National Defence Committee on March 4th, 2008

[Claude Bachand, Bloc, Saint-Jean, QC]

Yes. I notice that in 349 of the 1,220 cases, the individuals concerned are between the ages of 17 and 25, but it does not say how many of them suffer from mental problems. This is the overall problem with your sample. Would we not have been interested in knowing that people in the 35- to 44-year-old age bracket, for instance, experience these symptoms most often, or in seeing data based on the gender and level of education of these individuals?

This list represents the 17- to 25-year-old age group that you interviewed during your study, but you do not tell us whether, given their profile, they are more likely to suffer from mental illness. Can we not find this information anywhere in the study?

[Alain Brunet]

In each document that we publish, we can only present a certain amount of data. Regarding this study, it includes all the persons who suffered from mental problems during the past year. The sample gives details of the characteristics of the 1,220 persons. Theoretically, we could cross-reference a certain amount of information, as you suggest. In any case, it is true that this information is not contained in this document.

[Claude Bachand, Bloc, Saint-Jean, QC]

Do you agree that the information would be of interest to us? Sometimes we wonder whether post-traumatic stress disorder is associated with a given profile. As we try to draw this profile, we are inclined to look at the divisions that you established, such as age, family, and so forth. Could a good statistician take your study and make the cross-references that you are talking about?

[Alain Brunet]

Studies have already been published on the basis of this survey. I would not be surprised if a part of the work is already done. For example, we know that women report more mental problems than men do but, this is probably also the case for younger individuals. A certain amount of the data that was published is not necessarily found in this study.

[Claude Bachand, Bloc, Saint-Jean, QC]

I noted that many of these studies involved the civilian population, but that the results could not be applied to military personnel. To your knowledge, have any studies been done on people whose jobs entail a high degree of risk, such as policemen and firemen?

I clearly remember that this question was put to professors in Great Britain who were studying the incidence of post-traumatic stress disorder in that country. I would like to know if, possibly, soldiers in a combat zone are under the highest level of stress, and consequently, experience mental problems more frequently.

[Alain Brunet]

I do not know how to answer your question. We tried to compare data obtained from the general population. Sometimes studies have been carried out on people in specific occupations, but it is always difficult to determine whether or not these studies are representative. Moreover, whether members of the target group have the same social and demographic profile also needs to be taken into consideration. For instance, if we compare an occupation that has more women than men, we have to adjust the ratios. A true comparison of studies side by side really involves a large number of statistical adjustments. Otherwise, we wind up comparing apples to oranges.

[Claude Bachand, Bloc, Saint-Jean, QC]

Is my time up?

[The Chair, Conservative, Rick Casson]

You have a minute.

[Claude Bachand, Bloc, Saint-Jean, QC]

Is it true that the criteria for diagnosis are now stricter and that it is therefore easier to diagnosis disorders? Could we have a clear idea of the grid used to evaluate the sampling? Is a universal measurement applied, or do the measurements vary from one study to the next?

[Alain Brunet]

We've become quite good at diagnosing mental problems. The diagnostic tools employed are fairly standard today.

[The Chair, Conservative, Rick Casson]

Thank you very much.

Ms. Black is next.

[Dawn Black, NDP, New Westminster—Coquitlam, BC]

Thank you for coming and giving us this information. I've read through two of the papers and found it very interesting.

My understanding is that the study was done on 8,841, and these were not Canadian Forces who had necessarily come back from combat; they were--for want of a better word--part of the general population of the Canadian Forces, not post-conflict. Out of that, you determined that 1,220 had a diagnosable disorder, and that 67% of them had no treatment or contact with mental health professionals. That's quite startling, I think.

You also made several observations in your article that I found quite interesting. One was in relation to comorbidity. I think other people on the street might call it dual diagnosis. I think it's clear that PTSD has been misdiagnosed as other disorders when there have been diagnoses in the past. So it brings to mind the question of which diagnosis most often comes first: is it depressive diagnosis, drug addiction, or alcohol dependency, and then you discover post-traumatic stress disorder, or does it most often come the other way around?

I also wondered what impact that has on treatment, because I assume, as a layperson, that treatments are different for severe depression than for post-traumatic stress disorder, and different for drug or alcohol dependence than for PTSD. So I'm curious about how that impacts on the treatment.

[Alain Brunet]

You want to know if there is a pattern to the disorders, for instance if post-traumatic stress disorder comes before depression. About 90% of those who suffer from chronic post-traumatic stress disorder also fall into deep depression.

Regarding the other disorders, I cannot answer your question. We observe various patterns. A person might begin by consuming large amounts of alcohol, and then fall into depression. We see all types of patterns.

Different treatments are applied, based on the most serious of the problems diagnosed. However, treatments can serve more than one purpose. For instance, anti-depressants are used to treat post-traumatic stress disorder as well as depression. In such cases, the treatment, if drugs are involved, is simplified.

[Dawn Black, NDP, New Westminster—Coquitlam, BC]

The treatment that I understand has the best end results, from what I've read in different studies, is the cognitive behaviour therapy, is that correct?

[Alain Brunet]

Currently, the most effective treatment for post-traumatic stress disorder and for most mental problems is psychotherapy, followed by drugs. Both treatments are more or less equally effective. We observe that among psychotherapy patients, positive results generally last longer. In many cases, in fact, the most widely used psychotherapeutic approach is the cognitive-behavioural approach.

[Dawn Black, NDP, New Westminster—Coquitlam, BC]

So in your experience then, when there is this difficulty in diagnosis, and when there is often more than one condition, does that present unique challenges in determining what kind of treatment to offer the person?

[Alain Brunet]

Yes. Those cases may be a bit more complicated. Nonetheless, health professionals often encounter cases of this kind, which they treat as well as the others.

[Dawn Black, NDP, New Westminster—Coquitlam, BC]

I have two more questions. One is--you outlined this in your paper, but it would be good to get it on the record--why do you think 67% of the people in your study with a diagnosed disorder had no contact with mental health professionals?

The second question is, if you had the power to make a recommendation to this committee or to the Canadian Forces, what recommendation would you make about steps that should be taken to improve the diagnosis and treatment of people in the Canadian Forces with PTSD or other disorders? What about acquired brain injuries? How do they fit in with the other ones you've identified here?

[Alain Brunet]

As I mentioned, the main obstacles to treatment were a lack of confidence in the authorities, the fact that mental health problems are not recognized by members of the Canadian Forces and the desire to solve the problem on one's own.

I spoke of the problem of confidentiality and the stigmatization of mental illness. We would recommend, among other things, offering more psychological education to members of the armed forces regarding mental problems and their symptoms. People should be aware of the fact that such problems can be treated quite effectively.

I also mentioned the need to protect the confidentiality of the relationship between the health professional and the patient. I also said that assessments should be mandatory.

[The Chair, Conservative, Rick Casson]

Thank you.

Mr. Lunney.

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

Thank you very much, Mr. Chair.

I have a few questions, Dr. Brunet.

First, I wonder if you'd clarify the statistics for us, because of the 1,200 I understand you studied, I heard figures saying that 43% of those sought contact with health services. I thought I heard originally that 67% did not. Those numbers don't add up.

[Alain Brunet]

It was 57%.

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

It was 57%, thank you.

Just for the record, let's get that right.

You also said even traditional peacekeeping missions are stressed, as opposed to combat missions. I'm wondering about the difference between PTSD and what the department calls operational stress injuries? Are you equating these, or are you saying there are clear criteria for diagnosing PTSD that are different from operational stress injuries?

[Alain Brunet]

Operational stress injury is not a diagnosis.

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

Thank you.