THEBACHA/FORT SMITH
For the past six months, a Fort Smith woman has been fighting to get help for her suicidal teenage daughter who was diagnosed with major depressive disorder.

Italian painter Aurora Mazzoldi painted this acrylic piece titled Depressione in 2007. A family in Fort Smith is questioning the quality of youth mental health care in the territory after going through nightmare experiences with one of their own family members. - photo courtesy of Aurora Mazzoldi

Amy Johnson's child has been prescribed a slew of medications with little warning that the same drugs meant to help her could be exacerbating her condition. Now, after jumping through a number of hoops to get more substantive care, she's questioning the effectiveness of mental-health treatment for youth in the territory.

Johnson's nightmare began last summer when Sarah, her previously happy 15-year-old, began spending time alone in her room and withdrawing from friends and family.

"I thought her actions were kind of regular teenage moodiness," she said. "I wasn't thinking it was anything more until she started cutting herself. Then that was kind of, OK, something more is going on."

Sarah was taken to the Fort Smith Health Centre 10 times between August and January, after incidents of cutting herself or talking about suicide. She was admitted seven times during this time period, but only for a night or two.

"They would just admit her into what they called the bubble room, or the safe room, and that's where she would stay for the night," said Johnson.

"But then we'd go out to reality because we weren't living in a bubble."

If she was kept for more than one night, it was only because her family had begged staff to keep her.

"I think two nights was the most and that was more with us pushing for her, telling them we didn't feel safe." she said.

During that time, Sarah began meeting with a nurse at the health centre about twice a month. Although she told the nurse about her suicidal thoughts and would sometimes be admitted to the health centre, nothing changed.

"If she actually did mention something like drinking bleach, the nurse called me in and said, "You need to get the bleach out of your house if you have bleach,'" Johnson said. 'As much as I could lock up everything at home, I was the only place that was doing that. Even if she got a hold of some money, no one is going to question her if she's going to go buy a bottle of pills, no one is going to stop her. That was my fear all the time."

In September, staff at the health centre prescribed the girl a 10-milligram dose of Prozac - the first of four medications that would eventually become her regimen.

While all of the drugs she was prescribed carry the potential risk of increasing suicidal thoughts, Prozac is the only one that came with a warning from a health-care professional. Health Canada has not approved the use of antidepressant medication for children or adolescents, but a process exists called off-label use, where drugs are prescribed "beyond the criteria set out in the product's approval," according to a report published in 2014 by the federal Standing Senate Committee on Social Affairs, Science and Technology. The report highlights the importance of clinically monitoring children and youth who take these drugs. The Canadian Paediatric Society recommends professionals check in with teens taking antidepressants every week for the first month.

In the NWT, monitoring is usually done by physicians, mental health workers and psychiatrists, a communications representative with the Department of Health and Social Services stated in an e-mail to News/North.

"Monitoring is provided by the family practitioner and the mental health team in between visits to the psychiatrist," stated Damien Healy. "If (their condition destabilizes), the mental-health team or family physician will work with the on-call psychiatrist to make a plan of care."

While Johnson said her daughter continued to see the nurse at the Fort Smith health centre, her suicidal behaviour escalated rapidly. In October, Sarah made her first suicide attempt. She took more than 30 ibuprofen tablets and was medevaced to the Royal Alexandra Hospital in Edmonton. She stayed for two weeks and was sent home with a prescription for a higher dose of Prozac and a new prescription for Abilify, an antipsychotic typically used to treat bipolar disorder and severe psychotic disorders such as schizophrenia, according to Health Canada. It is also a common add-on medication for individuals who aren't responding to other forms of antidepressants.

Abilify also comes with a warning about suicide. However, Johnson said she and her family were never told about it.

"They just explained to me that it would help speed up the effects of the Prozac," she said.

After Sarah's first suicide attempt, health centre staff talked to her about seeing a newly hired psychiatrist at Stanton

Territorial Hospital in Yellowknife who specializes in children and youth.

However, the appointment would only be available by Telehealth, a form of long-distance health care provided by teleconference.

"They were telling us we should do counselling and stuff over telehealth, which I thought was ridiculous," Johnson said.

She told staff her family would take Sarah to Yellowknife to see the psychiatrist in person, even if they had to pay for it out of their own pockets. The health department then agreed to pay for the trip. Sarah met with the psychiatrist once in November with another appointment scheduled to take place two months later. Sarah attempted suicide again at the end of November, this time taking nearly 100 Advil. She was again medevaced to Royal Alexandra where she was kept for a week and her Prozac prescription was again increased.

Sarah saw the psychiatrist in Yellowknife again at the beginning of January. But at the end of the same month, she made a third suicide attempt. She took about 80 Benadryl while at a friend's home, resulting in seizures.

This time, she was medevaced to Stollery Children's Hospital in Edmonton for four days, where her treatment was the same.

"Maybe just a bump up in her medication, they didn't do any sort of counselling there or anything," said Johnson. "She was basically just being watched and sent home."

Sarah was sent home with her dose of Prozac increased once again. She was also given a third prescription for a medication called Intuniv, typically used to treat Attention Deficit Hyperactivity Disorder (ADHD), in consultation with a psychiatrist in Yellowknife.

Johnson said Sarah does not have ADHD but doctors in Edmonton told her the medication could help with impulse control.

Like the Abilify, Johnson said she was never told about a Health Canada warning that Intuniv can increase the risk of suicide and that patients should be closely monitored.

"If they're going to release you home with your kid, then they need to provide more of a direction on what to do, who to turn to, who to ask for help," she said.

Mental-health services in Fort Smith currently consist of two mental health and addictions councillors, two community wellness workers and a clinical supervisor, said Andy Langford, executive director of territorial social programs with the Department of Health and Social Services. Johnson said it wasn't until after her daughter's repeated suicide attempts that she learned of the services available in Fort Smith. Frustrated at Sarah's ongoing cycle of being admitted to the health centre, kept overnight and sent home, her family met with health centre staff and a representative from the department in January. The staff member then told them about a treatment facility in Calgary that Sarah might be eligible to attend.

"At that point I didn't even know social services did any kind of help for families," she said. "I didn't know they did any support for anything like that. So I'm glad that in the end we did get hooked up with them but it took a long time to even know that was a possibility."

After Sarah's January suicide attempt, she was finally sent to the Calgary facility the following month.

"I don't know if they finally realized how serious it was," said Johnson. "I don't know what actually helped with that final push."

In total, Sarah now takes 60 milligrams of Prozac, five milligrams of Abilify, 1 milligram of Intuniv and five milligrams of Olanzapine, another antipsychotic, every day. Johnson said doctors told her the Olanzapine would help Sarah sleep. All of these drugs come with a Health Canada warning about suicide.

Dr. David Juurlink, a drug safety researcher and head of the division of Clinical Pharmacology and Toxicology at Sunnybrook Health Sciences Centre in Toronto, said he couldn't comment on Sarah's specific case, but explained it can be necessary for an individual to be prescribed multiple drugs to help treat mental illness. However, this can also make it difficult to determine whether a person is experiencing side effects.

Daryl Dolynny, a Yellowknife pharmacist and former MLA for Range Lake, said the same.

"It's going to be very, very difficult to create a profile of side effects of normalcy because when you're taking multiple drugs at the same time, side effects could be exacerbated, side effects could be minimized or there could be new side effects created because of the drugs competing for the same receptor sites," he explained.

That's why monitoring is so important, especially in the first weeks of treatment, Juurlink said.

"Patients need to be warned, family and friends need to be watchful for the signs, have ready follow up with their physicians, especially in the first few weeks of therapy," he said.

While Johnson doesn't know if the medication worsened Sarah's condition, she knows her mental health deteriorated rapidly after she started taking it.

"I don't know if it would have got worse anyway ... but it's definitely, in every sense, progressed negatively," she said.

Ken Hudson, president of the Fort Smith Metis Council, is related to Sarah. He said he believes the GNWT is failing the territory's youth when it comes to mental health treatment.

"It's like the kids are walking around with a loaded gun and every once in a while, they get it in their head they're going to shoot themselves. They shoot themselves, they end up in the hospital," he said. "They get no treatment whatsoever, they're just babysat and then released with another shell in the gun, basically."

Individuals aged 15 to 44 are twice as likely to commit suicide than older residents of the territory, according to the most recent NWT Health Status report published in 2011. Youth aged 15 to 24 had a suicide rate of 3.9 per cent per 10,000 people - the highest of any age group in the territory. The risk of suicide doubles for residents in smaller communities at 3.1 per cent per 10,000 people, compared to Yellowknife's rate of 1.4 per cent. There were eight suicides in the territory in 2012, according to the latest numbers from the NWT Bureau of Statistics.

NWT youth can be referred to the Royal Alexandra Hospital in Edmonton if health-care providers determine their needs surpass what is available in his or her home community, said Christine Mummery, Edmonton's director for child and adolescent mental health services with Alberta Health Services. Though it can vary, an in-patient stay is usually about 20 days long.

"Two or three weeks in the hospital is not enough time to actually have a round of, say, cognitive behavioural therapy, which is what we would hope would be carried on back in the home community," she said. "We try to really make sure we're working as efficiently as possible ... it's very intrusive to the child and the family to be away that long."

Hudson has sent a letter to all MLAs condemning the lack of help available to young people struggling with mental illness in the NWT. He believes the territory's new Mental Health Act should have a specific provision for youth. Langford says the health department is currently developing a youth component within the territory's new mental health strategic framework.

"There will be several action plans, one of which will be specific to mental health services for children and youth," he said.

Hudson also said responses at health centres and hospitals for youth exhibiting signs of mental illness should be improved.

"Does it take 10 times for a kid to go to emergency? Does it take three times out to Edmonton? (Are these) the hoops kids have to jump through to get treatment?" he asked.

Right now, Sarah is staying at a treatment facility in Calgary for a 45-to-60 day term. In the meantime, Hudson said families in the NWT shouldn't have to fight like his did to get the help they need.

"There is something that's gotta be done now," he said. "We can't continue to allow our kids to die because we're not acting."

August

Sarah begins showing signs of depression. The teen quits her summer job and begins spending more time alone. She finally reveals she has been cutting herself. Sarah is taken to the Fort Smith Health Centre 10 times between August and January after incidents of cutting herself or for talking about committing suicide. While she is admitted to the centre seven times, she is sent home after a day or two.

September

Sarah is prescribed a 10-milligram dose of Prozac. She and her mother are warned Prozac can sometimes increase the risk of suicide and self-harm in certain individuals.

October

Sarah attempts suicide. She takes more than 30 ibuprofen tablets and is medevaced to the Royal Alexandra Hospital in Edmonton, Alta. She is kept at the hospital for two weeks. Her Prozac prescription is increased and she is given a prescription for Abilify, an antipsychotic that is also used to amplify the effects of antidepressants. Neither Sarah or her mother are warned Abilify can also increase the risk of suicide.

November

Sarah has her first appointment with the psychiatrist at Stanton. Another appointment is scheduled to take place in January. At the end of November, Sarah attempts suicide again. She takes 100 Advil pills and is again medevaced to Royal Alexandra Hospital in Edmonton. She is kept for a week and sent home with her Prozac prescription increased.

January

Sarah sees the psychiatrist in Yellowknife for a second time. At the end of the month, she attempts suicide again, this time taking about 80 Benadryl tablets. She is medevaced to Stollery Children's Hospital in Edmonton where she stays for four days before being sent home with her Prozac increased to 60 milligrams a day and a new prescription for Intuniv, a medication typically used to treat Attention Deficit Hyperactivity Disorder. Again, neither Sarah or her mother are warned Intuniv can also increase the risk of suicide.

February

Sarah is admitted to a youth mental health facility in Calgary. Ken Hudson, a relative, sends a letter to members of the Legislative Assembly condemning what she had to go through before getting help.

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