Veterans Affairs Committee on Nov. 23rd, 2010

[Ben Lobb, Conservative, Huron—Bruce, ON]

Is there any place that you're aware of where certification is required to treat this disorder?

[William Maguire]

That's a million-dollar question.

[Ben Lobb, Conservative, Huron—Bruce, ON]

I mean, you go to all the courses and conventions, and—

[Dr. John Whelan]

I am receiving an answer of “no”, which I trust. So the answer is, no, there isn't.

It really comes back to vetting, really scrutinizing who the system takes on as providers for the care of veterans.

[The Chair, Conservative, Gary Schellenberger]

The final question goes to Monsieur Vincent.

[Robert Vincent, Bloc, Shefford, QC]

Thank you, Mr. Chair.

Mr. Whelan, Mr. Cann, are you able to diagnose PTSD? As psychologists, are you able to diagnose PTSD when you see a person, a client or someone who was referred to you by the Canadian Forces? Do you make the diagnosis? Or have the people already been diagnosed and then come to you for care?

[Dr. John Whelan]

In terms of referral, if people are referred, and they've already been diagnosed by a physician or another psychologist or psychiatrist, they can already have the pre-existing diagnosis of PTSD. As psychologists, we will also assess and we can diagnose them as PTSDs or some other related disorder.

There is a very structured interview, testing, all those sorts of things, that ask pertinent questions to come up with either a diagnosis of PTSD or other things. There are other things that happen under an OSI that is not only PTSD. It could be major depression. It could be panic disorder. It could be other issues as well. So yes, we can diagnose those.

[Robert Vincent, Bloc, Shefford, QC]

From the people who were diagnosed with PTSD and were referred by the Canadian Forces, and from other veterans who took the phone book and decided to go see a psychologist, how many had National Defence reject their PTSD diagnosis? How many of them had to fight for years to have their diagnosis recognized? You made the diagnosis, you are treating those people. You said earlier that you are case managers because people don't know where to go anymore, since their diagnosis has been challenged.

In your opinion, how many of your clients had their diagnosis challenged by the Department of National Defence or by the Department of Veterans Affairs?

[Steven Cann]

We can't give you an exact number. We didn't know you were going to ask that question.

[Robert Vincent, Bloc, Shefford, QC]

Do you have a percentage?

[Dr. John Whelan]

It would be that they were not identified--not so much that they were refused but that they were not identified. The system was not in place.

Back in 2005, we were still being referred people who had left the military and were just not identified. But for them to come forward and say, “I have a problem”, and for the military to say, “No you don't”? I would say it would be none of those cases; it would be more the member not wanting to be treated or seen on a military base because they--

[Robert Vincent, Bloc, Shefford, QC]

I don't think you understood my question. I will try to make it clearer. If someone comes to you with PTSD, you treat them for PTSD. But their status has not yet been recognized by the Department of National Defence or by the Department of Veterans Affairs. The diagnosis was established and the person wants to have it approved for compensation. Is it disputed for a number of those people? Are they told that they have to provide concrete evidence, although you yourself diagnosed them and established there was a cause and effect relationship? How many cases are disputed?

[Dr. John Whelan]

It's a low number, 10% to 15%. All the information is there, the assessment is there, and they're struggling to have it accepted.

[William Maguire]

I would go higher. I would say it's 20%.

As well, we have one case in Stadacona where the man has PTSD and is being refused help by DND. I'm not sure how it goes. I haven't got to the full extent of it yet. But I've been told so far that the man has been warned that if he goes for medical help, he'll be in caca. So that's a threat.

[The Chair, Conservative, Gary Schellenberger]

I apologize, but I have to bring it to a close.

Mr. Vincent used up your minute, Peter.

We'll recess for a short time to get ready for our next witnesses.

[The Chair, Conservative, Gary Schellenberger]

We're back.

Everyone will have slide sheets in front of them. They are bilingual.

The visual on the wall is only in English.

Is that acceptable, sir?

Okay. Thank you.

I welcome for our next hour, or 55 minutes—time flies when there are short sessions like this—Lieutenant-Colonel Stéphane Grenier and Lieutenant-Colonel Rakesh Jetly.

Welcome, gentlemen. Please make your presentation.

[LCol Rakesh Jetly, Advisor to Surgeon General, Psychiatry and Mental Health, Department of National Defence]

Thanks very much, sir.

Basically, we have chosen to leave as much time as possible for questions, so we won't make opening remarks.

Steph and I started this journey about ten years ago as majors. I'm the clinical lead and he's been on the non-clinical side for all the changes that have occurred in DND.

My understanding was that this committee was particularly interested in suicide and suicide prevention, so what I'll try to do--cut me off whenever I've run out of time--is give you a brief overview of the Canadian Forces suicide prevention, including the expert panel we had last year, just in terms of the broad interdisciplinary approach we have within our own organization.

Veterans Affairs colleagues were at this meeting, and they have modified...and they have their own program as well, which is somewhat different. It will become evident, as I speak, that it's very difficult to compare both organizations. We're a large organization; we have 6,000 people in the Canadian Forces health services; we run large clinics; Stadacona has 50 mental health professionals working in this very model. It's a very different thing to try to compare.

The first slide looks at our suicide rates, which are male suicides that are tracked. Contrary to what the media says, we have been tracking very carefully since 1996. I'll speak at the end about how we're tracking them even more closely. We haven't had an increase of serving members since the Afghan conflict began. Nobody can predict the future, but those are the stats we have for now.

In September 2009, the Surgeon General convened, asked us to put together, an expert panel on suicide prevention. The goals were to review what the CF is doing now, evaluate our approach against the scientific literature and the practice of our allies, and recommend opportunities to strengthen the program.

The reason for this was not that we are having the crisis that the U.S. is experiencing with a very high rate, but that suicide and suicide prevention is a major public health issue in this country. It behooves us, as the CF, to have the best practices in place that we can. We're not “happy” that our rate is below civilian society--the loss of every soldier is a loss to us--and if we can do anything to reduce that number, to prevent it, that's our goal.

Very briefly, I'll give you the range of people. We have our CF folks. With our team we have deployment health and epidemiology folks. We have psychiatrists represented, and social workers, primary care physicians, mental health nurses, as well as some of our educators.

We have external consultants. We have our colleagues Dr. Thompson and Dr. Ross from Veterans Affairs. Professor Links is a very important person. He's probably the most renowned suicide expert in Canada, as the chair in suicide studies at St. Michael's Hospital in Toronto. Colonel Ritchie is the advisor to the Surgeon General, so a big player in the U.S.; Lieutenant Colonel Bell, likewise. Andrew Cohn travelled all the way from Australia. Australia does some very interesting things--similar force, similar history, and they don't have all the big hospitals that the U.S. has. It's the same idea of where do we put our high-risk patients; the Australians have a similar thing. We have colleagues from the U.K., Neil Greenberg and Nicola Fear.

The name of a Dutch colleague is not appearing on the slide. I apologize for that....

Oh, there she is: Lieutenant-Colonel Horstman.

[A voice]

We can't forget the Dutch.

[LCol Rakesh Jetly]

Yes, we can't forget the Dutch.

The key message from the panel, as I mentioned, is that it's an important public health problem. In terms of the three cornerstones for our suicide prevention program, really what we could put, for an effective mental health program, is excellence in mental health care. When people come, we have to have evidence-based practice. We have to have team-based practice. We have the professionals there.

Within our clinics across the country, we have close to 400 mental health professionals. We're funded up to 440. We're watching the wait-list, we're watching the times, so that when people get ready, they're available, as well as the contract professionals out there.

My colleague here is instrumental in the second of the two, which is effective leadership. Leadership needs to set the tone. Leadership funds mental health care and keeps it as a priority even when we stop the conflict in Afghanistan.

A leader is a gatekeeper. A tough job for a leader is whether I pat a guy on the back, kick him in the butt, or tell him to get help. I think the point was very well taken that being a good leader means knowing your people and knowing when they change. Many, many of the programs, which you can specifically ask Lieutenant-Colonel Grenier about, are aimed at that.

The other part, again, is about aware and engaged members. Members have responsibility. We are educating members to understand mental illness, to understand they're not going crazy and they have something that would benefit from help. They can understand, when they're 40-something years old and dragging ass, that it might be a depression, not just getting old.

These are the three pillars. All three need to be up and standing in order to have effective suicide prevention or an effective mental health program.

JAMA, the Journal of the American Medical Association, published a very comprehensive suicide prevention campaign. Dr. Mann is actually leading the U.S. DOD. I think they are probably going to spend $150 million studying what we did with $50,000, in our Canadian way.

I'll go to the next slide and expand on some of these points. I'll show you how we have actually adopted it, from a suicide point of view.

Up to 90% of those committing suicide—depending on the study you read, it will be from 75% to 95%—have mental health problems, especially depression. Now, PTSD does elevate the risk, and of all the anxiety disorders, PTSD is the highest risk factor.

Then there's usually a stressful life event. Stressful life events can trigger suicidal thoughts. I think this is really important. Quite often we'll see both things happening. As an organization, as a society, it's looking after both sides that's important.

The illness in most cases, plus the stressful life event—which to the rest of us may not seem stressful, but if you're ill, the financial stressors or family stressors can be quite big—lead to suicidal thoughts, intents, plans, and actions. Your last witness talked about putting his hand up, asking who has thought about it, who has actually tried it. These are all lumped into that ideation.

These are really important factors that I've highlighted in the next box: impulsivity, hopelessness, pessimism, and emotional dysregulation. Emotional dysregulation is part of an illness.

Steph and I quite often talk about hope. We champion a few different kinds of things, that outside-of-the-box thinking within our organization about occupational transfer or keeping people within the organization--this kind of thing. A lot of it is that we don't have the science but we've argued we should give them some hope.

These are really important. When we hear people talking about hopelessness, that's when we worry, and that's when we tell our clinicians and our leaders to worry.

With respect to access to lethal means, again, it's what's out there: gun control, different kinds of devices, looking at how pharmacies are packaging drugs. These kinds of things become an issue. It's not always something we can control, but certainly within our organization we do what we can in order to not give people lethal amounts of medication, for example. How we manage our weapons is certainly an issue as well.

Imitation is very controversial, considering we had a really sad suicide in Ottawa lately. There is literature that says talking about suicide too much in the media can be a bad thing, a contagion. We all know about Kurt Cobain and things like that.

People like me don't say hush it, drive it into the ground and don't talk about it, but responsible media reporting presents it in a responsible way. It's dangerous to romanticize it, which Shakespeare did very well, or to rationalize the suicide. “Well, what could the guy have done? He killed himself.” If it's reported in a balanced way, it says this unfortunate thing occurred and there was help available if only the person had gotten help.

So with respect to imitation, some of the suicides I've specifically looked into, where a colleague has killed himself shortly before by the same means.... We worry about the clusters of suicides that occur in universities, for example, for that reason.

The Canadian Forces has limited control over a lot of the access to lethal means. We can't get Home Hardware to stop selling rope, for example. These kinds of things are impractical. The imitation is also difficult because they occur elsewhere. We can certainly look at clusters, if they occur within our own organization, and we can engage media at a certain level, if that is one of our next steps.

We go from where do we get a suicidal ideation, a thought, to the act. All of these factors mediate between them. Basically, then, all of these are potential targets for suicide prevention. So we can look in the box. There are education and awareness programs for primary care providers, members, gatekeepers. Gatekeepers are leaders. One thing we've done is we've gone away from having the mental health professional, the doc, always standing in front of people telling them what they should do. We have people who are peers, who have been trained, who also deliver the message, saying, “I went for help; it helped me too.” The credibility of people who have the experience, who have the time in, the operators, and engaging them in our education programs have been very effective.

There was a question about screening and assessment. We do screen. Like all of our allies, we screen three to six months after deployment. We're asking specific questions about PTSD, depression. On our periodic health exams and your annual medical exam, when you have it—I just had mine recently and looked at the latest questions—we're asking about drinking behaviours. We're asking about that. Unlike our allies, with our screening it's not just the pen and paper. We actually sit and have a professional talk with the person for about 40 minutes as well. So we're screening for PTSD, depression, physical health issues, drinking behaviours, and we've added MTBI since about late 2008, since hours of expert panel on MTBI. So we're doing it, and we know it doesn't end there. You're catching a lot of people there, but there will be people afterwards, so the ongoing initiatives are going on there.

We've split from the Mann model to really realize the advantage that the Canadian Forces has, which Ford doesn't have and Chrysler doesn't have. We have a lot of control over the environment of people. We are the Canadian Forces. People work for us. We provide their health care. We set the tone within the environment. We can decide to work people hard, to rotate people, to rest them. So we've split the work-related stressful life events and other stressful life events. We can't always control what happens at home, but we can certainly have influence over the kind of work environment that we create for our soldiers.

That whole group, which is sort of added onto Dr. Mann's model, is the leadership and organizational factors, in which we have the luxury of actually training our leaders, stepping out in front of them. General Dallaire is certainly an example, as is our Chief of the Defence Staff, standing up talking about the “Be the Difference” campaign, where mental health, the health of folks, is everybody's business. Maybe with mental illness the Surgeon General and his people can do their part, but when it comes to the health of soldiers, leadership has a responsibility of knowing its people and getting them to health because they are our most valuable resource.

So leadership policies and programs can mitigate work stress.

There's also selection, resiliency training, risk factor modification: selecting the right people, enhancing their resilience, decreasing their risk factors. The idea here is let's make sure people are ready for their deployment. Let's train them well. Screen them ahead of time. If they're not, let's have a backup plan. We have had mental health professionals, including in psychiatry, in theatre since 2006.

So making sure people are well is there. We have our “Road to Mental Readiness” five-phase package that's going on throughout the deployment cycle, where people are getting trained a few months prior to going. They have consolidation training during their last exercise in Wainwright or in Fort Irwin.

They're learning the skills from sports psychology. They're learning the breathing, the self-talk, all of these skills. When they go into theatre and they're having trouble, their leaders are taught to ask, “What have you tried? Have you tried the skills?” If not, backup is there as mental health professionals. We're identifying the guys who are having difficulties in theatre, and they can have an appointment by the time they return home. So the continuity we have around the deployment cycle is there.

In terms of barriers to care, most suicide victims have mental illness, but less than half are in care. That's what we're finding as we're investigating our suicides. This is where the non-clinical side comes in. It has to be okay to go for mental care. Leadership has to encourage it. The courageous thing is to step forward and say you're having trouble.

That's a huge issue. We can have the best program in the world--remember our three pillars--but if we don't have leadership that's engaged and keeps the stigma down, then we're not going to get the members into care.

On the delivery of effective care, Dr. Whelan is absolutely right in the sense that we have been in such a hurry to set up phenomenal treatment programs that the actual quality assurance, making sure that what we're doing is working, has sometimes not been emphasized. The next step is to set up the outcome measures. We have little pockets of outcomes. We have satisfaction surveys; we have all that. But in developing a program, we need to look at reducing symptoms across the board. Our next step is to ensure that our programs are giving us effective mental health care for suicidal members.

I think part of the issue there is that we can focus on the person when he is on the bridge about to jump, or we can go back, and through effective leadership and education, and try to stop it before it gets to that point. That's what our targets are.

We talked about mass education, increased suicide awareness, and a mental health program. We have cradle-to-grave mental health education. We give people education at the recruit level. At the junior leader level, they're learning to look after not only themselves but also their subordinates. The officers are getting similar training. I just lectured about 50 or 60 captains in Kingston. People are getting it. It's a matter of training and education.

Psychotherapy and pharmacotherapy are team-based. They have access to clinicians, and there are no co-payments or limits, so members are getting access to evidence-based best practices.

I've just signed off on a new follow-up policy. If a patient doesn't show up, sometimes the CF tends to take a punitive approach. They will write a letter to the soldier's commanding officer, saying it costs this much money and he didn't show up. As soon as this policy gets published, it will be different. If you're a mental health professional and your patient doesn't show up, and you had an hour booked, before you do your paperwork, you call that patient up. You say you missed him, you ask if everything's okay, and you make another appointment. This will be standardized across the country. What the dentists do and the physiotherapists do may be different, but every mental health professional in our organization is going to take that approach.

With respect to media engagement, organizations like the CDC have guidelines for responsible and ethical reporting. One of our hopes is to meet with them at the higher level. CF members tend to be front-page news, even though there are 4,000 or 5,000 suicides in our country a year. We'd like for them not to bury it or hide it, but we'd like to point out that there's a balanced way of reporting. There are guidelines developed not by us but by organizations like the Centers for Disease Control.

Leadership has a great effect on the mitigation of work stress. A fellow is having trouble with finances. You can reprimand him and charge him, or you can give him Friday afternoon off to go see his bank manager to try to get things sorted out. That's the idea, the little things that leaders can do to keep things from becoming big.

Colonel Grenier can tell you all the initiatives we've done over the last ten years in terms of barriers to care.

Finally, you have to understand that not all suicides are preventable. We'll do our best. We'll do our absolute best. The way we've set this up is that the ancillary benefit of such a program will actually be improving the overall mental health of the Canadian Forces. That's our aim.

The last thing that we've been doing has been since April 1...and I just want to tell you the interest within our organization. In September last year we had our panel. Within a month we presented to the chief of military personnel. Two weeks after that, he sort of said, “Hey, this is good”, and he took us to the Chief of the Defence Staff. In his private office we presented it to him again. By February, Armed Forces Council was interested, and in February they endorsed the entire thing, all 61 recommendations.

As of April 1, the Surgeon General was directed, and now we're doing these investigations of every single suicide that occurs within the regular force where a team flies out. I've done two of them. A mental health professional and general duty medical officer will go into the unit, not wait for a board of inquiry of six to eight months, and speak to the members, speak to the treating people, review the person's medical files, speak to the MPs, speak to the chain of command, speak to the spouse, speak to the mother, and find out if we can learn something from this, if we could have done as an organization something different.

Within a month, a report is written, and the Surgeon General has the recommendations. Anything within health services that we can do to change, that we can modify, he can initiate that immediately. If it's something beyond health services then he will have to channel it to the chief of military personnel or the CDS, if necessary.

I'll stop there because I know we're running out of time. Let's get the questions going.

[The Chair, Conservative, Gary Schellenberger]

I know we went a little over time, but it was a tremendous presentation.

The first questioner is Madame Zarac, for five minutes.

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

You mentioned that screening is done 36 months later and that it takes about 40 minutes. We just heard Mr. William Maguire say how important it is to establish trust between people. Then it is easy to talk.

Is it possible to build a relationship of trust in 40 minutes? Is it enough to detect that someone has problems?

[LCol Rakesh Jetly]

That's a great question.

Our organization is light years ahead of where it was years ago. In 2002 I actually walked down to Stadacona with a whole bunch of forms to do the very first screening on sailors. These are the guys who went out after 9/11, the 2,000 guys who went out. I'm sitting there I'm thinking, “Jeez, they're going to crucify us. Here I am in an army uniform and I'm going to walk on the ship and do this.”

One of the crusty old petty officers that was on the ship said, “It's about fucking time. It's about time you're asking us how we're doing.”

Many times over the years I've seen people who have come from the post-deployment screening, and I've asked, “You've been sick: so why now?”, to which they've said, “It's the first time somebody has asked me.”

Nothing is perfect, but you get education, you get training, you learn about these things, you have courageous people who are suffering illness stand up and say, “Hey, it happened to me, and I got help.” In the context of--

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

I am sorry to interrupt you, but here is my question.

Do you think 40 minutes with someone is enough? Shouldn't the meeting be longer?

[LCol Rakesh Jetly]

Yes. For a mental health professional to sit face-to-face, look somebody in the eye, and say, “How are you doing?”, it's enough.

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

Can a trust relationship be built in 40 minutes?