Public Safety Committee on March 10th, 2016

[The Chair (Mr. Robert Oliphant (Don Valley West, Lib.)), Liberal, Rob Oliphant]

I call the meeting to order.

Thank you to our witnesses for waiting.

This is our first meeting on our study looking at PTSD and OSI. We are going to be studying the issue over the next several weeks, starting with some foundational witnesses.

Just so you know, you are foundational witnesses. From your testimony today and the questioning, we'll be developing our study over the next several weeks and moving ultimately with a report to Parliament with recommendations for government actions. That's the context of what we're doing.

We welcome Jitender Sareen, professor of psychiatry, from the University of Manitoba, as well as Dr. Shlik, the clinical director at the Royal Ottawa. I'm going to suggest that we begin with Jitender Sareen.

You have 10 minutes to present. Then we'll have a second presentation of 10 minutes. Then the committee with ask questions, and they can direct them to either of you as we go.

The floor is yours. We'll let you know at just around 10 minutes, so if you're running out of time, you might....

[Dr. Jitender Sareen, Professor of Psychiatry, University of Manitoba, As an Individual]

Thank you very much for inviting me. It's a pleasure to be here. I really appreciate the opportunity to speak to this important issue for us.

To give the committee a context of who I am, I'm a psychiatrist at the University of Manitoba, and I've worked here for 16 years. I've worked at the Winnipeg operational stress injuries clinic for about seven years, and I've also done work with our team in post-traumatic stress epidemiology research as well as military mental health research and suicide prevention work. Currently I chair the research committee and I'm a board member for the Canadian Psychiatric Association.

Today I'll summarize what we know about operational stress injuries and my suggestions for future work in helping public safety officers in Canada.

An operational stress injury, as defined by Veterans Affairs Canada, “is any persistent psychological difficulty resulting from operational duties performed while serving in the Canadian Armed Forces or as a member of the Royal Canadian Mounted Police.” It is used to describe a broad range of problems which include diagnosed psychiatric conditions, like post-traumatic stress disorder but also other conditions.

Operational stress injuries are associated with substantial morbidity, mortality, health care utilization, and financial cost to our society. They not only affect the member but also the member's family, and it's important that we address these issues carefully.

Here I'd like to underscore that most people exposed to traumatic events are actually resilient. Almost all of us have struggled with trauma and have faced traumatic events, but the vast majority of people do recover. Post-traumatic stress is the signature condition, but other difficulties like anxiety, depression, alcohol problems, and physical health conditions can also result from traumatic events.

It is also important to note that there is a dose-response relationship between the number and severity of traumatic events, for example, seeing dead bodies and being physically assaulted. If there's an increased number of events at work there is a dose-response relationship with mental health difficulties. However, it is really important to understand that mental health problems are a combination of biological risk and protective factors, psychological risk and protective factors, and socio-cultural factors.

Biological factors that are known to increase the risk of operational stress injuries include being female, having a family history of mental health problems, which increases the genetic risk, as well as physical health problems, very commonly, traumatic brain injury.

Psychological factors that are known to be associated with mental health difficulties include an impulsive, aggressive personality style and a highly perfectionist and self-critical cognitive style.

Socio-cultural factors are also very important, including the experience of adverse childhood events, poor social supports, family violence, racism, and poverty and financial stress.

From the international literature, there are six main approaches that are important in the prevention and treatment of work-related mental health problems and post-traumatic stress.

First, prevention strategies include selecting people who are resilient and have little history of severe mental health difficulties.

Second, workplaces that provide systematic training, an organized work environment, and supportive colleagues and managers reduce the risk of mental health difficulties.

Third, the military has developed resilience training programs for personnel and families to help them learn skills in managing stress before they're deployed as well as after they're deployed. At this time we're not aware of evidence-based national resilience training programs that are being implemented among public safety personnel. We're working on developing a mindfulness-based cognitive behaviour therapy course to help people learn coping skills when they enter a stressful job.

Fourth, there is strong evidence that cognitive behaviour therapy and prolonged exposure therapy—another psychological treatment—are useful in treating people who have acute stress disorder and post-traumatic stress disorder. These treatments are delivered by trained mental health providers. Due to the limited number of providers and large number of people who could benefit from this type of intervention, the latest research is testing innovative strategies for providing cognitive behaviour therapy through Internet-based platforms, telephone-based strategies, as well as large classroom platforms.

It is also important to note that medications are important in treating people who are suffering with post-traumatic stress and other mental health conditions. Antidepressants, like paroxetine and sertraline, have been approved for the treatment of anxiety and depression.

Medications that specifically target insomnia, which is often a major concern of people who come to us for care, are very important. Prazosin is a high blood pressure medication that has been shown to be quite effective in helping people with nightmares, sleep difficulties, and PTSD symptoms. Trazodone, another antidepressant, and zopiclone, which is a hypnotic, can also be used.

Benzodiazepines are generally not recommended for post-traumatic stress disorder. However, they can be used carefully among people with severe anxiety. Atypical antipsychotics have also been shown to be effective in people with severe anxiety and depression.

Here it is important for me to clarify that none of the practice guidelines support the use of medical marijuana for PTSD. Although this is a common question from clients, the evidence weighs in the favour that marijuana use can actually worsen PTSD symptoms. I think it is important for us to carefully study the impact of marijuana and medical marijuana in PTSD, not just in short-term outcomes but long-term outcomes, especially around functioning.

Here are some specific recommendations for policy.

Although there is increased awareness of operational stress injuries in public safety officers, we do not have good Canadian information on the prevalence, prevention, and treatment of these conditions in our unique Canadian environment. Much of what we know comes from the U.S. and other countries.

However, we can learn from our Canadian military and veteran partners that have systematically addressed mental health problems and suicide over the last 15 years. Although a lot of work can be done in this area, the military has placed significant strategic initiatives that have been very successful in improving the lives of military and veterans.

The military has invested in getting accurate estimates of mental health problems among their populations by conducting state-of-the-art epidemiologic surveys that are nationally representative. They have also implemented post-deployment screening tools to identify and treat people quickly.

Veteran Affairs Canada has funded a national network of operational stress injury clinics that include interdisciplinary teams to help people recover from operational stress injuries. They've also worked with Queen's University to develop the Canadian Institute for Military and Veteran Health Research, which encourages unbiased, arm's-length research with university partners. Over 35 institutes across Canada are involved with this Canadian institute.

Similar to the approach taken by the military, I suggest that we need to do three things. First, we need to invest in a national mental health survey of public safety personnel. Second, we need to create an arm's-length institute that engages academics, policy-makers, and key stakeholders to advance the knowledge in this area. Third, we need to develop clinics that are funded in partnership with federal, provincial, and workers' compensation boards to help people have quick access to appropriate treatments.

To give a bit more detail around this, there is a need for a national mental health survey, because the rates of mental health problems in this group range from between 10% to 40%. Some argue that because of the selection, people who are public safety officers might have lower rates of mental health difficulties, where others argue that because of the high-stress environment, there are actually higher rates than in the general population. We actually don't know.

A national institute—

[The Chair, Liberal, Rob Oliphant]

I'm just going to ask you to wind up a little bit if you can.

Thank you. I'll give you another minute or so.

[Dr. Jitender Sareen]

I have two last comments.

The national institute would guide a national action plan for research; create a national online resource for clients, families, and providers who have evidence-based information; and have standards of minimal intervention.

Thank you so much for the attention. I look forward to your questions.

[The Chair, Liberal, Rob Oliphant]

Thank you very much.

Mr. Shlik.

[Dr. Jakov Shlik, Clinical Director, Operational Stress Injury Clinic, Royal Ottawa Health Care Group]

Mr. Chair, esteemed members of the committee, Professor Sareen, I'm speaking to you from the Royal and just using the opportunity to acknowledge that we are very privileged to contribute to work on this important topic here at the Royal. The Royal, as you may know, is an academic health science centre and it has been contributing to the leading edge of research on a variety of topics, amongst them depression and suicide.

The Royal has some experience in work with first responder services. For example, we have provided extensive mental health training to nurses within the correctional services. I work at the operational stress injury clinic here at the Royal, and at some other clinical programs at the Royal. I am a psychiatrist and clinical director of the OSI clinic. I have a few notes about the OSI clinics, which Professor Sareen also mentioned in his introduction, which, by the way, was an excellent overview.

The Royal has operated the OSI clinic since 2008, so this is part of the network funded by Veterans Affairs. We provide specialist care and support to the members, and mostly veterans, of the Canadian Armed Forces and also to the current and past members of the Royal Canadian Mounted Police who are experiencing mental health problems, as well as their respective families. I will speak to my experience as a clinician providing services to this particular population. To the issues of public safety officers and first responders we can easily apply some of our experience to that population as well, although, as it was mentioned before, particular aspects of their mental health issues, operational work stress problems, definitely need a further, more detailed survey and study.

We have some experience with paramedic services. Our department of psychiatry has been engaging in a round table around the issues that paramedic services, first responders, are struggling with, and they, in their grassroots-level initiative, have been collecting some data on the impact, on the consequences, on the services required, and this type of work needs to be done in a more coordinated and integrated way.

As was mentioned before, operational stress injuries in public safety officers and first responder types of workers, may be in some ways similar to those experienced by federal police and armed forces personnel and veterans, but there are certain specifics and certain cultures and subcultures that need specific attention. For example, the issues that corrections workers deal with in their day-to-day life and those of paramedics overlap somewhat, but also have many specific differences. This may lead to a certain fragmentation of the system of care and approach. We, on the site, have been witnessing certain developments that may lead to a variety of approaches, a lack of coordination, and the resources, as a result, are not used properly and not accessed in a way that leads to impact.

One obvious aspect, especially from our work with the federal police, which is really important to emphasize, is the importance of promoting a positive culture and perception around the work-related stress and operational stress injuries. To give some examples, Professor Sareen mentioned work done by the Department of National Defence. We found that for one of the programs, which is named road to mental readiness, R2MR, this approach has been adopted now as far as we know by the RCMP as well. The process of training and implementation has been done in various units and this program takes into account the continuum of mental health difficulties in operational work and also provides certain ways to access help and also how to help themselves.

This type of program may be easily adopted by the first responder services, and as was mentioned before, the models of care and expertise of the existing hubs of research and care should perhaps be taken into account, and correspondingly, a data-driven integrated strategy would be very helpful to have with all the input of stakeholders on national and provincial levels.

Perhaps I will stop now.

I will be happy to answer any questions and comments. Thank you very much for your attention. It's definitely a privilege to contribute to this important work.

[The Chair, Liberal, Rob Oliphant]

Thank you very much, Dr. Shlik.

We turn to the questions, and we have seven-minute rounds with four questioners.

Ms. Damoff, you'll begin, please; thank you.

[Pam Damoff, Liberal, Oakville North—Burlington, ON]

Thank you very much and since I am the first one to ask questions, I would like to comment on the fact that a parliamentary committee is studying this issue. I think it's a huge step forward and I can't say how thrilled I am that we're doing this and we're going to get it out there.

One of the things that you mentioned, Dr. Sareen, was the definition of operational stress injuries. You mentioned it was defined by Veterans Affairs Canada. I know from reading some information it's not recognized by the American Psychiatric Association. Is it recognized in Canada?

Before you answer that, one of the issues I've come across is different terminology. There are operational stress injuries, there's operational—my mind's gone blank—occupational.... What is the difference and what is the recognized terminology within your organization?

[Dr. Jitender Sareen]

That's an excellent question.

Operational stress injuries is the term that has been defined by the Canadian Forces and Veterans Affairs. I think the important piece is that it shows that post-traumatic stress is not the only disorder that can happen related to combat stress or trauma. It is a signature condition but generalized anxiety disorder, panic disorder, and other conditions can also be linked.

The other thing that's important for you to know is that there's a move in psychiatry away from dichotomous “does the person meet the full criteria for a condition or not?” Lots of people who come with some threshold PTSD symptoms are resilient. They have lots of supports but they're struggling with nightmares or having difficulty with irritability, and it's linked to their service. The Canadian Psychiatric Association agrees with this terminology.

The other question is occupational stress versus operational stress, I think that is a bit of semantics because there's a whole literature on occupational health, and I think the aim is to try to link the mental health difficulties to the occupation. I'll try to make some comments around this at another opportunity. The most emotional difficulties are an interplay between the stressor and pre- and post-vulnerability. When I'm sitting with a person it's hard to try to figure out if it's exactly related to their work or not, and we've done work showing that it's a combination. Adverse health experiences—family stress, financial stress—impact on and worsen symptoms as well as a person's recovery.

[Pam Damoff, Liberal, Oakville North—Burlington, ON]

One of the other things you talked about were clinics where partnerships between federal, provincial, and the WSIB, for example, provide quick access. There's a stigma attached to this. Even providing the quick access, people may not want to go to it because they're afraid other people they work with in corrections or in policing or firefighting will look at them differently. How can we go about removing the stigma? I like what you were saying about not putting terminology on it, but do you have any comments on that?

[Dr. Jitender Sareen]

That's an excellent question.

What we're trying to move toward is giving people lots of different options as far as care is concerned. There's a lot of work now being done on Internet-based cognitive behavioural therapy, so people can have access to evidence-based psychological treatment on their own. That might help people with mild to moderate conditions.

There's some very nice literature showing that Internet-based CBT actually has similar effectiveness to face to face. That's one piece. We need to think about a range of different options.

Yes, there is stigma in the clinics. You could argue that people who develop cancer, and are going to the cancer care building, are going to have to deal with some of that stigma. What we find is that people often suffer alone and feel they are the only ones dealing with this. As you know, suicide is an outcome of people feeling alone and not feeling there's anybody there for them. We have used a lot of classroom and group-based work. People learn from each other and often recover faster because they challenge some of those concerns.

I think this is where there has to be some support within the leadership for destigmatizing mental health issues. You can get burned and have a physical injury that everyone can see. PTSD is a silent injury, but it's probably just as severe.

[Pam Damoff, Liberal, Oakville North—Burlington, ON]

I only have a few seconds left. I've asked this of a few other people before.

Do you know of any research being done on the cost of these mental health issues, the cost to the RCMP or corrections? Do you know of any work that's been done on that?

[Dr. Jitender Sareen]

We don't have good estimates in Canada about the costs to the system, but what we know from other countries is that they cost the system a lot, huge amounts of disability payments.

If you look at disability claims, the most common reason for disability claims is depression. This is where the fractionation and the fragmentation of the system is. People often suffer, they are off on disability, they don't have timely access to psychological treatment and medical treatment, they fear going back to work because they might have difficulties performing, and then they are on disability and can't get back to work.

[The Chair, Liberal, Rob Oliphant]

Thank you, Dr. Sareen.

Go ahead, Mr. O'Toole.

[Erin O'Toole, Conservative, Durham, ON]

Thank you, Mr. Chair.

Thanks to both of you gentlemen. I found it very illuminating, dealing with some of the issues I've been working on as a passionate advocate before I became a parliamentarian. Your work is appreciated. I've also had the opportunity to go to the Royal on a few occasions, so thank you for your work.

I think most of my questions are going to be for Dr. Sareen, based on your testimony here today.

Your comments on medical marijuana struck me because, as you may know, I was veterans affairs minister, and I tried to have a clear discussion on the use of medical marijuana, which as you know, veterans affairs approves when prescribed by a physician.

There's a real divide between use for some symptom relief—which is known for chronic pain or a variety of other things—and some suggestion by advocates and some commercial companies that it is a cure or recognized treatment for PTSD.

That concerned me, so I went out clearly on that because people who are striving for assistance should not be preyed upon by the growing commercial practice. I still get notes from some of the online folks suggesting there's clinical support, and then I look at the article and it's not clinical support at all. Can you talk about that for a moment?

[Dr. Jitender Sareen]

Absolutely. There was a systematic review done last year on the use of medical marijuana in medical conditions in The Journal of the American Medical Association. What it showed was that in certain non-psychiatric conditions there might be some benefit, but in psychiatric conditions the data is not strong enough to say that medical marijuana is a long-term useful treatment.

I think that, as you were saying, there is a divide between what the public perception is and industry. I made that comment specifically because I think it is important for this committee to appreciate that there is a lot of wish.... Every single week I get questions about prescribing medical marijuana. I don't do it. The reason is that we know and have known for a number of years that marijuana use is associated with worse outcomes in PTSD. Especially in young adults, in whom there's a developing brain, there is a risk of psychosis that has been shown repeatedly.

I think there is a major divide between the medical knowledge...and I think it calls for important research that is unbiased and that looks not only at short-term but also at long-term outcomes. If you think about alcohol, it helps with anxiety, but we also know that alcohol problems can happen, long term. I don't disagree that it may have short-term benefit, but we're trying to help people, long term, return to their best level of functioning and get back to helping their family.

[Erin O'Toole, Conservative, Durham, ON]

Thank you.

I appreciate your raising it, because I think it's important, particularly for the cohort you talk about, the young person who is trying to transition to a new career and who is looking for symptom relief, that we not hold this out as some solution when it can be more a detriment. I appreciate that.

I also appreciate, because we are starting to look at this, and my colleague Todd Doherty is here, who has been long advocating for a national strategy on operational stress.... Your three recommendations were very helpful. I'm going to explore number two for a moment, on the national institute.

In many ways, the previous government, working with universities, Veterans Affairs, DND, CIMHVR, and Dr. Aiken at Queen's, and their network of I think as many as 25 or 26 universities now.... Is that institute, in some ways, or do you think it could be....? Does it need a broader mandate? Can it be that national institute you're talking about?

[Dr. Jitender Sareen]

I think it probably requires a separate institute or a partnership.

I want to highlight the importance of the institute. First, everybody has a bias, including me, drug companies, and police. One piece is to try to bring people together to really look at the science and try to understand the truth—does this work or does it not?

The other important reason there's a need for an institute is that we know from research that usually a research discovery sits on a bookshelf for 30 years before it comes into clinical practice. These kinds of institutes really drive the relationship among policy-makers, stakeholders, and academics. We academics like to sit in an office and write papers. This gets us out to understand what the questions are: what are the firefighters and the national firefighters association dealing with at this time, and can we work together on addressing these questions in a timely manner?

[Erin O'Toole, Conservative, Durham, ON]

Can I jump in? I want to get one more question in, and I'm conscious of my time.

You talked a little bit, under the national institute section of your recommendation, about the online resources. One thing we developed while I was minister—and I was very happy to see the new minister roll it out—was online tools for caregivers particularly, or for people working with somebody struggling with OSIs in the home. Have you had the chance to look at or contribute to what Veterans Affairs produced, and what are your thoughts on these tools going forward?

[The Chair, Liberal, Rob Oliphant]

Be very quick, please.

[Dr. Jitender Sareen]

I think it's the future. I think that trying to get people to have access—and we use large classrooms where we give people self-help tools they can utilize at home—is the future of care.

[Erin O'Toole, Conservative, Durham, ON]

Thank you.

[The Chair, Liberal, Rob Oliphant]

Monsieur Dubé.

[Matthew Dubé, NDP, Beloeil—Chambly, QC]

Thank you, Mr. Chair.

Thank you, gentlemen, for being here today.

In the context of this study and related issues, the situation facing corrections officers is being somewhat overlooked. An officer once told me that the people who perform those duties sometimes feel like forgotten police officers, in the sense that most people have no idea that officers on the front lines have to deal with extremely difficult situations.

We have learned that, in recent years, the number of accidents in that work environment has been on the rise, especially in 2014. These are often called accidents, as though these incidents were happening in a factory, but in fact, these accidents are often associated with violence and very troubling situations.

I would like you to comment on the resources that may or may not be available. I actually think this is a major problem. Of course, I mean no disrespect to the RCMP, the Canadian Forces, police forces, and firefighters, but I note that we are talking about them a lot, even though there is often a tendency to forget these officers.

Based on your expertise, can you tell us how it might be possible to learn more about the problems these people face, and therefore provide them with the resources they need?

[Dr. Jitender Sareen]

I'll give the opportunity to respond first to Dr. Shlik.