National Defence Committee on Nov. 26th, 2013

[Tarik Brahmi, NDP, Saint-Jean, QC]

Thank you, Mr. Chair.

My first question is for Dr. Germain.

Like a lot of Quebeckers who see people like you, I want to ask you a question. You said that you studied at the University of Montreal. Why did you decide to go to the United States? It's not really what we're looking at here, but it has to do with the issue of retaining doctors. Did you choose to go to the United States because you had an opportunity to do studies there that you couldn't do in Canada or to get access to programs we don't have here?

[Dr. Anne Germain]

When I left Montreal to do my post-doctoral training in Pittsburgh, my main goal was to learn how to use the various neuroimaging methods so I could study sleep in people with post-traumatic stress syndrome. I've been doing the same thing for a long time. For 20 years now, I've been studying sleep in people who have nightmares, who have post-traumatic stress syndrome. I was trained in neurology, and I was familiar with various methodologies, but Pittsburgh gave me the opportunity to learn to use neuroimaging. Those types of studies enabled me to answer the research questions I was asking and to improve my clinical practice in sleep medicine.

I had to return to Montreal. I left thinking that I was going to return to Montreal and bring back this expertise and do the studies here. My training was demanding and took longer than I initially thought.

It also has to do with when I left. I left in 2001, which was when NATO operations in Afghanistan started. Then in 2003, the United States invaded Iraq. At the time, there were various possible grant sources for research related to post-traumatic stress syndrome and sleep, which was not very popular up until 2001. I applied for grants and had access to a fairly large research program that developed very quickly. That's what kept me in Pittsburgh.

[Tarik Brahmi, NDP, Saint-Jean, QC]

Okay.

I also wanted to have you talk about the graphs showing sleep in the deployment cycle. We see the data during deployment periods, and the actual hours of sleep, as you said, or the perceived hours of sleep that the individuals in the study report. Does the methodology take into account the fact that certain operational constraints during deployment, such as guard rotations or interrupted or unplanned night operations, prevent a person from sleeping? During deployment, soldiers don't necessarily get to sleep for eight hours, even if they want to.

[Dr. Anne Germain]

Absolutely. You reminded me of something else that's important to mention. The issue was trying to determine how many hours of sleep people get in a 24-hour period. It wasn't necessarily 6 consecutive hours. People might get close to 6 hours of sleep in a 24-hour period.

So yes, you are absolutely right.

[Tarik Brahmi, NDP, Saint-Jean, QC]

Perfect.

I have a question for Ms. Zipes.

The study mentions the number of patients treated in your laboratory. Most often, you're treating cases of brain injuries. You said there are two types of brain injuries: traumatic and acquired. Can you quickly explain the difference between the two and perhaps give us some examples? The examples of applications that you gave us are particularly interesting. Could you give us some examples of rehabilitation methods for the two types of brain injuries? I imagine we aren't talking about post-traumatic stress syndrome in this case. We're really talking about lesions or physical injuries that affect the brain directly.

Could you give us a bit of an explanation of the difference between the two and provide two typical examples?

[Helen Zipes]

Sure, with pleasure.

When you have a brain injury, whether it comes about through illness, if there's a brain tumour, if there's a space-occupying lesion, depending on what area is affected.... It could be that a certain area is affected because of, as I said, some sort of an illness, an infection, or a tumour, or there could have been an accident. If you're in a car accident and you have actual trauma to the head, or you have a gunshot wound or something that's not illness, that's what we usually consider traumatic.

You can have the same outcomes though. It doesn't matter the method of the brain injury. What's important is where the injury is and whether it is stable or it's progressing.

The brain is very interesting. Depending on where the injury or the illness was, there are different effects. Some of our brain injury patients can have memory problems. Some of them are aggressive. We have four beds that are actually in an area of our unit that we're able to lock, because they just cannot control their aggressivity. There are other patients who, if we left them alone, would just sit in a chair all day. They wouldn't get up. They wouldn't eat. They wouldn't get out of bed. We have to stimulate them.

It depends on what area is involved, and it also depends on whether the injury is progressive or static. These are the symptoms.

With all of our patients we always do an assessment. We see what the deficits are and then we determine what we have to work on.

[The Chair, Conservative, Peter Kent]

Thank you, Ms. Zipes.

Mr. Bezan.

[James Bezan, Conservative, Selkirk—Interlake, MB]

Thank you, Mr. Chair.

I want to thank our witnesses for coming today. It's especially nice to see Dr. Germain again. Last year we had a PTSD forum, and that's where I got to see your work and hear all the great things you have to say about the importance of sleep.

Mr. Brahmi was talking about why you're in the States. You do have opportunity, though, to come back to Canada, I'm sure, at other institutes. My understanding is that you have been actually involved with the Canadian Institutes of Health Research.

[Dr. Anne Germain]

Yes. I'm starting discussions with them just as I did today, promoting sleep as a core component of mental health. I'm very interested in depression and anxiety. I think PTSD has a unique position to play in that institute with regard to integrated sleep.

I know Dr. Merali has been here, and one of his three recommendations was focused on sleep disturbances, so I was pleased to read that.

There are many opportunities now in Canada. When I decided to stay in the U.S. in 2005, I had been thinking of coming back to Canada, but I could not find an institution that had the sleep research and the neuroimaging capabilities I needed to push my research forward. I knew down the line they would be. From what I understand now, there are very rapid developments that bring all of these resources together in Ottawa and in different centres in Canada as well.

As I mentioned to the chair earlier today, all I hear consistently from the Americans, the Dutch, and the Australians is that Canada is ahead of the curve in the kinds of programs the Canadian Armed Forces has for mental health, from training all the way to post-deployment, and even when veterans are separated from the military.

I think on the military side, for different reasons, there's definitely a very different approach already in place in Canada, and for people like me, and for young investigators, that will provide very unique opportunities for research and for translation of research into clinical and practical applications.

[James Bezan, Conservative, Selkirk—Interlake, MB]

The work that you're doing, whether it's here in Canada or whether it's down in Pittsburgh, is being shared with all our allies. You said the CAREN system is in operation. It's a Dutch invention used in—

[Helen Zipes]

Four countries.

[James Bezan, Conservative, Selkirk—Interlake, MB]

—four countries, including Canada. It's available to anyone, I suspect, who wants to make use of it, the same as the research that you're doing now.

[Helen Zipes]

Yes, absolutely. In fact, there is a CAREN conference going on out west right now that Sean is going to go to tonight. We hope he'll be able to get out. Yes, we share. Israel was great sharing with us. When we went there, they gave us all their protocols. We were so much farther ahead because of what they shared with us, and we are looking down the road at some shared collaboration and research projects. We've been to Walter Reed. We've seen again how they used the machine. We've learned from each other.

[James Bezan, Conservative, Selkirk—Interlake, MB]

Dr. Germain, with your study on sleep and PTSD, have you been able to quantify an improvement in PTSD outcomes by having better sleep patterns?

[Dr. Anne Germain]

Yes, we usually see reductions or effect sizes above 0.5. There is moderate to large effect size in improvements in daytime PTSD. That would be a reduction of at least 30% to 50% in daytime symptoms severity by treating sleep. If you sleep better, you're less reactive. You're in a better mood. You're less anxious. You're less fearful of different things. Now we don't treat PTSD; it's very rare. It's happened, but it's very rare that only focusing on sleep is enough to treat PTSD, but it does give us a leg-up in the treatment of post-traumatic stress, which is emotionally demanding and often scary for people.

[James Bezan, Conservative, Selkirk—Interlake, MB]

I know a lot of the members have been focusing on your finding that non-deployed service members sleep less than civilians. About 72% are sleeping six hours or less in the military, while 73% of civilians are sleeping more than seven hours. I'm trying to extrapolate here, based on your categories of non-deployed, during deployment, and post-deployment. Are you saying it's 30 minutes less sleep during deployment?

[Dr. Anne Germain]

That is reported over a 24-hour period.

[James Bezan, Conservative, Selkirk—Interlake, MB]

If you reduce that by 30 minutes, all of a sudden that number is going to be climbing up. Close to 90% of our military in deployment are getting less than six hours.

[Dr. Anne Germain]

I'll take a wild guess and say that this is what I would expect to see, except for the American air force. I'm sure it's the same thing in the Canadian air force. There is so much emphasis placed on making sure that people are not fatigued, that they're well rested, that they can operate during long flights in different kinds of missions. Those are probably the 10% of the people who have protected time for sleep in the air force, and the rest of the service members will have much less than the six hours.

[The Chair, Conservative, Peter Kent]

Thank you.

We have time for one final round.

Mr. Harris, do you have final questions?

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

Yes, thank you.

In your comparison of service members with civilians, I'm assuming you're choosing males and females of the same age.

[Dr. Anne Germain]

No, I used two samples: active duty service members in the army, which was where most of the studies have been done; and one of the largest civilian studies that we have about sleep needs and sleep duration in the general population. This is a contrast of what we expect to see in the general civilian population versus what we find with active duty service members, in this case, army members.

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

I'm interested in the implications of your work for the mental health of soldiers in general. Mr. Opitz comments that soldiers are used to taking catnaps, but what you're telling us is that they don't. What policies could we adopt to account for what you've found?

[Dr. Anne Germain]

I don't know because they would have to be informed not only by the kind of observations we have and we find when we look at this relationship between sleep and mental health. With military service members from the get-go, I believe, there's a self-selection bias. To be able to even complete the training, you have to be able to take quite a bit. I've always said that the people I've worked with have constantly reminded me of how resilient and how tough they are, and I do believe that it's a self-selected population that is just at a higher capacity to take on and sustain chronic challenges, relative to the general population.

Regarding the kind of policies we would make, we would have to be careful that the signal we convey with these policies does not therapeutize or make the military people seem or sound vulnerable because of the kind of work they do. Those are people who choose to do what they do, and I think there's a selection bias in who chooses to do that. We'd have to be able to evaluate, which we haven't done much, what the factors are that provide resilience and strength to allow these people to take it much more than I can, for sure.

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

The caveat, though, is the very first quote that you gave us, that this is great, except that it produces gradual weakening leading to sudden and unexpected collapse.