Mr. Chairman and members of the House committee on veterans affairs, thank you for the opportunity to speak with you today. For the past decade I have been a senior epidemiologist for the directorate of force health protection, more colloquially known as DFHP, which is part of the CF health services group. I hold a master's degree in science in epidemiology from the University of Toronto, as well as a Ph.D. in epidemiology from the London School of Hygiene and Tropical Medicine in the U.K. Prior to joining DFHP, I worked as an epidemiologist at the provincial and regional levels as well as in the academic sector.
As an epidemiologist my primary role, really, is to respond to the needs for statistics and data on the part of the decision-makers within CF health services and the larger Canadian Armed Forces—also known as CAF, which I'm sure you know by now. Clinicians and decision-makers who develop the policies, implement clinical practice, or work towards keeping the CAF healthy really need to know who their population is and what their needs are, and that's where I fit into the larger picture. I'm behind the scenes, providing those who “do” with the statistical information they need to proceed in an evidence-based fashion. I do so as part of a larger directorate, the directorate of force health protection.
DFHP functions similarly to how a provincial health authority would work, but does so specifically for the CAF. The key pillars of public health are surveillance and assessment of the population's health, health protection, health promotion, and disease prevention.
With respect to public health surveillance, an important part of what we do is to monitor the health of the CAF, primarily through surveys such as the health and lifestyle information survey, as well as through other health surveillance functions. These can be broader in scope, as is the case with the CF disease and injuries surveillance system, which monitors disease and injury during deployment specifically, as well as the CF health evaluations and reporting outcomes surveillance system, which can be adapted to look at a number of health-related conditions and concerns. These systems can also be a lot more specific, as is the case with the mortality database or the suicide surveillance system, the latter of which is the source of the information from which the report on annual suicide mortality in the CAF is created. The trends and the patterns that we identify through our work using these diverse sources of information are then used by policy- and decision-makers in developing and implementing evidence-based, health-related policies and programs across the CAF.
As mentioned, one of our reports that you're most likely familiar with is the “2016 Report on Suicide Mortality in the Canadian Armed Forces”, which covers suicides between 1995 and 2015. I'll refer to it from here on in as the 2016 suicide report.
We within the CAF, both civilians and military, consider every suicide a tragedy. Suicide is firmly recognized as an important public health concern. As such, this report has been produced since 1995, with annual releases since 2008, in an effort to gain greater insight into suicide in the CAF. Monitoring and analyzing suicide events of CAF members provides valuable information to guide and refine ongoing suicide prevention efforts.
While we do collect and monitor data on all suicides, including males or females and regular or reserve force members, the annual reports cover only regular force male members. The reason is that reserve force and female suicide numbers are too small for us to release detailed information about the cases without running the risk of identifying the individuals and compromising their privacy. Although their experiences are included in the evidence used to drive mental health policies and suicide prevention endeavours within the Canadian Armed Forces, the information is not presented in the annual reports.
All suicides are ascertained by the coroner from the province in which they occur. The information is then provided to and tracked by the directorate of mental health, which cross-references it with the information collected by the administrative investigation support centre. The centre is part of the directorate of special examinations and inquiries.
Whenever a death is deemed to be a suicide, the deputy surgeon general orders a medical professional technical suicide review report, or MPTSR. The investigation is conducted by a team consisting of a mental health professional and a general duty medical officer. This team reviews all pertinent health records and conducts interviews with medical personnel, unit members, family members and other individuals who may be knowledgeable about the circumstances of the suicide in question. Together, all this information is used to create the findings in the annual suicide report.
Over time, the picture of suicide in the Canadian Armed Forces has changed. While the rates may vary somewhat from year to year, a consistent and clear picture has emerged over the last decade. Canadian Army personnel, more specifically those in the combat arms trades, are at a greater risk of suicide than the Royal Canadian Navy and Royal Canadian Air Force members.
There’s some emerging evidence that deployment may also be a concern. However, we need to be careful with this broad description of deployment, since it can include many types of deployments—for example, humanitarian, peacekeeping or active combat—and many different experiences, both good and bad. Further research and analysis is required in order to determine whether, on its own, deployment is really linked in some way to the risk of suicide.
We're starting to get a much better understanding, through the work done by my colleagues from the directorate of mental health, as well as within DFHP, about underlying risk factors for suicide. For example, amongst the regular force males who took their own lives in 2015, over 70% of them had documented evidence of marital breakdown or distress prior to their deaths. Debt, family and friend illness, and substance abuse were identified risk factors.
These are also often seen in the general population. Most of them had more than one non-mental health risk factor at the time of their death. While troubling, this is consistent with what is being seen by other militaries, and I think it highlights the direction in which our research and surveillance efforts should be increasingly concentrated moving forward.
With this in mind, DND, as part of the Public Health Agency of Canada, led an interdepartmental working group on suicide-related surveillance data, which is one of the expected deliverables of the federal framework for suicide prevention. Membership within this working group is an excellent venue to see what work is being done by fellow federal agencies around suicide surveillance and prevention, and to share information on how to be more effective and consistent in our collaborative approaches.
We also have a long-standing relationship with VAC. We have been collaborating for a number of years on the CF cancer mortality study, which has looked at suicide risk over an individual's lifetime, both during and after service. We're currently collaborating with them and Statistics Canada on a second iteration of the study. We plan on looking at cancer and causes of death, including suicide, in still serving and released regular force and reserve class C personnel who enrolled in the CAF between 1976 and 2015.
We also sit on the steering committee for the veterans suicide mortality study, which will be looking at suicide risk amongst all former regular force and reserve class C veterans who released from the Canadian Armed Forces, also between 1972 and 2015.
In summary, surveillance is an important and integral component of understanding the risk factors and trends associated with suicide among serving and released personnel. Collaboration between departments and researchers has been ongoing, as demonstrated through the CF CAMS 2 and other research initiatives, and will prove to be extremely helpful in understanding this complex issue.
It's a very good question. Thank you for that.
Again, I'm a psychiatrist. I work in the mental health world. Certainly, from my perspective, from the time I started working for the Canadian Armed Forces, the big change has been our participation in Afghanistan. People coming back from those deployments have been suffering from trauma-related injuries and other mental health injuries. Everyone who deploys does not necessarily develop PTSD; they can develop other mental health problems as well, and sometimes they develop several.
As those members were released from the military over time, Veterans Affairs Canada has seen a similar increase in younger veterans coming into their system with mental health problems and needing care. As I remember from when I was still in the military, Veterans Affairs Canada has been very forward-looking. In the early to mid-2000s it started setting up what are called operational stress injury clinics across the country. We now have 11 of them across Canada. We also now have satellite clinics coming out of those clinics. These are clinics where we have multidisciplinary teams, specially trained and with a great deal of experience, treating post-traumatic stress disorder and other operational stress injuries.
People were recognizing that something was happening. Because of our very good relationship with our colleagues in the CF, we were able to see what was happening and the growth in the numbers of those with PTSD coming back from deployment. We were able to say that we had better set up some services, because we're going to have these men and women coming into our system.
And thank you very much for this. It sounds very complex and that there are clearly multiple pieces to this puzzle, so please forgive me if I'm trying to sort this out.
Regarding the people coming into the CAF, I wonder if some pre-screening is possible with regard to their emotional health, because it seems to me that this is all tangled up together.
Dr. Rolland-Harris, you said that 70% had documented evidence of marital breakdown, distress, debt, family/friend illness, substance abuse, which it would seem to suggest a susceptibility to suicide rather than the other way around. Do you, then—if you can—say that this individual may be predisposed, may have a background such that we had better be very careful, and monitor and watch for potential suicide?
Let me answer that question. We do a great deal.
We do a great deal in Veterans Affairs Canada. As I said, from 2000, on the whole issue of suicide, even though, as I said before, there are challenges for our knowing about suicides in the veteran population, we have worked on putting many things into place, both for suicide prevention and for getting people access to mental health care.
Again, as I said, we know that leads to.... It's one of the most important things for us to do to help prevent suicides. All of our case managers receive suicide prevention training, and that training is updated every year. Also, any front-line worker at Veterans Affairs Canada now receives suicide prevention training. If you phone and somebody answers the phone, they've received that kind of training. They have a sense of what to do if they are concerned about the person on the other end of that line.
In addition to having case management and front-line workers who, again, can coordinate care for anybody who comes in and has a service-related mental health injury, they can be referred to an OSI clinic. If they're in an area where there are no OSI clinics, we have 4,000 mental health providers in Canada who we can access from Veterans Affairs Canada to serve our population.
Dr. Rolland-Harris, this has been touched on in a couple of questions so far. We talked about tracking the female suicides.
I'm a physician. I've had to learn statistics, and I know the challenges of analyzing data when the numbers are small. I think we both agree it's fortunate that the numbers are small, but it does cause that challenge.
In medicine in general we've had an issue over the years where so much medical research has been gender-based, usually towards males, right from basic science research onward. I was a medical researcher before I was a physician. We always used male rats, because if you used two genders there was too much variation. Hence, you develop medications that might not work for females. Although I understand that putting it in a report is one thing, because, as I say, the numbers are so low you might identify....
Are you looking at methods that can better analyze and maybe get more conclusions from the female population, where it's so challenging?
Thank you, Mr. Chair, for giving me the floor.
I want to welcome Ms. Heber and Ms. Rolland-Harris and thank them for being here today.
My first question was provided by the person I'm replacing today, Cathy Wagantall, a very honourable woman.
Many veterans have repeatedly told us that a number of their brothers in arms committed suicide after taking mefloquine, an antimalarial drug. One of the veterans who wrote to my colleague, Ms. Wagantall, told us that he personally knew 11 veterans who committed suicide and that all 11 of them had taken mefloquine.
In the 21 years covered and of the 239 suicides recorded, how many of the brave men and women had been in malaria zones?
Do you have this information?
Perfect. Thank you for that insight into National Defence.
A year ago, when I was on this committee as the Veterans Affairs critic, on May 9, 2016, I filed an Order Paper question. For the region of Quebec City, I asked what percentage of persons had financial prestations for each physical and mental illness—for example, knees, hearing, and so on.
Interestingly, for one year, 2015-16, in the Quebec region, 8% of the claims for money concerned post-traumatic syndromes, 2% deep depression, 1% anxiety, 1% lack of sleep, and 1% alcohol and drug abuse. Overall, almost 13% of the claims for money were put forward by people suffering from mental health issues that we could probably sometimes connect to suicide.
Of the 15 members, or sorry, I think it's 14, who committed suicide in 2015, how many of them were in the process of claiming?
Good evening, everyone. My name is Johanne Isabel, and I've been working at Veterans Affairs Canada since 2001. My spouse is a retired member of the Canadian Armed Forces.
Mr. Chair and committee members, we're pleased to be talking about the Veterans Affairs Canada assistance service, a counselling and referral service offered 24 hours a day, seven days a week to our veterans and retired RCMP members and to their family members. The service is confidential. If a veteran isn't registered for a Veterans Affairs Canada service or program, the veteran can still use this program.
Here's a brief history of the program.
In 2000, Veterans Affairs Canada worked with Health Canada to provide a service that was similar to the Canadian Armed Forces member assistance program. We wanted to make sure that veterans and their families could transition more smoothly from military life to civilian life. We wanted to provide this service to serve our clients properly during the transition.
On December 1, 2014, your committee recommended that the assistance program for veterans be improved. From 2000 to 2014, veterans could receive up to eight individual counselling sessions with a health professional. As I already mentioned, based on your recommendations and since April 1, 2014, the program has been providing 20 individual counselling sessions to all our veterans and their family members and to retired RCMP members.
I'll now turn the floor over to Ms. Malette.
Hello. My name is Chantale Malette.
The services that are offered through the VAC assistance service are mainly confidential, bilingual services, accessible via a 1-800 number and through the Health Canada phone line 24 hours a day 365 days a year. Mental health professionals answer every call. All counsellors have at least a master's or a Ph.D. The veteran then has access automatically, right away, to a mental health professional.
Telephone services are also offered for the hearing impaired. There is immediate access to crisis support and counselling by a mental health professional with a minimum of a master's degree. If the person calling is in crisis, the mental health professional will take whatever time is necessary to stabilize the person before referring them for face-to-face counselling.
We refer to our national network of specialized private practitioners, according to needs, anywhere in Canada. We have face-to-face counselling. We also offer telephone counselling, especially when services are required in an isolated area or if they are required by the client. We also offer e-counselling when appropriate.
We refer to external resources or VAC if the time required to resolve the issue exceeds the coverage provided by the program. We use the sessions and the hours covered under the program to bridge the person, to support the veteran until long-term care is available.
In terms of suicide prevention, for every call the client's state is verified. We verify the level of stress. We verify the suicidal or homicidal thoughts. If the caller is identified as having suicidal ideation, the counsellor will ask for the caller's authorization to contact their VAC case manager and inform him or her of the situation.
In terms of counsellors, we have access to over 900 mental health professionals across Canada. They all have a minimum of a master's degree in a psychosocial field and at least five years' experience in private practice. They have had a government security screening. They have malpractice insurance. They're registered with a recognized professional association. Professional references are checked as well.
In terms of quality assurance, every time a veteran consults a mental health professional, we provide this person with a satisfaction survey to get more information on their satisfaction with the program. We also do yearly visits to counsellors' offices. We visit at least 5% every year. We also are accredited by EASNA, the employee assistance society of North America, and COA, the Council on Accreditation. We adhere to the highest standards in the industry.
I'll answer that, if you'll allow.
You have heard that suicide is not a simple issue. Many factors play into it. I know people don't always like to hear about research, but research is very important because it provides us with so much information, so we can formulate programs, services, and strategies to confront this issue.
There are several aspects to the strategy. There is prevention, intervention, and what we would call “post-vention”. That's just a fancy way of putting things in baskets and organizing our activities.
I would say that everything that you've heard here about the VAC assistance line and, I would say, all the programs that Veterans Affairs offers to the veterans, is all part of the prevention strategies or prevention actions.
We also learn from research that the transition period is an important period of vulnerability for our releasing members, so we want to concentrate on that. What more can we do besides exit interviews, getting them case managers, helping them navigate the system, and getting them the benefits and the treatments that they need. All of that exists. All of that will be improved and that's all part of the strategy that we're developing with our Canadian Forces colleagues.
Quickly, I would like to follow up on Mr. Fraser's question. He commented about using peer support.
I want a little more clarification on that and whether you have ever looked at it or thought about this. It's one of the things we're hearing a lot about from our veterans. They're asking, “Isn't somebody there?” We haven't taken our veterans to actually help our veterans. There's this opportunity when you get a call like this where you might be able, on a conference call, to access someone 24-7, someone who can speak the language, because oftentimes people can't speak the language. I know a lot of psychologists and a lot of M.A. and Ph.D. students who do not know the language.
To me at least, having access for that veteran easily attainable in that crisis situation would be a valuable asset for your services. I'm wondering (a), if you have thought about it, and (b) if you haven't and this is the first time, if you see that being of some value.