Veterans Affairs Committee on Nov. 17th, 2016

[Dr. Heidi Cramm]

That particular study is part of a funding relationship we have here, at the Canadian Institute for Military and Veteran Health Research, where the government can actually internally define; so the research directorate within Veterans Affairs Canada looks at its strategic priorities and its needs for research, and it looks at what it can manage internally and what it can't. Those things can get outsourced through a contract that we provide, and those go out to tender, essentially.

What happens is that instead of it just being a tender process it's actually a peer review process. Research teams will apply for a given contract, and then our college of peer reviewers here at the institute will review them. Then the best study proposed, with the most rigorous design and the best mix of expertise, will end up doing a particular task contract. There's already a fair bit of definition around what the study needs to look like to meet some of the policy needs within the scientific directorate at Veterans Affairs in that case.

[Cathay Wagantall, Conservative, Yorkton—Melville, SK]

Thank you.

What I think I'm hearing, too, is that it's much more difficult to track our veterans, obviously, than the armed forces, where you have a very structured situation and so many control variables. When you look at the database that I can only imagine exists with our Canadian Armed Forces, and then with VAC, we're finding a need to be able to have more of a transition of that information along with the veterans.

Would that be helpful? I think of 600,000 veterans, and 100,000 of them need help from VAC. Then there are the more serious cases, which are really the ones that we have to deal with, who need a case manager and have really serious issues. Would it not be helpful to have that information available even in those big-picture formats, and then be able to peg these veterans, in some way, as they're coming out, to realize where they are similar and where they may end up having these issues more than others?

[Dr. Heidi Cramm]

There are two parts to that. One is that there is a lot of activity across the Canadian Armed Forces and Veterans Affairs to close that seam, to improve that handover, to give that warm handshake. That's a very active initiative, with a lot of different invested parties within government working hard to make that happen. I'm not saying that it's there yet, but there's a lot of activity around that.

On the other end of it, when you have people who are leaving the military because they already have an identified mental health issue, and they are having a medical release as a result of this mental health issue, often we know where they are in that first two years. They get connected directly in with Veterans Affairs, with the joint personnel support units. We know where those go.

In fact the people who have the mental issues, who are identified prior to releasing service, may not be the ones we are most worried about. It may be the people who are releasing because they have a mental health issue that hasn't been identified and they aren't ready to address it. They may elect to leave service and try to manage it on their own, and they decompensate over that release period of the first two years. They may go out into nothing. They are not obligated to register with Veterans Affairs Canada, so they may not have a link in where Veterans Affairs can even provide them services, and the services may not be related to their military service, their issues.

It's complicated on that end. We do have concern that we're missing a number of people moving through the system who aren't already identified or whose issues emerge after release. A longitudinal study will hopefully give us more information about some of those patterns of trajectories as people move through the release period.

[Cathay Wagantall, Conservative, Yorkton—Melville, SK]

So it would be beneficial then. We've also talked here about some kind of positive recognition that our veterans can carry with them that enables us to stay in touch with them, once they are released, in some way that isn't demanding on them. It would be an opportunity to be able to track them, to ensure that we're in touch and are able to ensure that they're receiving the care they need as they make that transition and perhaps can't manage what they thought they could on their own.

[Dr. Heidi Cramm]

Credibly, yes, the idea of a registry for veterans...and if that could be tied to some of their anonymized health data so that we're able to understand the health needs and issues and health utilization patterns for veterans, because they may not be all defined at the point of release. Some of these things do emerge. We know that in the case of people who have post-traumatic stress disorder, some of those things may take a significant amount of time to present at a level of symptomology that's impacting daily function and must be dealt with. That can happen five, seven years after someone releases. We have to be flexible in our understanding of how those things can evolve.

[Cathay Wagantall, Conservative, Yorkton—Melville, SK]

Thank you.

Dr. Sareen, you're shaking your head. Are you agreeing or is there something else you would like to add?

[Dr. Jitender Sareen]

I just like to shake my head.

[The Chair, Liberal, Neil Ellis]

Go ahead, please, but it will have to be a short answer.

[Dr. Jitender Sareen]

Yes. There is some literature that I didn't get into that basically describes what you're saying: caring contact. If someone has made a suicide attempt, having a letter from the institution that says, “We're thinking about you”, and there's no expectation to contact VAC, has shown in randomized trials to reduce suicide deaths. We've been talking about caring texts. Outreach is a really important piece, but how you implement that in a system is important.

I didn't want to get into that, but because you were describing it, I thought it was important for you to know that there is evidence behind that.

[Cathay Wagantall, Conservative, Yorkton—Melville, SK]

Thank you.

[The Chair, Liberal, Neil Ellis]

That's great, thank you.

Go ahead, Mr. Fraser.

[Colin Fraser, Liberal, West Nova, NS]

Thank you very much, Mr. Chair.

Thank you so much for testifying today. It's actually very helpful, and I appreciate the expertise.

Dr. Sareen, I have a very general question. When we're undertaking this study on mental health and suicide prevention, it's important that we understand terminology. I wonder if you can help me understand what suicide ideation actually is, the levels of severity that it undertakes, and how it's recognized.

[Dr. Jitender Sareen]

Regarding suicidal ideation, a question that is usually asked is: “Have you thought seriously about taking your own life?” When we present these kinds of numbers, that's a question that's asked in a mental health survey. But when you're sitting with individuals clinically, it's really important to get into the details of trying to understand. When did they last have those kinds of thoughts? Is it something they've been thinking about for a number of months? What triggers them, what brings up those thoughts? And then getting into even more detail, it's to try to really understand if the person has actually come close to attempting. Have they actually made preparations, or figured out whether they would use a gun or pills?

When we think about suicidal ideation, that's one level. Concerning whether someone has made an attempt, there has been controversy in the field about whether it was a serious suicide attempt or a self-harm where there was not an intent to die. What we know at this time is that people who self-harm, whether they say they're intending to die or not, are at risk for later attempts. That's another level, to say how lethal the attempt was. That's a gradation of going from thinking about suicide, planning it, to attempting. A number of scales actually measure the depth and severity of suicidal behaviour.

[Colin Fraser, Liberal, West Nova, NS]

With regard to suicidal ideation and regarding the intervention that may be required, then, is there any difference between armed forces members or veterans going through a transitional phase, who have suicidal ideation, and somebody who is an ordinary person?

[Dr. Jitender Sareen]

I don't think there is specifically a different intervention, but as has been discussed, a transition period is so challenging around identity, financial stress, and sometimes relationship stress that it's really important to try to help, if there is a depression, to treat the depression, and if there are alcohol difficulties, to try to reduce that. But it's really important to understand the person in the context of their family, as well as how they're trying to leave the system. It requires both individual help and advocacy, and also working to try to ensure that the family understands what's happening, and to help through the financial issues as well.

The only thing I would add is that it's a very similar issue when you have youth who have mental health difficulties and who are then transitioning into adulthood. Our youth mental health systems have usually both the individual and a family, and there is a lot more attention to the whole system. But when they become an adult it's like they're on their own, and we've been advocating that the transition period between youth and adult is similarly a challenging part, so it's important to understand that.

[Colin Fraser, Liberal, West Nova, NS]

Thank you.

Dr. Cramm, in your comments on the project you've undertaken for the study on well-being during the transitional phase, you said that obviously the goal is to optimize a successful transition. I wonder if you can comment, then, on how we know whether a transition is successful and what that looks like in your mind.

[Dr. Heidi Cramm]

That's not a simple question to answer, because that's been the subject of some international debate around what exactly that looks like. There's quite a bit of perspective around a successful outcome being equated with the experience of well-being and whether well-being is a proxy for success. A lot of social determinants appear to need to be in place to promote the experience of health and wellness.

Unfortunately, we're trying to in some ways define, through our pattern analysis of people's experiences, what different kinds of success might look like. I think that will emerge. It's not going to be the same for everybody, depending on where you start and what kinds of resources you have available to you. If you choose to re-engage in paid work or what have you, some of these outcomes can look different. I think it will be a by-product of the study to help better answer that question.

[Colin Fraser, Liberal, West Nova, NS]

You may have mentioned this, so forgive me if I'm asking you to repeat yourself, but is the study itself going to be broadly done, showing people with different access to resources in rural versus urban and various locations across the country, to know what that looks like for people in different situations?

[Dr. Heidi Cramm]

Yes. The recruitment process will become embedded within the Canadian Armed Forces release process. People will become aware of the study, and they can elect to release at that time. For many people, if they're medically releasing, they would have a date well in advance of their six months. For people who have been in service for 20 years, they can elect to go within 30 days. There are different amounts of lead time before that release date comes in. If you're a reservist, you don't release; you do not renew your contract. This is where we talk about when you're ending your service, because not everyone is going to be releasing from regular forces.

[Colin Fraser, Liberal, West Nova, NS]

Thank you both very much for your help.

[The Chair, Liberal, Neil Ellis]

That's great. Thank you.

Mr. Brassard, you're next.

[John Brassard, Conservative, Barrie—Innisfil, ON]

Thank you, Mr. Chair.

You'll be glad to know that Dr. Sareen and I did not go to medical school together.

[Voices]

Oh, oh!

[The Chair, Liberal, Neil Ellis]

But you went to fire college together.

[John Brassard, Conservative, Barrie—Innisfil, ON]

I'm not sure: have you ever done that, Dr. Sareen...?

Thank you both for being here. We are having an absolutely fascinating discussion today.

In the context of any of the research done by either of you, have you ever come across any instances of the impact that battlefield medication has had on the development of OSI or PTSD symptoms or the heightening of a preconditioned diagnosed or undiagnosed mental health issue?

The question is to both of you.