National Defence Committee on March 4th, 2008

[The Chair, Conservative, Rick Casson]

One minute.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

Okay, I'll try to make it quick.

I think you mentioned that SSRIs are still the preferred treatment for people with certain post-traumatic symptoms. Haven't SSRIs recently been in the media?

All over the world they're discussing major studies that are showing them to be hardly better than a placebo in addressing this. I was watching Westminster, where questions were being asked of the Prime Minister of Great Britain at the time. Is that not the same class of drugs that are under discussion right now?

Are you aware of a non-drug approach, EMDR, that is approved by the American Psychiatric Association? Israel uses it, and Australia.

[LCol Theresa Girvin]

Yes, I have training in EMDR, and for select patients that is a very good approach. It's not for everybody, just as medications aren't for everybody.

I haven't seen that meta-analysis looking at SSRIs in treatment of depression, but I would say it's in treatment of depression in moderate and mild cases, not severe. So I don't know that it's appropriate to generalize that lay media coverage of the study results to PTSD patients with whatever degree of symptoms.

[The Chair, Conservative, Rick Casson]

Thank you.

Okay, that ends the first round. We're going to run out of time, but we'll get as deeply into this as we can.

Mr. Coderre, for the second round for five minutes.

[Denis Coderre, Liberal, Bourassa, QC]

First of all, thank you very much for appearing before the committee. I particularly like your frankness, it is like a breath of fresh air today. We like getting this type of answer.

I'd like to talk to you about decompression. We see in today's newspapers a report that Canadian soldiers administered a beating to someone living in Cyprus. Of course, this is an isolated incident. If appropriate, justice will take its course.

There was a time when people were sent home immediately after their mission. There were some rather pathetic cases. Does decompression really work? What actually happens? We hear that PTSD does not appear overnight. During the decompression period following a mission, it is impossible to tell whether a person will suffer from PTSD.

How do assess what is done during the decompression period? Is it possible to determine whether there will be more cases? It is true what there are some stressful situations in any mission. However, the mission in Afghanistan is a new situation for our troops—they are experiencing a different kind of stress.

During the decompression period, can you determine the number of cases of PTSD that will emerge?

[LCol Theresa Girvin]

First of all, I'm not an expert on decompression, but I do know that it is decompression. It's not assessment and it's not treatment. It's a chance for a person who's been in desert...some place austere or a combat environment to shift gears to come back to Canada.

And historically the roots of this go back to World War II. One of the things the Brits did was have health halfway houses for their veterans coming back from the front. They found it was prohibitively expensive but quite effective.

So that's what decompression is. It's a transition and it's an opportunity to provide them with information. People are going to misbehave, given the opportunity, and I'm glad to hear you recognize it's a rare incident. I believe there was--

[Denis Coderre, Liberal, Bourassa, QC]

It is isolated.

[LCol Theresa Girvin]

Yes, it's isolated, and that's a good thing, because it's an embarrassment, and I wouldn't want it to affect this opportunity, which is very well received by the troops. I wouldn't want to see this taken away from them.

[Denis Coderre, Liberal, Bourassa, QC]

One of the issues that I have felt from the beginning.... Of course, everybody will find out there has been some improvement, but it seems that it's more at the cure level and in evaluation after the fact. I don't feel we're putting enough emphasis on prevention; specifically, I think we should do better regarding recruitment. We never know what will happen with major stress, but I guess there is a grid or a check and balance that we should use.

What would be your recommendation?

[LCol Theresa Girvin]

I'm really glad you asked that question, because in my reading of history, back in World War II the American military—

[Denis Coderre, Liberal, Bourassa, QC]

I was much too young at that time.

[LCol Theresa Girvin]

The American military made efforts to recruit people who would be less likely to drop out from combat stress. There's probably an equivalent there: combat stress, then stress reaction, and later, PTSD. Toward the end of the war, they were screening out up to 70% of their recruits, saying, no, you're too high a risk. Yet this had no significant impact on the numbers of soldiers with CSR.

Other than a few people, those actively distressed and suffering from symptoms of a mental disorder at the time, or who are perhaps mentally retarded and untrainable, there aren't many others you can screen out. If your expectation is that we're maybe going to be able to find a configuration of factors that would say no, that person can't be recruited because their risk is too high, I don't think we're there yet, or able to identify that.

[Denis Coderre, Liberal, Bourassa, QC]

Is there any simulation where we can, after the fact, maybe have some results from a potential case?

[LCol Theresa Girvin]

No, there aren't laboratory simulations, but there is basic training and ongoing training. Before a person ever gets to the point of being deployed on a mission, they have gone through their basic training, they have gone through the mission training, they have gone through their trades training. All of that is like a screen or series of hoops that a person has to go through and prove their mettle before they're fit for deployment. So that's how it can function, in that way.

Is that exactly why it's constructed? No, the training is provided, and it's provided in a stressful and realistic way to prepare people, because there is some evidence that very realistic and very tough mission-specific training helps decrease the incidence of stress on deployments. So that's one of the pieces, I guess, in which leadership has a very important role in reducing stress casualties, taking care of the basics, for example.

Leadership, in taking care of the basics for the troops, will decrease stress. Stresses on deployment include things like not having enough water early on in roto zero, and physical stresses like that, such as not being able to shower, or these very basic needs that are stressful. These can be addressed, and they are addressed. You were there and would have seen that there are a lot of amenities. I remember that I did one of the first rounds of post-deployment screenings, and one of the best things that a lot of the soldiers described was getting the gym. Then, instead of using whatever they were working out with before—rocks, or whatever—they could go to the gym and work out.

So providing amenities, taking care of the basics, and providing tough and realistic training all go a long way to help reduce stress casualties in the field.

[The Chair, Conservative, Rick Casson]

Thank you.

We're just about out of time, but the next spot is for the government.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

To follow up then, I was glad to hear you mention that you're familiar with EMDR. I know it is approved by the American Psychiatric Association in its practice guidelines as effective for PTSD; and it's also approved as one of three approaches in Israel; and it's approved in Ireland, England, Holland, France, and in a number of countries.

I wonder if you would briefly define EMDR for committee members and give a brief description of this approach and the role of the EMDR in the CF.

[LCol Theresa Girvin]

Eye movement desensitization and reprocessing was developed by Francine Shapiro. She observed in her treatment of people who were dealing with traumatic memories that they would have saccadic eye movements. There were other observations she made that made her wonder whether, if she duplicated these for her patients while working with them on their trauma memories, they might be helped with their symptoms of post-traumatic stress disorder. She then developed a process, manualized it, and studied it to see whether or not it was effective for treatment of PTSD.

You do an assessment, obviously. You want to know what you're treating; you make the diagnosis. Then you have to identify in the patient that they are able to recall certain memories associated with images or imagery that symbolize for them their most distressing memories. You then have to help guide them through a way of describing in words what it is that's distressing about that. Basically, you have them hold that image and those thoughts in mind. You ask them to think about those things, and then you have them go through a series of rapid alternating eye movements while they sit with that. You would have them do a certain amount of that, and then you'd check in with them and ask where they are.

That's a very brief description. But I believe it draws on a component of exposure. We know exposure therapy helps with PTSD, having people face their demons, if you want, or confront their most distressing memories. It draws on cognitive behavioural therapy in encouraging a person to look at alternative thoughts in response to those, and it draws on suggestion. It gives them something to do. I think there's a component of suggestion in there.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

Could you comment on how commonly you or others in the CF health team are applying this?

[LCol Theresa Girvin]

I believe that every base, every OTSSC base, has people trained in doing EMDR. They certainly do in Edmonton. I know they do in Halifax.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

Can you comment on how commonly it's being used and what results you're seeing compared to other approaches?

[LCol Theresa Girvin]

No, I can't give you numbers, but I can tell you that some patients reject it as a possibility right out of hand, just like some reject the possibility of trying a medication to reduce their symptoms. There are some people right from the start who aren't interested. Using Dr. Brunet's analogy, you have to have a number of tools in the tool box, and that's one of them.

[The Chair, Conservative, Rick Casson]

Thank you.

We are being summoned to the House for a vote.

I want to thank you very much for your contribution today and thank you for doing what you do for our men and women in uniform. If there is anything you feel we didn't get to in the short time we had with you, you can submit it to us in writing. One of your responses was that you were glad that question was asked. If there was a question that wasn't asked that you would have been glad to hear, please submit it to us.

Thank you.

This meeting is adjourned.