Mr. Chairman and members of the House committee on veterans affairs, thank you for the opportunity to speak with you today. For the past decade I have been a senior epidemiologist for the directorate of force health protection, more colloquially known as DFHP, which is part of the CF health services group. I hold a master's degree in science in epidemiology from the University of Toronto, as well as a Ph.D. in epidemiology from the London School of Hygiene and Tropical Medicine in the U.K. Prior to joining DFHP, I worked as an epidemiologist at the provincial and regional levels as well as in the academic sector.
As an epidemiologist my primary role, really, is to respond to the needs for statistics and data on the part of the decision-makers within CF health services and the larger Canadian Armed Forces—also known as CAF, which I'm sure you know by now. Clinicians and decision-makers who develop the policies, implement clinical practice, or work towards keeping the CAF healthy really need to know who their population is and what their needs are, and that's where I fit into the larger picture. I'm behind the scenes, providing those who “do” with the statistical information they need to proceed in an evidence-based fashion. I do so as part of a larger directorate, the directorate of force health protection.
DFHP functions similarly to how a provincial health authority would work, but does so specifically for the CAF. The key pillars of public health are surveillance and assessment of the population's health, health protection, health promotion, and disease prevention.
With respect to public health surveillance, an important part of what we do is to monitor the health of the CAF, primarily through surveys such as the health and lifestyle information survey, as well as through other health surveillance functions. These can be broader in scope, as is the case with the CF disease and injuries surveillance system, which monitors disease and injury during deployment specifically, as well as the CF health evaluations and reporting outcomes surveillance system, which can be adapted to look at a number of health-related conditions and concerns. These systems can also be a lot more specific, as is the case with the mortality database or the suicide surveillance system, the latter of which is the source of the information from which the report on annual suicide mortality in the CAF is created. The trends and the patterns that we identify through our work using these diverse sources of information are then used by policy- and decision-makers in developing and implementing evidence-based, health-related policies and programs across the CAF.
As mentioned, one of our reports that you're most likely familiar with is the “2016 Report on Suicide Mortality in the Canadian Armed Forces”, which covers suicides between 1995 and 2015. I'll refer to it from here on in as the 2016 suicide report.
We within the CAF, both civilians and military, consider every suicide a tragedy. Suicide is firmly recognized as an important public health concern. As such, this report has been produced since 1995, with annual releases since 2008, in an effort to gain greater insight into suicide in the CAF. Monitoring and analyzing suicide events of CAF members provides valuable information to guide and refine ongoing suicide prevention efforts.
While we do collect and monitor data on all suicides, including males or females and regular or reserve force members, the annual reports cover only regular force male members. The reason is that reserve force and female suicide numbers are too small for us to release detailed information about the cases without running the risk of identifying the individuals and compromising their privacy. Although their experiences are included in the evidence used to drive mental health policies and suicide prevention endeavours within the Canadian Armed Forces, the information is not presented in the annual reports.
All suicides are ascertained by the coroner from the province in which they occur. The information is then provided to and tracked by the directorate of mental health, which cross-references it with the information collected by the administrative investigation support centre. The centre is part of the directorate of special examinations and inquiries.
Whenever a death is deemed to be a suicide, the deputy surgeon general orders a medical professional technical suicide review report, or MPTSR. The investigation is conducted by a team consisting of a mental health professional and a general duty medical officer. This team reviews all pertinent health records and conducts interviews with medical personnel, unit members, family members and other individuals who may be knowledgeable about the circumstances of the suicide in question. Together, all this information is used to create the findings in the annual suicide report.
Over time, the picture of suicide in the Canadian Armed Forces has changed. While the rates may vary somewhat from year to year, a consistent and clear picture has emerged over the last decade. Canadian Army personnel, more specifically those in the combat arms trades, are at a greater risk of suicide than the Royal Canadian Navy and Royal Canadian Air Force members.
There’s some emerging evidence that deployment may also be a concern. However, we need to be careful with this broad description of deployment, since it can include many types of deployments—for example, humanitarian, peacekeeping or active combat—and many different experiences, both good and bad. Further research and analysis is required in order to determine whether, on its own, deployment is really linked in some way to the risk of suicide.
We're starting to get a much better understanding, through the work done by my colleagues from the directorate of mental health, as well as within DFHP, about underlying risk factors for suicide. For example, amongst the regular force males who took their own lives in 2015, over 70% of them had documented evidence of marital breakdown or distress prior to their deaths. Debt, family and friend illness, and substance abuse were identified risk factors.
These are also often seen in the general population. Most of them had more than one non-mental health risk factor at the time of their death. While troubling, this is consistent with what is being seen by other militaries, and I think it highlights the direction in which our research and surveillance efforts should be increasingly concentrated moving forward.
With this in mind, DND, as part of the Public Health Agency of Canada, led an interdepartmental working group on suicide-related surveillance data, which is one of the expected deliverables of the federal framework for suicide prevention. Membership within this working group is an excellent venue to see what work is being done by fellow federal agencies around suicide surveillance and prevention, and to share information on how to be more effective and consistent in our collaborative approaches.
We also have a long-standing relationship with VAC. We have been collaborating for a number of years on the CF cancer mortality study, which has looked at suicide risk over an individual's lifetime, both during and after service. We're currently collaborating with them and Statistics Canada on a second iteration of the study. We plan on looking at cancer and causes of death, including suicide, in still serving and released regular force and reserve class C personnel who enrolled in the CAF between 1976 and 2015.
We also sit on the steering committee for the veterans suicide mortality study, which will be looking at suicide risk amongst all former regular force and reserve class C veterans who released from the Canadian Armed Forces, also between 1972 and 2015.
In summary, surveillance is an important and integral component of understanding the risk factors and trends associated with suicide among serving and released personnel. Collaboration between departments and researchers has been ongoing, as demonstrated through the CF CAMS 2 and other research initiatives, and will prove to be extremely helpful in understanding this complex issue.