Thank you, Mr. Chairman.
To speak of a topic as weighty as operational stress injuries in a brief ten-minute span is not an easy thing, especially for a former general who has now become a fledgling politician.
I'm going to do a quick overview in order to leave the time needed for questions, when the topics of particular interest to you can be broached in greater detail.
I know that prior to this, other committees of the House and of the Senate have studied post-traumatic stess. However, it is a fact that studies require revisiting and updating. And so I congratulate your committee for having undertaken this study of injuries sustained in combat or conflict. These are not diseases, but truly operational injuries, and they should be treated with the same urgency and empathy as physical injuries, that are often easier to detect.
The stigma of having an operational stress injury within a very Darwinian organization like the forces has taken a fair amount of time to make its way into the acceptability, in the culture of the forces, that someone who is injured between the ears--not overtly visible--has the same requirements of urgency and need of care and return opportunities to either full employment or partial employment, or the support from Veterans Affairs, as someone who has any other physical injury. It took us years to simply identify this as an injury. From the minute we mentioned mental health, everyone went running. No one wanted to live with that stigma, which exists still today in the civilian world.
I'll provide a very short history before we can go to questions. Prior to 1997 we had one small clinic at National Defence headquarters that was at about 40% capacity. I was then chief of staff of the assistant deputy minister of personnel and was responsible for all of the medical staff and that clinic, which fell under my authority. It became evident that we were missing the boat in regard to this injury, with an increasing number of family breakups; of early retirements due to pressures from family; of increased substance abuse, including alcohol; and of increased discipline problems, even to the extent of a number of excellent soldiers all of a sudden seeming to turn bad and ending up in front of judges and prosecutors, who couldn't figure out why such circumstances had arisen.
In 1997 I was to present a report to the media that essentially said that although we had a raft of suicides.... Remember, ladies and gentlemen, we really started this new era with the Gulf War, and so we are talking about 1990-91. By 1997 we had troops in Bosnia, Rwanda, and Somalia. So we already had a fair amount of visible casualties, but certainly a lot more non-visible casualties, by 1997, and we had adjusted nothing by that time. However, the report that I was supposed to present said specifically that the 11 suicides over the past were not directly related to operational stress. There were said to be a whole variety of other reasons that all of a sudden simply got exacerbated by the fact that the member of the forces was deployed and was predisposed ultimately to maybe taking their own life.
I refused to recognize that as a reality and started a campaign after becoming assistant deputy minister of personnel of looking, with Veterans Affairs Canada, at the whole arena of operational stress and “PTSD”, as we finally had it coined, recognizing the fact that PTSD could be a terminal injury. In so doing, the care, the therapy, the institutions, and the recognition by the chain of command and the forces of this injury had to make a massive leap forward, or we were simply going to continue to lose a lot of very good soldiers, sailors, and air persons not only because they were injured but also because the impacts on the families were simply not sustainable. We were going to lose our shirts with regard to our enormous investments in very qualified people who, after one or two missions, could not continue to serve or who had become administrative discipline problems, ending up in jail, or worse, with some of them killing themselves.
We have been at it for 13 years now, and over that time there have been numerous initiatives at both National Defence and Veterans Affairs. In early 1998 I was able to have a brigadier general transferred to Veterans Affairs as liaison instead of a lieutenant colonel. His name was Pierre Boutet and he'd been the judge advocate general.
For five years he and an assistant deputy minister called Dennis Wallace worked on a massive reform inside Veterans Affairs for the recognition of this injury, but also the recognition that they were in a new era where they were going to pick up casualties, versus the era of anticipating simply losing clientele due to the previous wars.
Larry Murray, an ex-admiral of the forces, became deputy minister of Veterans Affairs after 2000. He continued this significant review that ended in 2004 with the Neary report, which I participated in tabling with him. It recommended that we have not only a new Veterans Charter, but a new way of looking at the casualties and their care.
We've now created clinics. Both Veterans Affairs and National Defence have clinics. We've created joint offices to exchange information, although the computers still don't talk to each other, so there's still a major problem in medical documentation. We have moved into the arena of prevention before deployment.
My son was on a ten-week course for recruits in Saint-Jean. They had a three-hour session with a new-generation veteran who suffered from PTSD, but who was part of the peer support structure. My son said it was the most riveting three hours of the course. The next day four guys quit because they felt it was too much. This whole preparatory exercise has matured, and still needs to be worked on.
There's the in-theatre recognition of casualties, and actually deploying therapists into the field. In 1992, when I commanded my five brigades and had troops in Bosnia, I mentioned that we should have some of that sort of scientific knowledge there to pick up the casualty data. It was said to be unnecessary. We have rectified that.
I think the strength right now is in the coming home and recognition of those who are casualties. The system that is now in place is pretty sophisticated in identifying those who might be at risk. The question, however, is what do we do beyond that recognition? In particular, what are we doing about the reservist who has gone back to Matane, is 500 kilometres from the nearest base, 200 kilometres from the nearest hospital with any real psychiatric capability, and is isolated out there after serving maybe up to 18 months in a high-intensity operation, and maybe more than that due to multiple deployments?
The risk arises when the soldier returns home. Preparation in the theatre of operations can always be improved, but the risk arises when the armed forces member returns home. We have to see what can be done to minimize the consequences of this injury for the individual, to convince him to seek therapy and take medication. It is important that he or she receive support from peers. Families must be helped to understand the individual who comes back injured, and care must be taken to prevent substance abuse, and to prevent the individual from committing criminal acts and winding up in jail. And ultimately, the person must be prevented from committing acts that could lead to suicide.
I will give you a short anecdote, if I may, to indicate that if you're studying operational stress injuries and the impact thereof on the forces, it is essential that you study the families also. When I returned from Rwanda, my mother-in-law said that she would never have survived World War II if she'd had to go through what my family went through. My father-in-law commanded a regiment in World War II. The whole nation was at war, so everybody had something to do with it. There was very little information that was let out, and even the technology of that time was quite limited.
In this era, however, the families live the missions with the troops. They are continuously zapping every communications means they have in order to find out if we've been killed, injured, captured, if the mission has gone sour, about any frictions there might be. So when you return from missions, you're not returning to a household that “held the fort”, as it historically used to be called, but in fact you're returning to a family that has already gone through significant stresses of seeing what's going on but not necessarily being able to influence it. I must say, though, that the availability of the Internet and those communications have alleviated somewhat the distance between the troops in the field and the families.
So we are now at the stage of looking into the future. Last week I was at a symposium in Montreal, an international symposium on operational stress, that was led by Veterans Affairs and an international body now garnering more and more data and building the capacity in regard to research on this injury, the sources of it, and the means of attenuating it.
I also was two days ago at a forum in Kingston called the Canadian Military and Veteran Health Research Forum--led by Queen's and RMC--that was meeting one criteria that I was most fearful of maybe falling through the cracks. Afghanistan was supposed to end in 2011. We will end the combat element, but we will still have troops in the field and potentially in harm's way, so we will continue to have need of support. But it was feared that as we tone down that mission, we would also start to tone down the needs of the casualties, and Veterans Affairs Canada and DND would not recognize that the girls and boys who have done three or four tours are now going to come down from that adrenalin high. The impacts of those missions are going to start to hit them as they come back to a certain level of normalcy, and that's when operational stress comes in spades. So you're going to have a significant increase of those and their families who have now so far been able to sustain it.
The other thing is that we started with nothing in 1997. I went to the United States veterans affairs clinic in White River Junction, Vermont, to meet the head of that. His name is Dr. Matthew Friedman. I asked him to help us build ours, because they'd had Vietnam and we'd had nothing of real significance except a bit of Congo, a bit of Cyprus, since Korea. There was no depth in our capabilities.
They readily helped us. They gave us a statistic that was interesting, and I'll end with that, before we go to questions. They told us they didn't want us to go through what they had gone through in the Vietnam War. On that black wall in Washington, there are 58,300 names of those who were killed in theatre in Vietnam. However, by 1997, 22 years later, they had on the books, for those they were able to record, just under 102,000 suicides directly related to the Vietnam experience.
So how many real casualties did Vietnam cost them? Was it 58,000, or was it maybe closer to 160,000?
I ask you the same question: how many real casualties have we taken? Is it 152, or maybe 170 or 175? I can tell you about my mission in Rwanda; I had casualties in the field, and two years ago, 14 years after the mission, one of the officers committed suicide.
Ladies and gentlemen, you're into a subject of enormous import to those who are serving and to their families. I would contend it's also of enormous import to the operational sustainability of the Canadian Forces in order to keep the experienced troops healthy and able to sustain such injuries.
I'll respond with a couple of points.
For those who remain in the forces and go through a process of follow-up at three months and six months--my son came back six months after a tour of duty in Sierra Leone and went through the process--although they may be identified with PTSD at a different level, which is essential to identify early, the availability of care is not necessarily immediately there. So with the follow-up, the care, there's a deficiency, both on civilian street but also with the military, although both DND and VAC have increased the contractual arrangements to get more therapists available.
One of the downsides is that we're not putting enough emphasis on psychologists versus psychiatrists. I like to use the analysis that if a person puts their hand on a burning stove the psychiatrist will give you the pills and so on to attenuate the pain and to try to watch it heal. The psychologist is going to ask why you put your hand there in the first place.
The deficiency is not in giving them that initial stabilizing, and in some cases creating zombies; that stabilizing effect by therapists is more and more available, and it comes out. It is in fact the therapeutic side of bringing them back to a level at which they can sustain a reasonably normal life--i.e., build their prosthesis to live with--because that's what you have to do. So it's professional therapy, medication, and accepting that.
Then the third one is peer support. That is to have someone there between those sessions who's willing not to ask any stupid question but to listen for hours, to let you talk. Rarely is it the family, because they're too close. My family hasn't even read my book. It can be uncles, peers, and so on. In building of the peer support, recently Veterans Affairs opened up their peer support for families, which is interesting, and for children it would be needed.
There are processes in motion for those in the regular force. Those in the units are staying within a cohesive group, like in a regiment. But there are a lot of individual augmentees, who end up all over the forces, who are not necessarily followed up on because nobody else in that unit has gone there. There's not the same concern by the chain of command on the follow-up of the individual, or the leadership won't even understand what the problem is. In so doing, they can fall through the cracks.
However, the greatest deficiency is with the reserves. For the reservist who ends up in all kinds of villages across the country and decides to quit, there is very little follow-up on how they're being taken care of. That's why you're ending up with more soldiers in front of the courts. You'll see a lot of reservists there because they've been nearly abandoned.
That is a great deficiency for the reservists. We are counting more and more on them to be operationally capable, which is a whole world of difference from what we were doing in the seventies and the eighties, when we thought them to be the mobilization base during the Cold War.
In 1971 they had a plan called “Restore”. That was when we massively cut, hugely cut, the forces. We offered people a golden handshake, even people who had been Korean vets, and we let them go, like that.
Within three years, we were getting reports that a lot of them had died. It was not suicide; they had simply died of broken hearts, because they entered a world they didn't understand, and they were abandoned.
One of the areas looked at, and which we were seeing as a deficiency, was that being released from the forces and handing in your ID card and your uniform doesn't mean that the forces are out of you. When you instill loyalty, it stays ad vitam aeternam. What you need is a bridge to the next entity, in a sort of paternalistic way, to continue that loyalty you've committed to, particularly if you are a veteran, particularly if you've been in combat, have actually been injured, and have seen people killed. And there was no bridge. They were dropped off the forces, and they had to climb their way back into the veterans system, and then the veterans system took them as they could within the old system.
That process of rehabilitation and reintegration was introduced with the new Veterans Charter, but not many have taken them up on it. One of the interesting reasons is that not many of them have actually been released yet. A lot of them, particularly those from the Afghan war, are still in the forces. When they start to be released after their accommodation period of three years or sometimes four years, we're going to see whether that rehabilitation and reintegration program Veterans Affairs has built to pick them up before they leave--in fact, they're looking at six months beforehand--and help them through that transition to civilian life is going to work.
It's interesting; there was an article today about an interview I did yesterday. With the universality of service, the forces can't keep them, because there are too few to do the job to start with. But you might want to create a sort of subservice, where people who are injured can remain in uniform, maybe under different conditions. They can continue to serve in different jobs, because they have skills and experience, and not necessarily be released out. In so doing, you'd minimize, in fact, that trauma of moving to civilian life. Some don't want to see a uniform anymore and are happy to get out, but others simply want to stay on.
The forces would have to get an extra sort of manpower level, or person-power level, to absorb them, because what will the number be? Post-Afghanistan, there may be 1,500 to 2,000 who are significantly injured, not including all the post-traumatic stress. And we must remember that from 1991, with the Gulf War vets, whom we have treated rottenly, right through to 2006, when we started to bring in the new Veterans Charter, we have taken a lot of casualties. More than 10 were killed and more than 100 were significantly injured, and a couple of thousand were psychologically injured, everywhere from Somalia to Rwanda to Bosnia, and so on. That gang is sort of feeling a bit left out. Yet only with the changes we've seen today, with this coming legislation, are they going to start to be able to benefit from the new Veterans Charter, if that rehabilitation and reintegration starts.
Yes, Veterans Affairs Canada has a program. It's yet to be tested to know if it really works. But maybe DND should be given the option of trying to keep them.
I end that with the following. In 1998, when I was the ADM, I was brought on the carpet, for the forces, in front of our Human Rights Commission. The fourth pillar of it--that is to say, the hiring of disabled people--we were not meeting. The civilian side of DND was doing not too badly, but on the military side, no, because they all had to be universally deployable.
We could actually answer more appropriately the Human Rights Commission the right of employing injured veterans...but within the context that it does not affect the operational effectiveness of the forces--that is to say, those who are committed to deployment.
You've managed to insert 15 questions in one. I congratulate you, that is clever.
First of all, what I had recommended in 1998, and this was done, was that the individual seek therapy voluntarily. Without therapy, those who are affected by operational stress will not be able to recover. That is the first principle. If your arm has been ripped apart and you don't go and see a doctor, you will die. It's the same thing with this kind of stress.
So I tried to convince the therapists not to wait in their offices for the people to come to them, but to go to them and try to promote their services. First, the role of the therapists is not explained sufficiently, people don't know what they can do and how they are integrated into the organization, particularly the civilian therapists who are assigned to the Department of Veterans Affairs or even to National Defence, without any experience in the armed forces. They would have to be taken to the field and given some experience so that they get to know the culture.
So, the first step is for the therapists to promote their services.
Woody Allen said it was “in” to have a psychiatrist. Remember his movies? And so it is: it's in to have a psychiatrist. I have been 13 years under therapy, psychiatrists and psychologists, and with medication.
The other aspect is how to bring these people around and not let them fall into a state of depression that can lead to suicide.
Suicide can happen in two minutes, any time. An odour, a noise, anything can trigger this catastrophe. In my case, it took four years before I suddenly became completely dysfunctional. I was dismissed from the Canadian armed forces because of this injury. Following that I became suicidal because there was no system aside from therapy and so on. There was no peer follow-up.
The peer support structure for the individuals and the families has to be the most innovative, cost-effective, and progressive—all the superlatives you can find—of the tools we have in prevention. A couple of years ago, the OSISS gang, the peer support gang, said they were preventing a suicide a day; these are just members.
What I have found disappointing, however, until now, was that the 400 involved in operational stress--who do a lot of volunteer work, who spend a lot of time in Tim Hortons with people, listening and so on, very low-budget—are getting a certain recognition, but there are nearly no officers. I've seen a warrant officer go into a jail cell to get a colonel out, and be that colonel's reference, for over a year.
In my opinion, operational stress is the element that should be the topic of in-depth study.
Senator Kirby, in his work that he's doing now on mental health across the country, has the founder of the operational stress program working with him, Colonel Stéphane Grenier, and he would be an excellent witness. He created it. I remember I was still serving, and we didn't believe it. The professionals really pooh-poohed it, yet it has proven to be outstanding to the extent that Senator Kirby is now looking at creating this capability within society at large.
I won't talk about the charter, because I'm the chair of the veterans subcommittee. We've been studying it for the last eight months, and we hope to continue to study it and get into the nuts and bolts of not only the charter but how it's being applied and interpreted in the regulations. I am also the one who, in 2005, passed it through the Senate, so I'm committed to it.
It is resultant of the studies. The question is how effective it is. Well, we're learning how effective it is, and that's how we'll continue to improve it, of course.
In regard to the state of mind and the impact thereof, what is creating a lot of the injuries is not only the sights and the smells and the sounds. Often you're in the midst of it, you're busy doing things and you're trying to save other people and so on, so there's a kind of a film in front of it. It's when you come home and you're sitting at home having a beer that all of a sudden--boom--it starts to come clear. Or it's at night, or on a bad day like today and stuff like that.
If you don't build that prosthesis of knowing places to avoid.... For instance, I don't go to grocery stores because of the opulence of the fruits and vegetables and the smell and the odours literally paralyze me. I can't move, because it brings me back into the food distribution points and where people were trampled to death and so on. So there's a building of the prosthesis that takes time and must be nurtured by therapy and peer support.
Where we really we see the casualty levels, or that difficulty of living with life around, is in the moral and ethical, and sometimes legal--depending on the mandate--dilemmas of actually.... Contrary to World War II, where the rules of engagement were that you knew what uniform they were wearing--bingo. It was very linear, a very set piece, and so on. Today they are in all directions. Today the other side, the extremists, the terrorists, play by no rules. It could be a 14-year-old pregnant girl who is a suicide bomber, just as it could simply be a 14-year-old pregnant girl who is looking for protection.
It is those dilemmas and how we respond to them that are really burning up the cells. PTSD is a physical effect on the brain; it's not simply psychological.
When it comes to the numbers, I keep hearing all those numbers, that there's no more than on civvy street and so on. But let's think about it. I mean, these people are selected, these people are trained, these people are sort of weeded out, those who will not be able to meet the requirements. They are prepared for the operations. They're under a whole system of control and command and so on. They entered a way of life, a culture that instills pride and all that kind of stuff.
So you have all that positive baggage, and yet we say that our figures are no more than on civvy street? Well, if they're the same as on civvy street, we have one hell of a problem. Surely, even though they see these traumatic experiences, they should have, because of the selectivity of it, less than equal, let alone more.
A year ago I was lecturing at the U.S. Marine Corps where they were having a symposium. The Americans were having massive problems of suicides that all of a sudden appeared because of the stressors of coming back to a normal life that simply was not there any more: I'm not who I was when I left and my family is not who they were when I left.
So bringing that back together is where some of those stressors really create the traumas.
I'd like to take this opportunity to first thank the committee for inviting us to speak here today. My name, as you've mentioned, is Shay-Lee Belik, and I'm a Ph.D. student in the department of community health sciences and a research associate in the department of psychiatry at the University of Manitoba.
I'm here today with Dr. Jitender Sareen, who's a professor of psychiatry at the University of Manitoba and also a consulting psychiatrist at the Operational Stress Injury Clinic in Winnipeg. I'd also like to acknowledge Dr. Gordon Asmundson at the University of Regina and Dr. Murray Stein at the University of California San Diego, who have closely collaborated with us on this work.
I'd like to thank the Canadian Institutes of Health Research for their funding support for our research. I just wanted to note to your group that we've been conducting research in this area of military mental health since 2004 and have been working on suicide prevention strategies in Manitoba first nations communities since 2005.
My understanding is that I have been invited here today to discuss my knowledge and work in the area of suicide among Canadian soldiers. My initial remarks today are going to be focusing on what we know about suicide in military populations and more specifically in the Canadian Forces. It has been well established that of course suicide is a major public health concern worldwide, and most recently, suicide has also been noted as one of the most common causes of death in military personnel.
Recent U.S. news media have emphasized the toll of military suicides, sometimes referring to what they call a suicide “epidemic”, estimating that suicide accounted for more military deaths than the war in Afghanistan. Although the media reports focus on the high number of suicides, there is much controversy in the research literature as to whether the rates in military populations are in fact higher than rates in the general population. Some studies suggest a lower rate among military personnel, likely due to what has been termed the “healthy soldier effect”, which describes the fact that military personnel generally have better physical and mental health compared to the general population as a natural consequence of the selection procedures for military service.
Other studies have shown opposite findings, demonstrating higher rates of suicide among soldiers than the general population, and some studies have demonstrated no difference in rates. Yet again, if we take into account the healthy soldier effect and the fact that the overall mortality risk is generally lower for military personnel than civilians, findings of no difference in rates between military and non-military samples may actually be taken to represent greater risk for suicide among soldiers. This conclusion would indicate that aspects of the military or post-military experience may be a potent risk factor for death by suicide.
Debate exists in the research literature as to whether or not combat exposure, peacekeeping experiences, and deployment play a role in risk for suicide. Still, the Institute of Medicine has recently concluded, based on data from Vietnam veterans and veterans with war-related traumas, that there is sufficient evidence to support an association between deployment to a war zone and suicide in the early years after deployment. However, suicide risk does not appear to be shared equally among all soldiers. Two studies from the U.K. indicated that the overall rate of suicide in veterans was not greater than that in the general population. However, young males, particularly those under age 24, did appear at increased risk when compared with civilian males of the same age. Younger age has been noted as a common risk factor for suicide across both military and non-military populations. Additional risk factors that are common to both populations include being unmarried, low social support, the diagnosis of a mental disorder including PTSD, a prior suicide attempt, impulsivity, and access to lethal means, especially firearms.
When we think about these common risk factors, it becomes apparent that although the risk is similar, oftentimes these factors are more prevalent among military personnel specifically. For instance, previous work in a Norwegian veterans sample illustrated a preference for veterans to choose firearms and other more lethal suicide methods, and that these methods accounted entirely for the increased rate of suicide noted in this cohort over the general Norwegian population. This preference may stem from soldiers' increased experience with weapons and a possible easier access to such methods compared with the general population. And these differences in the prevalence of risk factors may account for some of the differences noted in rates of suicide, and little work has accounted for this disparity.
Other risk factors that have been noted are specific to military populations, including being an active-duty regular force member rather than a reservist; being hospitalized for a combat wound, or experiencing two or more wounds; short length of service and premature repatriation; lower rank; feelings of shame and guilt related to service; and more recent evidence has suggested an increased risk among soldiers with traumatic brain injury.
Protective factors that have been noted include discussions around military exposures, unit cohesion, comradeship, and military leadership.
It is important to note that the majority of the research to date has focused on U.S. military personnel. One must keep in mind that the U.S. military experience is quite different from military experience in other countries, including Canada. The tempo of deployment, the maximum deployment length and, most importantly, the role of the military and its mission are just some of the ways the U.S. military differs from the role of the Canadian Forces.
Turning now to Canada, media reports have also created alarm with headlines about dramatic increases in suicide rates in the Canadian Forces in the past few years. Recent figures from the Report of the Canadian Forces Expert Panel on Suicide Prevention suggest that the suicide rate among active-duty regular force Canadian Forces personnel is quite similar to rates in the Canadian general population. The average rate of suicide between 2002 and 2006 in the Canadian general population of males of all ages was 17.8 per 100,000 population, whereas the average suicide rate for male regular force members during the same time period was 16.9 per 100,000. As well, it appears that Canadian Forces suicide rates have been decreasing as measured in five-year increments since 1995. To date, the suicide rate among Canadian veterans has not been reported.
There have only been four studies that have directly examined suicide in the Canadian Forces. Tien and colleagues recently published a study on the leading causes of death among Canadian Forces members. From 1983 to 2007, 1,889 active-duty Canadian Forces members died, 17% of whose deaths were attributable to suicide. In contrast, combat-related deaths accounted for less than 5% of all deaths. Suicide was noted as the third leading cause of death among Canadian Forces personnel, with motor vehicle crash-related deaths being first on the list.
Interestingly, alcohol-related fatal accidents among military personnel have been found to share many common features with suicide deaths in terms of risk factors, suggesting an overarching self-destructive tendency among a subgroup of military members, whether the result is suicide or a fatal accident, which highlights the risk of death associated with impulsive behaviour.
The second study, by Wong and colleagues, investigated peacekeeping as a risk factor for suicide among veteran Canadian Forces members. In a case-control design, they retrospectively compared 66 military suicides with matched military controls. The results illustrated a greater risk of suicide among soldiers who were unmarried, childless, of lower rank, who had not completed high school, and had French as their first language. They found no increased risk of suicide in peacekeepers and, in fact, the rate among them was half that of the comparable civilian population. However, those in the military who had committed suicide had experienced more psychiatric illness and psychosocial stresses than matched controls had. Psychosocial stressors included relationship problems, pending military release, and conflict over their military job. Importantly, a prior suicide attempt was one of the strongest predictors of suicide completion.
Two other studies were undertaken by our research group and examined suicidal ideation and suicide attempts among active-duty Canadian soldiers. One study focused on the relationship between exposure to traumatic events and suicide attempts, noting that exposure to sexual and other interpersonal traumas, including rape, sexual assault, spousal abuse, and childhood abuse, was associated with an increased likelihood of suicide attempts—yet exposure to combat and peacekeeping did not increase the risk.
Our most recent study compared rates of suicidal ideation and suicide attempts in Canadian Forces members with the Canadian civilian population. The study demonstrated no difference in the rate of suicidal thoughts when the two populations were compared, yet Canadian Forces members were less likely than civilians to have reported a suicide attempt in the past year. Few differences were noted among risk factors for suicidal behaviour between active-duty soldiers and the general population providing evidence of common pathways to suicide.
Recent findings from U.S., Canadian, and U.K. military surveys show that most service personnel do not receive mental health treatment, highlighting the need for outreach. Gatekeeper training is one example of an outreach program, which has been noted as one of the most promising suicide intervention strategies to date. Gatekeeper training, as part of a broad suicide prevention strategy, was shown to reduce suicide rates by 33% in a sample of over 5 million U.S. Air Force personnel.
A recent review of suicide prevention programs for active military and veterans indicated that multi-faceted interventions for active duty military personnel were well supported by consistent evidence. However, there was insufficient evidence of programs in veteran populations.
In line with the air force suicide prevention program, the Canadian Forces has implemented an extensive suicide prevention program around the theme of “Be the Difference”. Part of this training program includes gatekeeper suicide training for all personnel, based on a well-known gatekeeper training program called ASIST, or applied suicide intervention skills training. Evaluations of ASIST have demonstrated the effectiveness of the training to increase knowledge and skills in dealing with suicidal individuals. However, its impact on suicide rates has not been determined.
In the U.S., Veterans Affairs has similarly initiated a comprehensive suicide prevention strategy, which is designed to span the Institute of Medicine's suicide prevention recommended categories: universal interventions, selective interventions, and indicated interventions.
As such, we would recommend that a similar comprehensive suicide prevention strategy be initiated for Canadian veterans. A recent Canadian study, based on a systematic audit of 102 suicides in New Brunswick, indicated a need for better coordination of addiction services with mental health specialists; public awareness to encourage individuals to seek treatment; and training for primary care to better detect mental illness, substance-related problems, and suicidal behaviours.
Along these lines our recommendations would include, first of all, better aftercare for veterans who have attempted suicide, since previous attempts are known to be one of the strongest predictors of suicide death. Second, education and training for the veterans and their service providers in mental health literacy and suicide intervention skills could lead to better recognition of those at risk. Third, greater coordination between and across health services is required to comprehensively address the needs of returning soldiers. Finally, we would recommend increased screening for suicidality and mental disorders among veterans in care settings. One example of a screening program that exists in both Denmark and Norway features questionnaires that are sent to all soldiers six months after being discharged to civilian life in an effort to detect mental disorder development and suicidal risk.
Whether or not the risk of suicide among Canadian Forces veterans is higher than civilians, there is little doubt that suicide prevention programs should be developed with hopes of reducing suicide rates, since any suicide is an unnecessary tragedy. Moreover, suicide may lead to serious trauma and stress for bereaved family, friends, and co-workers, and it may actually induce suicidal thoughts and behaviour in others.
It is essential for steps to be taken to address this important public health concern.
I thank you today for your attention.
First, thank you very much for appearing before us today and thank you for your presentation.
One of the concerns I always have is in comparing military or veteran suicide rates with those in the general population. Years ago I used to live in the Yukon, and we had a couple of suicides in our small town of Watson Lake. At the time there was a conference in Whitehorse that I went up to. I remember talking to some first nation chiefs about the issue, and they said, “We never want to be compared with the general population. We're first nations people. We're aboriginals. Our concerns, our issues, our thoughts, our views, our beliefs are different, and we don't want to be compared with the general population.”
I notice here that you mentioned several times the comparison with the general population.
In your brief you say “yet exposure to combat and peacekeeping did not increase the risk”. Obviously I can't question your study, but I find it rather hard to believe that people who serve in a combat role or a peacekeeping role are not subjected to this risk. I remember folks who served on the Swissair disaster picking up body parts off the rocks. Some of them had to leave the service because of what they were exposed to.
Now, they may commit suicide many years down the road. As Mr. Dallaire said, one of his soldiers committed suicide 14 years later.
Second, later in your brief you say that gatekeeper training reduced suicide rates by 33%. Does that mean they reduced 33% in that year? Suicide tendencies can last for the rest of your natural life. You can commit suicide in your fifties because of something that happened in your twenties, if I'm not mistaken. So I'd like to know how you quantify these types of statistics.
I say this with great respect. You said you started this in 2004. The Afghan mission really got kicked into high gear around that time. Are you planning to do enhanced studies down the road to follow these veterans and their families, many years down the road, or is this more or less it?