National Defence Committee on Feb. 7th, 2008

[MGen Walter Semianiw]

At this point, it would be very important to define PTSD. Can you do so, Ms. Jaeger?

[BGen Hilary Jaeger]

I'll try it in English because I will lose my French.

The current DSM-IV definition of post-traumatic stress disorder requires a stressor that was so important, that made such an impression on you, that you thought your life was in danger. You were convinced you were going to die or that somebody next to you felt peril for you, somebody very close to you, and you had a reaction to it. Most people would have racing heart, trembling, you might have vomited, you might have messed your drawers—a very, very intense reaction, a flooding of stress hormones at the time. If that didn't happen, it's not impossible, but most psychiatrists would say you may have an operational stress injury; you may have persistent psychological problems linked to stress, but it's not PTSD, it's something else. It could be a simple anxiety disorder. It could be you've triggered a depression that is not PTSD. It's important because the treatments are different.

[The Chair, Conservative, Rick Casson]

Thank you, Mr. Bouchard.

Thank you, ma'am.

Mr. Rota.

[Anthony Rota, Liberal, Nipissing—Timiskaming, ON]

Thank you, Mr. Chair.

If I could continue with the definition, post-traumatic stress disorder has a very abrupt beginning, so the operational disorder includes pretty well everything else that creeps up slowly. A lot of dysfunction and a lot of the problems that arise don't always do so right away. They build up over time in multiple exposures. The operational disorder—and this wasn't one of the questions I was going to ask, but the two of them are grouped together. Both have devastating effects. Could I have a bit of clarification on that?

[BGen Hilary Jaeger]

First of all, never say never in medicine. If you look in the psychiatric literature, I doubt you will find the term “OSI” anywhere. It's a term that was coined by the Canadian Forces to broaden the discussion of mental health issues beyond PTSD. It's any persistent mental health disorder that can be linked to your service with the CF.

While PTSD usually has a pretty abrupt cause, that doesn't mean that from that moment on you are suffering from the symptoms. Sometimes it takes a while for the symptoms to rise to a bothersome point.

[MGen Walter Semianiw]

The issue becomes one...and we've talked about this issue, looking at it as a soldier. I would not recommend you repeat what I say, but I look at it from a credit card point of view. Why me, not you? I may have a higher level of credit than you, and it affects me, or it could be the incident or it could be the situation. That's why it's not so clear-cut. That becomes the real challenge, not only the diagnosis but the treatment as well.

[Anthony Rota, Liberal, Nipissing—Timiskaming, ON]

That leads to my question, the one I was going to ask initially about the assigned health team that goes with every rotation.

I'm imagining you've got a group of people who go along with the troops assigned to that rotation. Do they develop a relationship with them, or is it a health unit that sits and waits for people to come to them? What is the ratio of the people within that unit to the number of people serving?

[BGen Hilary Jaeger]

The people who stay on an intimate basis with the troops at the pointy end are primarily med techs, physician assistants--more about physician assistants to come, I'm sure, in your study--and general duty medical officers.

The mental health team is usually centralized at Kandahar airfield and sees people on a referral basis. But they also go out when they can get transport. One of the riskiest things you can do in that theatre is move from place to place. The FOBs themselves are usually pretty secure once you're there. It's getting there, whether you take a helicopter or a vehicle, that can kill you. So movement is not something you want to do too much of.

The mental health teams do go and visit the FOBs periodically, but usually they stay centralized back in Kandahar airfield. The front-line providers are the med techs, physician assistants, and general duty medical officers; they are what we call “role one”. That just means they're the front-line guys.

[Anthony Rota, Liberal, Nipissing—Timiskaming, ON]

Who identifies the OSI? Is it someone on the front line? Are they trained to identify it? What success rate do they have? Or is it the individual who just doesn't feel quite right, describes himself, and then you kind of...? It's not a clear black and white illness.

[BGen Hilary Jaeger]

No, it's not clear.

The answer is both, or any of the above. The individual may notice it. His peers or his section commander or his platoon commander may notice something is not quite right. You'd generally send them to see the med tech or the PA at the forward operating base, and he may have an idea, he may not. If he needs help, he'll send the guy back to Kandahar airfield.

At that point, you're probably not going to say this is an OSI. The term that would probably be most appropriate at that point is either combat stress reaction or acute stress reaction, depending on whose book you last read before you deployed.

It's actually a slightly different thing--that is, the old sort of World War II, George Patton slapping the soldier in the hospital kind of scenario. Most of those people, if you give them rest and recuperation, will return to duty.

In fact, it's very important not to label them as mental health problems at that point because it does very damaging things to you from a self-image point of view to get labelled as deficient. So you don't want to do that. Most of the operational stress injuries we see come to light...and that's why we picked the four- to six-month point. Starting at about three months after the mission is over, you still pick new cases up, going up to about a year.

[MGen Walter Semianiw]

Plus, to be fair, we've also added to the screening. When I went to my medical a couple of weeks ago, the doctor asked me a number of questions--buried in there--that I didn't know had to do with my mental health.

There's a danger in saying it's psychologists, psychiatrists, social workers—that's the team. The team is pretty big.

Every day, Brigadier-General Jaeger comes and talks to me, she looks at me, and she makes sure I'm still all there and all okay.

[Voices]

Oh, oh!

[MGen Walter Semianiw]

I'm okay. It's actually a pretty big team that supports the people.

[The Chair, Conservative, Rick Casson]

That's interesting, sir.

You probably have a document that says you're okay. Some of the rest of us don't have that document.

[Voices]

Oh, oh!

[MGen Walter Semianiw]

We could provide it to you.

[The Chair, Conservative, Rick Casson]

We'll go to Mr. Lunney for five minutes, then back to Mr. Coderre, and then back to Mr. Blaney.

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

Thank you very much.

You'll have to excuse me. My voice isn't at full wattage today. I hope the rest of me is, actually; it's just the voice that's weak.

I wanted to pick up on the prevention angle that a couple of the colleagues talked about here. Mr. Bachand talked about psychological preparation for prevention. Mr. Comartin talked about training.

I don't see anything in what's presented here, or in your presentation, that would indicate this type of approach, but I'm wondering if any consideration is given to nutritional support for soldiers going out. The rest of us, or a lot of Canadian society.... There are stress vitamins out there, for example, the B vitamins, B1, B6, B3--

[An hon. member]

Folic acid.

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

Folic acid is for the heart, my friend, but the B vitamins are for stress. The amino acids...I'm sorry, Dr. Jaeger; you're a doctor, so we do have a doctor here. Acetyl-L-carnitine and phosphatidylserine are known to influence cognitive function.

Is there any nutritional support? And in the team of folks we saw there--the psychologists, psychiatrists, social workers, etc.--is there any consideration for people from the orthomolecular world who actually have some expertise in this area of helping people nutritionally with this type of problem, with depression? A lot of these conditions are actually being managed fairly well with nutritional supplementation.

So in your discussions, or other models around the world, is anybody looking at that?

[BGen Hilary Jaeger]

I'm not aware of any evidence that demonstrates that any particular nutritional approach is any better than any other. The average Canadian soldier's biggest nutritional problem is over-nutrition. We are fighting our BMIs all the way to Afghanistan and back. Probably one of the best things about the mission is that most of them lose weight while they're there.

[MGen Walter Semianiw]

I lost 18 pounds while I was there.

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

Doctor, with all due respect, we call that over-consumption rather than over-nutrition.

[BGen Hilary Jaeger]

It is called malnutrition. It's just excessive intake of certain products.

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

Trust me, as members of Parliament we understand the over-consumption problem. Most of us are trying to lose weight here as well.