Ladies and gentlemen, I'm calling this meeting to order.
Good morning, everyone.
Today's meeting is meeting number eight of the House of Commons Standing Committee on National Defence. We're in a hybrid format, as agreed by the House order of September 23, 2020, so the proceedings will be made available on the House of Commons website.
Our meeting today will be twofold. Our first panel for the first hour will be composed of Ms. Sheila Fynes, who is the parent of veteran Corporal Stuart Langridge, who died by suicide in 2008.
Also, we have Ms. Jackie Carlé, the executive director of the Esquimalt Military Family Resource Centre. Good morning, Ms. Carlé. I know it's early in B.C., and we thank you for joining us today.
After a short pause around noon, we will engage with the second panel.
I want to start by thanking Mrs. Fynes for her testimony and for joining us here today. Thank you for having the courage to join us here today. I know it's not easy, but it's really important that parliamentarians actually hear from people like you, and that we listen, even though it might be difficult to do so. We have to try.
The programs we put in place, the policies we put in place, are designed so that we can make people's lives a little easier, maybe a little bit brighter. We do that by talking to the people with lived experience and experts, and bringing all that information together.
As a veteran as well, I acknowledge your son's service to this country and let you know that we're deeply sorry for your loss. I must say that your courage... I mean, it's inspirational to all of us that you still keep going, as painful and as frustrating as I can just imagine, and I can only imagine, it must be. It's hard and difficult, but I wanted to thank you. I wanted to acknowledge what you're doing. It's important. What you have to say to us today is so very important for us to hear, because this is all about people.
With that, thank you for joining us today, and I thank you in advance, and I will now ask you to take the floor, Mrs. Fynes.
I believe that, even if never used, this subsection provides an unintended negative consequence simply by remaining in force.
In 2007, while completing the last phase of training towards his next promotion, Stuart admitted in a questionnaire that he suffered from chest pains. That triggered a return to his unit, where he was placed under military medical care. We did not know at that time that chest pain is symptomatic of post-traumatic stress disorder. In the year following, until his death, Stuart was dispensed multiple prescriptions, but went progressively downhill and suffered nightmares and night terrors. He also began to self-medicate, primarily with alcohol, supplemented by marijuana, the latter now being an accepted and provided treatment.
As his condition deteriorated, Stuart began what became a series of suicide attempts and accompanying emergency hospitalizations. He became more and more isolated from his military comrades and began to see himself not as a good soldier but rather, as he put it, “one of those losers”.
In desperation, towards the end, he took himself to a local civilian psychiatric hospital for help and was admitted. At the end of the standard 30-day mental health certificate, he wanted to continue in treatment but was surprised when he was ordered back to base instead. A few days later he was placed on what were later described as restrictions, but they in fact closely resembled defaulter's discipline. He was subjected to a curfew, as well as an extended work day. He had to report all his movements on a form at the regiment and report in every two hours. He was required to sleep with the door open in the defaulter's room behind the duty desk at the regiment. He was completely shamed and humiliated.
Reportedly, a decision had also been made that he would not be allowed to attend a treatment program at a cost of about $50,000, and Stuart became even more dysphoric. He gained access to a room at the barracks, purportedly to do laundry, where he instead hanged himself.
Fifteen months after his death, we were informed that Stuart had left a note apologizing to his family that he could not take the pain anymore. The application of quasi discipline to a mental health problem was a spectacular failure that cost our family a son, a brother and a grandson. It also cost the military a dedicated, extremely well trained and experienced soldier.
Indicative of the prevailing attitude at that time was a bizarre suggestion at the board of inquiry that followed: Officers opined that Stuart could not have acquired post-traumatic stress disorder from his deployment as a recce soldier and his patrols in the mountains of Afghanistan.
Thankfully, much has been learned since then, and post-traumatic stress disorder or, more generically, operational stress injury, is now accepted as a bona fide injury. In that paradigm shift, effectuated by a new generation of leadership in the forces, extensive new suicide prevention strategies have been implemented and more treatments are becoming available. Victims are no longer written off as just discipline problems. The institution now encourages a more contemporary warrior ethos, which recognizes that soldiers, however exceptional, are humans and not machines. Even thinly disguised discipline is misplaced abuse of the subordinate and is no longer a default alternative to medical treatment.
Currently, the military justice system has come under general scrutiny, and a review headed by former Supreme Court Justice Morris Fish has been undertaken. Hopefully it will address the broader issues of impartiality and fairness within the system.
Contrasting section 98(c) to civilian criminal justice in Canada, I would point out that a possible sentence of life imprisonment equates self-harm in the military to the most serious offences, such as murder or treason. I believe that the concept of punishing for self-harm is a relic of the World War I era. Back then, some soldiers weighed the lesser evil of self-harm against that of charging on foot through no man's land against waiting machine guns. Canadian soldiers were punished and some even executed for perceived cowardice. Of note, all those executed have since been pardoned on humanitarian grounds.
Now, in the age of a professional, volunteer military, trench warfare-era punishment for self-harm has lost any true relevance.
In recent times, our military has suffered a slow-drip epidemic of soldiers being lost to suicide. Today, any soldier inflicting self-harm is more likely to be suffering from an operational stress injury than trying to avoid combat. Suicide attempts resulting in self-harm should summon immediate help, not punishment.
By contrast again, in Canada the criminal offence of attempted suicide was repealed almost five decades ago. Such incidents are now managed under mental health provisions rather than by criminalizing and punishing victims.
I worry that the lingering stigmatization of operational stress injuries faced by members of our military inadvertently dissuades them from seeking help. That reality is oppositional to the hope that early medical interventions can offer better outcomes.
Members of the military intuitively understand the difference between “talk the talk” and “walk the walk”. It is not enough to tell them to put their hands up and ask for help when they see that they may be punished instead. In this instance, continued reliance on arbitrary discipline undercuts efforts to support members who may be struggling. To a soldier attempting to end their pain by taking their own life, the possibility of future discipline holds no deterrent.
Because section 98(c) prescribes punishment for self-harm, it frames it as a discipline problem. Because discipline is administered for misconduct or failure, it invokes shame and thereby actually reinforces the stigma around mental injuries. Members of Canada's military have earned our respect and support, not disdain or punishment.
Our sincere hope is that some good will come from Stuart's death and that positive changes regarding treatment of victims of OSI will form a part of his legacy.
The provisions of section 98(c), when applied to those with mental injuries, are a travesty and opposite to how wounded Canadian patriots should be treated. It is inconceivable to me, and hopefully to you, that threats of Code of Service Discipline and possible life imprisonment will in any way help address the high numbers of suicides in the forces.
In a volunteer military with professional leadership, punishments under section 98(c) of the National Defence Act have become inappropriate and may, in a deleterious way, undermine good order and discipline. I would respectfully suggest that there is no appreciable downside to removal of that section.
Proper administration of the forces should rely not simply on threats but on effective leadership. Our injured troops are not to be treated as disposable military assets, and if repeal of section 98(c) saves even one life, you will have had a profound impact.
Thank you for your efforts to effect positive change and to look after the best interests of each and every one of our service women and men.
Good morning. Thank you for having me here today. I'm in beautiful Victoria, British Columbia.
I am the executive director of the Esquimalt Military Family Resource Centre, and I've worked in military family services programs for 23 years.
I'll give you a bit of background about military family resource centres.
A lot of people don't realize that we are not-for-profit societies. There are 32 such centres across Canada, and we are all specialists and subject matter experts in the military family lifestyle. We receive some funding from the Canadian Forces morale and welfare organization, and we also receive funding from the local base for what we call site-specific services. I'm telling you that is because later on I will talk to you a little about some of our mental health services that are supported by CFB Esquimalt.
We have the ability as not-for-profits to fundraise, to apply for grants and to charge user fees for things such as day care to meet our budget requirements.
Military family lifestyle is unique and involves frequent and unpredictable geographic relocations. It involves the endurance on the home front of military members who head away for long missions and deployments and their exposure to risk. As we are also learning this morning, it's about families dealing with operational stress injuries.
In terms of that and in terms of our mental health services towards families, we offer a variety of programs and services. I'll briefly go over those for you.
We offer counselling. During the pandemic, we have moved to a virtual platform for our counselling services, but I'm sure you can understand that when we have cases of interpersonal violence in the home, we have created opportunities for people to meet with our counsellors in person, following all the appropriate COVID protocols. That's very important, because in some households it's impossible for a family member to receive counselling support when the military member or other family member is around. This has also proven to be something for the youth we support, who are often more comfortable going for a coffee or a walk. Again, this has been somewhat of a challenge during the pandemic, but we have been able to create appropriate protocols so that we can work with those folks.
Part of the work that we also do is preventive. That would be facilitating groups and workshops that relate to things such as parenting, maintaining wellness and relationship issues.
We're just about to launch into return-and-reunion workshops. We have a ship returning after six months away, with 220 members on board. We'll be working with their families to help to integrate that military member back into the household and to talk about things such as operational stress injuries and how they can support their families as they return back into their homes and into their communities.
We're also very fortunate to be able to offer specialized services, and this refers to my previous comment that we receive funding from our base commander. These would be services such as therapeutic play for children and youth, as well as navigation services. I'm sure you can imagine how it feels for families who have a child who is on a wait-list for exceptional needs when they finally get to the top and then have to relocate again. We're doing some work on harmonizing those wait-lists across provinces. Our staff also help people navigate the local services so they can integrate quickly and get the help they need for themselves and for their families.
We have a strong partnership with base mental health services, and this is very important, because families are complex. When we see them, we're not just seeing the family members; we're seeing the military member as well, and providing wraparound service. It's very important for us, with the appropriate confidentiality agreements in place, to have a close working relationship with base mental health as well as close working relationships with partners in the community, so that we can make meaningful referrals for families who are experiencing issues that are a little beyond our scope.
The Canadian Armed Forces has a construct called a transition centre. This is for members who are ill and injured. We have a counsellor who is co-located there. The purpose is to support families who are dealing with an injury, including an operational injury. Sometimes it can be an illness.
What they do in this unit is work with the military members. We work with the families, with the ultimate goal that the member might be transitioning out of the Canadian Armed Forces due to an illness or injury or might be needing some specialized care in order to get back to duty. We engage very heavily in this centre with military members, as well as with families, to create what we hope is a healthy transition.
What happens then is that the member gets passed along to our veteran family program coordinator, who works with families of veterans to assist with that very difficult transition, especially when it's a transition that was unpredictable due to a member's illness or injury.
I want to speak to you for a few minutes about some of the things that concern families when it comes to accessing mental health care for their military member.
One of the things we have certainly experienced is that at CFB Esquimalt, and I think at many bases across the country, there is a lack of mental health care after hours. During the day, if a military member is having any health issues, including mental health issues, they go through the clinic system, although there are some barriers to that for those members. Our big concern is when the office is closed down and it's after hours. Then organizations like ours, the chaplain team and the military police become the go-to resources under those circumstances. It almost seems inevitable that once a military member goes home, in the evening or over the weekend is when they or their family will reach out for help and support.
As I mentioned, I've been in this program for about 23 years. Previously, there was always a mental health professional from the base on call and ready for those after-hours emergencies. We have, in Ottawa, as part of military family services, a family information line that includes virtual counselling. The problem is that there is a lack of understanding of the local communities and how to support somebody over the telephone when there is a crisis under way.
I would have to say kudos to our chaplain teams, who are the ones taking those after-hours calls. I hope at some point that the committee gets the opportunity to speak with a member from the chaplain team to begin to understand the unique pressures that they experience in terms of caring for families and military members.
The other issue that has concerned us in the past is that our military police force are not, in British Columbia, able to transport someone under the Mental Health Act. They're deemed not to have the proper credentials that the city or municipal police might have. What we've experienced, for example, is that a member might come through our doors with thoughts, for example, of suicidality. The military police are limited in terms of negotiating with that person, getting them into their vehicle and getting them to appropriate care, whether that's at the base hospital or at our local hospital in the psychiatric unit.
It's heavy negotiation for somebody who is already in an extreme situation. Oftentimes we find we have to divert ourselves to the municipal police or ambulance which, of course, adds to the trauma. Our goal is to be providing trauma-informed care, and we find this does undermine that.
We often get some assistance from the chaplain team and chain of command for those things, but I think that relates to the previous testimony that we just heard: that it can be a very bureaucratic and a traumatizing experience for a military member who is undergoing mental health issues.
We've had a very difficult journey, and it's been a very long one. We were initially notified of our son's death by phone. It was actually a telephone message that was left. We returned a call to the base and were told that Stuart had died. Later on that evening, a padre and an officer came to our home and spoke to us.
Our first reaction was that we'd told them this would happen. We knew Stuart was in trouble. We knew he needed help. We knew he wasn't getting the appropriate help. We knew that when he left the hospital the base didn't have a plan for him. It turned out that he was living in his car in the parking lot at the base. Eventually, he ended up at the duty room and had a further hospitalization. There were a lot of things that happened in succession. When we were notified, the first words out of my mouth were, “I told them this would happen.”
I think that because we wanted to know why this could have happened when everyone was aware of how much trouble he was in, we asked questions. The more questions we asked, the more the military closed in. I think, to be honest, they recognized that they'd messed up. They had a soldier who was dead and really didn't need to be. The more they closed up, the more questions we asked.
We went through a very painful funeral. We weren't given his suicide note for 15 months. We'd asked if he'd left one, and they said no. They designated someone else as his next of kin, and when we looked at the paperwork, it turned out that the person was definitely not his next of kin. It was a series of events that just kept piling on and piling on. Of course that made us angry, and in a way it almost helped put the grieving process on the shelf because by then we were asking, “What's going on here?”
We ended up having a board of inquiry that didn't really answer our questions and was definitely designed to have an outcome that protected the military. From there, eventually, as some of you may know, it ended up being a military police complaints commission inquiry that went on for some time and cost the military a tremendous amount of money. We became very vocal advocates.
There's nothing we can do to bring Stuart back. We recognize that, but we came to know a lot of serving members and people who had been released who were really at risk and were going through comparable situations. We would get phone calls. We became this very informal family whom they knew they could call. We still get calls from soldiers, sometimes in the middle of the night. Sometimes they've had a few drinks or whatever. We will always make time for them because our job is never to have another Stuart again.
We also have a secondary purpose, in that military people are really smart. When someone is seen to be struggling, they start walking this walk of shame, and they're disenfranchised and all the rest of it. They're not stupid. They know that if they put their hand up, this is not going to go well for them. Eventually they'll be released. They'll lose everything in life that's important to them.
Our goal now is for every single one of these soldiers.... They didn't die on the battlefield. If they die in an airplane between Dubai and here, their name is on a wall. If they come home and they're on sick leave and they die, for whatever reason, their name goes up on a wall. There is a recognition of their service. It's really important to this family, and I think it would send a really good message to other military serving members and their families that their service was important as well.
Sorry. That was a very long answer.
In the initial circumstance, I would really wish that Stuart had been seen as a mental health problem—and I hate those words, but he needed help—rather than as a discipline problem.
This incident when he was at the duty desk really sticks in my mind. There were a bunch of cadets in the base. He asked if he could go and help out. Now, this is a soldier who has served overseas. He represented Canada and the United States, because he was a really good gunner on the tanks. He represented them there. He had a lot of accomplishments, and all of a sudden he wasn't even good enough to go and help with the cadets. That really hurt. That was the day he killed himself. There was a funeral for another soldier that he wanted to attend. He wasn't allowed to do that.
Their default position was “We have this guy, he's living behind the duty desk, and we're going to get rid of him.” I think he could have been saved. All he really wanted was to return to being a good soldier.
Paragraph 98(c) is a little-known section in there. When I found out about this, I was absolutely astounded. What do you mean, you have a soldier who is sick and you're threatening him with life imprisonment? I'm not quite sure how that saves anybody, and the message it sends to everybody else is awful. When other soldiers see a soldier struggling, they really are scared to put their hand up. There's a stigma attached still to all of this. I think mental health professionals' number one message is “It's okay. Come on in. It's fine. We are going to help you,” not “Come on in, and by the way, we need to start the paperwork to do something else.”
Yes, thank you very much.
The challenges we experienced during this pandemic around access to mental health supports really relate to the pivot that organizations were able to make to serve people on a virtual platform.
From our perspective, we were able to make that move very quickly because we are an independent organization. What we have seen, however, is that the Canadian Armed Forces have a lot of restrictions around connectivity on a virtual platform. Early on in the pandemic, there were some huge challenges in terms of members accessing mental health supports. I would say that the situation has improved over the course of the pandemic.
I think that one of the major trends we have seen and continue to experience is an increase in interpersonal violence in the home relating to the situation of isolation, and the extra stress and pressure that could be financial, and certainly has been emotional and psychological, during this pandemic.
The Canadian Armed Forces have responded to that in terms of increased resources around interpersonal violence. We are finding that our caseloads have become quite heavy.
This is something that we do experience all the time, but we've certainly experienced a spike during the pandemic.
First of all, I don't see a downside in removing it, and I definitely see an upside to that happening.
A good soldier, a well-trained soldier, learns very early on what the rules are and what's expected of them. This rule doesn't have to be enforced for it to have an effect. They know that it's kind of dangerous to them, right? There's always this little thing lingering in the background.
I think that when they're not well, they don't need one more thought of, “Oh, my goodness, would they really do that to me? Would they lock me up?” I think that the National Defence Act is a fairly succinct act. I think every soldier is well schooled and disciplined, and I would respectfully suggest that if there's just one more thing that might make a difference, then what's the downside? Just get rid of it.
As I said before, I was personally astounded when I found out about this. I'm sure Stuart would have known about it, so yes, if it disappeared, it would just be a really good thing.
Certainly, yes. Thank you. I really appreciate the opportunity to be here.
What the testimony is telling us today is how important the voice of family is and how compelling it is to create a culture shift so that families can have a voice when these occurrences happen.
As recently as two weeks ago, we experienced the suicide of a military member at CFB Esquimalt. The way it affects our services is that we rally to support that family, and we often find that it takes on an advocacy role. For example, this member was part of a very small unit, and the other members in the unit were devastated by the loss and also by a feeling that somehow they missed something. There was a comment this morning from a witness who, upon hearing the news, said, “Yes, I knew this was going to happen.” We hear this very frequently in these cases of completed suicide and attempted suicide and family members are working really hard to get that military member to the care they need.
Our involvement, as a military family resource centre, is literally to walk alongside of that family and to help them in terms of their inroads so that they can have a voice and so that the military can become more trauma-informed. What I do see with our military members is that they struggle so much with this kind of loss, and so our work, along with the base mental health team, is to support the colleagues of these members. I'm sure colleagues of Stuart would have appreciated some support, because there is quite a legacy that lingers.
There is probably a very aggressive approach to operational security, and sometimes information isn't forthcoming that should be forthcoming, so we're really talking about a shift in culture here.
Thank you, Madam Chair.
My name, as you were just told, is Dr. Elizabeth Rolland-Harris. I am an epidemiologist by training. I hold a Master of Science in epidemiology from the University of Toronto as well as a Ph.D. in infectious disease epidemiology from the London School of Hygiene & Tropical Medicine in the United Kingdom.
From June 2006 to September 2019, I worked as a senior epidemiologist for the directorate of force health protection within the Department of National Defence, and during my tenure there, I was responsible for the military suicide epidemiological surveillance file as well as being the project lead and co-primary investigator for the Canadian Forces cancer mortality study II. This study was conducted in collaboration with Veterans Affairs Canada and Statistics Canada, and it endeavoured to describe the types and numbers of deaths in both still-serving and released military personnel. These deaths included suicide deaths.
In September 2019, I left the Department of National Defence and accepted a new role with the Public Health Agency of Canada. I want to make it clear that my appearance today is based solely on my duties and knowledge related to my former position with the Department of National Defence.
I am not here today as a representative or employee of the Public Health Agency of Canada, as the subject matter of this study is not related to my current position with the agency.
Thank you for your invitation to appear before the committee.
It's a real honour and a pleasure to be here today, and the testimonies of the previous speakers were really heartfelt. Thank you to everyone.
I'd like to also acknowledge that I'm a psychiatrist at the University of Manitoba, a department head, and I have worked at the Veterans Affairs Operational Stress Injuries Clinic in Winnipeg as a consulting psychiatrist since 2009.
The research I'm presenting today is funded by the Canadian Institutes of Health Research, as well as the Canadian Institute for Military and Veteran Health Research and the True Patriot Love organization.
The focus of the presentation will be on the 2016 report of the mental health expert panel on suicide prevention in the Canadian Armed Forces. I co-chaired this panel with Dr. Rakesh Jetly. It included a number of national or international suicide experts, DND policy-makers and VAC representatives.
The key observation of the mental health panel in 2016, which met for two and a half days, was that there are approximately 11 suicide deaths per year in the Canadian Armed Forces.
The 2013 Canadian Armed Forces survey that was conducted by Statistics Canada showed that the past-year suicidal ideation rate among active military personnel was 4.3%, and the rate of suicide attempts was 0.4%.
The panel recognized that suicide is a behaviour that is extremely difficult to predict at an individual level. Although the goal is to have no individuals die by suicide, the expert panel recognized that at times not all suicides can be prevented.
On the risk factors for suicidal behaviour among military and veterans, we looked at all of the literature internationally as well as specifically in Canada, and a number of the risk factors that are well known include being male and having relationship difficulties or being unmarried. Depression, post-traumatic stress disorder, and substance use disorders such as alcohol use can often combine to lead to an increasing risk of suicidal behaviour.
More recently there's been understanding that traumatic brain injury as well as chronic pain conditions and new onset of physical health conditions can also increase the risk of suicidal behaviour. We also know that adverse childhood experiences have been strongly linked to suicidal behaviour, not only in military personnel but also in civilian populations.
Our work and the work of others internationally has shown that exposure to traumatic events during deployments is associated with suicidal behaviour. Witnessing atrocities, combat exposure or seeing a fellow member die in combat can increase the risk, but deployment itself is not a risk factor for suicide. Incidents of self-harming behaviour as well as the transition to civilian life are seen to be very important vulnerable periods.
One of the other important areas that have been discussed by previous witnesses is that important time of crisis when people are either admitted to the hospital or in an emergency setting. The periods before and after can be times of great vulnerability.
The report that was completed and submitted had 11 specific recommendations for the Canadian Armed Forces.
The first recommendation was to have a new position called a suicide prevention quality improvement coordinator. This recommendation was based on a strong understanding that suicide prevention requires a coordinated effort between the health system and the social system, and that similar coordinators have been implemented in the U.S. Department of Veterans Affairs.
There has been an increase in awareness and improvement in access to mental health services, but as previous witnesses have said, there is still a stigma about receiving care.
The suicide prevention coordinator would develop a patient and family advisory committee, review characteristics of suicide in military members, determine the needs for education among staff for suicide-specific interventions—and I'll talk about those, as there are a number of them that have evolved more recently—and then determine the need for education in primary care and specialty services and highlight the gaps that can be improved.
Recommendation two was to make a systematic review of all CAF member suicides since 2010. The medical professional technical suicide review occurs for every individual suicide death, but it would be very, very important to look at all the deaths consecutively to address specific questions such as where the suicide occurred, what the pattern of recent work and psychosocial stressors was, what types of physical health problems were prevalent at that time, what proportion of individuals were actually getting evidence-based suicide prevention treatments and, among firearm-related suicides, what measures were taken to limit access prior to death.
This type of review could help us guide policy to target suicide prevention in an evidence-based model.
There is, as I mentioned before, this pivot in the field of suicide prevention. Previously, the idea of suicide prevention was to treat the underlying depression, alcohol and substance use problem, but now the field is really shifting to the view that we need to both treat the depression and underlying condition and also target interventions specifically for suicide.
One example is a suicide risk assessment. There is a program called the suicide assessment and follow-up engagement, so if a veteran in the U.S. has an emergency visit due to a crisis, there is brief intervention and safety planning afterwards around means restrictions, coping skills and social supports and outreach after that program.
We recommend that the Canadian Armed Forces review some of those novel programs that are being implemented in the U.S., which could be helpful.
Thank you, Madam Chair.
It's indeed a pleasure to be able to, first of all, thank our witnesses.
I know that Sheila Fynes is still with us. I want to thank her for her advocacy and for telling her story, which is difficult to do.
Again, it's because of your voice that we've been able to address a lot of these issues over the years. I'm all too familiar with the loss of Stuart, as well as Shawna Rogers. I was parliamentary secretary when we dealt with those. All too often we ran into roadblocks, with provost marshals and DND blocking the timely release of information and treating families with disrespect.
I think that because of Sheila Fynes's advocacy, a lot of that now has changed. Despite the incredible agony and the tragedy of every suicide that we experience, at least there is I think a better process in place now than there was 14 years ago—in Stuart's case, 12 years ago.
I want to ask our witnesses some questions about the clinical analysis of suicide. I know that we always like to talk about PTSD. I can tell you that 10 years ago there was still a debate as to whether it even existed. Ms. Gallant was just talking about the trail-blazing work of some psychiatrists on that, but we were still trying to put everything in a box, saying it was depression or it was anxiety or there were other mental health issues.
Have we ever been able to break down which of those issues—if we don't lump them all together as PTSD—is the leading cause of suicide within the Canadian Armed Forces? I've had conversation in the past with Colonel Rakesh Jetly about how often the trigger can be attributed to service versus how many suicides are happening because of relationship breakups, financial difficulties, and so on. Are those the triggers, or is the trigger actually service-related?
Depression and often another mental health issue like PTSD, as well as alcohol, are the most common things that trigger the increase in risk for suicide, as well as a history of having made a previous attempt. Those would be the most common and the most important risk factors.
Life stressors, whether they are work-related or home-related, and especially financial stress, have all been shown to increase the risk as well. Specifically in the military and with veterans, that transition to civilian life and that sense of identity after leaving the military—who am I, and how is that impacting my social life as well as my family?—often become very important components.
We know that specifically deployment-related experiences that are traumatic have been shown to trigger PTSD and trigger depression. Legal issues in the military, if somebody's had those, can also trigger suicidal behaviour. The important thing is that the vast majority of people do not die by suicide when they have depression or anxiety; there's usually a culmination of all of those things together.
As you mentioned, often the military member, if they require admission to a hospital, has to go into the provincial civilian hospital, and that transition out is a high-risk period for everyone who is admitted. The panel recommended looking at those key time points during crisis when things have built up and then looking at some of the means-restriction processes for which there is the strongest evidence—for example, not having access to a firearm during the crisis or not having access to a number of different medications.
Jitender, do you want to take that one?
Personally, I can't explain it. Given the data we have, we're not really able to answer that question.
As Dr. Sareen said, suicide is a multifactorial reality. So many factors may be involved that it is not so simple to pinpoint; it is very complex. However, while the underlying reasons cannot necessarily be explained, perhaps Dr. Sareen could say a little more about it.
Nevertheless, it's like a red light, a flag that goes up, telling us that we need to do more, for example to do what is necessary to support this particular group. Since we can't necessarily always define the underlying criteria, it tells us that this group may be more at risk. More time, effort, and resources may need to be invested to explore this issue further.