- by Nadine Yousif, Local Journalism Initiative Reporter, Toronto Star

The majority of gun-related deaths in Ontario are suicides by men over the age of 45 who live in rural areas, a new study reveals.

The research, released Monday in the Canadian Medical Association Journal, looks at firearm-related injuries and deaths in the province between April 2002 and the end of 2016. Of 2,700 fatalities in that period, 68 per cent were due to self-harm — and most were middle-aged or older men living in rural Ontario across all income levels.

 “Downtown Toronto is more exposed to violent injuries in young men,” said study co-author Dr. David Gomez. “But every rural Ontario community is touched by suicide, mostly by older men.”

Researchers say there are many reasons behind the disproportionate number of deaths among older men in rural Ontario. Part of it deals with lack of access to mental health services. Other factors include isolation and historically higher rates of gun ownership.

Gomez, a trauma surgeon at St. Michael’s Hospital and assistant professor at the University of Toronto, said he took part in the study — conducted by St. Mike’s and the Institute for Clinical Evaluative Sciences — with hopes of shedding light on the commonality of self-harm using a firearm, and that gun-related injuries aren’t only caused by gun violence or assault incidents.

“A usually underappreciated aspect is how common self-harm with firearms is, and how lethal it is,” Gomez said.

Researchers note that between 2013 and 2017, 16 of Canada’s metropolitan areas experienced an increased rate of firearm-related violent crime. During the same period, there was a 20 per cent increase in the homicide rate in Canada, with almost half of the incidents occurring in Toronto.

Despite this, the study found that rural Ontario, particularly communities in the northern part of the province around Sudbury, have the highest rates of firearm fatalities throughout the province, with most due to self-harm incidents. Just over half of firearm-related deaths occurred in those aged 45 or older, the majority of whom are men. The death rate is also highest among those with a higher income.

This is in contrast to firearm-related deaths due to violence or assault, which occurred in predominantly urban neighbourhoods. Gomez said these firearm deaths typically receive prominent media attention, but those caused by suicide in rural communities are often overlooked.

Gomez said he hopes this research will highlight the need for suicide-prevention strategies in rural areas targeted at men aged 45 and older — a demographic that doesn’t have adequate access to mental health resources, said Dr. Allison Crawford, Medical Director of the Northern Psychiatric Outreach Program and Telepsychiatry at the Centre for Addiction and Mental Health.

“I think we struggle in general with challenges around access to mental health care in rural areas,” Crawford said. “Many are underserved.”

Paul Jalbert, executive director of Canadian Mental Health Association’s Cochrane-Timiskaming branch — which serves an area with one of the highest rates of suicide by firearm in Ontario — said people in his community have access to mobile crisis units, mental health crisis services, walk-in access services and a 24/7 crisis phone line.

But there are still barriers. Many people assessed in rural Ontario across age groups, Crawford said, are already identified by professionals as having mental health concerns. “We realize there’s always going to be a population of people that aren’t identified,” Crawford said.

People in rural areas have a hard time accessing psychiatrists as many practise in urban areas instead, Crawford added. Another barrier is the type of care offered — innovative programs that offer targeted mental health services to older men living in rural areas are sparse, independent and often temporary, meaning they’re not integrated within mainstream mental health services.

One example of a targeted program is Men’s Sheds, Crawford said, a peer-to-peer support network where older men can meet and socialize together while doing a range of woodwork and other activities. The impact of such programs has been measured in research out of Ireland and Australia, which found that participation decreased self-reported symptoms of depression.

Though Canadian branches exist, the ones in Ontario are all located in the southern region of the province. The question remains then on how to test programs like this in northern parts where there are higher rates of suicide, “and then how do we make them a standard part of what’s accessible in rural communities?” Crawford asked.

Jalbert said the isolation of living in those rural communities itself is also contributing to poorer mental health.

“Some of the reasons that can contribute to isolation, amongst many others, can include living in rural areas, a lack of access to transportation, or the lack of opportunities for social connection,” Jalbert said.

Gomez said another factor may be the rate of firearm ownership in rural areas. American and international research, for example, has found a correlation between gun owners and the rate of self-harm by firearm in the community. “Having a handgun or a shotgun or a hunting rifle present allows for the opportunity for this suicide to occur,” Gomez said.

But Canadian data on legal gun ownership is outdated, Gomez said, making it difficult to identify a similar pattern in Canada. The last Canadian gun ownership data publicly available is from 1998. It shows that areas with a population of less than 10,000 have a 34 per cent rate of firearm ownership. That rate drops to 1.2 per cent in cities with more than 1 million people.

“There is a significant need for further study, or greater access to this data,” Gomez said, to further understand if there is a correlation between gun ownership and suicide in the Canadian context.

Other research, both Canadian and international, Crawford said, suggests that depression rates are lower in rural communities, but suicide rates remain higher in those areas.

The significant challenges men face with mental health, however, are not new. Crawford said it is well-established in previous research that men have a higher rate of completed suicide than women.

“That is largely linked to their use of more lethal means,” Crawford said. She added the way people express their distress is gendered, meaning there are cultural norms at play that influence how men deal with trauma or poor mental health.

“Men are also more likely to feel isolated and perhaps less likely to reach out,” Crawford said. “By the time they get to a suicide attempt, it’s perhaps more definitive, and the interventions that we have may not be as engaging for men in that age category.”

This has been worrying as of late with reportedly higher depression rates in the general population due to COVID-19.

Gomez’s research does not include firearm self-harm data from the pandemic, but Crawford said data from Canada’s national suicide hotline show that more people have been reaching out for help since the pandemic began, though access to care could be further complicated by social-distancing measures.

“If our hypothesis is that men in these communities … need a different means to engage, and that’s in-person or through some kind of peer-to-peer support, then that’s a challenge,” Crawford said. “We don’t yet know what impact those changes to services will have.”

If you are thinking of suicide or know someone who is, there is help. Resources are available online at www.crisisservicescanada.ca or you can connect to the national suicide prevention helpline at 1-833-456-4566, or the Kids Help Phone at 1-800-668-6868.

Nadine Yousif is a Toronto-based reporter for the Star covering mental health. Her reporting is funded by the Canadian government through its Local Journalism Initiative. Follow her on Twitter: @nadineyousif_