I call this meeting to order.
This is meeting number 55 of the Standing Committee on Health.
I want to thank all our witnesses for coming today. I apologize for the delay; these things happen here. I hope it doesn't inconvenience you too much, and I want to thank you for your patience. We will go later than we had planned. I hope that's all right with everybody.
Today, first we'll be studying Bill , an act respecting a federal framework on post-traumatic stress disorder.
Our witnesses today include Dr. Anne-Marie Ugnat, executive director of the centre for surveillance and applied research in the health promotion and chronic disease prevention branch of the Public Health Agency of Canada. Welcome.
By video conference, we have Dr. Jitender Sareen, professor of psychiatry at the University of Manitoba. Thank you very much for taking the time to do this.
As an individual, we also have Natalie Harris, advanced care paramedic in the county of Simcoe.
We'll offer you the opportunity to make a maximum of 10 minutes of opening remarks, and after that we'll go to questions.
We'll start with Dr. Ugnat.
Mr. Chair and honourable members, thank you for the invitation to address this committee regarding its study of Bill , an act respecting a federal framework on post-traumatic stress disorder.
Let me begin by reiterating a statement by the World Health Organization in 2004: that there is no health without mental health.
Mental illnesses, including post-traumatic stress disorder or PTSD, are recognized, medically diagnosable illnesses that result in the significant impairment of an individual's cognitive, affective, or relational abilities. Mental illnesses are the result of a complex interaction of biological, developmental, and psychosocial factors. Environmental factors, such as exposure to trauma, can precipitate the onset or recurrence of a mental illness.
Mental health in Canada is a complicated issue that has both direct and indirect impacts on a significant number of Canadians every year.
The federal government has a role to play in the coordination and collaboration of mental health activities. It also has a role in understanding scientific evidence related to the scope of the challenges and what works best to address them. This evidence informs the development of resources for information on best practices and innovation.
While the federal government also has responsibility for mental health services for specific federal populations, such as serving members of the Canadian Armed Forces, veterans, serving and former members of the Royal Canadian Mounted Police and the Correctional Service of Canada, indigenous populations, newcomers—including refugees—and federally incarcerated individuals, the Public Health Agency of Canada, where I work, is mandated to serve the broader Canadian population. As such, we work with other government departments, stakeholders, and partners in the promotion and monitoring of mental health for all Canadians.
Several federal and national partners play a role in mental health promotion.
Statistics Canada has a federal responsibility to collect data on the Canadian population, including through the census and population surveys. The Canadian Institute for Health Information, CIHI, holds and manages national-level health administrative data, such as hospital billing data. Health Canada manages the Canadian drug strategy, which includes the monitoring of the use of illicit substances. The Mental Health Commission of Canada coordinates a network of partners through the Mental Health and Addiction Information Collaborative, of which, we, Statistics Canada, CIHI, Health Canada, and other partners are members.
The Public Health Agency of Canada contributes an important piece to the understanding of mental health in Canada by conducting national monitoring of mental health, mental illness, self-harm and suicide, and family violence, and related risk and protective factors. These areas often have strong associations with PTSD, either as potentially precipitating factors in the case of the trauma experienced with family violence, or as outcomes with mental illness and even suicide.
Mental illness monitoring is a core public health activity relying on population surveys, such as those conducted by Statistics Canada, and on administrative data collected by the provinces and territories, which includes physician billing claims and hospital discharge records linked to health insurance registries.
Bill proposes improving the tracking of the incidence rates and the associated economic and social costs of PTSD. Currently, monitoring of PTSD in the general Canadian population relies on data from national population surveys conducted by Statistics Canada, such as the Canadian community health survey of 2012 on mental health.
In 2012, 1.7% of the population aged 15 and over reported that they had PTSD. This is an increase from 2002 when 1% reported that they had PTSD. This increase is primarily due to an increase in prevalence among women. It went from 1.2% in 2002 to 2.4% in 2012. It is important to note that estimates of self-reported diagnosed PTSD from survey data are thought to underestimate the true prevalence of the disorder.
Another consideration for the monitoring of PTSD is the use of provincial and territorial health administrative data, which has been successful for other chronic conditions, through the Canadian chronic disease surveillance system. The CCDSS is a collaborative network of provincial and territorial chronic disease monitoring systems led by the Public Health Agency of Canada and relying on linked physician billings and hospitalization data.
For PTSD specifically, physician billings are not available in all provinces and territories as not all provinces or territories go to the same level of specificity. Coding standards are jurisdictional issues in which CIHI plays a role. However, it could be possible to conduct monitoring for a few provinces and territories that can currently identify PTSD. At the national level it may be possible to establish monitoring using administrative data for broader categories, for example, adjustment disorders that include other conditions related to adjustment reactions to stress, such as but not limited to PTSD.
PTSD is often treated through therapy methods that are outside the publicly funded health care system, such as occupational therapy, psychologists' services, and social work. Therefore health care administrative data would underestimate the disease prevalence and be an indicator of health service utilization rather than disease prevalence. Currently no monitoring system captures data from community-based services outside the health care system.
It is important to note that while national population surveys have previously asked respondents to indicate whether they have PTSD, estimates based on self-reported diagnosis are thought to underestimate the true prevalence of the disorder as people may not have been diagnosed or may be unwilling to divulge their diagnosis.
Surveys that rely on the reporting of individual symptoms consistent with PTSD rather than self-reported, physician-diagnosed PTSD however, may be able to provide accurate information on the prevalence and the impacts of living with the condition for the purpose of monitoring. For example, in 2001 McMaster researchers conducted a study using symptom-based survey tools and reported a lifetime prevalence of PTSD of 9.2%, which is higher than the prevalence reported from the Canadian community health survey of 2012 on mental health. Due to the large sample of respondents that would be required as well as survey content and length, this would be costly to conduct.
Moving forward, as I've outlined, there may be opportunities to enhance the monitoring of PTSD using surveys and/or administrative data.
The Public Health Agency of Canada is committed to working with partners and stakeholders to develop ways of measuring and reporting on the burden of PTSD in Canada.
Thank you for your attention. I would be pleased to answer any questions you have.
Thank you so much. It's a pleasure to be here.
For the committee to understand the context of my comments, I want to tell you a little bit about myself. I'm a psychiatrist and head of the department of psychiatry at the University of Manitoba. I have provided psychiatric consultation and treatment at the Veterans Affairs operational stress injury clinic in Winnipeg as well as at the Health Sciences Centre in Winnipeg.
Over the last 17 years, I've had the opportunity to help and learn from people who have suffered with post-traumatic stress, as well as mood and anxiety conditions. I've also held Canadian Institutes of Health Research grants on military mental health as well as first nations suicide prevention.
Currently I'm working with and leading a team of researchers and clinicians in examining the impact of trauma and post-traumatic stress among Canadians. One of the studies is a large survey with Statistics Canada that follows the Canadian military over 15 years.
I want to comment that I'm very supportive of Bill that has been brought forward. As I understand it, this bill would increase the conversation federally as well provincially in developing a federal framework for recognizing and treating post-traumatic stress disorder.
I will summarize my understanding of the current knowledge of PTSD in Canada as well as internationally. There is increasing recognition around the world about the substantial impact of traumatic stress and PTSD. We know from studies around the world that PTSD is associated with enormous cost to the individual as well as society. We know that approximately 60% to 80% of Canadians, at some point in their life, will be exposed to a severe traumatic experience. Most people exposed to that traumatic experience will be resilient and will not require treatment. Social support is the most important protective factor after exposure to trauma.
However, we do know that 20% to 30% of people exposed to a serious traumatic event will develop a trauma-related condition, for example PTSD, but also other conditions like depression, another anxiety disorder such as panic disorder, or a substance-use problem.
There is more and more knowledge that is accumulating that shows that exposure to repeated trauma over time can increase the risk of PTSD. We also know that physical injuries, assaultive trauma, motor vehicle accidents, and rapid onset of critical illness are associated with PTSD.
Our group has shown that people with PTSD have about three times the likelihood of developing suicidal behaviour compared with those who don't have PTSD.
Women, refugees, public safety officers, health care professionals, military and veterans, as well as indigenous groups, are at higher risk for PTSD. This knowledge comes from some Canadian studies, but mostly from U.S. and other populations.
Most people who have a traumatic injury at work who develop PTSD have difficulty and have complex return-to-work issues.
We also know that co-occurence of physical health problems, such as chronic pain as well as addictions, are common and are associated with morbidity and mortality.
We also know that people with PTSD can have a significant impact on their family, intimate partner, as well as their children, and we also know that relationship conflict, divorce, and separation can trigger suicidal behaviour among people with PTSD and depression.
We know most people with PTSD in the public sector have long delays in receiving evidence-based treatments.
Canadians have limited access to psychiatric and psychological treatment, as well as rehabilitation, in the public system. Many people with PTSD receive medications and treatments that are not recommended by expert consensus guidelines, such as benzodiazepines like Ativan, or medical marijuana.
Marital and family therapy can improve outcomes but is often not available. People in remote communities have limited access to psychological and psychiatric treatment.
We know that early recognition and treatment of traumatic stress symptoms in PTSD can reduce suffering and improve functioning. We also know that a combination of psychological treatments and medication treatment can help in reducing suffering for most people with PTSD.
There is more and more interest in using novel approaches to deliver psychological treatments, such as Internet-based cognitive behaviour therapy as well as large classroom-delivered cognitive behaviour therapy.
There has been a rapid expansion of mental health services in the Canadian Armed Forces and Veterans Affairs' clinics in the last 15 years. This rapid expansion has reduced waiting times and improved outcomes among Canadian military and veterans with operational stress injuries. In Manitoba, we're highlighting the need for similar interdisciplinary models for providing timely access for civilians suffering with PTSD.
Telehealth and telephone-based care have also shown efficacy in reaching those in rural populations who suffer from PTSD in the United States. These models of care have also been shown to be cost-effective.
Finally, any investment in improving recognition and treatment of PTSD requires strong evaluation.
Thank you so much. I look forward to your questions.
Good afternoon, honourable members of Parliament and your staff, members of the Standing Committee on Health, analysts, proceedings and verification officers, and honourable chairperson.
My name is Natalie Harris, and it is my pleasure to have this opportunity to share with you how important MP Todd Doherty's Bill is to myself and to so many first responders, veterans, military personnel, and corrections officers across Canada. Establishing a national framework to address the challenges of recognizing the symptoms and providing timely diagnosis and treatment of post-traumatic stress is essential to saving the lives of those who passionately care for and protect the citizens of this great country every day.
It has always been easy for me to share that I'm an advanced care paramedic with the County of Simcoe in Ontario and the mom of two beautiful children, Caroline and Adam, but it's only been over the last two years with the support of my family and friends that I have developed the courage to share that I also battle post-traumatic stress disorder and attempted to take my own life in 2014 when I had no hope of getting the treatment and support I needed to survive.
You may be wondering to yourselves what in the world this seemingly normal girl could possibly teach you today. I may not be representing an organization, but that's okay, because what I do represent is very important. I sit here before you representing what could be your sister, mother, daughter, wife, friend, or partner, who may be silently battling a world of darkness all on her own because she is too afraid to ask for help for fear of no longer being able to do the job she so dearly loves, for fear of being ridiculed and labelled with mental health stigma for the rest of her life, and for fear of not being heard.
In October 2014, PTSD had caused me to live in a world filled with fear and sadness that constantly undervalued my fundamental necessity to breathe. It caused me to live in a world filled with darkness, distorted thinking, and illogical reasoning. It caused me to live in a world that harboured powerful voices that told me that I should hurt myself because I was worthless, and that everyone would be better off without me. In October 2014, PTSD caused me to know for certain that I was going to take my own life. On that dreaded day, after swallowing half a bottle of muscle relaxants, I wrote a letter to whoever would find me, “I'm so sorry. You will be okay. I love you.” I then swallowed the rest of the bottle.
I started feeling tired. I knew the medicine was working. I lay in bed staring at the ceiling, more numb than I'd ever been in my life, while I was literally waiting to die. I remember feeling sick, and somehow in my haze I made it to the bathroom. That's all I remember. For all I knew, I would never wake up again. For all I knew, I was dead.
What I didn't know was that my colleagues had found me and brought me to the hospital where I remained unconscious for 12 hours. The doctors and nurses pumped litres of fluid into me with the hope of saving my liver. As the hours went by, my abdomen grew full of fluid, and I turned jaundiced as evidence that my liver couldn't keep up.
My family and friends were seriously discussing funeral plans for me, but somehow I survived. It wasn't time for me to leave this planet quite yet. I still had some pretty important work to do, which has brought me here today.
I went to school in 2001 to become a paramedic. Not long after graduating, I was hired by a service. Going to work was like a dream come true, even during SARS, which is when I was hired. Not very many people can say that about their careers. I learned something new every day, was financially stable, and made such a difference in people's lives. I was in my glory, but no matter how much I loved it, each year became a bit tougher for me to cope with, and I didn't know why.
Through difficult calls, I would silently say to myself, “I'm not going to let this amazing career slip away from me. I've fought too hard. I've conquered so many difficult circumstances in my life. I'm sure I'll be okay,” but secretly I began to develop a repertoire of illusions used to hide my true emotions even from myself. Back then, I barely knew what post-traumatic stress was, because we didn't learn about it in school.
I started to see tiny changes in myself in the early years, as days just seemed to go by and calls just happened to add up. I could let most calls move through me in a healthy way, but looking back now I can recognize the deterioration of my coping skills as life as a quiet paramedic took its toll.
Over the years, while being a full-time paramedic, I literally became very comfortable with uncomfortable. I became acclimatized to living a life that included horrific memories, relentless nightmares, and ingrained images of sadness and pain. That may sound barbaric to anyone who is not in the emergency services field, but it is literally a part of our lives almost daily.
Devil's advocates out there may be saying to themselves that we signed up for it, but we didn't. We signed up for an amazing career that allows us to help people on an extraordinary level. No one signed up for mental turmoil. We signed up for the chance to save people's lives. No one signed up for memories of patients screaming in pain. We signed up for achieving educational goals. No one signed up for drowning our sorrows in vices.
We thought we would be strong enough to avoid being uncomfortable, but no one is. Strength isn't measured by the number of deaths we pronounce. It's measured by the number of deaths we recognize we need to talk about in order to sleep at night. First responders are some amazing people, but signing up to be one didn't mean we signed our hearts away.
It's not normal to have a person ask you to just take their leg and arm off because they were experiencing so much pain from being trapped in a car with multiple open fractures all over their body. It's not normal to learn that the patient who hanged himself the night before had a second noose waiting for his wife, had his son not called 911 at the right time. It's not normal to witness a young woman, seven months pregnant, rub her belly with the only limb that could move as she had a stroke that would leave her disabled. It's not normal to see the cellphone on the road beside the obviously dead driver, crushed between the pavement and the car, who was texting and driving, and it's not normal to know he made the three sisters in the other car now two. It's not normal to experience and see the look of true evil when you learn how two innocent women were murdered. It's not normal to be handed a baby who's blue. It's not normal to watch a child have a seizure for 30 minutes because your drugs just wouldn't work. It's not normal to see someone die before your eyes more times than you can actually count.
What we do isn't normal, so why would we think it's okay to be comfortable with that? Why would it be any surprise to hear that first responders are dying every month because they can't take their often hidden memories any longer? I'm uncomfortable with how comfortable we've become.
Honourable members of the committee, we can't wait any longer to acknowledge and act upon the cries of heroes and their families that are happening right now coast to coast. They need Canada to step up to the plate and value their sacrifices in the form of education and support.
So much more needs to be done to prevent the deaths of community heroes, and MP Todd Doherty's Bill is where this can start. It's on the table, and we can't push it aside. If we do, time wasted will equal lives lost.
I would like to end my testimony by sharing a poem I wrote in memory of my friend and colleague Bob Cooke who died by suicide in September, 2014. We miss Bob, and we will never forget you.
I wish you'd see, but never feel,
This illness dark, to some not real.
I wish you'd know, it hurts to breathe,
My lungs collapse, when comfort leaves.
I wish you'd cast my scars away,
Repair the marks I formed each day.
I wish that answers existed near,
To rid my soul of unfounded fear.
I wish each tear was never there,
They drown my courage left to care.
I wish I'm brave enough to smile,
Sustain down heartache's endless mile.
I wish you'd camouflage each sting,
The blackness seems to always bring.
Believe tomorrow's a brighter day.
But I can wish with all my might,
It won't discount this ceaseless fight.
This wish will sail up to the sky,
With all the rest who've said good-bye.
I'll wish tomorrow, just for hope,
Or conjure up some way to cope.
Through darkness black, I'll make my way,
I never had the opportunity to choose to hang up my uniform. Sadly, PTSD made this decision for me. I plead with you today to move forward with this bill and put Canada on the map with respect to having the best national framework for our heroes so that every uniform can be hung up when the time is right, with the hero's choice.
At this time I would like to present you, the committee, my own dress uniform. I hung that uniform up in my closet quite some time ago. I wasn't able to even look at it until yesterday. I was so sad, hurt, and heartbroken that I needed to end the job that I loved so dearly and still miss to this day. I'm asking you to please take care of my dress uniform. When this bill is moved forward, and we actually get to work on saving those lives coast to coast, would you please give it to MP Todd Doherty, so that he can keep it in his care?
Thank you for your time.
Once again, that's a great question.
Unfortunately it is still very prevalent. I've seen a lot of progress though over the last couple of years with amazing campaigns like Bell Let's Talk that are raising awareness and helping people not to feel weak. Sick Not Weak is another great campaign.
I'm fortunate to have a few of my paramedic friends here in the audience. We were speaking just before this meeting about how we never wanted to admit to ourselves that we could possibly be sick because of the passion that we have for this career. We didn't want to hang up our uniforms. It's not even that we keep it from each other; we keep it from ourselves. We don't want to see. That's what happens.
Unfortunately—I speak for myself—I turned to alcohol and drugs in the hope of coping with the demons that were in my mind and in my dreams so that I didn't have to hang up my uniform. Unfortunately that led to a suicide attempt.
I went to treatment. I've grieved the loss of my career; that is how much it is a part of who we are. It took a long time. With that being said, you can see how it's not an easy thing for first responders to admit. They don't want to have to admit it. Unfortunately, that's where we are, still.
With education, with this bill, with prevention, and with a decrease in stigma, I think we will have a lot more first responders with prolonged careers. I also give a lot of talks in colleges, and I present to peer support groups. One that I created is called wings of change. The purpose is to try to develop resiliency and awareness at the very beginning of a first responder's career, and to start the conversation then.
My daughter is in a police foundations program. People say, “Wow, how is that going to happen?”
You know what? I understand her passion. I support her for what she wants to do, but I'm in a wonderful position to be able to educate her. Hopefully with time, and a federal bill that brings a voice to not being weak if you are sick, it will improve and decrease the cost of the treatment that needs to eventually be addressed. I know that for myself, if I had had help earlier, I definitely wouldn't have had so many months in treatment, relapses, and so on. This is a great bill.
Thank you, Dr. Sareen; thank you to our guests.
Natalie, that was incredible testimony, as always. We know that.
I want to mention two points. We talk a lot about our first responders regarding the bill. In the bill, it's not just our first responders, but it is our veterans and our military, those who put their uniforms on every day to serve our communities and our country. I just want that mentioned.
Also, Dr. Sareen, you mentioned what the military, our Canadian Forces, have been doing very well in the last six or seven years. The R2MR program, the road to mental readiness, is exactly what our colleague Mr. Webber was talking about, and the framework of the bill or the gist of the bill is to get those best practices applied right across our country.
For the information of my colleagues who are here, an RCMP who is serving in Nova Scotia and is dealing with PTSD may not be eligible for services in British Columbia. So it's to make sure that there's consistent care and diagnosis right across the country. I'm just using that as one example.
I want to direct my comments to Natalie.
Natalie, you are an accomplished author and you have shared your experience, which is really changing the views of PTSD and giving people a look inside your head, if I can put it that way, during your darkest times. You have a blog that you started writing as you were hospitalized, and out of that you wrote a book called Save-My-Life School: A first responder's mental health journey. I would like you to talk a bit about both the blog and Save-My-Life School , if that's possible.
In 2014, I started my blog when I saw Clara Hughes, one of our amazing Olympians—a six-time Olympian—on TV. She was talking on the news about Bell Let's Talk. I can tell you that I felt stigmatized to the fullest extent. I was very proud of my career. I was a teacher for Sunnybrook Base Hospital for Georgian College. I was in the first advanced-care paramedic class in the County of Simcoe.
I really didn't want anyone ever to think that there was something I was battling with that would jeopardize my career. I saw Clara Hughes talking about how she battled with this, and it gave me the strength to start a blog. That blog started, I think, on my very first day of an out-patient course, which was through the Royal Victoria Hospital in Barrie. I documented every honest day and every up and down. I carried it on when I went to Homewood in Guelph, which is a rehabilitation hospital, for my PTSD and addiction.
Afterwards, I shared about my life now and how I manage symptoms that I still experience, and how my family and kids have contributed a little bit to the book as well. I have broken down the stigma for kids their age.
The foreword was written by our Olympian Clara Hughes. Also, an acknowledgement was made by our Ottawa councillor Jody Mitic. I was very fortunate to have a lot of amazing support, including that of Todd Doherty and John Brassard, for the book. It is opening a lot of eyes for people. As Mr. Doherty said, you don't need to have a mental illness, if you read my book. What people are enjoying is that it brings you into the mind of someone who has mental illness. It's very raw; it can be very dark. It's actually quite difficult for some people to read, because it's very truthful and honest.
Thank you for letting me share that part. I appreciate it.