Veterans Affairs Committee on April 10th, 2017

[The Chair, Liberal, Neil Ellis]

Good afternoon, everybody. I call the meeting to order. Pursuant to Standing Order 108(2) and the motion adopted on September 29, the committee resumes its study of mental health and suicide prevention among veterans.

Today, we have Colonel Jetly, senior psychiatrist, directorate of mental health, Canadian Forces health services group. We'll start our panel today with a 10-minute statement and then we will go into questions and answers.

Colonel, the floor is yours.

[Colonel Rakesh Jetly, Senior Psychiatrist, Directorate of Mental Health, Canadian Forces Health Services Group, Department of National Defence]

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.

[The Chair, Liberal, Neil Ellis]

Thank you.

We'll begin with six minutes.

Mr. Kitchen, go ahead.

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

Thank you, Mr. Chair.

Colonel, it's good to see you again. Thank you for coming back, and thank you for your service. I appreciate your presentation. There is so much that I don't think I'll have enough time in my short questioning to ask you all the questions.

As you are aware, all research chairs require funding. Can you tell us where that funding is coming from and how much that might be?

[Col Rakesh Jetly]

I can't tell you the exact amount. The funding is basically joint funding. It really is our own CAF health services that are funding it. Some of it is in-kind funding in terms of my contribution and my salary and that kind of idea. It's not an endowed chair in the sense or the idea of $5 million sitting there and then us living off the interest. It's really about my contribution and the Royal Ottawa's contribution of space and of some of their scientists and scientific committees. If you want the exact number, I can try to find it for you, but I don't have one offhand.

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

Thank you.

For the structure of how this will work, then, has that been devised at all?

[Col Rakesh Jetly]

There are two aspects around it. The chair is one thing, and the centre of excellence is a separate thing. We have clear terms of reference for the centre of excellence, which has the thrust of research, education, and training. That's staffed within the directorate of mental health. That works very closely with the chair, because it's the same person who runs both. We do have a structure and function in place, yes.

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

Thank you.

We've heard from a number of witnesses who have talked about providing pretraining for our soldiers before they go into situations. I realize that we do an awful lot of pretraining in the sense that we're training our soldiers, troops, etc., in how they perform things, but I think they were referring more to issues of being exposed to what they might see in the battlefield.

In particular, we heard from one witness who was talking about dealing with creepy-crawly things, such as when you see somebody's who's had an issue, for example, an injury that might expose their abdomen, and how they're going to deal with it and respond to that. How do you see that fitting into your programming?

[Col Rakesh Jetly]

I think militaries have always had the adage of realistic training, of exposing people to stress. I think we are doing that to the best of our abilities. There's the road to mental readiness program. Also, all the stress awareness, coping, and performance psychology stuff starts in basic training and then is throughout one's career.

At the same time, once you know the mission, you can do mission-specific training. It's a very dynamic field. As we learned more about what was going on in Afghanistan, we were able to set up realistic scenarios in Wainwright and places like that. For IED scenarios that occurred in theatre, you adapted those immediately to the training. Nobody's going to argue with the adage of realistic training within human rights and within all of those things, but it's very hard to prepare somebody for the death of their best buddy. It's very hard for somebody to prepare for actually being blown up or having the head of your friend fly up and land in your lap. You can try your best. We're using more simulation, more talking about where we will end up going next, and we're getting as much as intelligence as we can from the other countries that are in there.

Absolutely, realistic training helps. It doesn't absolutely guarantee prevention, but as part of training, you do need to stress the body, stress the mind, and recover.

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

Taking that to the next step, when our soldiers return and become our veterans, how do we decommission that? I guess I'm asking from a psychological point of view. How do we get to them so that they can express those fears and aren't forever dealing with them day in and day out?

[Col Rakesh Jetly]

I think it's very interesting. There will be a group who may be ill. With illness, you treat illness. You find them the appropriate evidence-based treatment and let them do it. As a group, I think transition is going to be adapting to a new identity—it may not be the old identity—and how we transition between. I think the challenge in transition becomes an “if I'm half there, half forward” kind of idea.

I think the idea of life after service can be meaningful. You can still contribute. If you choose to retire, you can still contribute to your community. It's a “thank you for your service” kind of idea. I think the emphasis on living day-to-day life is the piece. If they're stuck with trauma and there's an illness, of course we can treat the illness, but it really is about the whole determinants of life, such as shelter, food, social support, and all of those kinds of things.

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

Do you see programming coming out of your centre of excellence that will fairly rapidly allow us to use those programs with our soldiers?

[Col Rakesh Jetly]

Our CAF centre of excellence is going to be much more focused on treating the ill and helping the ill. It will certainly help those people who are struggling with illness. The larger group that's still facing transition won't be specifically addressed by us.

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

Okay.

I'm interested in the three points in your presentation here today. In particular, the issue of treatment in my life. When I go to seminars, when I go to meetings, I like to know what I can take home from that as the doctor. In your understanding of the biological underpinnings of mental illness, do you see being able to use that with GPs, with health care practitioners, so you can get that information to those practitioners? One of the things we hear from a lot of our veterans is the moment they've transitioned, they have no doctors to go to. If they have no doctors to go to who don't even have the understanding, it's an even greater challenge.

[Col Rakesh Jetly]

You've hit it on the head. It's a translation of that. The idea is that as we do more and more research, we're going to figure out promising things. We've made a concerted effort in the last decade or so to publish everything we find in the peer-reviewed literature. They're not military reports sitting on shelves. We take advantage every time we can present at a conference, the family practice associations. I'm presenting at the Atlantic Psychiatric Conference in Charlottetown. Disseminating is crucial, and we're working with the Canadian Psychiatric Association, family practice associations, all the different organizations, to get things out. It's absolutely essential that it reaches the people in the trenches who are looking after our soldiers and veterans.

[The Chair, Liberal, Neil Ellis]

Thank you.

Ms. Lockhart.

[Alaina Lockhart, Liberal, Fundy Royal, NB]

Thank you, sir, for being here today.

In November the Public Health Agency of Canada released the “Federal Framework for Suicide Prevention”. Sections were dedicated to serving members of the Canadian Armed Forces and veterans. How much of an impact has this framework had, seeing it's not a national strategy? Has it had an impact on the prevention initiatives and treatment methods for serving individuals?

[Col Rakesh Jetly]

They've been consistent with what we've been working on. Outside of an affirmation that we're on the right track, we were consulted as they were coming up with the framework. We had some good discussions in the prevention, the pre-post. The whole idea of the framework is consistent with where we're headed as a path, as a population we're looking after.

[Alaina Lockhart, Liberal, Fundy Royal, NB]

Okay. That framework concludes with the following statement:

Ultimately, these actions will help reduce rates of suicide by breaking down the stigma and silence around suicide, encouraging people to have an open dialogue about suicide prevention, and promoting the development of suicide prevention initiatives throughout Canada using best practices that are informed by knowledge and research.

How has the conversation changed in the armed forces to include free and open discussion about mental health?

[Col Rakesh Jetly]

We are light years ahead of that statement. We've been on this journey for at least 15 to 20 years. There probably isn't an organization in Canada, or NATO writ large, that talks about mental health and suicide more openly than us, so again it affirms the direction we're on. We have colleagues, the Dutch, the Germans, and all of this, and they're just amazed at some of the programs we have.

We'll continue to do the same. We'll continue to talk about it. There's no shame in talking about it. The courageous thing to do is to put your hand up and let people know you're struggling. Canadian Forces members, by StatsCanada's own research, seek help more than the average Canadian when they're struggling with mental health issues, so we absolutely agree with that statement, and we've been on that journey for some time, and will continue.

[Alaina Lockhart, Liberal, Fundy Royal, NB]

Okay, that's great.

I know too that General MacKay testified in the defence committee that a mental health education program was starting the second week of basic training, as well as communication plans and campaigns, like Bell Let's Talk and that sort of thing. Have you seen any changes in the pickup of mental health services because of the program?

[Col Rakesh Jetly]

Yes, that's a great question.

We've done so many things over the last 15 years, or close to 20 years now, to dismantle and ask which one is the one who has done it.... But our stigma rates are down. When you ask a battle group coming back from theatre if they would think less of someone else who had a mental health issue, it's about 7%. If you asked that for a bank or other corporation, it would be four or five times that, so we've seen a reduction in that.

We've seen an increase in help-seeking. Canadian Forces members sought help more in 2002 than average Canadians. The gap has widened in our last study, so we're seeing things moving in the right direction with higher utilization of our services, more people coming forward. You're never done, it's a journey, but whether that's because of the R2MR or because of leaders who have stood by and said, this is the way we're going to be, it's going to be very hard to tease out what's.... We have more mental health professionals than ever as well, so access has also increased, which is again one of the barriers to care.

[Alaina Lockhart, Liberal, Fundy Royal, NB]

Very good. Thank you.

We've also heard a lot in the testimony about contributing factors to mental health and suicide, including alcoholism and drug abuse. We've talked about what leads to PTSD and suicidal tendencies. A couple of weeks ago, Dr. Heber, the chief of psychiatry for VAC, was here as a witness. She said, “It's important to remember that there are many factors leading that person onto that suicidal pathway. Deployment may be one of them, but not necessarily.”

In your experience at the Department of Defence, what's your opinion on that?

[Col Rakesh Jetly]

It's extremely complicated. That's not a cop-out, because there are many, many factors. Many people who don't deploy kill themselves. It's clearly not the single factor.

The common factors really are mental illness or a crisis. It can be a crisis with a big C or a little C, because when you're ill you can interpret different kinds of things. There's also the hopelessness and the impulsivity I mentioned, as well as other things.

For some, deployment could be the mediator toward getting mental illness. It's not binary in terms of whether you have deployed or not, it's what happens during that deployment. One person may be in a deployment where they're on the base camp, relatively safe and comfortable. Another person may be outside the wire, facing the bad guys every day. Clearly those two people haven't had the same experience. There are pre-enrolment factors as well—who you are, how you cope with stress and day-to-day things.

I think there are a fair number of things.

[Alaina Lockhart, Liberal, Fundy Royal, NB]

I'd like to ask you a quick question about the pre-existing issues. Is that something you are able to identify or are looking at during recruitment?