National Defence Committee on Feb. 23rd, 2017

[The Chair, Liberal, Stephen Fuhr]

I call the meeting to order.

Thank you very much for coming to the defence committee today.

I would like to introduce Brigadier-General Hugh MacKay and Colonel Andrew Downes. Thank you very much.

Before we start with your opening comments on the “2016 Report on Suicide Mortality in the Canadian Armed Forces” and the ensuing conversation, I want to let the committee know our agenda.

We'll go for about one hour and 45 minutes, and then we'll suspend and go in camera for 15 minutes for committee business.

This has been working for me, so if you ever see this piece of paper come up, you don't have to stop immediately, but you have about 30 seconds to wind down on your thought because then I'm going to have to give the floor to somebody else, and it just makes it a more smooth transition. This paper is the 30-second warning.

Gentlemen, thank you very much for appearing today.

General, you have the floor.

[Brigadier-General Hugh MacKay, Surgeon General, Commander, Canadian Forces Health Services Group, Department of National Defence]

Thank you very much, Mr. Chairman.

Mr. Chairman and members of the Standing Committee on National Defence, thank you for the opportunity to present the results of the “2016 Report on Suicide and Mortality in the Canadian Armed Forces”.

Every suicide is a tragic premature loss of life which we all mourn; it has far-reaching negative repercussions on the lives of family, friends, the military community, and health care providers. This is an issue that is of great concern to the military leadership, and has been a particular focus of attention within the health services group for many years.

The Canadian Armed Forces has a strong and comprehensive suicide prevention program, as noted by the 2009 Canadian Forces expert panel on suicide prevention, and the implementation of recommendations from that panel have enhanced it even further.

We have a nationally and internationally recognized resiliency training program called “the road to mental readiness” and a suite of health promotion programs that include such topics as stress management, addictions awareness, mental fitness, and suicide awareness. Those who are suffering with mental illness are at risk of suicidality, so it is critical that we get them the support they need and get them into care.

We have accessible primary care clinics on bases across the country and several overseas, most of which have a multidisciplinary team of mental health clinicians. We also have our seven specialized operational trauma stress support centres distributed across the country at our larger centres. We have implemented telemental health within the system to improve access to care from more remote locations, to provide care in the language of choice, and to help improve access to care. We have also installed virtual reality systems in our larger clinics to help better treat people with operational stress injuries, and we have implemented a project to include direct entry mental health notes into our electronic medical records.

Military personnel have access to support from the Canadian Forces members assistance program 24-7, or they can access emergency medical care at civilian medical facilities after clinic hours.

Mental illness and suicide are complex problems and, unfortunately, there is still much that we have to learn. So we conduct research to better understand the health issues within our Canadian Armed Forces population, like the 2013 mental health survey that was conducted on our behalf by Statistics Canada. We are also exploring new ways to improve the quality of care available in our clinics.

The Canadian Forces health services group tracks all suspected suicides and sends out a clinician team to gather information related to each case in order to better understand the circumstances surrounding the event and to learn lessons that may prevent future suicides.

Information gathered from this process and other sources is collated and analyzed annually, and a report is produced. The report we are discussing today is one of these, and it includes data from 1995 to 2015.

It's important to know that the analysis is done on data from regular force male suicides, as the number of regular force female and reserve suicides is too low for proper statistical analysis, and reporting on them could actually breach privacy rules.

We know that suicide is a multidimensional event in which many factors contribute. These include biological, psychological, interpersonal, and social-cultural aspects, and this complexity can make it difficult to predict who is ultimately going to die by suicide. Most people who die by suicide have symptoms of mental illness, and typically experience one or more acute stressors such as marital breakdown, or legal or financial problems. People in crisis feel overwhelmed and hopeless, and have trouble seeing a better way out of their situation.

However, there are some who show no signs of distress even to their closest friends. Thinking about suicide is not uncommon in people with mental illness, but most people do not act on these thoughts and reach out for help. I am saddened every time I hear of another suicide death, knowing that help was just a call away and knowing that we have the resources that could have saved their life.

The overall suicide rate in the Canadian Armed Forces is largely unchanged over the past 20 years. However, over the past five years we have seen a significant increase in the suicide rate specifically among those serving in the army command as compared to other commands, such as the air force or navy. The reasons are not fully understood, especially given that all elements of the Canadian Armed Forces share the same recruiting, administrative, and disciplinary processes and have the same health care system.

At the same time, though, we have noted a small increased risk of suicide in people who have a history of deployment and also in combat arms occupations. It is reasonable to hypothesize that these groups are at higher risk for psychological trauma during operations, which would increase the risk of developing mental illness. However, there may be other explanations that we have not been able to accurately measure, such as adverse childhood experiences, which we know to be higher in military members than in the general Canadian population. It is known to be a risk factor for both mental illness and suicide.

In looking at specific, diagnosed mental health conditions in those who complete suicide, depression and substance use disorder are seen most frequently, followed by anxiety disorders, with post-traumatic stress disorder being the fourth most common. This is important because it highlights the need for a broadly focused mental health program.

Within the Canadian Forces population, the most common life stressor that likely triggered the suicide was a failed intimate partner relationship. Other stressors associated with the suicides were work-related, debt, and legal problems. These suggest that the opportunities for early suicide prevention go far beyond health care. The Canadian Armed Forces does have many programs and services to help address these types of stressors. As is the case in the civilian community, about half of those who complete suicide are in care, but the other half are not. While the care available within our health services is central, there are also suicide prevention opportunities for leaders and peers to assist members in distress and to encourage them to seek care. The Canadian Army's sentinels program is one such example.

In summary, through ongoing suicide surveillance as well as through rigorous reviews of suicides, the Canadian Forces continues to evaluate and improve policies and procedures to refine its suicide prevention activities.

I would also like to add that we recently convened a second expert panel on suicide prevention. We are still awaiting the report, however, following that review of our suicide prevention activities. We also have work under way now to develop a Canadian Forces-wide suicide prevention strategy.

Thank you for your attention, and we are happy to take any questions you may have.

[The Chair, Liberal, Stephen Fuhr]

Thank you for your comments.

I'm going to turn to floor over to Ms. Alleslev.

You have the floor for seven minutes.

[Leona Alleslev, Liberal, Aurora—Oak Ridges—Richmond Hill, ON]

Thank you very much for coming today to explore such a significant and, of course, disconcerting topic.

You mentioned that you compare to the Canadian general population. Could you tell me why that might be, because I wonder whether or not the military is actually a reflection of the general population when we have such stringent intake procedures and screening? We don't take the full spectrum of the Canadian population into uniform, and of course we have a significantly higher training element through which we can influence the culture and society within the department. What is your thinking on that, and how are you making that comparison to the Canadian population?

[BGen Hugh MacKay]

It's a good question, and we realize that the Canadian population is not a perfect match for us to use, for some of the reasons you mentioned, such as the mental health screening that we do or the medical screening we do before they enter.

However, we feel that it's important to make a comparison, so we do try to do the best we can to make sure that the comparison we conduct is as close as possible, as close as can be made. We do adjustments in looking at the suicide rates within the Canadian population and match them for age, because age is a very significant factor as we look at suicide and the risk for suicide in the Canadian population. It's not perfect, and I recognize that, but we think that it's the best population we can use to compare ourselves against.

We've had a little bit of a look at what would happen if we removed the aboriginal population from that general Canadian population, because as we know, unfortunately the aboriginal peoples do have a fairly high suicide rate. They're a small percentage of the general population, and we've identified that even taking that population with such a high suicide rate doesn't really change the comparison for us too much.

[Leona Alleslev, Liberal, Aurora—Oak Ridges—Richmond Hill, ON]

Do you make any comparisons with other comparable militaries?

[BGen Hugh MacKay]

At the present time, we are not making comparisons with other militaries. There is such a difference across the various militaries that it would be, we think, a worse comparison than comparing us to the population from which we actually recruit.

When you look at the different experiences on operations and at the baseline rates of suicide in the various countries that they recruit from, there are considerable differences. Even across Canada, you see differences from province to province to province that we really can't explain very well.

[Leona Alleslev, Liberal, Aurora—Oak Ridges—Richmond Hill, ON]

Okay.

You mentioned that there is a slight uptick in the trend, particularly in the army. Can you give us some sense of this? Obviously we would hope that these numbers would be going down, particularly with all the measures you've put in place. We have increased measures, yet the rate appears as though it might be increasing. How are you measuring, then, the success of the programs against the actual outcomes of the suicide rate?

[BGen Hugh MacKay]

It's very difficult to measure programs that are trying to prevent things. Measuring what you have prevented is a challenge across any health jurisdiction.

We have seen an uptick particularly in the army. In the air force and navy, there was a bit of a decline in the suicide rate, and then it came back up and stabilized. We saw the increase in suicide in the army starting to surface around 2011 and 2012, and it has more or less stabilized now. We think that's there because of the impact of Afghanistan, and the impact that Afghanistan has had on mental illness across the army.

[Leona Alleslev, Liberal, Aurora—Oak Ridges—Richmond Hill, ON]

Can you tell us if RMC cadets are included in these numbers?

[BGen Hugh MacKay]

Yes, any suicide, including RMC cadets, will be included in these numbers.

[Leona Alleslev, Liberal, Aurora—Oak Ridges—Richmond Hill, ON]

Are veterans, people who have taken their release, also included in this number?

[BGen Hugh MacKay]

These numbers do not include the veteran population. They're strictly based on serving members.

[Leona Alleslev, Liberal, Aurora—Oak Ridges—Richmond Hill, ON]

Are you looking at some kind of joint study with veterans to be able to understand that bigger continuum? It's quite possible, I would presume, that some of the conditions that might have led to the suicide might have actually occurred while they were in uniform. Even if the outcome wasn't recognized while they remained in uniform, it might still inform and would also perhaps give us a different perspective on the statistical relevance of the sample size. Would that be something you have been considering?

[BGen Hugh MacKay]

We have been working with Veterans Affairs. The first time we did a report that included veteran population suicide rates was a Canadian Forces cancer and mortality study that we did. That was the study in which we identified that there was perhaps a 1.5 times greater risk of suicide in veterans.

We continue to work with Veterans Affairs to try to enable them, using a database we've built that includes everybody who joined the Canadian Armed Forces from 1972 to today, and we add to it every year for all the new recruits. We're building and helping them maintain that database, and then we use mortality data from Statistics Canada to see what's going on with rates of suicide in the veteran population.

We collaborate with them frequently, and we are collaborating with them in the development of a joint Canadian Armed Forces and Veterans Affairs suicide strategy. Part of that will be examining where we need to go next and examining what's going on with suicide in veterans—not us, but helping Veterans Affairs where possible in looking at what's going on with suicide in the veteran population.

[Leona Alleslev, Liberal, Aurora—Oak Ridges—Richmond Hill, ON]

Thank you.

I think I'm out of time.

[The Chair, Liberal, Stephen Fuhr]

You are.

Ms. Gallant, you have the floor.

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

Thank you, Mr. Chairman.

What is the authority that the surgeon general has over military doctors? Is that a chain of command? Are they answerable to you for the different diagnoses? How does that work?

[BGen Hugh MacKay]

At the present time, there isn't a clear delineation of my authority over clinicians with respect to the work that they do, in fact. Primarily, my authority is through the chain of command at the present time.

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

Okay, so the clinicians are not answerable to you.

[BGen Hugh MacKay]

The clinicians are answerable to me through the chain of command, yes.

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

It's through the chain of command. Okay.

I noticed that when you were listing out the different causes and potential causes resulting in suicide, or the contributing factors, you didn't mention traumatic brain injuries or brain stem damage resulting from neurological toxicity that, in turn, arises from mefloquine. Has there been no evidence to that effect, that among the suicides there is an increase in the proportion of people who've taken this? Is there no positive correlation?

[BGen Hugh MacKay]

We have seen no evidence to date of mefloquine's relationship to suicide. In fact, if you look at our current data with respect to our mefloquine use and our data on suicide statistics, starting in 2003 the use of mefloquine in the Canadian Armed Forces started to decline from about 85% to where it is today, at about 5%. The curve on use of mefloquine was going this way. When you look at the curve for suicide in the Canadian Armed Forces, we started to see the rise in suicide in the army starting in 2006. You have a curve of mefloquine use going down this way, and suicide going up this way. I know it's a crude comparison, but if there really was a strong linkage between mefloquine and suicide, you might not have expected to see opposing angles on those curves.

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

Unless there's a latent effect and it's more predominant the more it's taken, and with consecutive deployments.

What protocol is in place to ensure that forces members give informed consent for vaccinations when they're being “dagged” in preparation for deployment? Do soldiers know what they're being vaccinated with when they're preparing for deployment?

[BGen Hugh MacKay]

When soldiers are vaccinated for deployments, yes, they meet with a clinician and are advised on what the vaccines are. We do a screening for contraindications, allergies, and those kinds of things. They don't necessarily sign an informed consent, but the discussion is with their clinician as to whether or not they want to receive the vaccine.