National Defence Committee on April 29th, 2013

[Jack Harris, NDP, St. John's East, NL]

He says he's been asking for this for almost 10 years. He says we're not really measuring performance, in the sense of what treatments work when it comes to OSI. Where are we on that? I understand the database that Stats Canada is doing will be helpful, but what about measuring for which treatments work and which don't? I think that's pretty key to determining whether we're doing a proper job to help people. This is not a criticism of people's intentions. But we're still hearing these stories about people who aren't being helped, who think they could be helped. We don't have a handle on it. We hear, for example, that measuring the length of waiting lists is a good way to measure whether we're providing the service, but I'm not sure that's accurate.

[Dr. Mark Zamorski]

This problem is an international one and it is a Canadian one, which is to say that if you were to go to any out-patient mental health care setting in Canada and ask, what treatments are you providing, how well are you providing them, what outcomes are you seeing, and how do those outcomes compare to the guy next door, the answer you would get is the blankest of stares.

This is a problem we're facing, and it's a problem the nation is facing, in terms of understanding what it is delivering and what kind of outcome it's seeing.

We face these same challenges. If this were an easy problem, we would have fixed it long ago and my life would be a lot easier. I'd be happily analyzing all this wonderful data, as opposed to trying to build the kind of system we need to answer these questions. Specifically, what we need are systems that capture in detail the exact content of care, in particular the exact content of the psychotherapy, and then what the outcomes are.

If you're looking at cardiac disease, you can count how many days people stayed in the hospital. You can count whether they had a second heart attack within a year. You can count whether they died or they didn't die, and all these sorts of things, relatively easily, and those are clear markers of quality of care. It is much more difficult in mental health.

We have three initiatives in the CF. The first is that the mental health survey will provide us with important insight into some of these questions. We'll be asking people in a very careful way if they were satisfied with the care. We'll be asking people who know if they had a mental disorder or not. We'll know whether they sought care or not. That reflects on the quality of our institutions. We'll be looking at if they did seek care, how are they functioning now. How much better has that care gotten them, and we'll be asking them the perceived value of that care.

That survey will get at a bunch of other things that will help us understand how the quality of our care compares to what we aspire to.

The second thing we are doing is reinforcing our health information system in ways that will make it much more functional in terms of understanding mental health care.

Then the last initiative is institutional, what's called a mental health outcomes management system. This is a computerized system whereby patients complete a questionnaire on their symptoms at each visit, on their well-being and on their functioning. The computer compares this against the expected treatment response of similar people and it informs the clinician that this person is or is not making expected progress. Where it finds that the person is not making expected progress, it provides feedback to the person about things they could do to perhaps better help the person.

Those are the three primary initiatives we're working on.

[The Chair, Conservative, James Bezan]

Thank you.

Mr. Harris, your time has expired.

Ms. Gallant, you have the floor.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

Thank you, Mr. Chairman.

First, to Major Compton, how did you train for the JTTS before insertion into theatre?

[Maj Lisa Compton]

That's an interesting question because it has an interesting answer. I was deployed as part of Roto 4, in 2007 and I was in theatre at the time when I was told I was going to become part of the trauma system. Initially, I didn't know what it was about.

So I left theatre, and within 24 hours I left Kandahar and was in San Antonio, Texas. I went there on a three-week course, where we were taught about performance improvement and the trauma registry. Then I was delivered back to theatre, where I continued for a nine-month tour.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

What would be the most challenging situation you encountered at Role 3?

[Maj Lisa Compton]

I think we've already talked about that with Dr. Wiss's presentation. It was the night we lost a med tech and that med tech's spouse was at Role 3 that night. That was one that probably hit home.

Also, I'm a mom, so any time we had little kids come in it was very difficult, and any time we had Canadians it was difficult.

It's really hard to put a finger on it. I was deployed six times. I spent a lot of my life in that plywood shack, so I think we've had a few.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

Dr. Zamorski, we've made some giant strides since 2000, when we were just getting out of Bosnia, in terms of mental health and how we look at it. Certainly, General Natynczyk ensured that the military took on a new attitude toward that.

I remember when the support systems on bases were not highly regarded by the psychiatrist. Now, for example, at Petawawa we have over five psychiatrists to take care of a population on base of about 5,000, whereas the rest of the civilian population, around 90,000, have two psychiatrists. So we are taking much better care, and we're taking it far more seriously.

The stats we hear are that the number of suicides in the military are really about the same across the board in the rest of society; however, it seems there are so many more. There seems to be a skew in what we read and what the statisticians from DND are telling us. Are there more attempts that we don't know about? Can you shed some light on the apparent discrepancy?

[Dr. Mark Zamorski]

The issue is that suicide is an important public health problem in Canada, obviously, and we're part of Canada. It's also a particularly important public health problem in the demographic that tends to form the bulk of the military, which is largely young and middle-aged men.

These things attract public attention, so they seem very salient, and it seems that every time we turn around we hear another story about another suicide. Unfortunately—I have the same feeling myself when I pick up the paper, so I don't want this to sound dismissive—it's not a reliable way to understand the magnitude of a public health problem.

We have a system where we know when people in the regular force pass away; we have a registry that keeps track of them and it captures the cause of death. Once a year we count up all the suicides, and we calculate rates every five years and report them.

It's also difficult because we're so close to the United States, where they have absolutely had a precipitous increase in the rates of suicide, specifically in the army and the marine corps. It's hard not to think that this somehow must be occurring in Canada as well, facing operational challenges and demands. That's just not what we've seen, for whatever reason.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

What are some of the common factors that may contribute to suicide, and what suicide prevention initiatives are currently in place with the Canadian Armed Forces?

[Dr. Mark Zamorski]

Suicide is a very complicated phenomenon, as you know. In any given case, there is a particular pattern of things that play together.

The things that are of the essence are stressful life events. Usually there is one or more stressful life event. Usually at some point there is an acute stressor that contributes as a trigger. That often intersects with mental disorders, notably depression and other related disorders. That then combines to form suicidal thoughts in people. Many people have suicidal thoughts, but then certain things that occur later on down the line actually condition to whether those suicidal thoughts turn into suicidal acts.

Those things that tend to tip someone one way or another include impulsivity. People who tend to be impulsive and have a suicidal thought may commit suicide, whereas other people who are just by nature not impulsive don't. Hopelessness, pessimism—all these psychological factors play roles.

The other factor that is underappreciated is the role that access to lethal means plays in suicide. There is abundant evidence that availability of handguns in particular is a strong risk factor for suicide.

There have been studies that have looked at the composition of household cooking gas. You hear the stories from the past of people sticking their heads in the oven and committing suicide. It doesn't work anymore because cooking gas no longer contains carbon monoxide. In the United Kingdom and elsewhere, where they've decreased the amount of carbon monoxide in cooking gas, they've seen significant decreases in the overall suicide rate.

Imitation of suicide events also plays a role. When people hear about suicide in the media, there is some evidence that it can trigger susceptible people to commit suicide.

Those are some of the factors that come into play.

[The Chair, Conservative, James Bezan]

Thank you. The time has expired.

Mr. McKay, you have the floor.

[John McKay, Liberal, Scarborough—Guildwood, ON]

Thank you, Chair.

I just want to continue on that line of questioning, Dr. Zamorski.

Recently a reporter generated some information out of access to information. He showed me five years' worth of stats on suicides, and it wasn't clear to me that there was a pattern. The pattern seemed to be that there was no pattern, or there was such a steady state among all categories of demographics, and it didn't seem to be whether it was in theatre or out of theatre, etc.

When I looked at it for a little longer, two things did seem to start to tease out. The first was that there seemed to be a bump in January and September, and there may be some explanation for that. I'm not quite sure.

The second thing was the clearance rate, if you will. Suicides going back three years actually didn't seem to have had reports attached to them. So there was not a final determination on...I don't know if it was causes or whatever, but it was quite noticeable that they weren't cleared for three years.

You mentioned the U.S. There does seem to be a discrepancy between U.S. numbers and our numbers. I don't know whether it's just the way they count as opposed to the way we count. There may be something...it may be attributable to good care. If there are five shrinks per 5,000 people, that's a pretty good number, and maybe that's where the payoff is. I don't really know.

There's another thing that I was curious about. You say in your paper that in some respects it's a self-selecting group, that you weed out the risk folks prior to their getting into the military, so they're almost below the national average, which is an interesting observation in and of itself. But in some respects they're misleading because they're only tracking the folks who are not discharged.

I've thrown at you three or four or five issues. I'd be interested in your observations on each and every one, if you will.

[Dr. Mark Zamorski]

I admit that I may have lost track of one or more of them, but to work backwards, no, I'm convinced that the differences between our own suicide experience and that of the U.S. military are not due to differences in technical ways of counting the events. We do them slightly differently, but that's not accounting for that. That's easy, I think, to dismiss.

I also share your perspective, which other people have pointed out, which is that you might expect that the suicide rate in the military would be lower than that of civilians because it's a selected population and it has access to care. We don't have the numbers that we would be able to start teasing all that apart in trying to understand that, unfortunately. We're really going to have to rely upon other people, in the States, for example, where they have enough numbers that they could actually start to sort that out.

I'm sorry, that's two out of your five questions and I've lost track.

[John McKay, Liberal, Scarborough—Guildwood, ON]

The clearance rate.

[Dr. Mark Zamorski]

I'm not exactly sure what you're referring to. I'm not actually the one who is responsible for maintaining those statistics. What I can say, though, is that about two and a half years ago, in response to the expert panel on suicide prevention, one of the recommendations we made was that the CF initiate what we call a professional technical military suicide review. Where we have a suicide, the medical people go in and try to figure out exactly what happened. The purpose of this is, first and foremost, to understand opportunities for prevention. They produce a report, and we have much greater detail in the immediate aftermath of a suicide than we used to. That happened about two and a half years ago.

[John McKay, Liberal, Scarborough—Guildwood, ON]

Why would it be three years behind? The numbers all seem to line up, and then the clearance rate basically ends at the end of 2010.

[Dr. Mark Zamorski]

I'm not exactly sure what you're referring to. Probably—

[John McKay, Liberal, Scarborough—Guildwood, ON]

Unfortunately, I don't have those stats in front of me, so I can't....

[Dr. Mark Zamorski]

Yes. I'm not sure what “clearance rate” means.

[John McKay, Liberal, Scarborough—Guildwood, ON]

What about a bump in January and September? Any observation with respect to that?

[Dr. Mark Zamorski]

Well, I know that people have looked at temporal effects on suicide, including seasons and days of the week and proximity to holidays, and I know that people have found some patterns there. In our own data, with an average of maybe 12 or 13 reg force suicides a year, it would be really difficult for us to come up with any kind of meaningful pattern.

[John McKay, Liberal, Scarborough—Guildwood, ON]

What's red force?

[Dr. Mark Zamorski]

It's reg force. Sorry.

[John McKay, Liberal, Scarborough—Guildwood, ON]

Oh, regular force.