A Consistent Approach to Suicide Prevention
Dr. Ian Dawe is a Psychiatrist in Ontario, Canada and an expert in suicide prevention. As a Fellow with the University of Toronto’s Arthur Sommer Rotenberg Chair, Dr. Dawe worked with many partners to advocate for the Luminous Veil, the barrier that now successfully prevents suicides at the Bloor Street Viaduct: “Getting people to pause and reconsider their decision frequently results in changed minds.”
As Chair of the Ontario Hospital’s Task Force on Suicide Prevention Standards, Dr. Dawe leads a group of provincial experts, including many with living expertise, to bring effective suicide prevention standards to all of Ontario’s hospitals.
Dr. Dawe envisions a zero suicide plan for Ontario. “The suicide rate hasn’t changed in 15 years—that’s because we haven’t decided to change it together. Like any quality improvement project, you first need a target.”
In 2014, Dr. Dawe was part of a Provincial Taskforce that explored improving care for people with serious thoughts of suicide across 150 hospitals in Ontario The team knew that a systems-level approach would provide residents with consistent clinical delivery and ensure high-fidelity, evidence-based care replicable at scale.
They selected the Zero Suicide Framework.
The Fifth Element – Treat
In 2016, Dr. Dawe took a position at Trillium Health Partners in the suburbs of Toronto as Program Chief of Mental Health. Trillium serves the most populous and ethnically diverse catchment area across three hospital systems: 2,000,000 people and 130 mental health hospital beds. Dr. Dawe continued to pursue the Zero Suicide Initiative. He also had the opportunity to attend a conference in Sydney Australia in 2017 where Dr. David Jobes gave a presentation on the Collaborative Assessment and Management of Suicidality (“CAMS”).
Trillium had previously invested in DBT, which was used to treat addiction, depression and other acute cases.
CAMS was different. It was suicide specific.
Dr. Dawe saw the benefits of the documentation and structure of the CAMS approach so that “patients with serious thoughts of suicide wouldn’t get [his] version of treatment; they would get a consistent version of CAMS.”
Partnering for Greater Patient Care
Active patient involvement is essential to patient-centered care for Dr. Dawe: “Patients and families are the experts—they have living expertise. We have training and compassion. When we collaborate with patients and each other, we create real change.”
He is a strong believer in meaningful partnerships that benefit patients, including aligned mental health care. “We are all of us—physicians and patients—so much better when we work together,” he says. “In both my patient care and administrative duties, I have endeavored to empower patients and their families to be actively part of the process, to make better decisions—this enhances their care.”
CAMS gave Dr. Dawe a blueprint to take to his team. CAMS shares the philosophy in which the patient is the expert in his/her own suicidality. The clinician has the knowledge, and together the patient and the clinician collaborate to create a treatment plan.
Elevating the Standard of Care
The Emergency Department “is still the biggest entry point for care, and yet hospitalizing patients and watching them didn’t do anything. It probably made it worse,” said Dr. Dawes. “The old way didn’t work!”
Trillium established a CAMS Clinic in September 2020 which is open 9 AM to 8 PM, six days a week. During the pandemic, people have not been seeking help in person as much, so the clinic switched to using telehealth for all 69 cases since it opened. Not everyone presents as suicidal during regular clinic hours, so it is imperative that each person receives the same standard of care regardless of time of day.
Dr. Dawe and his team believe that doing suicide care well is a treatment unto itself.
Step 1 – Admission to the ED and the Columbia Short Screener
The goal is for a suicidal person to be seen as quickly as possible, although people seeking mental health care often find themselves subordinate to the demands on the medical staff to treat physical health crises. When the patient is seen by a doctor or nurse, the medical staff are trained to use the Columbia Short Screener with its six questions. It takes roughly four minutes to administer. There was no singular reason for selecting the Columbia; the goal was to choose a single approach and implement it well.
Step 2 – The Crisis Team
When someone screens as suicidal, the crisis team gets involved, and a psychiatrist consults with the patient. Depending on the evaluation, patients may visit an urgent follow-up clinic or, in less acute cases, the CAMS Clinic. Many patients are hospitalized overnight because it provides a safe place, allowing the crisis team and the patient to re-evaluate the plan the following day.
Step 3 – The CAMS Clinic
The CAMS Clinic reaches out to the patient to set up an appointment 48 to 72 hours after the overnight stay. Then the treatment journey begins. At every step along the treatment journey, the patient receives the Columbia Short Screener. The rating scale on the CAMS Suicide Status Form, while not perfect, provides a judgement of patient progress that is more concrete than a gut feeling and points to how the patient improves over time.
Step 4 – Social Services
As a patient’s distress decreases and their hope increases, social services assist with job and food insecurity, housing, legal help and more to build a life worth living.
The Trillium approach is applied consistently while allowing for treatment tailored to the individual. The process is rapid and handoffs between providers are closely monitored.
Training in CAMS
The training and support in CAMS have been excellent. Dr. Ray Tucker, who led the roleplay training and consultation calls, is part of a system of care at Our Lady of the Lake in Louisiana that uses CAMS across psychiatric inpatient units, geriatric inpatient units, psychiatric consult services, and outpatient care at its Regional Medical Center in Baton Rouge.
Grand Rounds with Dr. Jobes was another highlight in Trillium’s training and implementation process.
Other hospitals in the region are aware of the traction at Trillium, which is the region’s Implementation Science center. Dr. Dawe believes it is only a matter of time before a growing number of Ontario hospitals implement CAMS at scale.