National Defence Committee on March 4th, 2008

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Thank you, Mr. Chair.

Thank you, Mr. Brunet, for coming. There's some valuable input.

There's a lot more awareness of PTSD and other operational stress injuries and so on, and obviously it's getting a lot or reporting, as it should. It's something that obviously we care about, because we're here.

People perceive that there's a lot more of it out there, and I'm sure there probably is. I know you can't give a precise answer, but how much of that is due to just more awareness and more reporting, and how much is due to actual increase in frequency?

[Alain Brunet]

As you say, it is difficult to answer that question. In my opinion, post-traumatic stress disorder is not really more prevalent than it used to be, it is just that we are more aware of it. It is not necessarily more prevalent. I spent a great deal of time at the Hôpital Sainte-Anne. I have met with many patients who were over 80 and who had traumatic nightmares every night and yet, they had never been diagnosed with PTSD at any time during their lives.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

I was in a hospital many years ago with a World War I vet, and every night he woke up screaming that they were coming through the ceiling at him. So I've had some exposure to that. The stress of getting shot at, and so on, is obvious.

We had a lot of people in Bosnia and places like that who were constrained by the rules of engagement from actually engaging in proactive defence. They were forced to stand by and watch atrocities take place without taking action. I believe a lot of the stress injuries or the PTSD that came out of Bosnia or places like that were probably exacerbated by their helplessness at seeing things happen.

How would you assess that generation of PTSD versus that from pure combat, where they're involved face to face with the enemy?

[Alain Brunet]

Earlier, I was mentioning that peacekeeping missions caused as much PTSD as many combat missions. That is what I was referring to. In many cases, to watch helplessly while atrocities are being committed can be just as traumatic as going to the front and being involved in military combat.

The nature of the trauma typically varies from one war to another. There is no doubt about that. The types of trauma vary, but the main symptoms remain essentially the same.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

When we're talking about protecting troops, you don't design rules of engagement for that reason alone, obviously. Would you say a consideration in designing rules of engagement in any particular environment is the protection of the troops from their exposure to that kind of risk?

[Alain Brunet]

I am not sure I understood your question correctly.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Should we take into consideration the risk to our troops from exposure to this kind of potential stress injury when we determine the rules of engagement in any operation we go on?

[Alain Brunet]

I think that would be difficult to do. Generally, when forces are deployed, things happen very quickly, and there is no time for this type of consideration. I think this might be desirable, but difficult to do.

[The Chair, Conservative, Rick Casson]

Please wrap up, Mr. Bouchard.

[Robert Bouchard, Bloc, Chicoutimi—Le Fjord, QC]

Thank you, Mr. Chair.

I would like to thank you for appearing before the committee today and I congratulate you on your recommendations, which seem very practical to me.

You say that there should be a systematic assessment process put in place, given that people are still embarrassed to turn to a professional for diagnosis.

Would it be costly to introduce a systematic procedure? Would we have to hire many more professionals, or could that be done with current resources?

[Alain Brunet]

This is not a costly operation. I think the cost-benefit analysis would show a heavy weighting for the benefits. I think the cost would be low compared to the benefits, in other words.

Assessments can be done very inexpensively using self-administered questionnaires. A great deal can be learned from a one-hour assessment, for example.

So I think the benefits would be great and the cost low.

[Robert Bouchard, Bloc, Chicoutimi—Le Fjord, QC]

You also say that 57% of the members of the military do not consult professionals because they are afraid that this will appear in their file and that it could harm their advancement or be seen in a negative way by their superiors.

Do you have any recommendation to help increase the understanding of military superiors? You have an approach for the ordinary members, but would it be possible to work with the superiors to provide them with information or to get them to understand that soldiers with mental health problems can be rehabilitated and become functional once again, just as some physical ailments can be treated?

[Alain Brunet]

Rehabilitation is possible in the case of a number of mental health problems. One thing is rather disturbing, however. Unlike other armies, the Canadian army does not give people a desk job if they have had PTSD. It might take a number of years, but the army does not keep people it cannot deploy someday. Efforts are made to try to place these individuals in other positions, but ultimately, the Canadian army is composed of people who can be deployed. That is a choice that was made. I think that also explains why the military does a great deal of recruiting, but also why there tends to be a rather high turnover. In my opinion, there are advantages and disadvantages to this. I would say that one of the disadvantages is the loss of some military expertise.

[Robert Bouchard, Bloc, Chicoutimi—Le Fjord, QC]

I have one last question. In the past 10 years, 132 members of the armed forces have committed suicide. Between 1997 and 2007, anywhere from 10 to 14 suicides were recorded annually. You did a study using 2002 data. I presume that was done before.

Have you looked at this aspect? Can you comment on it? Are suicides on the increase? It is difficult to determine whether the rate was higher in 1997 than in 2007.

[Alain Brunet]

I do not have any accurate figures, but I can tell you than in Quebec, the suicide rate is between 12 and 18 per 100,000 people. When a suicide rate of 130 is reported for a particular period, we have to take into account how many suicides occur each year and compare that to the total number of people in the armed forces. In other words, we have to look at the suicide rate and compare it with comparable people in the general population. The rate may be higher, or it may not be higher. That is the comparison that must be made in order to obtain this statistic or to come up with a meaningful number. To my knowledge, this has not been done.

[The Chair, Conservative, Rick Casson]

Thank you very much, sir, for coming in and offering us your expertise. We appreciate it.

Committee members, we'll quickly change witnesses and move on with our next presenter.

Thank you.

[The Chair, Conservative, Rick Casson]

I call the meeting back to order, please.

We welcome our next presenter, Colonel Girvin, psychiatrist, mental health services, CFB Edmonton.

You've seen the process here. You have a few minutes to make a presentation, and then there'll be rounds of questions from the parties. The floor is yours.

[Lieutenant-Colonel Theresa Girvin, Psychiatrist, Mental Health Services, CFB Edmonton, Department of National Defence]

Good afternoon.

By way of introduction, my name is Dr. Theresa Girvin. I'm a lieutenant-colonel in the military. I've been in for 19 years now. I have specialist training in psychiatry. I joined the forces 19 years ago while attending the University of British Columbia. Following that, I did my two-year family medicine residency at McGill, and some time later I did the psychiatry residency at the University of Ottawa.

Over my career, I have served at bases as a general duty medical officer in Esquimalt--that's Victoria--then I served in Ottawa with psychiatry specialist training at the National Defence Medical Centre. In my work there, I also provided advice to senior Canadian Forces leadership on matters of psychiatry and mental health. I have also provided clinical care. In addition to Ottawa, I did clinics in Petawawa, Kingston, and Gagetown and I also traveled to other places, including the staff college in Toronto and to Trenton, to teach on mental health topics.

I was posted to Edmonton in 2002 and I now work at the mental health services clinic there. In addition to assessing and treating the CF patients, I provide clinical leadership in psychiatry at the regional level, and I have also participated in national working groups on mental health for the Canadian Forces.

In September 2005, I began advanced fellowship training in forensic psychiatry at the University of Alberta. The year-long course of study there was interrupted when I was deployed to Kandahar from August to November of 2006, and I was able to pick up the last three months of the fellowship and finish that just last November. Although I have the specialist training in forensic psychiatry, my main area of interest and my main area of clinical work is in providing care, assessing, and treating members of the Canadian Forces--my patients--who have difficulties of a psychiatric nature.

That concludes my opening remarks. I'll be pleased to answer any questions you may have.

[The Chair, Conservative, Rick Casson]

Thank you very much for that. We will have questions, I'm sure, and we'll start with Mr. Coderre.

[Denis Coderre, Liberal, Bourassa, QC]

Colonel Girvin, bonjour. Since we can now ask questions on clinical issues, let's start.

We spoke about the psychotherapy and we spoke about medication. As a psychiatrist, you have the capacity to provide some medication, so what kind do you give to the soldier who has post-traumatic stress syndrome?

[LCol Theresa Girvin]

Intimately connected with that is an assessment process. So I don't just prescribe; I make the diagnosis. I do the assessment of the patient first.

[Denis Coderre, Liberal, Bourassa, QC]

I believe that.

[LCol Theresa Girvin]

So if I do the assessment and I make the diagnosis of post-traumatic stress disorder, the diagnostic interview that I do doesn't just focus in on post-traumatic stress disorder. It covers a broad range of psychiatric difficulties. So very often--and you heard this from Dr. Brunet as well--a person will also have comorbid or coexisting major depressive disorder, and that will impact on what medication treatments I might recommend.

Right now in psychiatry, for medication treatment of post-traumatic stress disorder, we have some pretty good randomized double-blind controlled studies that look at the effectiveness of treatment of post-traumatic stress disorder with medications called SSRIs or serotonin reuptake inhibitors. There are pretty good studies on two of them. I don't know if you want the names of them.

[Denis Coderre, Liberal, Bourassa, QC]

Please give them.

[LCol Theresa Girvin]

We have studies on paroxetine and on sertraline. There's also a fair amount of evidence for fluoxetine.

Now, these medications are anti-depressants, so they're also very effective for depression. So generally speaking, from my own clinical practice, they would be medications of first choice for treatment of a person who meets the criteria for diagnosis, who is informed of the choices, and decides that this is something they want to try.