Mr. Chairman and members of the House committee on veterans affairs, thank you for this invitation.
I'm the senior psychiatrist in CAF. I have several key roles, including advising leadership on mental health issues, and leading our relatively newly minted centre of excellence, which is a cell within our directorate of mental health that is charged with a more strategic nature to forward thinking. I'll describe it in a little more detail in a moment.
To some extent, I also represent all of the clinicians who are working every day with those within CAF who are struggling with mental health issues. At the headquarters level, I am charged with innovation and clinical research. In the area of suicide, I've had the privilege of co-chairing our CAF 2009 international expert panel on suicide prevention, and our recently completed 2016 panel. I am just also returning from a NATO symposium on military suicide prevention in Riga, Latvia, in which Canadian clinicians and scientists played a key role. We also served on the planning committee and I served as technical evaluator of the same symposium, at which 27 countries were represented.
You heard a great deal already about the CAF, including the statistics of suicide, the way the CAF investigates and tracks each occurrence. You've heard of clinical programs and numbers of professionals available to treat members of CAF. You've heard of our other programs to aid in resilience and mental health literacy, such as R2MR, and various ways in which transition issues are being addressed. I will try to share some of my own observations and thoughts briefly without repeating too much, and of course will answer questions to the best of my abilities.
Suicide is a significant issue for both veterans and serving members. As a psychiatrist with an interest in population health and suicide, I would like to remind you that globally about 880,000 suicides occur each year. That means that about 200 people will die by their own hand during the two hours that you meet this afternoon. About 4,000 Canadians take their own lives each year. Mental illness and suicide are a global phenomena and leading causes of disability and death. The CAF and our veterans are not immune.
One of our esteemed speakers in Riga stated there are no “neat snippets or sound bites” to explain suicide or suicide prevention within militaries, and unfortunately not all suicides are preventable. We cannot predict which ones will and won't be preventable, and as such we need to continue to work to the best of our abilities to prevent each and every one of them. This is the basis for suicide prevention strategies that are being utilized and expanded within both CAF and Veterans Affairs Canada
First and foremost, we know more about suicide now than we ever did. There are excellent models for suicide. For example, the Mann model of suicide was adapted to military populations by our 2009 expert panel and has been the guide for most of our prevention strategies. The model describes that most suicides occur in individuals suffering from mental illness and facing a crisis. The crisis is usually interpersonal, legal, or financial, and that leads to somebody developing suicidal ideation. Other factors come into play, such as feelings of hopelessness, the impulsivity of the individual, and of course access to lethal means. These factors have provided obvious targets for suicide prevention.
There are other models, such as the interpersonal model of suicide proposed by Thomas Joiner, who spoke at Riga at our NATO symposium just last week. Joiner's model proposes that suicide is the result of “thwarted belongingness”, “increased burdensomeness”, and a diminished fear of violence and death, which can often occur in military and veterans.
These models are helpful; however, the need for research and a better understanding remains. For example, the clear majority of individuals in mental illness and crisis do not kill themselves. Likewise, many who may see themselves as a burden and isolated, again, do not commit suicide. In fact, the existing tools created to predict suicide are accurate, at best, 5% of the time. This is always the challenge in predicting rare events.
More research is needed. Suicide itself is complicated, as is suicidality. For example, those with suicidal ideation or desire are different from those who attempt suicide and those who complete suicide. We need to better unravel this and determine if there are predictors of transformation between the three groups. The “when” is also important, because there appear to be times of higher risk from various sources, such as early in one's career. Some of our NATO forces are facing increased suicide in recruits within the first year, soon after deployment, or when leaving the military. So transitions occur throughout one's career and we need to be mindful of that.
Further to this, our own review demonstrated that about half of our recent suicides are in care and half are not. For the latter group, we need to ensure that we remain committed to all of our efforts to reduce the stigma and barriers to care. These include our commitments to mental health education and training: for example, partnering with Bell Let's Talk and reaching people through social media and other technology.
Members in care who complete suicide remind us of the ongoing need to have mental health programs that are well resourced and staffed to allow the timely access to evidence-based care that's required, but also that current treatments of mental health conditions are simply not good enough. This is not a CAF or Veterans Affairs issue, but rather the state of the science in the treatment of mental health disorders. We need to develop treatments and study them to ensure that they work. We need to better understand who responds to which treatment in order to reduce the trial and error. Funding and other support are required, as we need to conduct military and veteran research, since some civilian research may not translate and we may have our own priorities, such as combat PTSD.
One of my roles has been to run our recently formed centre of excellence, and I am privileged to have been appointed the first Brigadier Meakins chair of military mental health at the Institute of Mental Health Research here in Ottawa. We have an ambitious research agenda that has three thrusts.
The first one is understanding the biological underpinnings of mental illness. We will use neuroimaging and establish the biomarkers of disease. It is only through a better understanding of the biology that we can develop tools to better diagnose and track illnesses like PTSD. Treatment can also be developed that targets specific areas or abnormalities, perhaps even identifying a biological profile for suicide.
The second major thrust is leveraging technology. We are committed to studying and expanding the use of technologies within mental health. This could include various things, such as web-based therapies, repetitive transcranial magnetic stimulation, neurofeedback, big data analytics, etc.
Personalized medicine, also called precision medicine, is the last thrust. Unfortunately, even for the most common mental illness, the trial-and-error procedure is the usual process for treatment, which can be frustrating for both clinicians and patients, and of course their families. We can conduct studies using technologies such as pharmacogenomics or even EEG to try to predict who is going to respond or not respond to treatment, and then use those technologies later on to avoid some of the trial and error.
Our centre of excellence is also studying new treatment approaches. We are exploring them, and if they are promising, we'll recommend implementation within CAF, and of course share our findings with our colleagues at Veterans Affairs Canada. Two current examples include CBT-S, which is a cognitive behavioural therapy specifically targeting suicidality, and approaches that formally teach our clinicians to establish safety plans for at-risk patients. These types of interventions represent a shift in my own thinking, but more importantly the field's thinking, regarding suicidality.
Traditionally, when a person suffering from an illness such as depression became suicidal, the conventional thinking was that the driver of suicidality was the illness and we ought to redouble our efforts to treat the illness. More recently, there has been a shift in thinking, and the idea is to address suicidality as an entity in itself and give it a specific focus within therapy, safety planning, etc. Of course, treating the underlying illness will remain crucial. I am happy to expand on this with specific questions, and I am quite excited that this will enhance our current approaches.
Another concept for consideration is the issue of contagion as it pertains to suicide. Suicide contagion occurs when vulnerable individuals relate to or identify with those who have completed suicide, and attempt or complete suicide themselves. The phenomenon exists in groups such as university students, and clearly can occur in military and veterans groups. Recently, a lot of focus has been placed on the responsible reporting of suicides. In fact, the World Health Organization, the Centers for Disease Control and Prevention, and the Canadian Psychiatric Association have all published responsible suicide reporting guidelines. It is strongly advised that we refrain from rationalizing, glorifying, or romanticizing suicide, as other vulnerable individuals may use that as a justification to take their own life. This is an important issue, as we must balance the honouring of those who die with the risk of others following. As a result, the Canadian Psychiatric Association is in the process of revising and publishing a new set of guidelines.
Thank you for your attention. I am happy to expand on my opening comments or answer any questions you may have.