Alexis Nelson was in Grade 8 and had moved from her mother’s home in the Niagara region to live with her father and stepmother in Toronto, switching schools in the process. “It was a pretty rough transition,” says Gloria. (Their names have been changed to protect the family’s privacy.) “She felt like an outsider — her social anxiety kicked in.”

They went to their family doctor, and Alexis admitted that she had also been harming herself. Her GP referred her to a youth outpatient-therapy program, where she was prescribed antidepressants. For a time, her mood stabilized.

But in 2015, she moved back in with her mother. She no longer had a family doctor or additional mental-health supports. “She took herself off Prozac because she was too embarrassed to take it around friends,” Nelson says. “Later in the school year, she asked to be taken to the hospital because the suicidal ideation and cutting were so bad.”

That emergency-room visit was part of a rising trend: according to a recent study in the Canadian Journal of Psychiatry, although rates of self-harm visits fell in the province between 2003 and 2009, they more than doubled between 2009 and 2017, from 1.8 youths per 1,000 to 4.2 youths per 1,000. The increase was especially pronounced in girls: both sexes experienced an increase, but female visits rose at a rate almost five times faster than that of males. Experts say that the findings highlight flaws in the province’s mental-health system — and that change is needed if it is to meet the needs of youth with mental-health issues.

“Anyone who has any involvement in child mental health, at least in North America,” says lead author William Gardner, a professor of epidemiology and a research chair in child and adolescent psychiatry at the University of Ottawa, “is very conscious of the increase in adolescents who have been coming into the mental-health system through various routes, often with self-harm of some kind.” Even so, he says, he and his fellow authors “didn’t expect just how big the recent increase has been.”

The study identifies a number of factors that could have contributed to the steep rise. Smartphone use has contributed to the increasing ubiquity of social media, which may affect rates of self-harm “by normalizing it, by triggering it, by eliciting emulation of self-harming behaviours, or by exposing youths to cyber bullying.” And as social media can also work to destigmatize mental health, it adds, more youth may be encouraged to seek help. The authors also suggest that family discord resulting from the 2008 recession may play a role.

Research indicates that many of these young people end up in ERs because they have nowhere else to go. The Mental Health Commission of Canada estimates that 1.2 million young people across the country suffer from mental-health concerns — yet only 20 per cent of them find appropriate supports. In some parts of Ontario, young people can wait up to 18 months to be seen by a mental-health professional or agency.

While emergency departments are crucial for dealing with crises, Gardner says, they “don’t have reliable and effective ways to take a family who’s come in and successfully connect them with outpatient care in the community. And that’s a problem.” And, although community-based mental-health follow-ups have been shown to reduce subsequent self-harm, Gardner notes, such resources can be difficult to find and access, especially in rural areas.

“Part of the missing link,” he says, “is that it would be great if there were effective, easy-to-use databases that have comprehensive catalogues of services available in any given region … Provinces would need to be investing.” He’d also like to see doctors, nurse practitioners, and others involved in primary care receive better training on mental health and self-harm.

Kimberly Moran, CEO of Children’s Mental Health Ontario (CMHO), has first-hand experience of the system. “When my daughter was 11,” she says, “she became sad, and we reached out for help, and there were huge wait times. Within two and a half months, she went from sad to depressed to suicidal, and we were one of those people in the hospital rooms.” Her daughter, now 19, eventually found the support she needed and is now studying nursing. In Moran’s view, the situation hasn’t improved for young people with mental-health needs. “It doesn’t make any sense to me that you should have to wait until your child is in crisis, whether that’s self-harm or suicidality, to get care.”

One obvious solution, Moran says, would be to provide more funding for mental health, so that professionals could keep up with the demand in services. “The current government made a commitment of $3.8 billion over 10 years for mental health and addiction,” she says. “It’s been more than a year now, and we still haven’t seen a big investment to reduce wait times for mental health for kids and families. We’re working closely with government to make that happen, but we need them to move on this.”

Travis Kann, a spokesperson for Christine Elliott, Ontario’s minister of health and long-term care, told TVO.org via email that the province “is investing $30 million for child and youth community mental health services and programs” with the intent of reducing wait times. The CMHO, however, estimates that it would take a yearly infusion of $150 million to bring wait times down to 30 days.

Kann emphasized that the government is investing $27 million in mental-health supports in the education system. Almost 40 per cent of Ontario’s 11,000 students from grades 7 to 12 report experiencing depression or anxiety, according to a two-decade-long study by the Centre for Addiction and Mental Health. But Moran worries that “the situation is only going to get worse,” citing the Tories’ education budget, which has brought support-staff reductions in some boards. Layoffs, Moran says, “might have a potential impact on keeping schools mentally healthy and identifying kids who need mental-health services.”

According to Mark Sinyor, a psychiatrist at Sunnybrook Health Sciences Centre and an assistant professor at the University of Toronto, young people need to be shown “more effective and healthy coping strategies, so that [they] never self-harm in the first place, or to replace the behaviour once it starts.” He suggests that youth be encouraged to build a “toolkit” of personalized coping strategies that could include distraction techniques, meditation, and breathing exercises, adding that if they are also taught how to navigate the health-care system and access primary care, they’ll be less likely to seek help at emergency departments.

Gloria Nelson believes that Alexis, who still struggles with mental-health issues, would benefit from more supportive social connections and coping mechanisms. “I do think there’s a real issue with isolation,” she says. “They text, and they snapchat, and there’s not as much in-person communication.” But she’s proud of her stepdaughter, she says, for having “recognized that she was in trouble and being able to ask for help.”

Correction: An earlier version of this article misstated the source of the study on youth self-harm. TVO.org regrets the error.

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