A photo of Anthony Nauss and his father, Stephen, hangs in the basement of the Nauss family home in Bridgewater, N.S.Photography by Darren Calabrese/The Globe and Mail/The Globe and Mail
Anthony Nauss was 16 the first time he attempted suicide. His best friend, Michaela Maughan, and her mother found him at home alone, his speech slurred, with an empty bottle of sleeping pills. They called 911, and Michaela, just 16 herself, rode with Anthony in the ambulance.
At the hospital in Bridgewater, N.S., a town of 8,500 about an hour’s drive from Halifax, doctors flushed the pills from him system and admitted him overnight. Then they sent Anthony home, telling him to check in with his school counsellor. But Anthony would end up in emergency several more times, says Michaela, sometimes because he was self-harming and had cut his arm so deeply he needed stitches. Once, he was admitted for an entire week and was eventually diagnosed with anxiety, a personality disorder and post-traumatic stress syndrome.
His shtick, even then, was to make dark jokes about “offing” himself. People would laugh, Michaela says; Anthony had comic timing. But if you knew him well, she says, “it was actually him saying he wanted to die.”
Anthony's friend Kaytee Mullins, shown last October, hugs his old jacket at the spot on Nova Scotia Community College's campus where they met.
By 18, Anthony was what medical staff call a frequent flyer. Over the next two years, while attending college in Dartmouth, N.S., he visited the ER roughly 10 times. Michaela, then Anthony’s roommate, took him five times herself. Another close friend, Kaytee Mullins, once sat with him at Dartmouth General while a paramedic stitched up a bleeding gash on Anthony’s forearm, as if he didn’t see the older red lines cross-stitched across his skin. When asked by another hospital staffer what happened, Anthony admitted he had been trying to kill himself. “Try to stay safe,” Kaytee remembers the doctor saying before sending him home.
There are more and more Anthonys showing up in emergency departments across Canada each year, seeking help at the one place in the health care system designed to react swiftly and expertly when lives are at risk. And yet, the response to young people wrestling with suicide is not always expert and, more often than not, it is the opposite of swift.
That’s because the system is ill-equipped to handle them. In the past decade, the number of children and youth in Canada who visited the emergency department for a mental health issue nearly doubled, to 80,000 visits, in 2017-2018, according to statistics released this year by the Canadian Institute for Health Information (CIHI). For all the resources being invested in suicide prevention, it remains the second leading cause of death among teenagers and young adults, after accidents. Now, experts are predicting the fallout of COVID-19 could increase suicide rates, especially if unemployment continues to rise and if a second wave forces the country back into lockdown. Should that happen, the need for treatment based on the best science will only escalate.
If the kids turning up in emergency departments had cancer, they would be wrapped in care. If they were seniors coming in with a heart condition, there would be a diagnosis, a treatment plan, home care following surgery. Yet, for teens who think they want to die – who do, in fact, keep dying in terrible numbers – there is no consistent standard of care. Interviews with more than two dozen parents and young patients who visited emergency due to suicidal thoughts or actions describe a system where help happens randomly. The treatment they get depends on where and when they show up, who’s on duty, whether there’s a bed available, whether hospital staff consider them to be “attention-seekers,” if they have a parent who fights for them.
Wait times are getting longer, too. Thanks to already clogged emergency rooms, teenagers who seek help for a mental health problem wait roughly twice as long as all visits by youth combined, according to data from the CIHI. Compounding the problem, child psychiatrists are in short supply – there are 375 doctors officially identified as such across Canada, roughly one-fifth the number warranted by the total youth population. A recent study by Children’s Mental Health Ontario estimated that provincial wait lists for youth mental health services had doubled, on average, since 2017, with the longest stretching up to two and half years.
Families might wait for hours in emergency, only to be sent off into the night with a suicide hotline number and a pamphlet, and a child who feels even more hopeless. “Unless you have an actual plan for suicide, they won’t admit you,” says one mom in southwestern Ontario. “That’s like saying to a cancer patient, we are not going to do anything to help you, until you are so critical you could die.”
Michaela Maughan poses at Albro Lake Park in Dartmouth, where she and Anthony used to take long walks.
Michaela's mother, Bernie, holds a picture of herself with her daughter and Anthony. The tattoo on her arm honours Anthony and the superhero who gave him his name, Tony Stark, alias Iron Man.
If Michaela Maughan had ever been asked by an ER doctor about Anthony’s condition, she would have had a lot to say. That her friend had a long history of suicide attempts and self-harm. That his parents had separated when he was 10 and that in high school, he came out as transgender – not an easy trail to blaze in a small town. (He chose the name Anthony after Ironman’s Tony Stark.) How graduating from high school meant he no longer had the support of the counsellor who’d helped him the most. How he made so many jokes about dying that Michaela hid the knives in their apartment and searched his room for razor blades. How he was good at pretending he was fine and struggled to follow up with treatment plans.
This is what Michaela would have said – if anyone had asked her. “Every time we went in, it was like he was just a teenager going through life,” says Michaela. “I wish they had taken it more seriously instead of sending him home for another 18-year-old to deal with.”
For a long time, suicide has been perceived as unknowable, even inevitable – a message that experts say has been particularly harmful to people who already feel hopeless. At best, suicidal thoughts were seen as a symptom of mental illness. The thinking was that if a doctor treated a patient’s depression, for instance, those thoughts would go away. But new research has challenged those ideas, showing instead that suicidal behaviour requires specific treatment of its own. And while predicting suicide with precision remains a daunting challenge, there are ways to identify those most at risk and the interventions that can help – if a public health care system is willing to invest in them.
For instance, the risk is higher among LGBTQ youth, those who have experienced childhood trauma, have a history of self-harm and have been diagnosed with a mental illness. Unlike adult suicide, which tends to be linked to financial stress, teenage suicides are often preceded by bullying or social conflict such as a break-up or fight – events adults might dismiss as “teenage angst.” Thinking about suicide is also a major risk factor, as is a history of self-harm.
Many teenagers tick at least some of these boxes as they move through high school; only a tiny fraction will die by suicide. The goal of suicide screening, research now suggests, is to find the mix of risk factors that lead an individual down that path and to catch changes in behaviour that might be predictors, such as withdrawing socially or letting grades slip. Directly asking at-risk teens about suicide is effective care on its own, since having the means to take the fatal step and a specific plan to do so further spikes the risk, and keeping those plans secret spikes it even higher.
The strongest known predictor of suicide is a previous attempt – an act that can look different among young people, says Dr. Brett Burstein, an emergency room physician at Montreal Children’s Hospital. A 10-year-old, for instance, might take three Tylenol, believing the dose to be fatal. An inexperienced clinician might see that as a bid for attention and underestimate the grave intent behind the act.
Anthony and Kaytee Mullins, shown beside a note he left for her.
Anthony Nauss hit many of those risk factors, including one more: The highest risk for suicide is in the weeks and months after a visit to the ER. And Anthony made many visits, including at least three in the second half of 2018.
On Oct. 28, 2018, Carol Mullins woke to a call from Anthony’s boyfriend. Anthony had slashed his wrists and needed a ride to the hospital. Just 10 days earlier, the couple had been to emergency for another suicide attempt. “Make sure they understand this is a not about getting attention,” Anthony’s boyfriend pleaded with Ms. Mullins. “This is real.”
Ms. Mullins, a 45-year-old military veteran and mother of two, had met Anthony in class – both were studying to be paralegals. She drove Tony, as he was known, to school nearly every day and often brought groceries to his apartment. “He had a lot of roller coasters,” she says. “We were at a loss as to how to help him. But we believed in the system.”
In emergency, Anthony was rushed in. The blood was still seeping through his sleeves, and he needed a couple dozen stitches. Ms. Mullins took the nurses aside to make sure they understood that, however he might minimize his injuries, this was a legitimate suicide attempt. “They were very kind to me,” she recalls. “They said they would look after him.” Then she went home; her 12-year-old daughter would wake up soon. Anthony’s medical records show that by the time he saw a doctor, early the next morning, he said he wasn’t suicidal.
He was sent home with a number to call for counselling. When he did, he was offered an appointment in January, three months later.
In a message found later on his phone, he typed: “I don’t have three months.”
Michaela reads through notes that Anthony left for her, listing the reasons why they were friends.
Canada is the only country in the G8 without a national suicide strategy that identifies specific standards for how to reduce suicide rates, mandates governments to implement them and sets benchmarks to prove they’re working. The country does have a general “framework” that has supported some initiatives and research, but there’s no overall funding attached and no timelines to meet, and it is widely seen by experts as lacking teeth.
Meanwhile, other Western nations – including the United Kingdom, Ireland, Denmark and France – have raced ahead, investing many millions of health care dollars into sweeping suicide prevention programs based on the best science and recommended care guidelines available. Those measures go beyond hospitals. But in all cases, the strategies have specifically worked to improve the care people get after walking into an emergency department.
“There are very effective, evidence-based treatments,” says Peter Szatmari, head of the Child and Youth Mental Health Collaborative, a partnership between Toronto’s Centre for Addiction and Mental Health (CAMH), the Hospital for Sick Children and the University of Toronto. “We know about them. But trying to implement them on a wide scale takes resources that are not readily available.”
As Dr. Szatmari points out, physical illnesses have step-by-step standards of care. The same is slowly happening for mental illnesses, too. In the U.K., for example, the National Institute for Health and Care Excellence (NICE) has developed a set of evidence-based guidelines for suicide prevention in emergency department settings, which researchers at CAMH are now working to adapt for a Canadian context.
The U.K. standard-of-care guidelines look like this: A patient arriving in emergency with a mental health issue is screened for suicide risk. Those found to be in danger are assessed by a mental health specialist, who helps them write up a safety plan identifying triggers and coping strategies, and listing contacts to call in a crisis (including a crisis hotline). The plan is then handed out to friends and family.
One of the most important steps happens after the patient leaves emergency: ensuring they get a timely follow-up appointment or having someone check on them once they’re back at home. Research suggests that the simple act of reaching out – by phone, letter or text – with “caring contacts” could be one of the most cost-effective ways to prevent suicide. A 2016 Australian study estimated it could reduce future attempts by nearly 20 per cent.
In interviews with The Globe and Mail, many families across the country often describe this missing piece – a lack of follow-up care – as the hardest part, because it means leaving emergency with no hope and no next step, unless they can figure it out for themselves.
Ottawa mother Shannon MacDonald recalls taking her increasingly withdrawn 16-year-old daughter to emergency after she confessed she was suicidal on the last day of her Grade 11 exams. After hours of waiting, staff said her daughter was not in “imminent danger” and gave her a handout of crisis numbers and websites. On the car ride home, Ms. MacDonald recalls, her daughter began to sob, begging to go to another hospital because “all she can keep thinking about is killing herself.” At the next ER, Ms. MacDonald was told they could keep her daughter overnight, but only on a mental health unit with adults. Her daughter decided she’d rather go home. “We had such bad luck,” says Ms. MacDonald. “We would sit there for hours and just be shown the door again.”
Another Ontario parent describes being handed a sticky note with the number for a help line on it, after her teenaged daughter was given charcoal to absorb the pills she had swallowed. But calling that number, she knew from experience, would only send them back to emergency. “I’m laughing now, because it is so ridiculous. But at the time, it is traumatizing because you are so desperate to find help for your kid.”
In more than one case, parents simply refused to leave without a treatment plan. This past June, Lori Atta’s 10-year-old son drove his bike into traffic – the latest impulsive act that put his life at risk. Her local hospital in New Glasgow, N.S., sent them to the IWK Children’s Hospital in Halifax, two hours away. But the doctors there decided he was well enough to go home. He was admitted only after Ms. Atta threatened to make a scene and posted about it on social media. “I told the psychiatrist he could grab a pen and we could sit down and write [her son’s] obituary” if they were sent home, she said.
Still, most families are reluctant to point the finger at hospital staff, who they see as overburdened and under-resourced. In interviews with The Globe, psychiatrists and emergency doctors also cited the frustration of not having the time and trained staff to handle complex mental health cases in the ER, and the heartbreak of having too few options for patients they know need follow-up care.
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But when care isn’t consistent, it’s also not equal. Instead, it favours patients who live in the right places and have family members who keep pushing – patients like Emily Kowtiuk, an 18-year-old in Ajax, Ont., who went to her local emergency department with her mom, Glenna Wilkins, in 2018. Emily had struggled with depression and anxiety since she was 10, but that evening, while home from university, she told her mother “she wanted to go to sleep and not wake up.” At the hospital, her mother explained Emily’s history of mental health issues to the triage nurse and provided a list of her medications. They were sent back to the public waiting room for hours, with Emily weeping in her seat. When they finally saw a doctor, Ms. Wilkins says, he offered Emily medication to “calm her down.”
Emily refused. “I don’t want to calm down,” she told him. “I want some help.” The doctor said she would have to come back the next day, because the crisis nurse had “finished at 9.” He left the room, Ms. Wilkins recalls, as her daughter collapsed on the floor. “I wanted to join her on the floor sobbing,” she says. “And then it kicks in: I have to get her up and I have to get her home, and I have to keep her safe.” As for Emily, her mom says, she “felt at that moment that her world had collapsed, and no one cared whether she lived or died.”
A few weeks later, Emily’s symptoms escalated again – but this time, the experience was very different. Ms. Wilkins drove her to CAMH, the only 24-7 dedicated mental health emergency department in Ontario. When they arrived, Emily was taken immediately into a private room. The staff removed any items she might use to harm herself – her belt, her shoelaces. A nurse and social worker conducted a long interview. Emily’s answers were deemed serious enough to merit a second interview with another social worker, and she was then seen by a psychiatrist. A follow-up appointment was made one week later, and referrals were made on Emily’s behalf to a therapy program. Her mother and sister also received information on how to help Emily and participated in several therapy sessions themselves. “They took her seriously,” says Ms. Wilkins. “They believed her, and they believed me.”
But Ms. Wilkins wonders, What if her daughter hadn’t been able to wait for that do-over? “We all talk about how important it is to seek help,” she says. “What few talk about is how hard it is to get help when you need it.”
Certainly, that help shouldn’t be contingent on being able to drive to CAMH in downtown Toronto. The goal, then, is to develop system-wide standards that all hospitals and communities can strive to meet – as other countries are already doing.
Ireland has established a standard of care for people who present to emergency for self-harm or suicidal ideation at 24 hospitals across the country and at three children’s hospitals in Dublin. Created in 2015 and overseen by specially trained nurses, the program focuses on training emergency staff; creating better spaces for private assessments; involving family members in treatment plans and educating them on how to help in a crisis; and laying out standard steps for care when a patient is sent home, including a follow-up appointment. In 2017, according to a report published last year in the Irish Journal of Psychological Medicine, based on 11,567 cases at those 24 hospitals, 93 per cent of patients received an assessment, 81 per cent of which involved family members. In 88 per cent of cases, a letter was sent to the patient’s family doctor within a day of the ER visit, and 55 per cent of patients received a check-in call within 24 hours of going home.
In Denmark, a network of suicide prevention clinics provides specific talk therapies found to be effective at reducing suicide. The country also took a number of measures to restrict access to lethal means, including medications, while improving access to psychotherapy and creating specific places for people to seek help. These are considered key factors for why Denmark has not seen the same increase in self-harm cases among youth reported in countries around the world, including Canada.
Similar programs are underway in Scotland and England, which has set a target to reduce suicides by 10 per cent by next year. In Australia, the state of New South Wales – which includes Sydney and has a population of eight million – recently announced an $80-million suicide prevention strategy that includes an organized after-care program and is designed around the aspirational goal that every suicide can be prevented. France is also expanding a national program designed to provide follow-up care to every young person who arrives at an emergency department following a suicide attempt.
These programs aren’t perfect – complaints about a lack of funding are common – but where countries have set clear goals and tracked results, overall suicide rates have fallen.
Absent a publicly funded national strategy in Canada, a number of provinces and territories have taken their own steps to reduce suicide, although they haven’t typically set specific targets for emergency care.
And smaller-scale pilot projects are under way in communities and hospitals across the country. Toronto’s Sick Kids Hospital, for instance, is partway through a small-scale clinical trial to test a talk therapy program designed specifically for youth who arrive in emergency. Researchers hope to test it in other locations soon.
These projects are promising, but they tend to focus on single aspects of care. A new community-wide effort in Sourthern Ontario’s Peel Region, called Project Now, is in the early stages of trying to co-ordinate hospitals, schools and social agencies so youth at high risk for suicide get individualized care and never disappear on wait lists. A successful suicide strategy, suggests Ian Dawe, the medical director of mental health at Trillium Health Partners and an expert in suicide prevention who is taking a lead role in Project Now, would have to tackle not only emergency care, but also what happens well before and shortly after youth arrive there in crisis.
Standardized care doesn’t mean every young patient identified to be at risk of suicide needs to see a psychiatrist immediately or be admitted to hospital. In fact, says Dr. Dawe, there’s no evidence that admitting young patients into hospital and “just watching them” reduces their suicide risk.
But good care does require properly assessing young patients so those most at risk have rapid access to effective talk therapies, interventions that support their families in between appointments and follow-up contacts that prevent patients from getting lost once they leave hospital.
“That is the absolute antithesis of ’Take this pamphlet and go home,‘” Dr. Dawe says.
Ideally, of course, young Canadians struggling with self-harm would get help long before they find themselves in an emergency waiting room. But for the increasing numbers who are seeking help there, says Dr. Dawe, the lack of consistent care is “what keeps me up at night.”
Stephen Nauss sits in his basement with a blanket made from his late son's T-shirts.
Michaela still has a note from Anthony listing 'reasons to stay alive,' whose first item is 'you have forever to be dead.'
On Nov. 3, 2018, just days after his last emergency visit, Anthony Nauss stopped answering texts. At the time, he was living alone; Michaela had moved out in October. His friends went on high alert, calling around to see if anyone knew where he was. Anthony’s boyfriend finally managed to get into the apartment and found him in his bedroom.
When Michaela woke up that Saturday morning, she noticed that one of the notes Anthony had written to her had slipped off her wall and was lying on the floor. He was always doodling messages for her, and she kept them taped up in her bedroom to cheer her up. This one was titled: “Reasons to Stay Alive.” “That feeling when a cat allows you to hold him,” Anthony had written. “7 billion people you haven’t met.” “Bath bombs.” It’s a good list, full of charm and imagination, designed to make his best friend smile. But that was Anthony, says Michaela – he was always better at rescuing other people.
The police officers broke the news first to his mom, Colleen, at her home outside Bridgewater, and then arrived at the door of his father, Stephen. On the phone the night before, he and Anthony had discussed the latest Star Wars movie, out on Netflix. When he saw the police, he knew instantly his son was gone.
This past spring, Mr. Nauss sat down to write a letter to Nova Scotia Premier Stephen McNeil about his son’s death. He described how Anthony had tried to get help, how he had been left to wait for therapy in his darkest moment. He laid the blame on a system that treated his son as an inconvenience. “He was sent home to die, and that’s exactly what happened,” he wrote. “My son fell through the cracks of a failed mental health care system.”
He received a letter back from provincial Health Minister Randy DeLorey, saying a review would be conducted into his son’s death; he is still waiting to hear back.
Like many young people who turn up at the emergency department, Anthony’s case wasn’t simple. He did get help over the years – he spent time in hospital as a teenager, and he was seen off and on by a psychiatrist. When he went to emergency, his friends say, he may not have always admitted how poorly he was doing, and he was conflicted about how much help he wanted – a common pattern for younger patients, who are less likely than older adults to stick to treatment plans. His friends don’t know how Anthony presented to the nurses and doctors who saw him in private, or whether after long waits he even refused the care they proposed. Hospital records from his last visit suggests that by the time he finally saw the doctor, he was no longer saying he felt suicidal. “He probably got discouraged,” his father says. “If I was stuffed in a room for six hours, I would be pissed off and just want to go home.”
But a health care system can’t be designed only for simple cases, especially for a complex and highly individual problem such as suicide. And when young people are self-harming and clearly in distress, how many times do we just send them home? That’s why clear guidelines and standards are important, experts say – to simplify the steps for busy emergency department staff, to give the country a goal, to aim to do better.
After all, Anthony and his friends were following the advice of all those mental health campaigns: ask for help when you need it.
“I don’t understand how someone with a broken finger can get help, but a person with suicidal thoughts just ends up leaving with paperwork,” says Michaela. “He was doing what he was supposed to, and the system let him down.”
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Need some help?
If you need professional counselling right now or are having thoughts of suicide, call Kids Help Phone at 1-800-668-6868, text 686868, or visit kidshelpphone.ca, or Crisis Service Canada at 1-833-456-4566, crisisservicescanada.ca.