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We'll call the meeting to order.
We are meeting today on our study on health services in the Canadian Forces, with an emphasis on post-traumatic stress disorder.
We have bells, I believe, at 5:15 for a 5:30 vote, so we're not going to make it all the way to 5:30. We have two presentations today. I might try to make up a couple of minutes with our first witness to give to our second, but we'll see how that goes. We will certainly make sure everybody has an opportunity to ask a question or two.
We have Mr. Brunet, researcher at the Douglas Institute and associate professor in the Department of Psychiatry, McGill University, to start. Sir, we have you scheduled till 4:30 and we'll see how that goes.
The floor is yours for a presentation, and then we'll open it up to a round of questioning. Go ahead.
:
Mr. Chairman, ladies and gentlemen, thank you for the honour of appearing before this committee.
My name is Alain Brunet and I am a professor at the Department of Psychiatry at McGill University. I specialize in post-traumatic stress disorder. I have submitted a document that my group wrote recently. Over the past few years, the group has analyzed the results of the Canadian Forces Mental Health Survey, which is one of the largest surveys of the Canadian armed forces, or of an active army, ever conducted. Armies are usually quite reluctant to allow researchers to conduct surveys that are as in-depth as the one conducted in 2002. Beginning in 2004, researchers had access to the results, which had been made public. My team, which works in this field, began analyzing the data.
I am going to make a brief presentation on one of the documents that I submitted. I will then answer your questions.
There is very little data on mental health problems in armed forces. Armies are typically very reluctant to allow research of this kind. Therefore, the sample we had access to, which is representative of the Canadian Forces, is truly unique. However, bear in mind that this data was collected in 2002 and that all of the conclusions drawn were based on the premise that things have not changed since, which would be a harsh judgment of the army. I do not think we can make that judgment.
The survey involved 8,441 respondents. It was a large-scale survey, comparable to the best work that is done in the world. The survey was representative of the Canadian Forces.
What are the main findings from this research and, particularly, the data that we published recently? The first finding is that many so-called peacekeeping missions are as stressful, or as traumatizing, as combat missions. The concept of a peacekeeping mission has changed considerably over the past 10 to 20 years. We talk more often about peacebuilding rather than peacekeeping.
I would also like to draw your attention to the fact that, in the general population in the United States, the rate of post-traumatic stress, for example, is approximately 6.7%. It is important to compare the rates of the various disorders found in the army to those in the general population, to determine if they are higher or lower.
The document that I submitted examines behaviours linked to the seeking of care in cases where people had a diagnosable mental disorder within the past 12 months. Of a sample of 8,441 people, we found that 1,220 of them, or 15%, had suffered a diagnosable mental disorder within the 12 months preceding the survey. Of 1,200 people, 43% had contact with a mental health professional. On the other hand, 67% never sought help.
What disorders did these 1,200 people suffer from? Major depression affected 47% of them, alcoholism, 33%, social phobia, 22%, post-traumatic stress disorder, 16%, panic disorder, 12%, and generalized anxiety disorder, 12%.
So the most prevalent disorders were major depression, alcoholism, and a little farther down the list came disorders like post-traumatic stress disorder. Bear in mind that depression, alcohol abuse, phobias and panic disorders may also be triggered by a traumatic experience. If that factor is taken into account, the prevalence of mental disorders triggered by a traumatic event is higher than what this data would suggest.
We also looked at why people with a diagnosable mental disorder were not consulting anyone, particularly Canadian Forces members who have ready access to health care. What are the main obstacles to requesting a consultation? Three main factors came to light. The first is the lack of trust in authorities. The second is not acknowledging they have a mental health problem. The third factor is that while people may acknowledge having a mental problem, they believe that they can overcome it and want to try to deal with it themselves.
We also discovered that before asking for help, 73% of soldiers may have had up to five traumatic experiences, which means more than one deployment. They had been through many traumatic experiences before asking for help.
In light of these results, what can be done when people do not realize they are suffering from a diagnosable mental disorder? One of the things we should think about is more mental health education. People must be better educated so that they have a better idea of what they are suffering from. That is even more important because for most of the mental disorders I mentioned, effective treatment exists. The treatment is not 100% effective, but it is available. We believe that is an aspect that people do not understand. Not only are they not necessarily aware that they are suffering from a mental disorder, but even when they do know, they do not know that effective treatment is available.
Another consideration that emerged from the survey is the notion of confidentiality and the stigma surrounding mental health problems. As regards confidentiality, some participants in the survey felt that the contents of their medical file might come to the attention of their superior officer. Since Canada has an army of deployable people, you can see that if your superior officer were to learn that perhaps you were not as deployable as you should be, that might jeopardize your job. A kind of shame, a macho culture, that could fall under the umbrella of stigma, is also prevalent. It is as if becoming a hardened soldier who puts aside his emotions and everything else and recognizing at the same time that that soldier might be affected psychologically and emotionally by a very traumatizing experience were contradictory. It is as if expectations for soldiers were somewhat contradictory.
I think that committee members should look into the issue of confidentiality. Should confidentiality be improved? To what extent does confidentiality need to be breached? I think that question must be asked.
A final element emerged quite clearly. As regards psychological assessments, we should not wait for people to come and see us to say they may have a problem. Soldiers returning from a mission should undergo mandatory assessments.
Some of these recommendations have already been implemented or are already being tested on a trial basis in the Canadian Forces. However, perhaps some of these initiatives should be taken a little farther.
I will stop here and answer committee members' questions, in English or French.
:
Thank you, Mr. Chairman.
First I would like to congratulate you, Mr. Brunet, because we seldom see studies that are so advanced. I consider myself to be an experienced parliamentarian, because I have been an MP for 14 years, but I am sometimes stumped by certain specific elements of your studies. I would like to ask you some questions about this.
I imagine that you have the same concern as does the ombudsman of the Canadian Armed Forces, who says that the mental health trauma centres should not be located on bases, as is the case in Valcartier, for instance. When they are located on bases, there is less confidentiality, from the moment one is admitted to a mental health trauma treatment centre. Do you believe, as does the ombudsman, that these clinics should be located off base?
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Thank you for coming and giving us this information. I've read through two of the papers and found it very interesting.
My understanding is that the study was done on 8,841, and these were not Canadian Forces who had necessarily come back from combat; they were--for want of a better word--part of the general population of the Canadian Forces, not post-conflict. Out of that, you determined that 1,220 had a diagnosable disorder, and that 67% of them had no treatment or contact with mental health professionals. That's quite startling, I think.
You also made several observations in your article that I found quite interesting. One was in relation to comorbidity. I think other people on the street might call it dual diagnosis. I think it's clear that PTSD has been misdiagnosed as other disorders when there have been diagnoses in the past. So it brings to mind the question of which diagnosis most often comes first: is it depressive diagnosis, drug addiction, or alcohol dependency, and then you discover post-traumatic stress disorder, or does it most often come the other way around?
I also wondered what impact that has on treatment, because I assume, as a layperson, that treatments are different for severe depression than for post-traumatic stress disorder, and different for drug or alcohol dependence than for PTSD. So I'm curious about how that impacts on the treatment.
By way of introduction, my name is Dr. Theresa Girvin. I'm a lieutenant-colonel in the military. I've been in for 19 years now. I have specialist training in psychiatry. I joined the forces 19 years ago while attending the University of British Columbia. Following that, I did my two-year family medicine residency at McGill, and some time later I did the psychiatry residency at the University of Ottawa.
Over my career, I have served at bases as a general duty medical officer in Esquimalt--that's Victoria--then I served in Ottawa with psychiatry specialist training at the National Defence Medical Centre. In my work there, I also provided advice to senior Canadian Forces leadership on matters of psychiatry and mental health. I have also provided clinical care. In addition to Ottawa, I did clinics in Petawawa, Kingston, and Gagetown and I also traveled to other places, including the staff college in Toronto and to Trenton, to teach on mental health topics.
I was posted to Edmonton in 2002 and I now work at the mental health services clinic there. In addition to assessing and treating the CF patients, I provide clinical leadership in psychiatry at the regional level, and I have also participated in national working groups on mental health for the Canadian Forces.
In September 2005, I began advanced fellowship training in forensic psychiatry at the University of Alberta. The year-long course of study there was interrupted when I was deployed to Kandahar from August to November of 2006, and I was able to pick up the last three months of the fellowship and finish that just last November. Although I have the specialist training in forensic psychiatry, my main area of interest and my main area of clinical work is in providing care, assessing, and treating members of the Canadian Forces--my patients--who have difficulties of a psychiatric nature.
That concludes my opening remarks. I'll be pleased to answer any questions you may have.
:
What I would give is just general impressions. There are lots of people going through Afghanistan, so you see more of it.
On the screening that we do post-deployment, we get more coming in, whereas before, as Dr. Brunet's study in 2002 showed, a lot of people wouldn't even recognize they had a problem, so how could they go for help? This way they're recommended for a follow-up, and it's written down. They have to see their MO, they have to go in, they have to get told. So we're seeing a lot more people.
The more we know about the mission, the more people know what to expect. For missions like Rwanda, like Somali, for different tours in the Balkans, I think maybe people weren't expecting those things, and so in some ways it was more difficult for them. The popular perception of what a deployment is like is different now here in Canada, I think, with Afghanistan from what it was on those previous deployments. So a person is probably feeling better supported here in Canada now than perhaps on one of those previous deployments.
:
First of all, thank you very much for appearing before the committee. I particularly like your frankness, it is like a breath of fresh air today. We like getting this type of answer.
I'd like to talk to you about decompression. We see in today's newspapers a report that Canadian soldiers administered a beating to someone living in Cyprus. Of course, this is an isolated incident. If appropriate, justice will take its course.
There was a time when people were sent home immediately after their mission. There were some rather pathetic cases. Does decompression really work? What actually happens? We hear that PTSD does not appear overnight. During the decompression period following a mission, it is impossible to tell whether a person will suffer from PTSD.
How do assess what is done during the decompression period? Is it possible to determine whether there will be more cases? It is true what there are some stressful situations in any mission. However, the mission in Afghanistan is a new situation for our troops—they are experiencing a different kind of stress.
During the decompression period, can you determine the number of cases of PTSD that will emerge?
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No, there aren't laboratory simulations, but there is basic training and ongoing training. Before a person ever gets to the point of being deployed on a mission, they have gone through their basic training, they have gone through the mission training, they have gone through their trades training. All of that is like a screen or series of hoops that a person has to go through and prove their mettle before they're fit for deployment. So that's how it can function, in that way.
Is that exactly why it's constructed? No, the training is provided, and it's provided in a stressful and realistic way to prepare people, because there is some evidence that very realistic and very tough mission-specific training helps decrease the incidence of stress on deployments. So that's one of the pieces, I guess, in which leadership has a very important role in reducing stress casualties, taking care of the basics, for example.
Leadership, in taking care of the basics for the troops, will decrease stress. Stresses on deployment include things like not having enough water early on in roto zero, and physical stresses like that, such as not being able to shower, or these very basic needs that are stressful. These can be addressed, and they are addressed. You were there and would have seen that there are a lot of amenities. I remember that I did one of the first rounds of post-deployment screenings, and one of the best things that a lot of the soldiers described was getting the gym. Then, instead of using whatever they were working out with before—rocks, or whatever—they could go to the gym and work out.
So providing amenities, taking care of the basics, and providing tough and realistic training all go a long way to help reduce stress casualties in the field.