National Defence Committee on April 8th, 2014

[The Vice-Chair, NDP, Jack Harris]

I would like to call the Standing Committee on National Defence meeting 19 to order. I believe we have a quorum, so we can start.

The orders of the day for today are pursuant to Standing Order 108(2), the study of the care of ill and injured Canadian Armed Forces members.

Our witnesses today are from the Department of National Defence. We have Brigadier-General Jean-Robert Bernier, Surgeon General, Commander Canadian Forces health services group and Jacqueline Rigg, director general, civilian human resources management operations, assistant deputy minister, human resources - civilian.

I am sitting in for the chair, who is unavailable today. Mr. Kent is unable to make it.

I guess we can proceed. Mr. Bezan can come along when he is ready.

We have written remarks from General Bernier.

Sir, welcome to the committee to you and to Ms. Rigg. You may proceed, sir, with your opening remarks.

[Brigadier-General Jean-Robert Bernier, Surgeon General, Commander Canadian Forces Health Services Group, Department of National Defence]

Thank you very much, Mr. Chair.

Hello, honourable members of the committee.

Thank you very much for the opportunity to appear before you again and especially for your ongoing focus on the health of Canadian Armed Forces members.

The welfare of those who are willing to sacrifice their lives for the protection of Canadians deeply merits your attention, and your committee's commitment to studying it so closely sends military personnel a positive message that helps make the risks and sacrifices they accept more tolerable to bear. In saying that, I include all of my medical personnel, most of whom served in operations overseas, saw far more trauma in Afghanistan than any other arm in treating daily horrific casualties, and suffered the most physical and mental health casualties after the combat arms. Given that their own health so directly depends on the quality of their own work, they are powerfully motivated beyond just their duty and compassion for others to provide the best possible health care, research, policies, and programs.

You've already been briefed by me and some of my senior medical officers on the uniquely comprehensive extent of the health programs available to Canadian Armed Forces members, but there have been many developments since I last appeared before you in November 2012 to further address areas that could be improved.

Perhaps most relevant to your current focus was the development and launch last fall of my updated military mental health strategy based on a detailed year-long analysis of accumulated experience, data, lessons learned, and research over the past few years.

The existing military mental health program had been based on extensive research and analysis over several years, but it predated combat operations in Afghanistan. It was incrementally enhanced through annual reviews, but a longer-term and more detailed strategy was needed to guide and prioritize our efforts given the end of Afghanistan operations, the major increase in the military mental health budget from $38.6 million to $50 million, clinical and technological developments, a collective review of previous recommendations from your committee and other external bodies, and our greater understanding of mental health in the Canadian Armed Forces through accumulated health surveillance data and research.

Our analysis of the “Medical Professional Technical Suicide Review Report”, our operational stress injury incidence and outcomes study, as well as the ongoing analysis of the 2013 health and lifestyle information survey, and the Statistics Canada mental health survey will further enhance the strategy's implementation over the next five years. They will also help us more objectively re-evaluate whether the professional composition and capacity of our targeted cadre of 452 mental health staff are appropriate to our current and projected mental health care demands. The strategy and its supporting analysis will help us further optimize use of our resources and data in dealing not only with our Afghanistan-related mental health burden, but also with our much larger baseline toll of mental illness arising from the normal stresses of military service and those that affect Canadians generally. At least four of Canada's top national mental health organizations have publicly praised the strategy as a comprehensive model.

The strategy and our mental health program were also praised by representatives of the major national mental health organizations at a recent meeting with the Defence and Veterans Affairs ministers and senior officials. They made excellent suggestions for enhancing our programs, and all of their recommendations were either already implemented or are part of our mental health strategy, particularly their emphasis on the critical need for mental health prevention and treatment measures to be based on solid evidence.

Other significant developments include greater success in the recruitment and hiring of public service mental health staff, which my colleague Ms. Rigg can address in greater detail. We are now much closer to our target of 452, which will help reduce our reliance on contracted mental health staff and on our external referral network of up to 4,000 clinicians.

Although our wait times for assessment and care have, in general, long been far below those in any other health jurisdictions, this is helping reduce the number of local situations where wait times exceed my aggressive targets, in concert with other measures to enhance efficiency through staff reallocation, process modifications, the use of tele-mental health, and others. Reaching and maintaining our staffing targets will unfortunately remain a persistent challenge, given the national shortage of mental health professionals.

Since 2013 our procurement of high-definition tele-mental health technology is also helping us accelerate care to underserved locations and reduce patient inconvenience of travel for care, while our procurement and trial of virtual reality technology for PTSD exposure therapy is promising. In parallel with the Canadianization of the virtual reality software through our partnership with the True Patriot Love Foundation , we plan to provide the technology to all our operational trauma and stress support centres.

There have also been beneficial new developments with some of our other external partners since 2012. We have now twice partnered with Bell's national Let's Talk campaign which, along with many other efforts by the Chief of Defence Staff and senior military leaders, is helping further reduce stigma surrounding mental illness in the military culture.

The Canadian Psychiatric Association has established a special military and veterans section to support its military and civilian members with an interest in the mental health of serving and retired military personnel.

The Canadian Institute for Military and Veteran Health Research, established at the behest of my predecessor, has added several more universities to its network and is receiving additional support from the Wounded Warriors project and the Royal Canadian Legion in the form of mental health research scholarships. The Legion is also expanding its efforts to disseminate information throughout the country about support programs available from the Defence and Veterans Affairs departments, an initiative that will help better inform veterans and reservists distant from military bases and Veteran Affairs offices.

With respect to research, several joint projects with our partners are providing new insights and technological applications that will help enhance understanding and treatment such as two ongoing joint projects on the use of transcranial magnetic stimulation for the treatment of mental disorders, a validation study of our road to mental readiness education and resiliency program, neuroimaging studies with magnetoencephalography and functional magnetic resonance imaging, and a military-civilian symposium hosted last month by the Toronto Hospital for Sick Children's research centre on neuroimaging for the diagnosis and treatment of PTSD and traumatic brain injury. The Canadian deputy surgeon general continues to chair NATO's health research committee and mentor its military suicide research task group, Canadians continue to have a leadership role in almost all its mental health-related research activities, and a year ago a royal Canadian medical service expert was asked by NATO to co-chair its international symposium on best practices in post-combat rehabilitation and reintegration of patients suffering physical and mental injuries.

Despite the need to focus continually on improving our mental health programs, I also have to maintain capabilities and improve them in all areas necessary to protect health and lives in humanitarian and combat operations as well as in routine domestic care. To that end, one of my surgeons, Colonel Homer Tien, continues to head Canada's top trauma centre and hold the military trauma research chair at Sunnybrook in Toronto.

In 2013, I also established a new military critical care research chair affiliated with Western University that is held by Naval Captain Ray Kao, one of the world's top critical care researchers, and other military health research chairs are under consideration. Through collaboration, training, collaboration with allies, and other measures, we have also enhanced capabilities and readiness in deployed surgical and critical care; medical defence against chemical, biological, and radiological threats; and health care in Arctic, humanitarian, and special operations.

With respect to the care provided by our domestic health system, we received accreditation with distinction last fall following a three-year assessment by Accreditation Canada, the National Health Service quality authority, and we recently established a more robust quality assurance and patient safety program in collaboration with the Canadian Patient Safety Institute.

I have noted only a few examples of improvements and recognition by national and international health authorities highlighting Canada's leadership in military medicine and mental health. The greatest recognition and the rarest of honours came from our sovereign last October with the presentation of a royal banner by Princess Anne to the royal Canadian medical service in recognition of the valour, sacrifice, and clinical excellence of its members during a decade of operations in Afghanistan. It was only the third royal banner ever presented to a Canadian Armed Forces element since Confederation, and the second royal banner had also been presented to the medical service by Her Majesty the Queen Mother.

[The Vice-Chair, NDP, Jack Harris]

Thank you, General Bernier.

Our first person for questioning the witnesses is Mr. Norlock, for seven minutes.

[Rick Norlock, Conservative, Northumberland—Quinte West, ON]

Thank you, Mr. Chair.

Through you to the witnesses, thank you for appearing today.

My first question will be to the surgeon general. According to your mental health strategy from 2012—I will give you a quote—

Combat exposure and exposure to atrocities are risk factors for post-appointment mental illness. Deployment, however, accounts for relatively little of the overall burden of mental health disorders in the CAF. Military personnel experience nearly all the non-operational risks and vulnerabilities to mental illness as their civilian counterparts.

I wonder if you can address and explain this? I want to deal specifically with the change in the type of battle our Canadian Armed Forces face, in particular in Afghanistan and in modern times recently in other places in the world. The difference is that traditionally the enemy had a uniform or you were somewhat protected because the roads you were travelling had been previously travelled on. What we were faced with in Afghanistan is the enemy could be anybody out there. Our Canadian military were at the pointy end of the spear as they drove through cities, towns, and villages, as well as the countryside. The enemy could have been anyone they saw. We heard stories from serving members from that area who basically gave anecdotal evidence to indicate that this posed a significant burden for them when they got back into regular society and there was no decompression, I guess.

The other is even the roads they drove on, they never knew what road had an bomb on it or you didn't know what street.... So I'm just wondering how you could say what you said based on...if you could explain that I guess is what I'm asking.

[BGen Jean-Robert Bernier]

Yes, sir. Thank you.

It's the quantitative burden of mental illness. Mental illness affects anywhere from one in four to one in five Canadians in their lifetimes according to the Mental Health Commission of Canada. So it's purely the math.

We experience a similar prevalence of mental illness in the Canadian forces. The one study we have from 2002 shows double the risk of depression in Canadian forces members related and unrelated to military operations. So from the pure quantitative perspective overwhelmingly we have a far greater burden resulting from mental illness that we have to treat that's not related to combat or deployment operations.

There is an increased risk, proportionately, among those who do deploy to operations, particularly operations that involve the risk factors of combat and risk to life and threat to not just themselves but particularly, as you described, the inability to respond when atrocities are being committed. So there is a general consensus in the mental health community that the risks of being deployed in operations where you have rules of engagement and a mandate that permits you to intervene when innocent people are being harmed is somewhat less stressful than being deployed in operations where rules of engagement are imposed, for example by the United Nations authorities, in order to maintain a neutrality and the perception of neutrality; that is more stressful on soldiers who are prevented from intervening except where their own personal lives are at risk.

So that was a major stressor for people who deployed in operations in the 1990s, particularly where the rules of engagement were very difficult. One particular case for example is the Dutch commanding officer of the battalion at Srebrenica. That was the Dutch battalion during Bosnian operations that was charged with the protection of the Muslim population that was subsequently massacred when the Serb army arrived. That individual was directed... It is well-documented that many people at that time suffered mental illness as a result of their inability...in fact, their direction not to intervene.

So you are absolutely right, the inability to intervene when atrocities are being committed against innocent people is an extreme stressor.

[Rick Norlock, Conservative, Northumberland—Quinte West, ON]

Thank you.

My second question surrounds the appearance before the committee in November 2013 of Dr. Anne Germain. She was studying the link between sleep and mental health. The committee heard evidence that a disturbance to sleep procedure occurred shortly after exposure to stress or traumatic events and was a very strong predictor of poor psychiatric outcomes, and she went on with further evidence and said that there was improvement when there was proper sleep.

I have another three or four questions surrounding that. I think you are probably familiar with that evidence and with that study or that area of study. I guess my questions would be as follows. To what extent is the Canadian Forces incorporating sleep treatment into its clinical mental health care programs? To what extent is the CF incorporating sleep training into its cradle-to-grave mental readiness and resilience programs such as the road to mental readiness? Third, the American military personnel are receiving warfighter sleep kits before and after deployment. Is the Canadian Forces considering this? Last, Dr. Germain also noted that sleep issues are a non-stigmatizing entry into mental health care. Would you agree with that statement?

[The Vice-Chair, NDP, Jack Harris]

Mr. Norlock has left you 30 seconds to deal with these questions.

[Rick Norlock, Conservative, Northumberland—Quinte West, ON]

You could perhaps respond in written form later if you don't have time.

[BGen Jean-Robert Bernier]

I can answer all of that. Yes, we recognize that. Everything we do and all of our practices are based on the best evidence. We are actually involved in a sleep research study to find better ways of enhancing sleep. It's a major problem with PTSD. Some people in particular have gone 10 years without sleep. It's part of our patient care protocols for PTSD and for any other mental health issues, because people cannot get better until they get over that. We're even sponsoring research involving drugs that enhance sleep and reduce nightmares in order to address that particular problem.

Education about it is in our road to mental readiness program. I'll have to look up whether the sleep kit.... I'm not sure exactly what it is the Americans are providing other than education.

[Rick Norlock, Conservative, Northumberland—Quinte West, ON]

Thank you.

[The Vice-Chair, NDP, Jack Harris]

General, perhaps you could provide us with something in writing on this whole issue of sleep. I would suggest there are more of us than just Mr. Norlock who are interested in it. I think the committee was interested in that testimony and that would be helpful to us.

We now have Ms. Michaud for seven minutes.

[Élaine Michaud, NDP, Portneuf—Jacques-Cartier, QC]

Thank you for your speech, Brigadier-General Bernier.

In your speech, you mentioned that the Canadian Armed Forces intends to re-evaluate its target of hiring 452 mental health staff. Has that process already begun?

[BGen Jean-Robert Bernier]

We will be re-evaluating all of our programs on a yearly basis. In this specific instance, the re-evaluation is more comprehensive and based on a larger quantity of data. We are awaiting the results from two major studies that are currently under way. All of the data has been collected from our military personnel. There was a health and lifestyle survey, as well as a major Statistics Canada survey on the mental health of armed forces members.

We are expecting that Statistics Canada's analysis will be equally as thorough as the one from 2002-03, which formed the basis of the current program. Once we have the results of these analyses, we will re-evaluate and determine what abilities, delivery methods and skills we require in order to provide the best care possible.

[Élaine Michaud, NDP, Portneuf—Jacques-Cartier, QC]

In other words, you are working on meeting that target of hiring 452 mental health professionals and will continue to do so until the studies are completed.

[BGen Jean-Robert Bernier]

Yes.

[Élaine Michaud, NDP, Portneuf—Jacques-Cartier, QC]

Since the civilian hiring freeze was lifted last fall, how many mental health professionals and support staff have been hired?

[BGen Jean-Robert Bernier]

I will let Ms. Rigg answer that question.

[Élaine Michaud, NDP, Portneuf—Jacques-Cartier, QC]

Of course.

[BGen Jean-Robert Bernier]

However, I can tell you that despite the freeze, we have still been able to continue hiring people, recruited through Calian, who can provide health care. We can also access our network of 4,000 external clinicians.

[Élaine Michaud, NDP, Portneuf—Jacques-Cartier, QC]

I would like to know how many civilian professionals were hired for internal positions, not as part of the external network, since the freeze was lifted.

[Jacqueline Rigg, Director General, Civilian Human Resources Management Operations, Assistant Deputy Minister, Human Resources - Civilian, Department of National Defence]

I am thankful to have the opportunity to appear before you once again in this committee and I am glad that I can provide you with some progress that we've made on those hires since the last time I appeared before this committee.

In my previous speaking address on March 4, we shared with you that we had 29 letters of offer out, 18 hires, and 11 conditional offers. As of yesterday that has increased to 46 letters of offer that have gone out, 27 mental health practitioners have been hired, 10 offers have been accepted, but they're pending conditions to be met such as medical or security clearances. Nine have declined.

We had a gap of 54 hires to do. We are now only down to 17 positions. We are currently doing staffing actions to finish those other 17 positions. So far with our rate we're having an 80% acceptance rate for our letters of offer that we get out.

[Élaine Michaud, NDP, Portneuf—Jacques-Cartier, QC]

Thank you very much for that information.

Brigadier-General Bernier, in your speech, you spoke about the various measures that have been taken that have allowed the Canadian Armed Forces to increase their ability to offer health care, including critical care during deployment.

We recently learned that there were no on-site psychologists available for francophone soldiers deployed in Afghanistan. They had to rely on care provided by American military personnel, in English only. That issue was raised in the past and was in turn acknowledged by National Defence. A solution was found but, in my opinion, it was far from ideal and didn't comply with the Official Languages Act.

Have steps been taken to address that issue so that a similar situation does not arise during a another mission?

[BGen Jean-Robert Bernier]

For one thing, there's a major shortage of mental health professionals across Canada. For another, we can only deploy uniformed military personnel abroad. As a result, we have to rotate our psychiatry and mental health personnel. We typically do whatever we have to to make sure that at least one of the three members of the mental health team is bilingual.

[Élaine Michaud, NDP, Portneuf—Jacques-Cartier, QC]

That didn't happen that time.

[BGen Jean-Robert Bernier]

I don't know. I would have to look at exactly what happened that time to find out why.