Mr. Chairman, and members of the House Standing Committee on Veterans Affairs, as surgeon general, I am responsible for the delivery of health services, the provision of deployable health services capabilities to support operations, and the provision of health advice to the Canadian Armed Forces.
I am very pleased to be back and to have the opportunity to speak with you about how we care for members of the Canadian Armed Forces who have mental illnesses and how we work with Veterans Affairs Canada to facilitate transition for those leaving the Canadian Armed Forces.
Members of the regular force are not covered under provincial health care plans. For this reason, the Canadian Armed Forces has its own comprehensive health system that addresses the health needs of members wherever they may be stationed in Canada or abroad. Health services are provided predominantly in our 37 health services centres and detachments across the country and in Europe. In addition to the care provided at the health services centres, we also purchase care from the civilian sector, particularly specialist services and hospital-based treatments that are not available internally.
On operations, Canadian Forces Health Services often deploy to provide health support, but there may be situations in which we work with our allies or a host nation to deliver health services.
Across the system, we have over 450 established mental health positions, including mental health nurses, social workers, psychiatrists and psychologists, within our clinics' mental health departments.
As of July 2016, 93% of these positions were filled. Staffing these positions is a dynamic process, one which is impacted by normal staff turn-over, competition with the civilian sector for mental health personnel, and challenges in recruiting personnel to some locations.
To ensure timely access to care, there is also a large network of over 5,000 civilian mental health professionals registered as external service providers to which patients can be referred.
As in the civilian health care sector, our primary care clinicians capably care for many patients with mental illness, and 31 of the 37 health services centres have some level of specialized mental health services to support the primary care clinicians and to deliver direct patient care by providing rapid access for urgent care needs, as necessary.
The seven largest clinics have operational trauma and stress support centres, or OTSSCs, which specialize in treating operational stress injuries, or OSIs. OSIs are those psychological problems that occur as a result of psychological trauma experienced during operations, which result in different diagnoses, including depression, PTSD, and substance-use disorders.
In cases of emergency after hours, Canadian Armed Forces members can contact the Canadian Forces member assistance program, or CFMAP, or a civilian crisis line. They can also go directly to a civilian emergency department or call 911. The seven OTSSCs are part of the joint network for operational stress injuries, which also includes the 11 Veterans Affairs Canada OSI clinics.
Through a tripartite MOU, this network allows for care of military members, veterans, and members or former members of the RCMP in either military or Veterans Affairs Canada facilities, when it is deemed appropriate for a given patient.
Technological advances have had a positive impact on the delivery of mental health services. In order to increase accessibility to mental health services, we have installed high definition, secure VTC systems in our clinics that are being used to provide telemental health services. These help us manage short-term health care demands in a given location and help reduce the need for some patients to travel to receive a higher level of care. They are also a way for us to ensure our ability to offer care in the language of choice, no matter where members serve.
We have also acquired a virtual reality system for use in our larger centres. This system simulates an operational environment, and it is used in exposure therapy.
The CAF is committed to ensuring that personnel suffering from mental illness have timely access to the medical care and support services necessary to either return them to duty or assist their transition to civilian life. We recognize the transition for our members as they release from the CAF can be difficult and stressful, particularly for those released for medical issues.
Canadian Armed Forces members with more complex medical needs benefit from the case management program. This program was established more than 10 years ago and offers services in all Canadian Armed Forces clinics located in Canada. Case managers are specialized nurses who are integral to the care-delivery team and who facilitate ongoing care for patients through complex periods of medical care. The intent of the case management program is to assist the CAF member in navigating the medical and administrative system. While the primary goal is to achieve a return to duty after a complex disease or injury where possible, for those members whose chronic medical conditions have led to permanent employment limitations and who do not meet universality of service, case managers assist with transition to civilian life.
Our case management program works closely with its counterparts in Veterans Affairs Canada. Moreover, analysis and work are currently being done to optimize the transition of the releasing member from the DND program to the VAC program. A working group under the VAC-CAF steering committee has been established to align programs and to analyze the elements associated with the continuum of care for members and their families in transition. The transition period around release is a critical time to ensure continuity of care for releasing members.
A standardized assessment of all transitioning CAF members is being done to determine the level of complexity involved in their transition from DND to civilian life in order to enable the handover of care to the civilian sector has taken place for those with ongoing needs.
Whenever a member is identified as having complex needs regarding transition, a multidisciplinary team works to proactively reduce or eliminate potential barriers to a smooth transition, either from a health, financial, occupational, academic or psychosocial perspective. In certain circumstances, additional transition time will be requested by the team in order to secure a safe transition. Each case is handled individually, on its own merit.
In addition to clinical care, we also have a nationally and internationally recognized mental health education and resiliency program, called road to mental readiness. There are now over 30 modules of this program, which are given at different points in a member's career, starting at basic training. We have recently expanded the program to include occupationally specific training for occupations like search and rescue technicians and military police.
Canadian Forces health services group also provides the strengthening the forces health promotion program. This important program includes education and skill development modules in areas such as suicide awareness, anger and stress management, healthy relationships, family violence, and addictions.
We continue to work with the strong support of leadership at all levels to reduce the stigma of mental illness and other barriers to care-seeking. This includes Forces-wide emails, newspaper articles, unit-level discussions and participation in events such as Bell Let's Talk. We also have produced a five-video series that addresses various topics such as stigma, transition and suicide.
Another key element of our mental health program is research. We have conducted a number of important epidemiological studies to better understand the impact of mental illness on CAF members. This includes the 2013 CF mental health survey, and the operational stress injury and outcome study.
The CAF is extremely interested in better understanding the biological underpinnings of mental illness and in exploring new treatments for PTSD and other conditions.
Much of this work is accomplished by the Canadian Military and Veterans Mental Health Centre of Excellence through collaboration with scientific experts, academia, government, private sector, and research consortia, and with NATO and our allies. Knowledge gained from leading-edge clinical research is then translated into clinical care.
My final comments will centre on suicide in the Canadian Armed Forces.
You will recall that in November 2015 we reported a trend of increased suicide rates over the preceding five years. This increase was among those serving in the army command in combat arms occupations, such as the infantry, as opposed to other commands. We've also reported that deployment is emerging as a risk factor for suicide, but it is important to stress that it is not so much the deployment itself but what some members experience during the deployment that might have an impact.
We conduct a medical review of each suicide to try to better understand the factors involved in each case and to look for opportunities to enhance our current programs. We find that about 50% of people who die by suicide have been diagnosed with one or more mental disorders, with major depressive disorder being the most prevalent condition. Typically, people also have one or more life stressors, with failing intimate partner relationships as the most common. Other factors often seen include work-related problems, debt, legal difficulties, and physical health problems.
The CAF suicide prevention program, guided by the 2009 suicide prevention expert panel, identifies three pillars of suicide prevention, namely, excellence in health care, effective leadership, and the awareness and engagement of members. We have a robust program that addresses these pillars, and we continue to make improvements.
In October 2016, we held another expert panel on suicide prevention to help guide future efforts, the results of which will be released once the report is finalized. My team will look carefully at all recommendations from this recent panel and ensure that the CAF has in place all elements of a robust suicide prevention program.
Thank you for your attention. We're happy to take any questions you may have.
Thank you very much. I'm pleased to have both of you here.
Brigadier-General, I wasn't here last week so I've just been reading your notes from last week's statements.
I just want to quote:
As you are likely aware, mefloquine remains an option for malaria prevention for many militaries around the world. We do, however, remain vigilant and open to assessing any new evidence related to mefloquine and other antimalarial medications.
Then you go on to say:
We will, accordingly, update our approach to malaria prevention in a scientifically sound manner and with an emphasis on critical appraisal of the evidence.
I did some research, and of course, this would be in relation to our allies. That would be where we would go to see what else was being done with those other militaries around the world.
I have a statement here from September 15 of this year from the Minister of Veterans Affairs for Australia addressing mefloquine concerns:
The Department of Veterans' Affairs has established a dedicated mefloquine support team for our serving and ex-serving community.... [and] additional support for current and former...members who have been administered mefloquine.
establish a formal community consultation mechanism to provide an open dialogue on issues concerning mefloquine between the Defence Links Committee and serving and ex-serving...;
develop a more comprehensive online resource that will provide information on anti-malarial medications;
establish a dedicated...mefloquine support team to assist...with...related claims, which will provide a specialised point of contact...and
direct the inter-departmental [c]ommittee to examine the issues raised, consider existing relevant medical evidence and provide advice....
Any former member who was administered Mefloquine...and is concerned about possible side effects...can lodge a claim for a condition that they think was caused by Mefloquine....
Current and former...personnel can also access free mental health treatment....
They go on to list all the different areas of mental health that need treatment, and they indicate that those services are there.
In Britain also—this is from July 2016—the former head of the army has admitted that he would not take a controversial antimalarial drug as he revealed his son had suffered severe depression while prescribed Lariam. Lord Dannatt said that the side effects of the drug could be “pretty catastrophic” and he apologized to troops who had taken it while he was chief of the general staff.
He urged the Minister of Defence to show generosity when reaching compensation settlements with hundreds of personnel alleged to have suffered mental health problems after being given the drug during deployment to malaria hot spots.
He says here:
We see no reason to disbelieve the very strong anecdotal evidence that such conditions have been ignored in dispensing it to large numbers of troops about to be deployed.... It is our firm conclusion that there is neither the need nor any justification for continuing to issue this medication to Service personnel except when the three conditions listed above have been met.
The conditions were as a last resort when they weren't able to tolerate the other alternatives.
Then of course, the U.S. has had witnesses here. Dr. Nevin has said it's been blackboxed in the States.
With this type of evidence from our strong allies, would it not be time for Canada, especially with the new definitions that Health Canada has come out with on side effects, to see that this is a mental health issue that we could deal with right now? These are people who think they have PTSD because that's what they were told, when it's clearly possible they have a brain injury. Is it not time for us to set up the same type of services for them whereby we can get this information from our veterans directly?