This past year alone marks the deaths by suicide of three students at the University of Toronto. Their aftermath opened a barrage of criticisms toward the administration for their lax services for at-risk youth. While alarm bells have been rung for increased mental health and substance use services across campus, systemic change has been slow to come.

Indeed, the issue of mental health accessibility for youth — on and off campus, throughout the province, and across the country — remains a pressing policy and health care concern affecting millions of Canadians.

Among the sobering statistics that shroud youth mental health are the following: some 12.6 per cent of people under 18 years of age in Canada experience mental health and substance use disorders, while Statistics Canada cites suicide as the second most common cause of death, after accidents, among youth aged 15 and over. Importantly, Indigenous youth are disproportionately affected by suicide and addiction, and little research thus far has focused on this issue.

Many youth facing mental health challenges avoid treatment

Who are ‘youth,’ anyway? The McCain Centre for Child, Youth & Family Mental Health at the Centre for Addiction and Mental Health (CAMH) roughly categorizes those ages 12–25 within this demographic, though CAMH more broadly includes those up to 29 years old in their definition.

Unquestioningly, this demographic is particularly susceptible to various mental health challenges as they pass through the hoops of development: commencing and finishing a university or college degree or vocational program, navigating the ebbs and flows of intimate relationships, and searching for employment.

Despite numerous treatment options available for youth, many still go untreated. Why is this? The reasons are plentiful: youth’s preference for self-managing, societal stigma, lack of assessments and screening, and even system fragmentation. With these barriers in mind, how can Canada’s health care system improve and cater diligently and efficaciously to youth across the country? 

The solutions, too, are plentiful

When I asked Dr. Joanna Henderson, Director of the Margaret and Wallace McCain Centre for Child, Youth, and Family Mental Health at CAMH, and Associate Professor of Psychiatry at U of T, if mental health services for youth are adequate, or even optimal, her answer was a hard no.

Henderson has worked with many teams and professionals to increase mental health and substance use services for youth. She explained that good services involve “creating spaces for young people who can walk in without an appointment or referral, and access high quality mental health and substance use services as an entry point.”

Long wait times, however, are a ubiquitously understood concern across the health care continuum, leaving young people with few, and often inadequate, options to choose from. The trope of “service delayed, service denied” captures this concern. 

“When young people have to wait for service, several things happen,” Henderson said. “One, the symptoms they were originally presenting for become exacerbated, so they get worse. Two, the impact on their functioning can have significant long-term consequences. And three, the overall [health] outcomes are poorer.”

“From a system perspective, that means our delays have increased the cost of providing care to young people.”

In Canada alone, the economic burden of mental illness is high, with an estimated 51 billion dollars spent per year. This includes “health care costs, lost productivity, and a reduction of various quality-of-life health indicators.”

To be clear, this also means that young people requiring mental health and substance use support resort to emergency rooms where they may be hastily ushered in and out, without receiving thorough long-term care. 

So what do youth-friendly mental health and substance use services look like? Among the many salient features, they are inclusive, safe, confidential, bright, and comfortable. Equally as critical, however, is that they involve consulting with youth for their input. 

“How is it that the whole commercial for-profit industry figures out how to sell their product or their service?” Henderson asked. “You engage with and learn from consumers. We fail to do that in mental health and in health largely.” 

Solutions to increase accessibility of mental health services for youth

The research on this is clear. A cardinal rule for youth-friendly services involves youth actively engaging with the system — from policy development to the implementation of strategies and programs. 

We know that youth-friendly services can benefit immeasurably by having youth co-design these spaces, but we also know that to do so, current systems that feature the old-fashioned clinical model of care, whereby one presents a set of symptoms and is discreetly greeted, treated, and discharged, ought to be neatly folded and set aside for more modern and progressive models. 

An optimal system, therefore, requires a flexible model of care. For starters, it’s making programs visible to youth so that they know where they can go when they need help, and one they can choose to enter and leave as they wish, without the rigidity of a treatment timeline and discharge date.

This includes drop-in visits and telephone conversations, where hours of operation are accessible, such as during weekends and evenings when youth would not need to worry about missing school or work. Artistic and innovative approaches to treatment, emphasizing non-verbal methods of communication such as music and drama therapy, could also be more accessible to youth. 

Additionally, youth-friendly mental health and substance use services ought to be accessible in communities where public transit exists. Costs, too, must be fair and inexpensive, as Hawke and colleagues note in their recently published paper on this topic: “Youth who cannot afford services will not likely access them.” 

Inclusivity mandates changing outreach platforms and engaging with technology to relate to and connect with youth. Social media platforms are pertinent sites of connection, as are websites that are colourful, up-to-date, and practical.

Steering clear from “disease language,” Henderson remarks, can shift the conversation away from pathologizing and lead youth to feel genuinely heard and understood.

Given also the wide range of development during this period of one’s life, youth services ought to be comprehensive and individualistic. There is no one-size-fits-all model, and clumping youth together under a monolithic category fails to address the transient and not-so-transient challenges children and adults experience.   

The solutions to providing youth-friendly services are exhaustive, albeit refreshingly so. It’s good to know that we matter, but it’s perhaps more important to know that the system, warts and all, is gradually shifting to welcome youth input.

This can be achieved by hiring caregivers whom young people can bond and relate to, and expanding our very conceptions of mental health and the unique pins and needles experienced by every young person.

If you or someone you know is in distress, you can call:

• Canada Suicide Prevention Service phone available 24/7 at 1-833-456-4566
• Good 2 Talk Student Helpline at 1-866-925-5454
• Ontario Mental Health Helpline at 1-866-531-2600
• Gerstein Centre Crisis Line at 416-929-5200
• U of T Health & Wellness Centre at 416-978-8030.

Warning signs of suicide include:

• Talking about wanting to die
• Looking for a way to kill oneself
• Talking about feeling hopeless or having no purpose
• Talking about feeling trapped or being in unbearable pain
• Talking about being a burden to others
• Increasing use of alcohol or drugs
• Acting anxious, agitated, or recklessly
• Sleeping too little or too much
• Withdrawing or feeling isolated
• Showing rage or talking about seeking revenge
• Displaying extreme mood swings

The more of these signs a person shows, the greater the risk. If you suspect someone you know may be contemplating suicide, you should talk to them, according to the Canadian Association for Suicide Prevention.

Content warning: discussions of depression and suicide.

The release of Netflix’s 13 Reasons Why has been severely criticized by mental health advocates for potentially harmful depictions of mental illness and suicide, which they say could lead to higher suicide risk among viewers.

These warnings were substantiated by a recent U of T-affiliated study published in JAMA Psychiatry that correlated the release of the series to an uptick in youth suicides in the United States over the three-month period following its release on March 31, 2017.

Results of the study

The study found that the number of reported deaths by suicide among 10 to 19-year-olds in the United States was 13 per cent higher than projected based on a “time series analysis” which took into account pre-existing trends. This is the equivalent of 94 more deaths than expected.

This sudden and significant increase in suicides was observed only in youth, and most prominently in young women, wrote co-author Dr. Mark Sinyor, Assistant Professor at U of T’s Department of Psychiatry, to The Varsity.

“[Our research team] can’t definitively prove that the show caused the rise, but this is precisely what we anticipated we would see if the show was causing harm,” he wrote.

To Sinyor, the results of the study are not surprising.

“This was an unfortunate yet predictable outcome,” he wrote, “because past scientific research has repeatedly established that media dissemination of the kind of content depicted in the show can lead to increased suicide rates.”

Sinyor noted that the series has violated guidelines recommended by mental health experts to media producers intended to avoid irresponsible suicide portrayal.

“The first season of 13 Reasons Why failed to show that suicide most commonly arises from a treatable mental illness,” wrote Sinyor.

“It romanticized the suicide, depicted suicide methods, presented the suicide as inevitable, and even [achieved] positive results in that it appeared to punish those who had hurt the show’s protagonist. It also presented the school’s mental health expert as incompetent.”

“There’s no single reason people take their own lives,” says Netflix

Netflix responded to The Varsity’s inquiry concerning the study.

“Experts agree that there’s no single reason people take their own lives — and that rates for teenagers [dying by suicide] have tragically been increasing for years,” Netflix wrote. “These two studies raise important issues but directly conflict with each other, even though they’re based on the same US government data.”

After inquiring about the second study referenced in Netflix’s reply, which supposedly conflicts with Sinyor’s findings, The Varsity did not receive a response.  

“And they don’t explain the increases [in suicides] for girls in November 2016 and boys in March 2017 — before the show had launched,” continued Netflix.

“13 Reasons Why tackles the uncomfortable reality of life for many young people today and we’ve heard from them, as well as medical experts, that it gave many viewers the courage to speak up and get help.”

To follow up, The Varsity also requested the names of medical experts who have said this to be the case. Netflix did not respond to The Varsity’s request for comment.

Remedies to the potential impact of media involving suicide

To ensure that the entertainment industry observes best practices with the influence it can have on the public, Sinyor urged for greater collaboration between the industry and suicide prevention experts.

He further underscored the importance of sharing messages of hope and distributing information on ways in which to seek help in order to decrease the number of deaths by suicide.

“The overwhelming majority of young people who think about suicide do not die by suicide and even those youth suicides that do occur should always be viewed as preventable tragedies,” he wrote. “That is the message that we need to disseminate.”

“The key is to find and present identifiable stories of resilience rather than stories of deaths. As only one example, J.K. Rowling has said in the popular press that she was depressed and suicidal and sought therapy which she credits with helping her overcome those feelings.”

“There are many other such stories in both celebrities and non-celebrities and we need to encourage the media to help us spread them in addition to crisis resources such as the new national crisis line in Canada.”

If you or someone you know is in distress, you can call:

• Canada Suicide Prevention Service phone available 24/7 at 1-833-456-4566
• Good 2 Talk Student Helpline at 1-866-925-5454
• Ontario Mental Health Helpline at 1-866-531-2600
• Gerstein Centre Crisis Line at 416-929-5200
• U of T Health & Wellness Centre at 416-978-8030.

Warning signs of suicide include:

• Talking about wanting to die
• Looking for a way to kill oneself
• Talking about feeling hopeless or having no purpose
• Talking about feeling trapped or being in unbearable pain
• Talking about being a burden to others
• Increasing use of alcohol or drugs
• Acting anxious, agitated, or recklessly
• Sleeping too little or too much
• Withdrawing or feeling isolated
• Showing rage or talking about seeking revenge
• Displaying extreme mood swings

The more of these signs a person shows, the greater the risk. If you suspect someone you know may be contemplating suicide, you should talk to them, according to the Canadian Association for Suicide Prevention.

Neuroscientists at the Centre for Addiction and Mental Health (CAMH) have found that patients with depression may have elevated levels of a particular protein in the brain, opening a pathway for developing a new type of antidepressant medication.

The research team, led by Dr. Jeffrey Meyer, the Head Scientist of the Neurochemical Imaging Program in Mood and Anxiety Disorders at CAMH, found that the MAO-B protein — short for monoamine oxidase B — was found in heightened levels in the prefrontal cortex area of the brains of depressed patients.

How Meyer’s research team first discovered the protein

The breakthrough of Meyer’s research team that led to this study was the discovery of elevated levels of the MAO-A protein in women who had recently delivered a baby.

Originally, researchers considered both MAO-A and MAO-B as the same protein, MAO, as they both break down the molecule tyrosine. However, medications developed to treat early postpartum depression – a mood disorder associated with childbirth – revealed that despite a 70 per cent overlap in the structures of the two proteins, the medications only affected the MAO-A enzyme.

Neuroscientists have therefore since considered MAO-A and MAO-B to be different types of chemicals.

The link between MAO-B levels and clinical depression

The recent study by Meyer’s research team evaluated images taken from the brains of 40 patients over a period of four years. Half of the volunteers had experienced episodes of major depression, while the remaining 20 were considered healthy controls.

Through positive emission tomography, a type of brain imaging, the researchers discovered that 50 per cent of the patients with depression had elevated levels of MAO-B compared to the healthy individuals.

The patients with depression were found to have, on average, a 26 per cent increase in the volume of MAO-B in the prefrontal cortex region compared to those without the condition. This region is primarily responsible for complex cognitive behaviour, personality regulation, decision-making, and moderating social behaviour and emotions.

The researchers also found a positive correlation between MAO-B levels and the duration of depressive episodes. That is, the longer the depressive episode, the higher the detected level of MAO-B in the prefrontal cortex and other brain regions.

While MAO-A breaks down serotonin, MAO-B promotes cell turnover by breaking down old and excess neurotransmitters, such as dopamine and norepinephrine, chemicals that are responsible for pleasure and reward.

Although this process is essential in maintaining a healthy brain, increased levels of MAO-B can lead to removing too much of the feel-good chemicals, which may lead to depression.

The limitations of current antidepressant medications

Although there are already antidepressants in the pharmaceutical market, they mainly only target serotonin. Meyer pointed out, in an email to The Varsity, that the current medications and treatment options are not effective for everyone with depression.

“While some people respond well to SSRI [selective serotonin reuptake inhibitors] medications half do not. A key problem is that there are subtypes of depression and we need to match treatments to the subtypes of depression better,” wrote Meyer.

There are already drugs on the market that inhibit MAO-B used for Alzheimer’s and Parkinson’s disease. The research team is looking for ways to direct them towards treating depression.

“There are medications purposed for other illness that shut down MAO-B and could be repurposed for depression,” wrote Meyer.

“With this study now in hand, published in what is traditionally the top psychiatric research journal, I am asking the companies that own the patent rights to these medications to use them for depression.”

How the discovery of MAO-B can lead to new antidepressant research

After the discovery of MAO-A, Meyer’s lab has made progress in developing a dietary supplement that would compensate for the sudden rise of MAO-A in early postpartum depression.

They are currently seeking to create a blood test that could detect monoamine type illnesses. This would help identify individuals who would respond better to MAO-targeted drugs as opposed to the usual antidepressant treatments.

“The main steps are to test medications in development and those available for use, (even if indicated for other illnesses) for their ability to shut down MAO-B. Then I would like to see if matching a medication that shuts down MAO-B to the subtype of depression with greater MAO-B would help increase the chance of cure,” wrote Meyer.

“We are also looking for low cost approaches to predict the subtype of clinical depression with the highest MAO-B level.”

Approximately 15 per cent of people are affected by depression at some point in their life and it is the main cause of disability around the  world.

Meyer wrote, “There is great reason for hope because we are increasingly understanding how the brain changes in clinical depression which is creating new opportunities for cures.”

Content warning: Discussions of suicide in the context of treating major depressive disorder.

Ketamine is a promising medication that brings hope to patients struggling with severe depression, offering potential therapeutic effects for those who are non-responsive to standard antidepressants.

The dissociative anesthetic is currently used by physicians and veterinarians to cause fast-acting insensitivity to pain during medical procedures. It is also used illicitly as a recreational drug, causing feelings of disconnection and relaxation among users.

Yet in controlled settings, ketamine also shows potential as a medication to help patients who are suffering from major depressive disorder. In April, a research review by U of T researchers found that ketamine offers significant effects as an antidepressant.

The lead author of the paper, Dr. Joshua Rosenblat, discussed the review’s findings with The Varsity. As a clinician-scientist in the Department of Psychiatry, Rosenblat is currently studying the antidepressant effects of ketamine.

He explained three major effects that differentiate ketamine from standard antidepressants: a different mechanism of action, a rapid onset of effects, and a response in patients who are not positively affected by commonly prescribed antidepressants.

Ketamine affects depression via a novel mechanism of action

For the past several decades, standard antidepressants have worked by affecting levels of serotonin, norepinephrine, and dopamine, explained Rosenblat.

In generalized terms, serotonin is a chemical messenger thought to regulate mood, while norepinephrine controls alertness and arousal. Dopamine affects attention and emotion.

But ketamine affects the brain differently. Rather than targeting these neurotransmitters, it instead changes levels of glutamate – the main excitatory messenger in the brain.

Ketamine’s unique mechanism of action could therefore explain why it may positively affect patients suffering from treatment-resistant depression, who do not respond to standard antidepressants.

Ketamine could provide a more rapid onset of affects, versus standard antidepressants

Ketamine also provides a rapid onset of effects. Standard antidepressants, said Rosenblat, usually take two months of prescribed usage to take effect.

He explained that with ketamine, alleviation of depressive symptoms can appear within two hours of consumption. This is especially promising as an option for patients suffering from suicidal thoughts.

A decrease in suicidal thoughts can plausibly reduce the number of suicidal attempts; however, Rosenblat noted that the evidence is currently too limited to make a conclusion. He explained that studies are lacking, as only a small percentage of patients affected by such thoughts attempt to commit suicide.

Ketamine could also be used for special applications. Depression is very common among patients facing terminal cancer, explained Rosenblat.

“If you were to start them on an antidepressant and they only have one month left to live, for example, [the patients may] only experience the side effects, and never get the benefits.”

Rosenblat is currently leading a clinical trial at Princess Margaret Hospital to research the use of ketamine for improving the final months of life for patients affected by terminal cancer.

The risks and drawbacks of ketamine as an antidepressant

While the prospect of applying ketamine for treating depression is promising, there are several discouraging factors to its application.

To start, ketamine carries the risk of substance abuse. While ketamine is not strongly addictive, said Rosenblat, recreational users of the drug can develop a dependence.

Ketamine may also be prohibitively expensive for potential patients, as it is not covered by OHIP. Furthermore, as a medicine that is only available for research study or private use, it cannot currently be prescribed by most physicians.

There are also limited studies on the rare side effects of ketamine. In the short-term, the main known side effects are disassociation, a daydream-like state, and nausea— which may occur during the administration of ketamine.

“We don’t know what we don’t know,” said Rosenblat. It is unclear whether ketamine may cause rare, adverse reactions in some patients. Long-term side effects of ketamine are also unclear.

Rosenblat therefore does not encourage self-medication for U of T students suffering from mental health challenges, as ketamine is not sufficiently studied.

Only a “very small percentage” would likely positively benefit from ketamine, explained Rosenblat, compared to standard treatment options supported by a much wider body of research.

The future of ketamine research

Although ketamine is not fully studied and is currently only used in special situations, it still brings “a message of hope,” said Rosenblat.

While ketamine is still not approved as an antidepressant, the U.S. Food and Drug Administration has approved esketamine, a structurally similar compound, as a nasal spray antidepressant. This became the first antidepressant of its kind to be used in the United States.

While Rosenblat notes that much more future research needs to be done with ketamine, he agrees that preliminary results are “very promising.” With a new avenue of research in treating severe depression, the future of research in the field seems optimistic.

The Labatt family has recently donated $20 million to U of T to support research into biological causes of depression. This field is regarded as the next frontier of depression research.

The donation has been used to create the Labatt Family Network for Research on the Biology of Depression, which also involves the Centre for Addiction and Mental Health (CAMH) and the Hospital for Sick Children (SickKids), both of which are partners of U of T. The network has established two chair positions at U of T with links to these institutions to further research.

Professor Benoit Mulsant of U of T’s Department of Psychiatry is serving as the inaugural Labatt Family Chair. According to Mulsant, the donation will fund more academic fellowships, help attract talent to U of T’s clinical research effort, and enable mentor residency opportunities. Mulsant’s research primarily focuses on the treatment of elderly people with severe mental disorders. He is also a Clinician Scientist at CAMH’s Campbell Family Mental Health Research Institute.

In Canada, mental health-related research at large receives about one third of the money that is invested in cancer-related research. From 2008–2015, the Canadian Institute of Health Research invested about $44.7 million a year in mental health-related research, compared to $133.8 million a year for cancer-related research.

A myriad of biological factors can result in mood changes and trigger mental health issues. In the human body, the nervous system, the endocrine system, and the immune system work in tandem, and any changes to these could result in behavioural changes that may manifest as depression or other mental health disorders. These changes can be wrought by physical stressors, like changing seasons, or psychological stressors, like abuse.

In 2007, the Labatt family donated $30 million to SickKids to support the Brain Tumour Research Centre and establish the Labatt Family Heart Centre, a facility dedicated to heart research, cardiology, and providing care for children with congenital heart disease.

Plans are underway to establish a $6 million endowment fund to support medical research conducted by U of T faculty members. The endowment, slated to be named the Drucker Family Innovation Fund, was proposed by U of T Professor of Medicine Daniel Drucker and is planned as part of the university’s celebration of the 100th anniversary of the discovery of insulin.

The Drucker Family Innovation Fund will be used to finance an annual grant competition focused on medical research. Those eligible to compete will be U of T faculty members in the Department of Medicine — stationed at either Mount Sinai Hospital or the University Health Network (UHN) — along with all faculty affiliated with the Banting and Best Diabetes Centre. Individual grants as high as $50,000 will be awarded.

As part of the proposal, Drucker has pledged to contribute $2 million, contingent on U of T and the UHN each gifting the same amount. The money invested by all three parties will coalesce into the $6 million endowment fund.

The UHN is a Toronto-based health care and medical research organization affiliated with the university. In addition to housing research facilities occupied by U of T faculty members, its constituent hospitals provide training for medical students and postdoctoral fellows. These researchers would be among the potential beneficiaries of the prospective fund. Due to an existing patent license agreement, the UHN has already benefited monetarily from Drucker’s research.

According to Vivek Goel, Vice-President Research & Innovation, U of T will derive its $2 million from revenue generated by Drucker’s discoveries. Like all U of T researchers, Drucker owes the university a certain percentage of earnings on inventions made using U of T resources; this arrangement is outlined in the university’s Inventions Policy. Thanks to the importance of his work, Drucker’s research has already generated $7.4 million for the university.

U of T’s share of inventions revenue, from inventions that generate over $500,000 in cumulative net revenue, is normally funnelled into the Connaught Fund, which distributes the money to faculty members through various research awards. However, the Inventions Policy allows the Vice-President Research & Innovation to invest this money elsewhere in exceptional cases. “The combination of the generous donation from Prof. Drucker, the level of royalty revenue and the upcoming anniversary represent a very exceptional circumstance,” Goel wrote in a report submitted to the Business Board of U of T’s Governing Council.

The 100th anniversary of insulin’s discovery is significant for the university — it was primarily a team of four U of T researchers that identified the hormone in 1921. Frederick Banting, John JR Macleod, Charles H Best, and James B Collip used a novel experimental technique to discern that insulin, secreted by the pancreas, plays an essential role in diabetes prevention. Following the team’s announcement of its findings, the university helped produce and distribute insulin to diabetics worldwide.

The upcoming celebrations and U of T’s connection to the discovery present a unique opportunity for the university. By capitalizing on the medical community’s excitement, fundraising initiatives might raise more money to finance U of T researchers. This is part of Drucker’s motivation for establishing a fund in honour of the occasion. “Professor Drucker is hoping that when we publicly announce this with the [UHN], it will be the kickoff for [a] much larger fundraising campaign,” said Goel at the latest Business Board meeting.

Drucker’s research has helped to create life-saving treatments for diabetes and other endocrine disorders. His work is closely tied to the research conducted by Banting and Macleod’s team. In addition to being a Professor of Medicine at U of T, Drucker is a Senior Investigator for the Lunenfeld-Tanenbaum Research Institute, located at Mount Sinai Hospital. His research there centres on the physiology of specific hormones responsible for diabetes, obesity, and intestinal disorders. Some of these hormones are known to regulate insulin secretion. Studies conducted by his personal lab have helped produce new treatments for both type 2 diabetes and short bowel syndrome — diseases that affect millions of people across the world.

The university made Drucker an Assistant Professor of Medicine in 1987. By then he was already familiar with the institution, having earned his medical degree from U of T seven years prior. He spent the intervening time receiving clinical training in endocrinology and internal medicine from both The Johns Hopkins Hospital in Baltimore and Toronto General Hospital, which is now part of the UHN. Additionally, he completed a research fellowship in molecular endocrinology at Massachusetts General Hospital.

As the fund has yet to be finalized, the university has not formally announced it. However, in an email to The Varsity, U of T spokesperson Elizabeth Church said that it is one of many initiatives planned. “We are working on university-wide celebrations for the 100th anniversary in 2021, and we will start to share those plans once they are finalized,” Church said.

The Business Board, responsible for conducting periodic reviews of university fund allocation, received information of the proposed fund at its latest meeting. The Connaught Committee, which allocates funds for further research, approved Goel’s reallocation of inventions revenue plan in December.