Veterans Affairs Committee on Nov. 18th, 2010

[The Chair, Conservative, Gary Schellenberger]

Thank you for that.

We have to move on. Perhaps we can keep our question and answer fairly quick.

Mr. Carrier, please.

[Robert Carrier, Bloc, Alfred-Pellan, QC]

Thank you, Mr. Chairman.

Good afternoon Mr. Dallaire.

I had the opportunity of going to Rwanda two years ago, and there I saw bodies lying about, that had been covered in lime to preserve them. I got a glimpse of what you went through in that country.

I rarely have the opportunity of sitting on the House of Commons Standing Committee on Veterans Affairs, but whenever I do I find the discussions very moving. It helps us to better understand the consequences of war. Very often, the Parliament discusses whether or not we should be at war, but here we talk about all of the consequences.

You mentioned that we have data on deaths that occur in combat, but we forget about all of the consequences that follow this combat, such as suicide or mental illness. To my knowledge, that information is not disclosed.

In your opinion, should this be catalogued better with a view to transparency and governmental responsibility, so that we at least have some idea of what happens when one goes to war and comes back from it?

[Senator Roméo Dallaire]

The same debate takes place in the civilian world: people don't want to talk about suicide because they are afraid that this will generate more suicides. So the reporting of suicides is censored.

Within the armed forces, for several years there was a terrible stigma attached to the individuals from a regiment who had committed suicide. Afterwards a lot of people said that the individual concerned was incapable, that he lacked courage and loyalty, that if he had killed himself, too bad for him, and that his name would not be put on the regiment's monument. For a period of time it was practically said that these people were not really injured and that they had not really died in combat.

This has changed. It is still that way in some places but generally people recognize that those who have committed suicide are still a part of the regiment. Certain regiments put the names of these people on the list and mention that they committed suicide. It is said that they served and that they died from their injuries. They do write that the person "died of his injuries". However, this philosophy is still not the prevailing one.

However, to the population in general, suicides are not recognized as the result of operations. As I said in the beginning, we may have lost 170 or 180 soldiers in this operation. However, that is not new. Neither Canada nor any other country seems to want to include these deaths among those that occurred in the theatre of operations.

Finally, I would like to say that the Department of Veterans Affairs does not really follow the issue of suicides. It does not follow the person's history, it does not try to see whether he received care or not. It does not keep statistics. The department does not seem to want to keep these statistics. I can understand that in the case of older veterans, but for new veterans, I think that this tool has to be promoted in order to allow the department to follow this matter.

[The Chair, Conservative, Gary Schellenberger]

I'm sorry, that's it.

We could be here all afternoon. I have really enjoyed your answers, sir, to our questions.

If we feel, going forward, that we would like to invite you back for some clarification, I would truly enjoy it.

[Senator Roméo Dallaire]

I have a final statement, sir.

I don't think there's a more magnificent time to serve than now, because the missions are just. But those in uniform who I've spoken to across the country ask two things of their leaders.

One, when you commit them to a mission, then you give them the tools to win. You leave when you've won or you've handed over or you simply cannot, and then it's recognized as a failure.

But, two, when they come back in body bags or injured, then you treat them and their families with respect and dignity so that they don't have to fight again to live decently as veterans in this country.

Thank you very much.

[Voices]

Hear, hear!

[The Chair, Conservative, Gary Schellenberger]

Thank you.

We'll have a short recess before we go to our video conference.

[The Chair, Conservative, Gary Schellenberger]

I hate to shut off any little side chats, but we have a couple of witnesses waiting for us in Winnipeg.

I would like to welcome our guests. Jitender Sareen is a professor in the departments of psychiatry, community health sciences, and psychology. Shay-Lee Belik is a research assistant in the mood and anxiety disorders research group, department of psychiatry.

Welcome.

Do you folks have a presentation to make first?

[Shay-Lee Belik, Research Assistant, Mood and Anxiety Disorders Research Group, Department of Psychiatry, University of Manitoba]

Yes.

[The Chair, Conservative, Gary Schellenberger]

Okay. Go ahead with it, please.

[Shay-Lee Belik]

Thank you.

I'd like to take this opportunity to first thank the committee for inviting us to speak here today. My name, as you've mentioned, is Shay-Lee Belik, and I'm a Ph.D. student in the department of community health sciences and a research associate in the department of psychiatry at the University of Manitoba.

I'm here today with Dr. Jitender Sareen, who's a professor of psychiatry at the University of Manitoba and also a consulting psychiatrist at the Operational Stress Injury Clinic in Winnipeg. I'd also like to acknowledge Dr. Gordon Asmundson at the University of Regina and Dr. Murray Stein at the University of California San Diego, who have closely collaborated with us on this work.

I'd like to thank the Canadian Institutes of Health Research for their funding support for our research. I just wanted to note to your group that we've been conducting research in this area of military mental health since 2004 and have been working on suicide prevention strategies in Manitoba first nations communities since 2005.

My understanding is that I have been invited here today to discuss my knowledge and work in the area of suicide among Canadian soldiers. My initial remarks today are going to be focusing on what we know about suicide in military populations and more specifically in the Canadian Forces. It has been well established that of course suicide is a major public health concern worldwide, and most recently, suicide has also been noted as one of the most common causes of death in military personnel.

Recent U.S. news media have emphasized the toll of military suicides, sometimes referring to what they call a suicide “epidemic”, estimating that suicide accounted for more military deaths than the war in Afghanistan. Although the media reports focus on the high number of suicides, there is much controversy in the research literature as to whether the rates in military populations are in fact higher than rates in the general population. Some studies suggest a lower rate among military personnel, likely due to what has been termed the “healthy soldier effect”, which describes the fact that military personnel generally have better physical and mental health compared to the general population as a natural consequence of the selection procedures for military service.

Other studies have shown opposite findings, demonstrating higher rates of suicide among soldiers than the general population, and some studies have demonstrated no difference in rates. Yet again, if we take into account the healthy soldier effect and the fact that the overall mortality risk is generally lower for military personnel than civilians, findings of no difference in rates between military and non-military samples may actually be taken to represent greater risk for suicide among soldiers. This conclusion would indicate that aspects of the military or post-military experience may be a potent risk factor for death by suicide.

Debate exists in the research literature as to whether or not combat exposure, peacekeeping experiences, and deployment play a role in risk for suicide. Still, the Institute of Medicine has recently concluded, based on data from Vietnam veterans and veterans with war-related traumas, that there is sufficient evidence to support an association between deployment to a war zone and suicide in the early years after deployment. However, suicide risk does not appear to be shared equally among all soldiers. Two studies from the U.K. indicated that the overall rate of suicide in veterans was not greater than that in the general population. However, young males, particularly those under age 24, did appear at increased risk when compared with civilian males of the same age. Younger age has been noted as a common risk factor for suicide across both military and non-military populations. Additional risk factors that are common to both populations include being unmarried, low social support, the diagnosis of a mental disorder including PTSD, a prior suicide attempt, impulsivity, and access to lethal means, especially firearms.

When we think about these common risk factors, it becomes apparent that although the risk is similar, oftentimes these factors are more prevalent among military personnel specifically. For instance, previous work in a Norwegian veterans sample illustrated a preference for veterans to choose firearms and other more lethal suicide methods, and that these methods accounted entirely for the increased rate of suicide noted in this cohort over the general Norwegian population. This preference may stem from soldiers' increased experience with weapons and a possible easier access to such methods compared with the general population. And these differences in the prevalence of risk factors may account for some of the differences noted in rates of suicide, and little work has accounted for this disparity.

Other risk factors that have been noted are specific to military populations, including being an active-duty regular force member rather than a reservist; being hospitalized for a combat wound, or experiencing two or more wounds; short length of service and premature repatriation; lower rank; feelings of shame and guilt related to service; and more recent evidence has suggested an increased risk among soldiers with traumatic brain injury.

Protective factors that have been noted include discussions around military exposures, unit cohesion, comradeship, and military leadership.

It is important to note that the majority of the research to date has focused on U.S. military personnel. One must keep in mind that the U.S. military experience is quite different from military experience in other countries, including Canada. The tempo of deployment, the maximum deployment length and, most importantly, the role of the military and its mission are just some of the ways the U.S. military differs from the role of the Canadian Forces.

Turning now to Canada, media reports have also created alarm with headlines about dramatic increases in suicide rates in the Canadian Forces in the past few years. Recent figures from the Report of the Canadian Forces Expert Panel on Suicide Prevention suggest that the suicide rate among active-duty regular force Canadian Forces personnel is quite similar to rates in the Canadian general population. The average rate of suicide between 2002 and 2006 in the Canadian general population of males of all ages was 17.8 per 100,000 population, whereas the average suicide rate for male regular force members during the same time period was 16.9 per 100,000. As well, it appears that Canadian Forces suicide rates have been decreasing as measured in five-year increments since 1995. To date, the suicide rate among Canadian veterans has not been reported.

There have only been four studies that have directly examined suicide in the Canadian Forces. Tien and colleagues recently published a study on the leading causes of death among Canadian Forces members. From 1983 to 2007, 1,889 active-duty Canadian Forces members died, 17% of whose deaths were attributable to suicide. In contrast, combat-related deaths accounted for less than 5% of all deaths. Suicide was noted as the third leading cause of death among Canadian Forces personnel, with motor vehicle crash-related deaths being first on the list.

Interestingly, alcohol-related fatal accidents among military personnel have been found to share many common features with suicide deaths in terms of risk factors, suggesting an overarching self-destructive tendency among a subgroup of military members, whether the result is suicide or a fatal accident, which highlights the risk of death associated with impulsive behaviour.

The second study, by Wong and colleagues, investigated peacekeeping as a risk factor for suicide among veteran Canadian Forces members. In a case-control design, they retrospectively compared 66 military suicides with matched military controls. The results illustrated a greater risk of suicide among soldiers who were unmarried, childless, of lower rank, who had not completed high school, and had French as their first language. They found no increased risk of suicide in peacekeepers and, in fact, the rate among them was half that of the comparable civilian population. However, those in the military who had committed suicide had experienced more psychiatric illness and psychosocial stresses than matched controls had. Psychosocial stressors included relationship problems, pending military release, and conflict over their military job. Importantly, a prior suicide attempt was one of the strongest predictors of suicide completion.

Two other studies were undertaken by our research group and examined suicidal ideation and suicide attempts among active-duty Canadian soldiers. One study focused on the relationship between exposure to traumatic events and suicide attempts, noting that exposure to sexual and other interpersonal traumas, including rape, sexual assault, spousal abuse, and childhood abuse, was associated with an increased likelihood of suicide attempts—yet exposure to combat and peacekeeping did not increase the risk.

Our most recent study compared rates of suicidal ideation and suicide attempts in Canadian Forces members with the Canadian civilian population. The study demonstrated no difference in the rate of suicidal thoughts when the two populations were compared, yet Canadian Forces members were less likely than civilians to have reported a suicide attempt in the past year. Few differences were noted among risk factors for suicidal behaviour between active-duty soldiers and the general population providing evidence of common pathways to suicide.

Recent findings from U.S., Canadian, and U.K. military surveys show that most service personnel do not receive mental health treatment, highlighting the need for outreach. Gatekeeper training is one example of an outreach program, which has been noted as one of the most promising suicide intervention strategies to date. Gatekeeper training, as part of a broad suicide prevention strategy, was shown to reduce suicide rates by 33% in a sample of over 5 million U.S. Air Force personnel.

A recent review of suicide prevention programs for active military and veterans indicated that multi-faceted interventions for active duty military personnel were well supported by consistent evidence. However, there was insufficient evidence of programs in veteran populations.

In line with the air force suicide prevention program, the Canadian Forces has implemented an extensive suicide prevention program around the theme of “Be the Difference”. Part of this training program includes gatekeeper suicide training for all personnel, based on a well-known gatekeeper training program called ASIST, or applied suicide intervention skills training. Evaluations of ASIST have demonstrated the effectiveness of the training to increase knowledge and skills in dealing with suicidal individuals. However, its impact on suicide rates has not been determined.

In the U.S., Veterans Affairs has similarly initiated a comprehensive suicide prevention strategy, which is designed to span the Institute of Medicine's suicide prevention recommended categories: universal interventions, selective interventions, and indicated interventions.

As such, we would recommend that a similar comprehensive suicide prevention strategy be initiated for Canadian veterans. A recent Canadian study, based on a systematic audit of 102 suicides in New Brunswick, indicated a need for better coordination of addiction services with mental health specialists; public awareness to encourage individuals to seek treatment; and training for primary care to better detect mental illness, substance-related problems, and suicidal behaviours.

Along these lines our recommendations would include, first of all, better aftercare for veterans who have attempted suicide, since previous attempts are known to be one of the strongest predictors of suicide death. Second, education and training for the veterans and their service providers in mental health literacy and suicide intervention skills could lead to better recognition of those at risk. Third, greater coordination between and across health services is required to comprehensively address the needs of returning soldiers. Finally, we would recommend increased screening for suicidality and mental disorders among veterans in care settings. One example of a screening program that exists in both Denmark and Norway features questionnaires that are sent to all soldiers six months after being discharged to civilian life in an effort to detect mental disorder development and suicidal risk.

Whether or not the risk of suicide among Canadian Forces veterans is higher than civilians, there is little doubt that suicide prevention programs should be developed with hopes of reducing suicide rates, since any suicide is an unnecessary tragedy. Moreover, suicide may lead to serious trauma and stress for bereaved family, friends, and co-workers, and it may actually induce suicidal thoughts and behaviour in others.

It is essential for steps to be taken to address this important public health concern.

I thank you today for your attention.

[The Chair, Conservative, Gary Schellenberger]

Great. Thank you very much.

First question, Ms. Zarac.

[Lise Zarac, Liberal, LaSalle—Émard, QC]

Thank you.

Thank you for your recommendations. In the first recommendation you say we should have “better aftercare for veterans who have attempted suicides, since previous attempts are known to be one of the strongest predictors”.

Would that also include prevention care for the family? Would there be assistance to the family to be able to help?

[Shay-Lee Belik]

Yes, I think it's really important to include the families in talking about suicide aftercare, absolutely.

[Lise Zarac, Liberal, LaSalle—Émard, QC]

I don't see it in the recommendation, but do I read that the aftercare would include families?

[Shay-Lee Belik]

It would, yes.

[Dr. Jitender Sareen, Professor, Departments of Psychiatry, Psychology and Community Health Sciences, University of Manitoba]

The idea would be that among the risk factors--there are a range of them--with suicide attempts, once somebody has either made an overdose or a gesture, a suicide attempt, and landed in emergency, the challenge often is that the risk period right after is quite high. We totally agree that family and outreach in trying to support the person is very, very important. That's the highest risk period.

[Lise Zarac, Liberal, LaSalle—Émard, QC]

Would you say there's more suicide when a soldier has been physically injured? Do you have any studies demonstrating this? Has it been followed?

[Dr. Jitender Sareen]

The short answer is no, there has been no study to look at that. The long answer is that with post-traumatic stress disorder and depression and alcohol problems, soldiers who are physically injured are more likely to develop post-traumatic stress and depression. Post-traumatic stress and depression are linked with suicide. The soldier often has the reminders of the trauma--they have physical pain and physical injury--which often then leads them to have depression. They might not be able to go back to work with the way they feel.

So we think that likely is an issue, but there is no specific evidence around it that I'm aware of. We can look at it.

[Shay-Lee Belik]

There's only evidence that injury may be a risk factor, but not that it's specific to....

[Dr. Jitender Sareen]

Suicide.

[Shay-Lee Belik]

Yes.

[Lise Zarac, Liberal, LaSalle—Émard, QC]

Thank you.

You mentioned also that some studies suggest a lower rate among military personnel is likely due to what has been termed the “healthy soldier effect”. I just recently viewed a case in Quebec in which that was the issue. The soldier was healthy--he had a good body--but he ended up losing a leg, and that's the reason he killed himself.

Is this something that you see often? Because you seem to say the opposite in your briefing here.

[Shay-Lee Belik]

The only studies that I looked at actually talked about the healthy soldier effect and this way of thinking that it should be a protective role. But I think what you're talking about is the huge impact it has on the person who does feel that they are healthy and fit, and in fact healthier than the general population. The way their life has been up until the point of injury can really have a severe impact. The injury can have a bigger impact on someone like that.

So I guess in that case, in the example you're giving, the healthy soldier effect may not be protective.

[Lise Zarac, Liberal, LaSalle—Émard, QC]

Okay.