Veterans Affairs Committee on Nov. 17th, 2016

[The Chair, Liberal, Neil Ellis]

I'd like to call the meeting to order. Pursuant to Standing Order 108(2) and a motion adopted on September 29, the committee resumes its study of mental health and suicide prevention among veterans.

Today we have three different witnesses: from the University of Manitoba, Dr. Sareen, professor of psychiatry; and from the Canadian Institute for Military and Veteran Health Research, Dr. Cramm and Dr. Bélanger, who are both interim co-scientific directors.

We'll start out with the witnesses, with up to 10 minutes each for testimony, and then we will come back to questions.

We will start with the Canadian Institute for Military and Veteran Health Research.

Good afternoon. I'll turn it over to both of you for your 10 minutes.

[Dr. Stéphanie Bélanger, Interim Co-Scientific Director, Canadian Institute for Military and Veteran Health Research]

Thank you, and good afternoon.

We are here to explain what our research institute can do in the research field for veterans. I'll start with a short background and then Dr. Cramm will carry on with some more specific examples.

The Canadian Institute for Military and Veteran Health Research was founded in 2010 and is now composed of 42 university members, which includes about 1,000 active researchers in military, veteran, and family health. What we do is bring the efforts of all the researchers together so that they can better inform policies and practices. We are here right now to talk about what our researchers do, what they produce, and what they publish to better inform policies and practices as opposed to saying what our own personal research projects are.

It's really important for the institute to ensure the knowledge translation of our products, meaning the publication of it, so that it goes as rapidly as possible from research to practices. For us to participate in parliamentary testimony like this is extremely important.

Because the main topic today is on transition, even though it is a pluri-disciplinary institute, we do have a lot of research that is being produced on the transition from military to veteran, to civilian life. It is a priority area for many university researchers as well as for the government, so we are lucky enough to have government advisers who tell our researchers what their needs are and what they need to know about transitions, and then researchers who can produce, at arm's length, the evidence-based and informed-based data.

Actually just last year there were three research projects that were completed under a contract we have through Public Works with DND and Veterans Affairs Canada. It allowed us to build knowledge around what constitutes a good transition, a successful transition; what mental health might look like during that transition; and what kinds of programs and supports are available during that time. All this has been published and it's on our website.

Right now there is another project that continues to build that knowledge around transition. It's a work-in-progress, and this is where Dr. Cramm could give a bit more detail.

[Dr. Heidi Cramm, Interim Co-Scientific Director, Canadian Institute for Military and Veteran Health Research]

Thank you.

The project that's currently under way is a study on well-being and military-to-civilian transition. I'm one of the co-principal investigators on that, along with Drs. David Blackburn and Maya Eichler from the Université du Québec en Outaouais and Mount Saint Vincent University in Halifax. This study is a qualitative, in-depth, longitudinal study. This is going to give us, for the first time, that perspective within Canada of what happens as serving members cross into civilian life.

We hope to recruit about 100 members about six months prior to their intended discharge release date, and to be able to follow them for up to two and a half years after that release. This study will really become a critical piece in helping us all understand a little bit better what some of the patterns or factors might be in optimizing a successful transition. Part of that successful transition includes positive mental health and well-being.

Right now we don't have a clear understanding, nationally, around what it is that may or may not create the conditions for successful transition. Some people leave service and we would expect them to do well, but after a period of time they really struggle. Their mental health struggles really emerge in a way that may happen post-release. Maybe they weren't identified prior to release, but it becomes apparent after release. Some of those issues may be contingent upon the reality that it's a significant change in identity, a significant sense of attachment and place. It's very different when you take off the uniform and you're now working to find that same sense of belonging and structure as a civilian. Some of those things may be part of a natural issue, and may not in any way be related to service exposures. We just don't know enough about that in a longitudinal way, so this really will be an important piece as we go forward.

We're just at the stages now where we're about to go into our ethics review for that study. We're looking to kick that off in the spring with full-on recruitment.

One of the biggest challenges we have in Canada to serving veteran health needs really comes from our current inability to identify veterans within health care systems. When serving personnel end their service, their health care transitions from the federal system to the civilian provincial system. Veterans live everywhere across the country, across all provinces and all territories, in urban and rural settings. You can imagine that quite a variety of services might be available in the wide range of what is Canada, but Canada does not have the ability right now to systematically identify where the veterans are, how they use health care services, how their health care needs compare to civilians', and how then, as a result, to understand their needs in order to provide the supports and programs at the right time, in the right place.

Last year, in the Journal of Military, Veteran and Family Health, researchers within the CIMVHR network identified, through collaboration with the Institute for Clinical Evaluative Sciences, or ICES, a way to study the health and health service utilization of veterans who re-entered the Canadian public health care system in Ontario between 1990 and 2014. Recognizing that veterans re-enter the system across Canada, we also do know, from some previous work from Veterans Affairs Canada, that about a third of veterans do seem to migrate to Ontario upon release. It is a good sample for us to be able to begin the important work.

Through this study, as they continue their analysis, this group of researchers will be able to give us more information that will inform the diagnostic and treatment patterns related to mental health, as well as to enable those comparisons between veteran and civilian health. Other research that has been published within the Journal of Military, Veteran and Family Health suggests that most recently released veterans do, in fact, adjust well, but there do appear to be chronic conditions that are experienced at a much more common rate for veterans.

Dr. Jim Thompson and his colleagues published a review of population studies on the mental health of Canadian Armed Forces veterans and found that veterans who have recently released experience higher rates of mental health issues than the broader Canadian population as well as veterans from previous eras and conflicts. There does seem to be something substantive happening that is different for this cohort of veterans as they are releasing.

Of note as well, we're not alone as a country in struggling to understand transition. We are working on the global stage trying to look to what is understood around military-to-civilian transition experiences and outcomes across countries to be able to compare across the countries, and also to take lessons learned that maybe we can leverage so that we can catalyze the whole structure better and get there faster. Some of those countries include the United Kingdom, the United States, New Zealand, and Australia.

Thank you.

[The Chair, Liberal, Neil Ellis]

Thank you.

Dr. Sareen.

[Dr. Jitender Sareen, Professor, Psychiatry, Rady Faculty of Health Sciences, University of Manitoba]

Good afternoon, everyone.

I'd like to thank everyone for inviting me to speak and be a witness to the committee. I also appreciate the presentation from Dr. Bélanger and CIMVHR. I think many of the points that were raised are very similar to the things I'm going to say, and I'll add some of my experience.

During this month of November, I also want to appreciate the Canadian Forces and veterans who have served our country, and their families.

For the committee to understand my comments, I'd like to tell you a little about my experience and what I do. I'm a professor and head of psychiatry at the University of Manitoba. Our university is involved with CIMVHR as well. I have worked in the Veterans Affairs operational stress injuries clinic in Winnipeg for the last seven years. I've also done mostly epidemiology research in military mental health for the last ten years and worked in first nations suicide prevention as well.

To move into some of my comments, I'll tell you a little bit about some of the mental health problems and suicidal behaviour; what the prevalence is in the military and veterans; what the common factors are around mental health problems that are general for everyone; and, what some specific factors are that are important to understand for the military and veterans environment. I'll then move into talking about what we are doing well in Canada and then move into a discussion of what we can do better.

As most or all of you are aware, mental health problems and addictions are very common. One in four military or veterans suffers from depression, post-traumatic stress disorder, or alcohol use problems in any one year. That's very,very high; it's 25% of the population. If you can imagine and step back and look at the impact from a family perspective, it really has a broad impact. Recognizing this as well as early interventions are really important.

Suicidal ideation is there in about 4% of the population in the Canadian Forces, so approximately four out of every hundred active military personnel have serious thoughts about suicide. Less than 1% attempt per year. As was mentioned by the previous speakers, veterans, especially during that first year or two, have a slightly higher rate of suicidal ideation. Dr. Thompson did a study of over 3,000 Canadian veterans and showed that the prevalence was around 6%.

Again, the main point is that this is a common issue. Why do mental health problems and suicidal behaviour occur among the military? I think it's really important to remember that the strongest risk factors for mental health problems and suicide are childhood and adult stressful life events. Those occur very commonly in the military population. Early adverse events as well as stressful life events, physical assaults, as well as losses, can occur. Other common factors are also a family history of mental health issues. Physical injuries and physical health issues are also very important. Specifically, financial difficulties and legal problems have also been shown to increase the risk of mental health difficulties and suicidal behaviour. Those are very common.

Things that are known to be protective around mental health difficulties and suicide prevention are community supports, workplace mental health programs, leadership within units, organizational structures. Social supports and peer supports are really important, as are, of course, families, and the understanding of the family of what the member is going through.

As far as military and veteran-specific factors are concerned, there's been controversy around deployment. Deployment in itself does not increase the risk of mental health problems or suicidal behaviour, but if there are high levels of traumatic exposure during a deployment, that can increase the risk of post-traumatic stress, depression, and suicide. I think it's really important to step back. When we look at suicide, the example that I would use is someone who has asthma. Asthma alone is not deadly. But if you have asthma plus someone who has a lot of other physical health issues, that together can lead to mortality.

Similarly in suicide, when we think about suicide, we have to understand that it's not one specific factor that causes suicide. It's the combination of a number of different factors coming together, usually a stressful life event, depression, alcohol, difficulties in the military and transitions, potentially legal difficulties. All those things coming together puts people at much higher risk of making an attempt at suicide or dying by suicide.

In Canada we've done quite well as far our efforts in trying to address stigma and improve the mental health care for our military and veterans are concerned. I think there's been a lot of effort that has been placed in increasing awareness. There's been investment in peer support. Also, I am going to say that it's really important to have an organization like the Canadian Institute for Military and Veteran Health Research where there can be an arm's-length scientific body, and professors and people can actually do unbiased, arm's-length work in trying to understand mental health problems and physical illnesses and how to improve them.

There are two things that I want to really highlight. One is that we did a study recently that was published in the Canadian Medical Association Journal that compared a nationally representative sample of Canadian military to a nationally representative sample of civilians, and we asked this question: if a Canadian active forces member is suicidal, do they get similar rates of service use in the civilian population versus the military? What we showed was that military members have much greater access to mental health services if they are suicidal than the civilian population.

There's still room to improve, and that's what I'm going to talk about next. But I think it's really important to have an understanding that the federal system of providing care to military and veterans around operational stress injuries has done a very important service in improving access to evidence-based care.

If we step back and look at where we can do things better, not just for the military and veterans but in the general population, we have not been able to reduce rates of suicide and suicide deaths in Canada in general. In the U.S. the suicide rates have actually been going up in the military whereas our rates in Canada have relatively stayed stable. I think we have been discussing and thinking about how do we prevent suicide both in the military as well as in the general population.

Let me go into some of where we are in the field. The idea of treating suicidal behaviour up until now has been to treat the underlying mental health problem or addiction. The new evidence suggests that we need to target suicidal ideation and suicide attempts much more directly.

There are specific psychological interventions that can be done, cognitive behaviour therapy that specifically focuses in on suicidal behaviour, and then another type of therapy, called dialectical behaviour therapy, that has also been shown to help people who have made multiple suicide attempts to learn to manage those symptoms. Those are two therapies that are suicide-specific that both the military and veterans systems need to look at and ask how they can implement those.

The second part is that in suicide risk assessment, it's very difficult to tell. If you have someone sitting in front of you, it's very hard to predict at an individual level who is going to make a suicide attempt in the future. There's a huge controversy in the whole suicide field as to which instrument should we use. Most of the instruments that have been tested so far do not predict, do not help a clinician at the individual level. It's very hard to predict behaviour, as all of you know, but to take a specific tool it's difficult.

Nonetheless, if the person is expressing suicidal ideation, specific training that can be done around safety planning, reducing access to lethal means, like guns or large quantities of medications, can actually be helpful.

I could continue for hours, but I'll stop at this point and open it up for questions.

[The Chair, Liberal, Neil Ellis]

Thank you, Dr. Sareen.

We'll start with our first round of six minutes.

Mr. Kitchen.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you, Mr. Chair.

Thanks to all three of you for being with us today. We appreciate your comments and the work that you do, and the work that our researches are doing, in providing services and coming up with ideas that we can use to improve the lives of our veterans and our soldiers.

I'm going to pick your research brain to start off, just because some people may not be aware of how research goes and the actual steps you have to go through in order to come up with a research project. When you come up with an idea, and someone comes with a null hypothesis, and you come up with an ideation on what you're going to do the research on, the researcher comes up with an idea, and they present that presentation to the university or to an ethics committee. Could you go into those steps that researcher has to follow for such a project—nothing specific, but just generally speaking?

[Dr. Jitender Sareen]

I think one of the key things that is really important is that the research comes from the people. The other presenters talked about qualitative work with people. The ideas really come for me, as a clinician, from sitting with patients and families, and understanding what they're experiencing. From there we come up with an idea, and we write a proposal.

In our laboratory we utilize Statistics Canada collected datasets that are nationally representative. Basically, our laboratory goes in and gets approvals from Stats Canada to be able to anonymously analyze a large sample so that we can understand, in 8,000 service members, the risk of suicidal ideation and the factors. We get that approval, we do the analysis in Statistics Canada datasets, and then we publish them in journals.

I think The Canadian Institute for Military and Veteran Health Research is also very important. We present at conferences, learn from each other, develop networks, and try to engage patients and families in making sure that the questions are relevant to Canadians.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you.

Dr. Cramm, I'm going to add a little bit to it and ask you maybe to comment more. My understanding is that while Dr. Sareen might be doing more epidemiological studies, you might be dealing with actual subjects. When you're dealing with subjects, and you're looking at issues such as consent, and informed consent, and the steps you have to follow through to make sure that project is done, I'm wondering if you could explain to us what sort of information has to be provided for that informed consent and what sort of documentation you would need to support that.

[Dr. Heidi Cramm]

Absolutely. Thank you.

Certainly Dr. Sareen does some very big data analysis in some of these population-based epidemiological studies, and that is a very different kind of research, because we don't have a lab when we do qualitative research. Once we have a proposal, once we have funding to actually do the study, then we can proceed. Part of the operationalization of a project involves ethical clearance. You have to have a scientifically sound design, and it has to be approved at the university level for any potential ethical concern. If there are multiple university researchers involved in a particular project, we actually have to go through multiple university research ethics boards.

For the study that I mentioned, we actually have to go through three different university research ethics boards to get approval before we can even begin to move forward with the recruitment process. Part of the evaluation at the ethics review board level involves looking at a letter of information so that people have informed consent. They find out what the study is about, how their information will be used, who will have access to the information they are providing, how it will be recorded, and whether they have rights to stop if they feel uncomfortable. All those kinds of things are outlined. The tri-council guidelines on ethics must be followed by all of the academic university researchers, and so the ethical review boards give an extraordinarily granular review of all documents, including what questions we intend to ask, what the samples are, whether there is undue burden on the sample, or whether we place anyone at any kind of enhanced risk. All of those things are considered at the university level, and often by multiple sites. That is before we can even begin the recruitment process.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

What would happen if it were determined throughout that study that those steps weren't followed?

[Dr. Heidi Cramm]

The protocols are in place so that we know that there is a plan. If there is an adverse event and something does happen, there is an entire reporting structure within the universities. Those things are often there for lab-based events, but most of it, from a qualitative end, is more around...and by lab-based I mean more biological science lab-based adverse events, to report a structure that way if there is an adverse event report. But there are processes and balances and checks in place within ethics, and all researchers are trained around the ethical guidelines and their duty to report anything that deviates from the protocol that's been agreed upon.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Great.

Thank you very much.

[The Chair, Liberal, Neil Ellis]

Next we'll go to Mr. Poissant, who is going to split his time with Mr. Eyolfson.

[Jean-Claude Poissant, Liberal, La Prairie, QC]

Thank you, Mr. Chair.

I would like to thank the witnesses for their brief. It was very interesting.

Earlier, I noted that you mention in your study that the suicide rate among veterans is higher in the United States than in Canada.

So my question is whether you have compared the situation with other countries. If those countries are doing some things better than we are to help veterans, how could we benefit from it?

[Dr. Jitender Sareen]

I can address that. I haven't looked recently at the other countries concerning suicide rates. I know that in the U.S., suicide rates have been going up in the military, and there has been quite a bit of concern, but I don't have an answer for you about other countries. I can look into that.

[Jean-Claude Poissant, Liberal, La Prairie, QC]

Thank you.

Was any follow-up done in your study with families who have lost a loved one to suicide? We know that it has major repercussions on them.

[Dr. Jitender Sareen]

Those studies we haven't done. This is a very important area, and going back to the previous question around the ethics and the impact of that on families, it's a huge piece. We haven't gone into that area. I'm not sure if the other researchers have.

That is a very important point. I think it is really important to look at suicide attempts and suicides to really understand what happened specifically, and what are the lessons learned with regard to quality improvement and trying to improve the system.

[Jean-Claude Poissant, Liberal, La Prairie, QC]

Thank you.

That's it for me.

[The Chair, Liberal, Neil Ellis]

Mr. Eyolfson.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you both for coming.

Jitender, it's good to see you again.

Just for background, we went to medical school together.

[An hon. member]

Just like every witness.

[Voices]

Oh, oh!

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Well, lots of them, yes.

There was a witness at our last meeting, Jitender, who I also went to med school with.

[The Chair, Liberal, Neil Ellis]

That was an awfully big classroom.