Veterans Affairs Committee on Dec. 13th, 2016

[The Chair, Liberal, Neil Ellis]

I'd like to call the meeting to order.

Pursuant to Standing Order 108(2), and the motion adopted on September 29, the committee resumes its study on mental health and suicide prevention among veterans.

Today we have, from the Department of Veterans Affairs, Dr. David Pedlar, director of research, research directorate, who is on video conference from Charlottetown, Prince Edward Island. We also have, from the Parkwood Operational Stress Injury Clinic, Dr. Don Richardson, a psychiatrist at Western University in the department of psychiatry.

We'll start with a 10-minute time frame for the witnesses' statements.

We will start with Dr. Pedlar. Good afternoon, Dr. Pedlar.

[Dr. David Pedlar, Director of Research, Research Directorate, Department of Veterans Affairs]

Thank you for this opportunity.

First of all, I just want to mention to the committee that I'm losing my voice today, so please bear with me. Also, to help compensate for that, I've taken the unusual step of bringing a colleague with me, so if my voice dies on me, there will be someone. Dr. Linda Van Til, an epidemiologist, is with me, and she has the same expertise that I do. Our goal is to be able to fully and completely answer all your questions.

With that said, I will start my statement.

I'm Dr. David Pedlar, and I'm the director of research at Veterans Affairs Canada. This year I also held the university faculty post of the Fulbright visiting research chair in military social work at the University of Southern California, in Los Angeles.

I want to thank you for the opportunity to speak on this very important topic. My goal is to share with you what we know about the state of mental health and suicide in Canadian Armed Forces veterans, as well as my views on some conclusions to draw from these research findings. Underlying this presentation is an evidence base of research studies that include large population surveys, published research studies, research technical reports, literature reviews, and veteran file reviews.

Let's get to it. First I will speak about the state of the mental health of Canadian Armed Forces veterans. I thought that the simplest way to do this would be through three straightforward comparisons.

Comparison one: how does the mental health of the population of Canadian Armed Forces veterans compare to non-veteran Canadians? The answer is that while the majority of veterans in Canada have good mental health, the findings of two large Statistics Canada surveys report that, compared to the Canadian population, the prevalence of common mental health conditions, like mood disorders, anxiety disorders, and PTSD, was generally about two to three times higher among the population of Canadian Armed Forces personnel released since 1998. We looked back to 1998 because that's how far back our records will take us.

Comparison two: how does the mental health of the population of reserve force veterans compare to the Canadian population? The answer is that the population of reservists who served full time for a substantial period of time had a higher prevalence of common mental health conditions than the non-veteran Canadian population. Their level of mental health conditions was similar to the one I just mentioned for the regular force—you know, several times higher than non-veteran populations. However, the mental health of other reservists who did not serve full time for a substantial period of time looked a lot like non-veteran Canadians of the same age and gender.

Comparison three: how does the mental health of the Canadian Armed Forces veteran population fare in comparison to veterans internationally? The answer to this isn't completely clear because direct comparisons of rates between countries is not possible. However, overall, the direction or emerging trend in findings is that veterans in Canada, the United States, Australia, and the United Kingdom have at least the same or a higher prevalence of mental health problems than non-veteran populations. In other words, what we see in Canada isn't completely unlike what we see elsewhere.

I have a couple of concluding observations on mental health.

First, there's no single factor associated with higher mental health conditions in Canadian Armed Forces veterans. In fact, there are many factors at play: previous life experiences, military service, genetics, physical health, employment, finances, and social support.

Second, in understanding mental health in veterans, it's really important to appreciate the connection between mental and physical health in Canadian Armed Forces veterans. Canadian Armed Forces veterans have a higher prevalence of both chronic mental and physical health conditions. In fact, 90% of veterans with mental health conditions also have chronic physical health conditions. Often these are musculoskeletal conditions and chronic pain. These are about two to three times more prevalent than in civilian populations. Those who experience mental health and physical health problems and chronic pain at the same time are especially likely to experience quality of life challenges. Therefore, it's really critical not to silo mental and physical health when we talk about veteran needs. They really have to be treated together in this population if we want to treat, diagnose, and manage them well.

Now I'll change to the topic of suicide. I'll start again with a question: do Canadian Armed Forces veterans have a higher suicide rate than other Canadians? The answer is that there is evidence of a higher suicide rate in male Canadian Armed Forces veterans. A large-scale 2011 study of suicide mortality among Canadian Armed Forces personnel who enrolled between 1972 and 2006 found that, over this 35-year period, the rate of veteran suicide was 1.5 times higher—that's about 50% higher—than in the non-veteran Canadian male population.

As a next step, please note that Veterans Affairs Canada—and I'm responsible for this work—is committed to the release of annual Canadian Armed Forces veteran suicide statistics by December 2017. These will allow us to monitor veteran suicide in Canada and will contribute to suicide prevention efforts. This work is complex, and that's why it takes a long time to do.

In addition to these studies, to understand suicide statistics, we have also undertaken analyses of data and file reviews. Here are some of the important findings overall. Typically, suicide is the result of several factors operating at once, and not just one factor. While psychiatric disorders, particularly depression, contribute to suicide, multiple stressors come into play, such as, physical health problems as I mentioned previously, difficulty participating in life roles, employment, financial problems, social factors, relationship problems or feeling like a burden on others, housing challenges, addictions, and finally, some people have personal predispositions to suicide, like personality factors and problem-solving styles.

Another important finding of ours is that very elderly veterans had distinct suicidality profiles, including stresses from social isolation, housing transitions, and the presence of multiple chronic physical health conditions and frailty.

I have two observations on suicide. The first is to reiterate the point that in addition to psychiatric disorders, a number of well-being and personal factors contribute to death by suicide. Therefore, all the services that Veterans Affairs Canada and other organizations provide in mental health, physical health, employment rehab, social support, and economic benefits play an important role in preventing suicide.

Finally, in closing, I just want to mention that transition from military service to civilian life is a challenging time to some degree for all military members, and also a time of vulnerability for some. We are undertaking a large-scale study now to better understand how the transition from military service to civilian life can impact veterans' mental health, what supports work best, and how to mitigate the kinds of problems that can contribute to suicide vulnerability in veterans.

Thank you for the opportunity to make an opening statement.

[The Chair, Liberal, Neil Ellis]

Thank you.

Go ahead, Dr. Richardson.

[Dr. Don Richardson, Psychiatrist, Western University, Department of Psychiatry, Parkwood Operational Stress Injury Clinic]

I'd like to thank everyone here for inviting me to speak on this very important topic of mental health and suicide prevention in veterans. I'm not going to speak for a long time, because it might be more interesting to have a question and answer presentation.

I'll give some information about my own background. I'm a consultant psychiatrist working at the Parkwood operational stress injury clinic. My academic affiliation is associate professor at Western University and assistant professor at McMaster University. For the past 20 years most of my clinical and research interest has been in still-serving members of the Canadian Forces and veterans.

In our topic today, as you probably already have heard from many other witnesses, mental health conditions are common in a significant minority of veterans. One of my colleagues, Dr. Jim Thompson, has published on this. Almost 25% of veterans in the Canadian population have a mental health condition, the most common being depression, followed by post-traumatic stress disorder, and then anxiety disorders.

Psychiatric disorders in general rarely occur in isolation, what we would typically call comorbidity, which is if you have one condition, what's the likelihood you have something else. When we talk about PTSD especially, it rarely will occur as one single condition. The most common conditions that co-occur with it would be major depressive disorder, other anxiety disorders, and also a whole host of addiction disorders.

When we looked at our treatment-seeking population, those who sought treatment at the Parkwood OSI clinic, almost 80% of those who had PTSD also met the criteria for probable major depressive disorder and about 40% had alcohol use disorder.

Suicidal behaviour, suicidal thoughts and attempts often co-exist with mental health conditions, especially major depressive disorder. In the general population—this was also research done by my colleague, Dr. Jim Thompson—the past year's suicidal ideations—these are thoughts—was found to be approximately 6.6% in veterans, while for those veterans in the community who were clients of Veterans Affairs Canada, their past year suicidal ideation prevalence was much higher at 12%.

When we looked at our treatment-seeking population, we found that 17% had endorsed having thoughts of suicide more than half the days or greater in the past two weeks. When you're looking at a treatment-seeking population, it's much higher.

I also want to point out some of the new research that's showing the association between sleep disturbances and suicidal ideation. Emerging evidence shows that sleep disturbance is a significant predictor of having suicidal ideation even in those without mental health conditions. However, when we look at the area of comorbidity—and we've examined this in our treatment-seeking population—once you have other mental health conditions, especially depression and the predictor of having problem sleeping is no longer significant.

In general, on the topic of suicide prevention, as you can probably imagine—and you've heard from other people already—this issue is very complex and there's probably no simple solution. You've probably already heard of the need for more research and statistics not only on suicidal ideations and thoughts, but also on suicide attempts and suicide deaths that would probably help in program development and public health strategies.

We also know that treating mental health conditions, especially depression, is an effective suicide prevention strategy. Therefore, it's important to stress timely care for veterans as well as a public awareness campaign for veterans to be aware that treatments are available.

At Western we are in the process of establishing a zero suicide strategy, where the fundamental belief is that suicide deaths for individuals under care within health and behavioural health systems are preventable. Adapting this strategy was one of the recommendations that was made by the Veterans Affairs Canada mental health advisory group.

My final comment would be in terms of treatment outcomes. There is much research that has been published on treatment outcomes and it's important to distinguish PTSD in the civilian population and PTSD in the veteran population, what we call military-related PTSD. In general, military-related PTSD has demonstrated a poor response not only to the psychotherapy, which is the talking therapy, but also to medication therapy or pharmacotherapy.

In general, when we look at the treatment outcomes, if an individual will participate in evidence-based care, approximately 40% to 60% will recover. We have been able to demonstrate that within our own treatment outcome studies at our clinic. However, this still means that a significant proportion of individuals, despite attending evidence-based treatment, are still suffering with significant symptoms of PTSD and depression.

Thank you.

[The Chair, Liberal, Neil Ellis]

Thank you.

We'll start with a first round of six minutes. Go ahead, Mr. Kitchen.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you both for coming here. It's great to have you provide us with information that will assist us in our study.

Dr. Richardson, I'm going to go to you first, because your numbers are still fresh in my head and I don't want to forget them. I'll go to Dr. Pedlar afterwards, if you'll bear with me.

Doctor, you said that about 40% to 60% will recover. You've mirrored that same finding with your studies at Parkwood. Can you explain that population base, 40% to 60% of how many, or 40% to 60% of what type? Can you expand on that for me, please?

[Dr. Don Richardson]

Some of this has been published in The American Journal of Psychiatry. In research that specifically looked at our treatment outcome data, for both one-year and two-year treatment outcomes, for those who are receiving psychiatric care, that's medication treatment in addition to psychotherapy, the talking therapy, these are individuals who, on average, would have suffered with chronic PTSD and the vast majority, almost 80%, had major depressive disorder.

By providing ongoing treatment, when I say they fully recover, they no longer would meet the criteria, if measured at that time, of having PTSD or depression.

Does that help you?

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

That gives me a better idea.

When you talk about pharmacotherapy, what sort of medications are you talking about?

[Dr. Don Richardson]

In terms of medication treatment for PTSD, there's very little indicated other than the SSRIs, the selective serotonin reuptake inhibitors.

What we would tend to do, as clinicians, is we would try to treat the comorbidities aggressively, so including treating major depression, other anxiety disorders and using general protocols that have been established for treating depression. We would start first with an antidepressant and follow them over time. If they do not respond, we might increase the dose, and if they don't respond, we might add a different class of antidepressant. If they still do not respond, we could add an atypical antipsychotic or mood stabilizer.

Are those the types of details you're looking for?

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Yes. Thank you very much.

Dr. Pedlar, I wonder if you could expand on some of the challenges that you've found soldiers experience during that transition stage, as you discussed at the end of your presentation, from military life to civilian life and how you might equate that.

[Dr. David Pedlar]

I think the statement I made was that almost all veterans will experience some kind of a challenge, because for many during transition almost everything can be changing at once. That could be military culture, housing, where they're living, social networks, source of income, and they may have physical and mental health conditions upon release. Therefore, by definition, there's vulnerability built into that period of change.

Some veterans will encounter special problems during that period. Some of those can come from really the way they experience the change themselves, for example, if they hadn't planned in advance about what it would be like to take the uniform off. A number of veterans I've run into will talk about this issue, that they've lost their sense of purpose. In a sense, they've lost their sense of self. Some veterans are angry when they leave. They had planned on spending their whole career in the military, and their career was cut short unexpectedly, so sometimes veterans will have a feeling of anger or even betrayal upon leaving the forces.

There are so many factors coming together in transition all at one time that it has to be done well, especially for people who can get stuck, or they can get onto this trajectory that can lead to serious outcomes that perhaps exacerbate mental health problems, or even things like suicide.

I hope that's helpful.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you.

I think I have a very quick question here. I'm interested in the research you talked about in suicide statistics in Canada. We know that a lot of veterans, once they leave the military, if they don't want to be found, they can't be found. I'm interested in this. Could you indicate to us how you plan on making certain that when you do your epidemiology study on this you're going to actually have the complete veteran-based population? How are you going to find these soldiers who are hiding, who are homeless, etc?

[Dr. David Pedlar]

This is about completed suicides that we're counting, not people who have suicidal ideation. In terms of the suicide statistics, with completed suicides, it's done through data linkage with Statistics Canada. What we do is we get the record for as far back as we can go for everyone who was released from the Canadian Armed Forces, and we link that with the Statistics Canada mortality database, which is contributed to by the provinces and two territories. We use the same standard of measuring mortality, including suicide, that we would for all other Canadians. In fact, it's a very strong and reliable methodology where we don't actually have to find people.

[The Chair, Liberal, Neil Ellis]

Thank you.

Mr. Fraser.

[Colin Fraser, Liberal, West Nova, NS]

Thank you, all, for being with us today and sharing this important information. We really appreciate it.

Dr. Pedlar, you gave a comparison between Canadian Armed Forces and veterans and the regular population when it came to mental health statistics, saying that it was two to three times higher, and that was similar to international statistics on the same. Then you went into suicide rates and said that among Canadian Armed Forces and veterans, it's one and a half times higher among the male population, which I didn't hear anything about in the international comparison. I wonder if you have those numbers as well.

[Dr. David Pedlar]

No, I don't have those numbers with me. We could provide those numbers. It's hard to do direct comparisons, though, because the veteran populations are different across countries.

[Colin Fraser, Liberal, West Nova, NS]

Fair enough.

[Dr. David Pedlar]

That's a challenge to actually do really true direct comparisons.

[Colin Fraser, Liberal, West Nova, NS]

Okay.

One of the things that I think we understand and we've heard before is that identifying these mental health issues at an earlier stage would help us hopefully identify what treatment is needed and available for our Canadian Armed Forces members and veterans. How can we encourage people to self-identify earlier in the process, or to encourage them to address their mental health issues in an earlier step, so that we can find them adequate treatment and hopefully deal with these problems before they become even worse?

[Dr. David Pedlar]

I think that zone of expertise is probably stronger with Dr. Courchesne, who was here a week ago, who's responsible for the areas of mental health service delivery and suicide prevention. It's not in my zone of expertise, so I won't answer that if you don't mind.

[Colin Fraser, Liberal, West Nova, NS]

I'll turn to Dr. Richardson then.

With regard to the OSI clinics, can you expand on what conditions there are other than PTSD that the OSI clinics deal with, and you would see on a regular basis? I think you mentioned a few other things, including alcohol addiction for example. What other things do you treat?

[Dr. Don Richardson]

I think not only at our clinic but in the network of OSI clinics, we don't have an exclusion criteria. As long as individuals have a mental health condition, we can assess and treat them.

When we look at our stats—and I don't have the exact stats but we can provide them for you in terms of the demographics—this is a treatment-seeking population referred by their VAC case manager or from National Defence from their medical officer. The number one condition is PTSD followed by major depressive disorder, and then generalized anxiety disorder, panic disorder, and alcohol use disorder.

[Colin Fraser, Liberal, West Nova, NS]

With regard to the OSI clinics themselves, in your experience is there any difficulty in finding the appropriate staff with the requisite experience to deal with these situations? If so, do you have any recommendations on how we could perhaps solve that problem?

[Dr. Don Richardson]

I'm probably not aware of the entire network across Canada, the challenge in recruiting and retaining clinicians. However, we haven't had that much difficulty. We provide a lot of education and training for new staff, and we also, in collaboration with the Canadian Psychiatric Association and the Canadian Psychological Association, so my colleague psychologists, provide education and training to civilian clinicians.

[Colin Fraser, Liberal, West Nova, NS]

Dr. Pedlar, we've heard this time and again that the transition is a challenging time. What makes this so difficult in particular for the mental health of the veteran or the transitioning member, and what can be done specifically regarding their mental well-being so we would be able to perhaps alleviate some of these problems? Could you comment on that?