Veterans Affairs Committee on April 10th, 2017

[Col Rakesh Jetly]

It is, and all nations are facing it. You want your military to be representative of your population. If we say that 50% of our forces have adverse childhood events, and 30% of society has, you're not going to kick out 50% of people because some bad things happened in life. We've actually found that joining the CAF helps those people, because the link between suicidality and adverse childhood events is lower in the military than it is in civilian life. So there may be something good about the military taking in people.

For some of us as psychiatrists, who are sitting there doing psychiatry stuff, some elements that put people at risk for illness and self-harm may also make them good soldiers. Throughout history, many people who have been heroes, with medals of honour and all of these things, have also had PTSD and difficulties. There's risk-taking, running across the battlefield during enemy fire, and that type of thing. We have to balance that.

Right now in declared mental illness—you're actually ill at the time, excluding, of course, serious schizophrenia and those kinds of things—when you start to look at risk factors of taking an illness, which can happen in a 3% risk or up to a 5% risk, people can easily argue, “I think I'm part of that 95%”. That's why the population-based approach of screening, education, and encouraging people to come forward is probably the logical way to go in a large organization.

[The Chair, Liberal, Neil Ellis]

Thank you.

Ms. Sansoucy.

[Brigitte Sansoucy, NDP, Saint-Hyacinthe—Bagot, QC]

Thank you, Mr. Chair.

You chose to start by providing statistics on suicide in general. You noted that soldiers and veterans were at risk of suicide and that, like the general public, they were dealing with this issue.

I'm from Quebec. I started working in social services in the mid-1980s. After several decades of research, it was determined that we needed to work ahead of the clinicians. In Quebec, what is known as a sentinel program was developed. As I'm asking you the question, I realize that a military term was selected to name this program.

You said that soldiers are the most likely to seek help, which is good.

That said, does your centre of excellence also study the approaches developed on the civilian side? I'm thinking of a system that teaches families and people how to detect the suicidal thoughts of a family member.

Since veterans are no longer part of a military social network, how do you plan to teach the families to recognize the veterans' distress, when it emerges, and to encourage the veterans to consult clinicians who can help them?

[Col Rakesh Jetly]

I'll answer in English, if that's okay.

[Brigitte Sansoucy, NDP, Saint-Hyacinthe—Bagot, QC]

Yes.

[Col Rakesh Jetly]

Quebec has done wonderful things in terms of reducing its suicide rate, which was once one of the very high ones within Canada. Not everything is being done in our centre of excellence, but overall within our health services and within the CAF, we definitely do have programs such as peer support. The sentinel program itself is developing more and more in the army, training peers to reach out and get each other. The operational stress injury social support, OSISS, has been around since the early 2000s. We recognize that.

Within our road to mental readiness, we are teaching people to look for the signs within themselves when they're recruits. As they become older and have more experience, they start to become a bit responsible for other people around them, so they detect difficulties. We have leadership training specifically for leaders as well. For leaders, we talk about authentic, genuine leadership, knowing your people day to day, having coffee or tea with them, getting to know them and then you'll notice the subtle changes. You're not going to notice the subtle changes if you don't know them well.

That has been part of our prevailing access. With our road to mental readiness, we've just developed specific gatekeeper training for military police—for example, how they will deal with people if they encounter them when they're struggling.

You're 100% right. There's a clinical piece and a non-clinical piece. One helps people in crisis but also may get them into care. So we're very mindful of that and we have multiple programs.

With our last expert panel, we had a lot of civilians from all over. Absolutely, any lessons learned or anywhere there's some evidence, we will apply it.

I'm going to defer answering on what Veterans Affairs is doing as I'm not involved in direct implementation of things, but we have the things in place.

[Brigitte Sansoucy, NDP, Saint-Hyacinthe—Bagot, QC]

You referred to a recent consideration that really piqued my interest. You spoke of suicidality as an entity itself and of the importance of focusing on therapy, safety planning and treating the underlying illness. There appears to be a great deal of substance behind these words.

I want to know more about this subject.

[Col Rakesh Jetly]

Absolutely. At our last dinner in Latvia, I was talking to my colleague, my counterpart from the U.K. In a way, to understand as a physician, let's say you have somebody who has obesity, high cholesterol, and they smoke. They're coming into your office and you're going to give them the talk about watching their diet and stopping smoking, and then you'll give them a cholesterol medication. However, if they came in with chest pain and were sweating, you wouldn't keep talking to them about that. You'd probably switch and do an EKG and see if they're having a heart attack.

In the same way, you're working on prolonged exposure for PTSD or cognitive therapy for depression, but now they're declaring or you discover that suddenly this thing has happened. So let's shift. Let's talk about suicide. Let's talk about what it means. Let's develop ways, so when you're feeling hopeless, what can you do? Who can you call? It's that kind of idea.

Let's take some time to specifically work on suicidality. We're not going to ignore the underlying condition, because that's paramount, but in the meantime we're thinking about what we can do for people who are already in care who are contemplating, to keep them alive so we can actually treat the underlying condition.

In some ways, that sounds obvious, but it's only four or five years old. We have colleagues—I have a couple of teams—who are off to the U.S. to take some of the training, take part of it and consider whether we can bring it back here. One is the safety plan, which is specifically in Washington state; every primary care physician has to have this training. So when you have somebody who you're concerned about, it's not “Are you suicidal or not?” If they are, it's “What are you going to do if you feel that way?” It's a very concrete way of trying to focus on safety and then carry on with the treatment.

There are two different things: cognitive behavioural therapy specifically targeting suicidality as a thing, as an entity in itself; and this other safety plan. There are more and more different kinds of things, such as virtual hope boxes. Lots of different things are targeting suicidality itself. Just like if your cardiac risk patient is actually having a heart attack, let's save his life, resuscitate and fix him, so that then we can worry about the smoking and all those things.

[The Chair, Liberal, Neil Ellis]

Thank you.

Mr. Bratina.

[Bob Bratina, Liberal, Hamilton East—Stoney Creek, ON]

Thank you for being here.

We have heard testimony from witnesses whose stress had a lot to do with their medical release from the armed forces. What would the decision-making process be that would lead to medical release as it relates to our topic?

[Col Rakesh Jetly]

Currently the medical folks themselves are advisers to the chain of command. Again, the psychiatrist would advise the family doctor that the general duty medical officer actually implements....

We have a medical category system with lots of different things—vision factor and all of that—but the important ones now are the geographic and the occupational factors. If any health condition, from knee pain to back pain to mental health conditions, has stabilized, then we will communicate in a way that's confidential, separate from disclosing the illness, the long-term prognosis and limitations that the person will have on a permanent basis.

If somebody needs to see a health professional once a month, if somebody can't walk on uneven ground, if somebody shouldn't be in stressful environments, shouldn't do shift work, shouldn't do this, you give those kinds of things. Then, the leadership makes a decision on whether that person can be retained or sometimes accommodated with those limitations—those kinds of ideas.

Universality of service comes into that, of course. I'm sure you folks have discussed that. The idea is that if I can't go overseas and put on a rucksack and drag an injured person out, I will violate universality of service, and the organization has to decide to keep me, keep me for a short time, or to medically release me. That's essentially the process.

We are looking at different ways within health services of better understanding the illness. It's not diagnosis-based, not based on “this illness means this”; it's the functionality. It often represents the risk to the individual themself, not necessarily the risk to the organization. If you go into theatre with an unstable C-spine or with significant mental health issues, nobody knows for sure how you will respond when you are exposed to those stressful situations, but it's the risk idea.

[Bob Bratina, Liberal, Hamilton East—Stoney Creek, ON]

You made a comment about the improvement in suicide rates in Quebec. It has been stated that there was an increase in the suicide rates past the Quiet Revolution, when people became apart from their religion.

Is there any data at all on persons of faith and whether they are able to respond better to these kinds of stresses?

[Col Rakesh Jetly]

Yes, there's work on spirituality, in a sort of non-religious sense. There's a tendency that more spiritual people are less likely to harm themselves. It's extremely complicated when you read the studies. The definitions are all over the place. The idea that there's something beyond me is protective in many people, and it is helpful in chronic illness also.

[Bob Bratina, Liberal, Hamilton East—Stoney Creek, ON]

You were appointed as the first chair.

What are your own hopes for accomplishment over the next couple of years?

[Col Rakesh Jetly]

I think it is to really push that research agenda, given those three thrusts. We have sat back with the whole trauma thing. We joined along, and for years we were happy to go along for the ride. Clearly right now, we're the leaders. We're leaders within this country, and other nations are looking to us. We need to start contributing to the dialogue, not just applying what is out there. That's the key.

There have been many, many large studies—meta-analysis they call it—where time and time again, the evidence-based treatments for PTSD seemed to work less in military people and veterans. In 1994, Bessel van der Kolk looked at Prozac. It works in car accidents, rapes, and not so much with vets.

There seems to be something unique that warrants study. We're not going to replicate all the civilian studies on depression and things. We need to do the knowledge translation to see things that are working out there, develop things, and see if things are working. Really, the emphasis is on those three thrusts.

There are a couple of NATO panels as well, on leveraging technology and things, which I'm involved with. I think psychiatry has been very slow in advancing in terms of adapting technology. We're still the pen and paper people, writing things down. There have been 20 to 30 years of incredible biological research that really hasn't translated into clinical practice. It's part of my hope to do that.

[The Chair, Liberal, Neil Ellis]

You have 40 seconds.

[Bob Bratina, Liberal, Hamilton East—Stoney Creek, ON]

In Riga, is there a general concurrence with the issue?

[Col Rakesh Jetly]

There is. Rates are different in different countries, the scope of the problem, so to speak. We need to continue with the idea of early education upstream as much as possible, as our colleague was saying. That's really going to be the key, as well as more mental health education, literacy. We're exposing our young men and women to incredibly stressful things and we need to be aware of that. I think overall, Canada, the U.S., and the U.K. were the three largest contingents there, which usually is the case. When I look at the tick boxes, I see we have a lot of the right things covered, and the things we're working on are very consistent with best practices.

[The Chair, Liberal, Neil Ellis]

Thank you.

Mr. Eyolfson.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you, Colonel. Welcome back.

You talked about how it's a common thing that you have physicians out in the community, family doctors, the primary care providers who don't necessarily have the specific knowledge, and you're trying to get that out there.

Has there been any work on approaching the educational bodies and certification bodies to put this in the curriculum of the medical school and residency programs?

[Col Rakesh Jetly]

We have. The problem, in a way, is that population-wise in Canada, we're small. But there are universities...UBC, for example. For the last two or three years I've been going there to lecture to the graduating class, and this year I had breakfast with some of the kids to try to recruit them and I just chatted with them. My last couple of slides always say, if you see a veteran, realize that they have this whole suite of services; ask people if they've served. At one level, you produce documents, you get it out there, you educate people, but in the other way, you can get out to physicians early in their training and just have people realize they can just ask that one question. In medicine, you ask a question only if it leads to something you can do. In this case, there's the whole suite of services—vocational rehab, treatment, all of this stuff beyond the provincially funded system.

We're trying. At Dalhousie University, it's been either me or one of our military psychiatrists for the last 15 years who gives the lecture to the psychiatrists on PTSD. So it's every opportunity that we get at the large gatherings, and then more and more documents and publications. That's how we're working on things.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Great.

I'm a physician by training. For 17 years I practised emergency medicine. One of the things, of course, in the emergency medicine practice is that when your patients come in, you don't know them; they're not your patients, as it were. Has there been any outreach to emergency departments as to the local services available, particularly if you have nearby bases or training centres?

[Col Rakesh Jetly]

Yes, we were having that discussion.

Again, CAF is a little bit different from veterans.

One of the things that came out in Riga, which we've all sort of known, is how high the risk is—for the whole year, but certainly within the first few days, the first week—of somebody presenting to an emergency department with a suicide attempt. The risk is 30 times or 40 times higher in that first period. One of the evidence-based things that came out of the U.K. is an empathic assessment, with hope and all of this stuff, in that short period afterwards. What we risk, as a CAF—and we've had a couple of suicides where people have gone to emergency—is because we don't run our own emergencies and they go into the civilian system, is whether the emergency doctor will necessarily call the doctor on the base, and what if the person says, “No, I'm fine,” and this kind of idea.

In small bases, in small communities, for example in Fredericton, where there's one main hospital, the Chalmers, we can go there; we can establish that relationship. Our own people sometimes work in the emergency. In larger centres it's harder. But we do need to look at that transition as one of the riskiest transitions, and we need to reach out. I know there are a whole bunch of things in the emergency room, reminders, but we need to have one of those reminders. I think the British national health system struggled for years trying to get a tick box on their record asking whether the person has ever served. If we can get emergency rooms to think about that, that should tweak people to the fact that if they're still serving, there's a whole bunch of people who care about them, who will look after them, not just their health, and if they're a veteran, there's OSISS and different things.

We had that discussion just today about reaching out more to the emergencies, whether that means buying people coffee, visiting, putting posters up. That's one of our really important things.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

That's good to know. One of the issues as well, from my experience and from the testimony we've had here, is that we've said very often when people are released, they're now in the provincial system, and it sometimes takes a long time to get a family doctor, and that's not just military people.

[Col Rakesh Jetly]

Absolutely.