National Defence Committee on April 29th, 2013

[Jean-François Larose, NDP, Repentigny, QC]

In a comparison to civilian life, where there's a lack of research on that, especially when it comes to people in uniform, do you see a correlation where one can help the other?

[Dr. Mark Zamorski]

If I may, I think the general population has a lot to learn by looking at our mental health survey. We have eliminated in the military almost all of these terrific structural barriers that make it very hard for many Canadians to access care—not enough mental health providers, wait times are exceedingly long, people can't get services in the language they're most comfortable in, people can't pay for care, they can't get transportation to care. All these things are problems that we have fixed.

For that reason, when we looked at mental health seeking in the CF, even in 2002, our members with mental disorders were more likely than their civilian counterparts to have sought care for the same kinds of problems. So despite these special barriers that we're concerned about, our members also have special access to care. I think civilians can learn an awful lot from us.

In addition, if you look at us and contrast what we know about our employees with what the average civilian employer anywhere in Canada knows about the mental health of its workforce, we know so much more. However imperfect the picture I have, through my lens of research, about what's going on in terms of mental health in the CF, it far exceeds what Ford knows about its employees, or BlackBerry, or whomever.

[The Chair, Conservative, James Bezan]

Go ahead, Mr. Opitz.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

Thank you, Mr. Chair.

Thank you to our witnesses.

Dr. Zamorski, let me start with you, sir. Towards the end of your written presentation, you mentioned that you do additional research. Recently there have been three expert panels—on brain injuries, suicide prevention, and the prevention of family violence.

I'd like to go into this question a little deeper: what is the correlation between OSIs and domestic violence? Perhaps you can elaborate on that.

[Dr. Mark Zamorski]

There's a fair bit of research on this. The most consistent observation is that being a victim of family violence is a risk factor for mental disorders, including PTSD. That is the primary linkage between family violence and traumatic stress disorders.

That being said, there are a number of studies, including research that we have done ourselves, that do show a correlation between having post-traumatic stress disorder and incidentally depression as being both a perpetrator of family violence and a victim of family violence. I think most people in the field who've looked at this acknowledge that there is likely a linkage there.

That said, it is only one factor of many that influences family violence. The average person with PTSD hasn't hurt anybody. They're minding their own business, trying to go about their business in the best way they can. I worry, when we talk about these things, that people get the picture that our service members with PTSD are homicidal, suicidal maniacs, which is profoundly unfair and very unhelpful for them as they reintegrate back into society.

So there is a linkage there, but let's not take it out of context.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

You make a good point, because it's those cases that are well publicized, and then all of a sudden people take them out of context and think they're more prevalent than they are.

If you were to make a prediction, what do you think you will see 10 years on in terms of our soldiers who have experienced OSIs, taking into account your U.S. data?

[Dr. Mark Zamorski]

Unfortunately, I think the gains that we have made in the prevention of physical casualties and the treatment of combat casualties to prevent death and serious disabilities have not been matched by gains in the prevention of operational stress injuries.

Arguably we've made no progress, or if progress has been made, we don't have any evidence of it. For every conflict, we look back and we say, “Aha. We figured it out.” And every time, we still see lots and lots of people with PTSD after the conflict.

We may one day make gains in terms of prevention. I don't see anything coming down the recent pipeline that's going to have a transformative effect. Above all else, then, we'll continue to see OSIs. Similarly, in terms of treatments, our treatments get incrementally better year by year by year. I don't see any magic bullets coming down the pipe.

Most people with an OSI will be okay. Some will recover completely. Many will recover substantially, to the point where they can live full and rich lives doing many things, but they will still not meet our military fitness requirements, which are extraordinary. And some, despite our very best efforts, will struggle for the rest of their lives. That will be the minority.

I think that's true today, and unfortunately, I think it will remain true for the next decade.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

Do you think we can ever prevent operational stress injuries? These are unpredictable events—an IED, a combat occurrence, where several of your buddies might be killed, a variety of other events. Do you think we could ever prevent it?

[Dr. Mark Zamorski]

I think there will be preventive measures that are effective, but I think they will be, at most, of modest efficacy. That is my guess. I don't think I will see the reliable prevention of PTSD in my lifetime, unfortunately. It's just too big of a task.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

So the main effort will be on the treatment?

[Dr. Mark Zamorski]

I think the main efforts will be to get people into treatment sooner, so as to provide better treatments that work more reliably and more completely, better tolerated treatments. Those are achievable things. Above all else, we have to make sure that, given the treatments we have, which we accept aren't perfect, we're doing the very best way we can.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

Am I done?

[The Chair, Conservative, James Bezan]

Yes, pretty much. There are only a couple of seconds left.

Ms. Moore, please go ahead.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

Thank you, Mr. Chair.

On the subject of medical evacuations and urgent cases, in other words, when someone's life is truly in danger, I would like to know something. I am wondering whether there are clear procedures indicating how the evacuation is supposed to be done, who is supposed to accompany the patient, what actions are supposed to be taken and whether there is a decompression period.

According to the scientific research we have, how can we make sure that these evacuations produce the least amount of stress possible for members who have to be evacuated and brought back home?

[Dr. Mark Zamorski]

Lisa, do you want to answer the first part of that?

[Maj Lisa Compton]

Typically, these soldiers would go from the point of injury in the field—they would be picked up and taken to Role 3, when we were in Kandahar. Then they would go from Kandahar to Bagram, which is another Role 3 facility. That one is American-led. Then they would go to Landstuhl, and from Landstuhl to home. Sometimes that would take 48 to 72 hours. Starting in 2010, we established a liaison position in Bagram, and from then on we've always had a casualty support team in Landstuhl.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

Before going further, I'd like to know whether there's a decompression period between those two steps or whether, within that 72 hours, the member goes from the battlefield directly home.

Does the person accompanying the patient have the same rank or higher? That might not matter. How do you choose the person who goes with them?

[Maj Lisa Compton]

Typically, there wouldn't be anybody who would go with that person, other than the medical team. Somebody leaving Kandahar would get on an American CCATT, critical care in the air. They would come and pick them up. Until 2010, we had the first liaison position in Bagram, but there was no Canadian with them until they arrived in Landstuhl.

As to decompression, depending on their injury sometimes they wouldn't even wake up in Bagram. I've been from point of injury all the way to Landstuhl and home. I've been fortunate enough to work throughout that continuum. I think in Bagram was the first time. Sometimes they would wake up and they'd think they were in Germany or they wouldn't know where they were. After my first tour in Bagram, the biggest thing was later I would get e-mails telling me that all they remember seeing was my maple leaf and they were so relieved to see my uniform. There was no real decompression.

TBI screening is done for anybody who's capable of answering questions and being assessed properly, that is, if they're not intubated or heavily medicated. Everybody who goes through Landstuhl has a traumatic brain injury screening done before they leave. When they arrive home, where they go depends on where their care needs to be given, according to what is the best medical care available in the area closest to where their family lives.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

I am not talking about urgent cases where the patients are unconscious. I am referring more so to individuals suffering from post-traumatic stress syndrome, for example, who cannot remain in combat and must be evacuated. You said that only medical personnel is there and that there isn't any decompression time, as when other military members leave the field. So those people end up at home within 72 hours or so.

Is that more or less what you are saying?

[Dr. Mark Zamorski]

If I understand your question, it sounds as if you're concerned about whether people who are medically evacuated are receiving some kind of psychological decompression as part of their repatriation.

Is that where your concern is?

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

I am just trying to compare two situations: what happens when a member experiences traumatic events during their mission but completes that mission, versus what happens when a member is evacuated for post-traumatic stress syndrome. I'd like to get a handle on that.

Is that procedure better to control the symptoms? It's the first steps taken following an incident that have a major impact on how the person will cope with the problem or get through it later on.

Does the scientific research show that medical evacuations are most effective in helping members deal with their symptoms down the road? If not, is it possible to take a different approach?

[Dr. Mark Zamorski]

I'm not familiar with any research that specifically gets at that aspect of the repatriation or evacuation procedure. The general approach is that these are people who have identified medical needs. They're in medical care and their psycho-social state is under consideration by the whole team that is taking care of them, from the nurse to the doctor. There are specialists available if they need specialty care. And to be honest, that aspect of what's going on is probably not highest on everyone's level of concern. If people have life-threatening injuries, no one's overly worried about the shock of the repatriation procedure. They're often focused very much on making sure these patients are safe and that their complicated medical needs are taken care of. It's at the other end, as they start to stabilize, that any good trauma team starts factoring in their psychological needs.

[Maj Lisa Compton]

And for a person who would be sent home, who is completely free of physical injury.... Often the whole PTSD diagnosis isn't really confirmed in theatre; there's another diagnosis. But they're basically not mentally healthy to be there any longer.

We get them home to medical care. The actual decompression that we get is very different from the care the person receives. The priority would be getting the person home to the mental health workers who need to care for them immediately.

So the importance would be not so much the decompression, but getting them to the care back home that they need right away, because we can't have them in an environment like theatre where they wouldn't be safe.

[The Chair, Conservative, James Bezan]

Thank you. We've gone over our time. It is the bottom of the hour.

Do you have a comment, Mr. Larose?

[Jean-François Larose, NDP, Repentigny, QC]

It's a point of order. The witnesses don't have to stay. It's just for the committee.

It's just a small question. I don't know if you'll take it into consideration, but I realize that when we wait for translation, it can be longer. Let's say we have a French witness. If anglophones have a hard time, they have to wait. I was just wondering if the chair would take into consideration giving maybe an extra 30 seconds, just to give that time for everybody to have that chance.

Ms. Moore was also waiting for translation.