Proceedings of the Subcommittee on
Veterans Affairs
Issue 11 - Evidence - April 22, 2015
OTTAWA, Wednesday, April 22, 2015
The Subcommittee on Veterans Affairs of the Standing Senate Committee on National Security and Defence met this day at 12 p.m. to study the medical, social and operational impacts of mental health issues affecting serving and retired members of the Canadian Armed Forces, including operational stress injuries (OSIs) such as post-traumatic stress disorder (PTSD).
Senator Joseph A. Day (Chair) in the chair.
[English]
The Chair: The Subcommittee on Veterans Affairs of the Standing Senate Committee on National Security and Defence is studying the medical, social and operational impacts of mental health issues affecting serving and retired members of the Canadian Armed Forces, including operational stress injuries, sometimes referred to as OSI, such as post-traumatic stress disorder.
Today, we are very pleased to welcome as our witnesses from Veterans Affairs Canada, Dr. David Pedlar, Director, Research Directorate, Life After Service Studies (LASS) program, Policy, Communications and Commemoration. He is accompanied by Dr. Jim Thompson, Research Medical Advisor.
We have received a deck from Dr. Pedlar that should be in front of each honourable senator. I will now give the floor to Dr. Pedlar to take us through his presentation. Then we will proceed with a question and answer period.
Dr. Pedlar, you have the floor.
David Pedlar, Director, Research Directorate, Life After Service Studies (LASS) program, Policy, Communications and Commemoration, Veterans Affairs Canada: Thank you, sir. We appreciate the opportunity to present to you today. In fact, in 2012 we visited this committee with the results of the first cycle of the Life After Service Studies. That was from information we collected from veterans across Canada in 2010.
Today, we will spend some time with you and present the findings from the second cycle of this study from information collected in 2013. We will focus on the mental health research findings, because that is your theme. There is good news: We do now we have an increasingly comprehensive understanding of veteran mental health in Canada, and that will help us guide our policy and program efforts.
With me today is Dr. Jim Thompson, Research Medical Advisor. He is our technical expert who has led the mental health research work. He also brings to the table years of invaluable clinical experience, and he will lead us through this short presentation.
Regarding the parameters of the our expertise today, note that we are researchers and our focus today is on understanding veteran mental health in Canada from the perspective of the veteran population. I am advised that another Senate presentation is being scheduled in the near future to bring in content experts to brief you on the very important subject of VAC's comprehensive service delivery efforts in this area.
I will now pass the floor to my colleague, Dr. Jim Thompson, to take us through the deck.
Dr. Jim Thompson, Research Medical Advisor, Veterans Affairs Canada: As my colleague said, we are pleased to report on further analysis of findings from the 2010 survey and introduce you to the findings from the 2013 survey, which extended findings for Regular Force veterans and for the first time included Reserve Force veterans. That was slide 2.
I'm now on slide 3. This slide tells you a bit about the Life After Service Studies program of research.
Slide 4 contains three high-level findings from this work. First, most are doing well, even many of those with mental health conditions. The implication here is that the idea that Canadian Armed Forces veterans are broken is a myth.
However, a significant number had mental health problems, and deployed reservists were more like Regular Force veterans. The implications here are, one, that there is ample population-level data supporting the attention that Veterans Affairs is paying to mental health and veterans, and, two, that deployed reserve veterans appear to require supports to the same degree as Regular Force veterans.
The third main finding overall is that non-deployed reservists were much younger and not much different from other young Canadians in the general population.
We're now on slide 5. Any veteran can develop a mental health condition, but we have identified subgroups in which diagnosed mental health conditions are more prevalent. The picture this slide paints is very similar to the picture we're getting for other dimensions of well-being we studied, like difficulty with adjustment to civilian life, quality of life, disability and suicidal thinking.
Mental health problems are most prominent in former junior non-commission members, who also have the highest rates of medical release, chronic physical health conditions, disability, difficult adjustment to civilian life and suicidal thoughts.
The next slide shows the prevalence rates —
The Chair: Dr. Thompson, you're going a little bit fast for us. If you could slow that down so we can follow. I know this is very familiar to you, but it's not as familiar to us.
Thank you.
Dr. Thompson: That's fine.
This slide shows the prevalence rates of chronic mental and physical health conditions in Regular Force veterans who released from 1998 to 2012. The mental health conditions are in red on the left, and the physical health conditions are in blue on the right. The slide also shows comparison to the Canadian general population. Those are the beige bars in this slide.
The rates of all three chronic mental conditions were considerably higher in Regular Force veterans — more than double the general population — but so were several chronic physical health condition prevalence rates such as arthritis, low back problems, hearing loss and other physical conditions that have distressing symptoms that can lead to mental health problems.
There are several implications here for Veterans Affairs and for others who provide services to Canadian Armed Forces veterans. First, this evidence supports ongoing mental health enhancements. Second, it's important to attend to chronic physical as well as mental health conditions, and I'll talk more about that in a minute. And third, although chronically painful musculoskeletal disorders and mental health conditions are common in Veterans Affairs business, veterans with a wide variety of other physical conditions have become Veterans Affairs clients through the service relationship tests, for both the Disability Benefits Program and the Rehabilitation Program.
Slide 7 gives us a bit more insight into the relationship of mental and physical conditions in recent Canadian veterans. A quarter of the veterans had a mental health condition, but more than 90 per cent of the veterans with a diagnosed mental health condition also had a chronic physical health condition. In our analysis of the survey data, we found that the combination of physical and mental health conditions has a disproportionate impact on quality of life, disability and suicidal thinking in the veteran population compared to having either type of condition alone. This is a very important point to remember when thinking about mental health issues.
The findings of physical health have three major implications. First, in the health care system, these are usually patients with the most complex types of health and well-being problems. Second, services need to be able to attend to both types of problems in collaborative multidisciplinary teams. And third, we need to be cautious about practices that deal only with either mental or physical health problems in separate silos.
On the next slide, there are two important findings. The first is that about a third of the one quarter who had diagnosed mental health conditions had very low levels of current psychological distress. The implication here is that not all of those with diagnosed conditions need intensive supports.
The second is that 15 percent of the 13 per cent who had moderate or severe psychological distress in this population did not have a diagnosed condition or did not report one. The implication is that there is probably an unmet need for recognition and diagnosis, just as there is in the general population. Failing to recognize the need to seek help for mental health problems is common, but there are potential barriers to recognition, diagnosis and care as well.
The next slide is about work and employment. Work is very important to health and well-being, so the findings around employment are significant. Of the 24 percent of Regular Force veterans with mental health conditions, just over half of them were in the employed group and half were in the three groups that were not employed. Most of the veterans were employed, and that's the large blue slice of the pie in this slide. Of those who were employed, about one in eight, or 17 per cent, had a diagnosed mental health condition.
However, mental health problem rates were much higher in the three "not employed" groups with 30 per cent of the unemployed, the red slice; 36 per cent of the green slice, the ones who were not working, not looking for work, and many of those were not retired; and 79 per cent of the smallest sliver, those unable to work for various reasons.
The first of the three big implications is that just like other Canadians, veterans with mental health problems are employable. Second, some of those with mental health problems at work might need supports to remain employed. Third, mental health problems are much more prevalent amongst those who are not working, indicating a need for better workforce engagement for those with mental health problems.
The next slide focuses on disability. The higher rates of physical and mental health problems in veterans translate into higher rates of experiencing disability, which we measure in our surveys as activity limitations. For example, in the bar graph on the left, the rate of health-related activity restrictions at work and those working was almost three times higher in Regular Force veterans compared to the Canadian general population.
In the table on the right with the red arrows, the odds of having health-related activity limitations or restrictions in any of the four major life domains were much higher in those who had both a mental and physical health condition than either type alone.
Two key implications here are the importance of supporting those working who have mental health problems, and the importance of access to both mental and physical rehabilitation services in those with mental health issues.
In the next slide, almost half of Canadian Armed Forces Regular Force veterans who were receiving services from Veterans Affairs have diagnosed mental health problems versus about one tenth of those who are not VAC clients. The reason is that the majority of veterans with complex health problems are already participating in VAC programs. For example, 71 percent of those with mood disorders, anxiety disorders or PTSD are VAC clients; 82 per cent of those with chronic pain are VAC clients; and 73 per cent of those with co-morbidity — meaning having both physical and mental health conditions together — are VAC clients. There are a number of other examples. The implication here is that mental health problems are pervasive in the selected veteran population seeking assistance from Veterans Affairs, and our front-line staff are dealing with veterans who have the most complex types of health and disability problems.
On the next slide, since the difficult deployments of the 1990s brought awareness of mental health problems in veterans to the forefront, Veterans Affairs, DND and the Canadian Forces have been collaborating to introduce an array of psychosocial support programs and services. The ones on this slide are the key ones that Veterans Affairs has introduced since 2000.
The next slide makes the point that mental health later in life occurs in response to genetic predisposition, past experiences, like adverse childhood experiences, occupational stressors, socio-economic stressors, physical health status and access to effective treatment throughout life. We're now starting to focus on that third pink box in our research, the period right around release from service, when members and their families are undergoing the most intense period of transitioning to civilian life.
That's shown on the next slide, which emphasizes that we know much less about that narrow period from a few months prior to about two years after, and that's where we are focusing our research attention now in collaboration with DND and the Canadian Forces.
The last slide shows the next steps. These are the steps we're planning at Veterans Affairs Research Directorate together with research partners, other departments and the universities. The first is further analysis of mental health findings from the life after service survey 2013 data. The second is two new studies looking at mental health in the few months prior to release to the two years after, from the perspectives of both serving members and their families. The third is follow-up longitudinal life after service surveys in 2016 and 2019.
The Chair: Thank you, doctor. I have a couple of points before I go to honourable senators.
First, you came to a number of conclusions as you went through, but those conclusions weren't on the deck we received from you. Is there a report that we're going to have access to where we can study and reflect on some of the points that you've made?
Mr. Pedlar: There's no report per se, sir, but we would be happy to share the speaker notes on the presentation, if that's suitable for you.
The Chair: If you would do that, it would help us in following the transcript. We went through this rather quickly, and I wasn't able to write down all the conclusions you were drawing on each of these pages. That would be helpful.
Mr. Pedlar: We'll be pleased to share that with you immediately, sir.
The Chair: Thank you. We'll have it circulated to all the senators.
I will start with the deputy chair of the committee, Senator Stewart Olsen from New Brunswick.
Senator Stewart Olsen: Thank you for this very good presentation. I share the chair's wish for your actual conclusions. I have your overview, but I'm at a bit of a loss. First of all, how are you looking at using the results of this study?
Mr. Pedlar: The results of the study were well integrated into all aspects of policy and service delivery. That means that when we're developing mental health policies and strategy work, we're literally sitting there in the policy and program development process, so all this material is used.
Senator Stewart Olsen: It has been incorporated, is that what you're saying?
Mr. Pedlar: That's correct.
Senator Stewart Olsen: I look at it and some of it is quite rosy. I have to confess that that's not what I hear from many of our veterans. I missed the first part, and I apologize. Did you give a number of how many people were surveyed?
Dr. Thompson: Yes. The survey sampled roughly 3,000. I don't have the exact numbers in my head, but we have initial reports out that explain the numbers. We developed the survey in collaboration with Statistics Canada to get the sample sizes so that they would be statistically representative of the populations we surveyed.
Senator Stewart Olsen: Of those 3,000, was there a concerted effort as to the various service deployments, army, navy, air force? I need to know your methodology in setting it up.
Dr. Thompson: The idea of the sample sizes was to be representative mainly of the Regular Force and Reserve Force, but then to have sample sizes large enough that we could look at factors such as service branch, gender, age, all of the well-being measures and socio-democratic and military characteristics we measured in the survey. The idea of the sample size was large enough that we could start looking at some of those associations, and that's what we've been doing.
Senator Stewart Olsen: This may not have been a part of your survey, but the returning veterans and reservists are those who served in Bosnia and Africa and are coming forward in quite large numbers now with various stages of injury and post-traumatic stress, both mental and physical. I'm assuming they would have been a part of this survey, but did you break it out by service fields or if they were ever in-theatre?
Dr. Thompson: In the 2010 survey, we had whether they had deployed outside of Canada for 30 days or more or not, for example.
Senator Stewart Olsen: And where they deployed?
Dr. Thompson: Getting more specific information about where they deployed was difficult because of limitations in the data sets available to us at the time. Some of that very precise information about exact deployment location is either being worked on or is not yet available, just because of the nature of the data sets.
Mr. Pedlar: An important point to note is that about 90 per cent of the people who responded to the survey said that we could link their data with our internal information at DND or Veterans Affairs, so that would allow us, if deployment data is available, to do linkage with deployed groups. We have not done that yet, but it's possible that we could do that, depending on the quality of the deployment data available.
The Chair: Could you, Dr. Thompson, tell us if the survey in 2010 dealt with the same questions, or did you redo the questions for 2013? I see where it is Regular Force veterans released for the same time frame, 1998-2012. What was the difference with respect to the Regular Force in those two surveys?
Dr. Thompson: Thanks for pointing that out. For 2010 on that slide, it should say "Regular Force veterans released in 1998-2007," and then in 2013, we were able to extend that to 2012. In 2013, we had the Reserve Force veterans as well.
The survey questions were largely similar between the two surveys, but based on what we'd learned in the first survey, we were able to refine some of the questions in the second survey.
The Chair: In 2013, then, it was from 2007-2012, or did you go back to 1998?
Dr. Thompson: It was 1998-2012. The first survey was 1998-2007, and then for the Regular Force in 2013, it was 1998-2012. That allowed us to do two things. It allowed us to get a second measure from the second survey to compare with the first, which reassured us that the findings were similar. It also allowed us to extend out five more years, from 2007-12.
The Chair: Thank you.
Next is Senator Lang from Yukon, who chairs the Standing Senate Committee on National Security and Defence.
Senator Lang: I would like to once again welcome our guests here. I appreciate the information you have provided us with. I have a number of questions.
In your opening comments, you talked about the Class C deployed with the Reserve Force and that there was no support, or you mentioned no support. Perhaps you could clarify that.
Dr. Thompson: No, the point there was that when we compared the Regular Force veterans with the Class C deployed reservists and the Class A/B non-deployed reservists, the Class C deployed reservists looked more like Regular Force veterans when we looked at their health and well-being profiles than they looked like Class A/Bs. The Class A/B reservists looked more like other young Canadians in the general population.
Mr. Pedlar: In other words, they were more likely to have mental and physical health conditions compared to the general population.
Senator Lang: If they had been deployed.
Mr. Pedlar: Correct, sir.
Senator Lang: The inference came to me that with the fact that they were Class C Reserve Force veterans who had been deployed, they didn't have the access that other categories had in respect to some of the programs. Is that correct?
Dr. Thompson: I'm sorry, but I'm not enough of an expert on the eligibility criteria and issues with respect to reserve versus regular. It's not an area that I've been focused on.
Senator Lang: I will flag that because I think that's something should we look at to make sure everybody's being treated —
The Chair: That's an issue that's been brought up a number of times, I agree.
Senator Lang: Having served for quite some time in a regional government — in my case the Yukon government — like the provinces or the territories, and knowing that the programs provided at the regional level, whether it be the Province of Quebec or the Province of New Brunswick or the Yukon government in the territories, are you doing any correlation in respect to the programs that are being provided to the general population, which includes veterans, as opposed to these other specific programs that are being administered through the federal government? Are we better off in some cases cost sharing with the province or the territory to administer a program so that it is administered most efficiently and perhaps provide more benefits? The reality is that in most cases they do have the services plus the facilities.
Mr. Pedlar: I think the answer is that within about the 30-minute time frame that we have to talk to veterans in a survey like this, the survey is more like the Canadian Community Health Survey. It looks at different dimensions of health and well-being. It looks at some issues around service use at a very high level but not at a detailed level where you would be able to do federal and provincial comparisons. So it's probably outside the scope of the survey to do detailed comparisons.
Senator Lang: I want to pursue that. Going forward, do you think it would be of some benefit to ask that question of the veterans that you're surveying to ascertain exactly where they are accessing some of these services and how satisfied they are with those services that are available?
Mr. Pedlar: It would certainly be worth exploring in more depth. I'm not sure this tool is the best one to look at the question of service delivery. There might be other ways where you could do linkage with provinces somehow or another. For example, some provinces do have service utilization databases. Perhaps you could identify veterans in those populations. There is some work under way in Ontario that might be like that. That would probably be a more detailed way to be able to collect that information.
When you ask veterans questions about health services, you can get into very long lists of possible services they could be using, so I think there would be methodology questions to answer about the best way to do that. I'm not sure the survey would be the best way, but exploring how it could be done in more depth would be worthwhile.
Senator White: Thanks to both of you for being here. I have a couple of short questions. Thanks for the information. You did go through it quickly.
I'm trying to see if there is any correlation to addictions that you found, in particular to mental health concurrent disorder, whether you gathered that information or whether you just didn't show it here, because I couldn't find it.
Dr. Thompson: This survey did not include detail on addictions. When the surveys were being designed in collaboration with Statistics Canada, as Dr. Pedlar pointed out, it was important to include information on a wide variety of health and well-being issues, which meant that some modules had to be left out.
The addiction module, for example, is lengthy and takes time, and there was some advice about where to do that. For example, addictions are covered in mental health surveys that have been done now twice in the Canadian general population as part of the mental health survey; one was done recently in 2012.
We don't have data on addictions. We have data only on drinking and smoking but not at the level of addiction or substance misuse.
Senator White: In the general population there is a strong correlation and connection between mental health and addictions, and many argue which came first, the chicken or the egg, I guess. Is there any consideration for a follow-up review specifically related to mental health, those who have identified mental health, and trying to zero in as to whether or not there is a correlation between the causation of mental illness come coming from addictions, or no?
Dr. Thompson: The other thing is we review international studies and studies done in other populations, both civilian and military, because much of that knowledge can be translated to the Canadian veteran population. So there are a lot of questions like that, very relevant and important, but we can inform answers to them by looking at research done in other populations.
The relationship with addictions is well known.
Mr. Pedlar: Another answer is that we are planning two more cycles of this study, one in 2016 and one in 2019. When we do that work, we will take input, like the input we're getting today, about what we should focus on, so your advice will be taken into consideration, sir.
Senator White: Thank you very much.
My second question relates to an earlier response. Where are we in comparison to like countries — and I look at Australia and New Zealand, maybe the U.K. to a lesser degree, but some of the other European countries — that have participated in a similar fashion that we have, similar numbers in similar or in some cases identical in-theatre commitments? Where are we in comparison to them from a results base?
Dr. Thompson: We've been looking at that over the past year and trying to compare results of the studies done in other countries with our findings from the Life After Service Studies. What makes these comparisons difficult is that the methodologies used in all the studies are slightly different. We, for example, were somewhat unique in focusing on all the veterans living in the general population. Other studies have only looked at certain veterans who return from specific deployments or look at them post-deployment, so comparisons with other countries get difficult for that reason.
Some of the new literature that has come out from the U.K. and the United States in the past year suggests that there may be increased levels of some health conditions in their veterans, too, compared to their general populations.
Mr. Pedlar: Generally speaking, for example with the United States, we do see higher levels of musculoskeletal conditions. They are commonly higher, about double the level in U.S. soldiers as well as Canadian soldiers, for example.
But you have to make decisions about how you're going to do comparisons when you set up these studies. The decision we made, partly because of its availability, is comparison with the general population. It lets us look at whether veterans are pretty much the same or quite a bit different than other Canadians. That's quite helpful when we're trying to think about whether we should treat them differently from a service delivery perspective. That's the direction we focused on, comparison with other Canadians.
Senator White: I do agree with that.
For me, a lot of this work will also hopefully lead to current or better or best practices. When you're talking about 2016 and 2019, have we given consideration to reaching out to some of those other countries to see if they want to do identical research at the same time so we do have a comparison that allows us to draw on? Australia, for example, if they have a much lower level of mental illness coming from the exact same theatre we did, maybe it's because they're doing something pre- or post-theatre that would assist us in dealing with the issues. Are we giving consideration to some of that work?
Mr. Pedlar: First of all, I think there is a network in NATO that the Canadian Armed Forces would be part of that has groups that work together on trying to make measurement more consistent so that comparisons are possible. Those would most likely be undertaken in studies of serving members at the present time.
We are in contact with our allies as well. There's a group of senior executives. I chair the research committee across five countries, and one of the subjects we focus on is to try to make an effort to make measurement more consistent. If we could get measurement more consistent, even with one or two countries, like the United States and Australia, even across one or two mental health measures, that would be an important step forward. So, yes, that's under consideration.
Senator White: Thank you very much and thanks for the work as well. I appreciate your time today.
The Chair: Wouldn't NATO be a place to look to get some of this consistency in terms of measurement that you have indicated would be important to draw conclusions by comparisons?
Mr. Pedlar: Yes, we would want to build on whatever NATO network work is being done. For example, in the past, groups that represent released populations, like us who focus on veterans, have not been part of those networks. And we recently joined a project on transition for military service to civilian life, and we're working side by side with our Canadian Forces colleagues and other countries so that we are now seeing a better fusion or connection between the NATO network and the veteran network, as it should be, of course.
The Chair: Can you tell us who is doing the study that you have indicated you have just joined with?
Mr. Pedlar: The study is being led by the United States. It's being led by a very well-known fellow named Dr. Carl Castro at the University of the Southern California who served for 31 years in the United States army. It was just a week or two ago that they met for the first time in Europe to work on the terms of reference of this study, which I think will focus on best practices in transition from military service to civilian life, although they have not formally completed their initial report. This project has to be approved by NATO after the terms of reference are developed, so sometime in the summer or fall it's likely to become a project that would go for a couple of years.
The Chair: Then questions like the impact of length of deployment would be something you could look into by a comparison between different armies and different policies, which is something you can't do at this time.
Mr. Pedlar: Dr. Thompson is well-read on this topic.
Dr. Thompson: That kind of information has been looked at carefully and is still going on. We collaborate and talk to our colleagues in other countries all the time. I was emailing this morning with a colleague at the USDA in the States about a similar research question that you just raised. There are lots of attempts to understand the differences, but there are important differences between the militaries and between cultures, and that complicates comparisons as well.
We're collaborating with our international colleagues because there are differences between militaries, cultures and veteran administration arrangements in all the countries, and those create important differences in understanding effects, so direct comparisons are difficult. Within each country, they're working hard to try to understand the answer for their military and their veterans about those questions.
For example, in the Canadian Forces, their epidemiologists have done very good work with deployed personnel in support of the military mission in Afghanistan, looking at the effects of the number and length of deployments. They've published that work. What we're trying to do with our transition research now is connect those findings with what we're seeing about the rates of health problems in the veterans, meaning military members who have released from service. That's why we're so interested in what's going on around that period of transition, to see what the connection might be.
Within each country, the researchers are busy trying to understand those questions within their country. At the same time, we're talking with our colleagues to figure out how we can compare across the countries.
The Chair: Am I to understand that all your studies focus on after-service or transition as opposed to during service?
Dr. Thompson: That is right. Up to now, the Life After Service Studies have been just that; they've been looking at the veterans who have released up to 15 years. We survey them up to 15 years after they've released from service. The Canadian Forces have done a lot of work on serving personnel, and the new program of research we're talking about is looking at that around-release period, from a few months prior to two years after, because we need to understand what goes on there better.
The Chair: To finish this line of thought, the work the Canadian Forces has done was introduced early on — I think it was when General Hillier was Chief of the Defence Staff — this decompression period, when they took men and women people who were on deployment. They were anxious to get home to their families, but it was felt important for them to have an adjustment period. So for about a week, I understand, they went to an island in the Mediterranean to help decompress from the intensity of Afghanistan before they came to North America. Are you aware of that situation?
Dr. Thompson: Yes, I'm certainly aware of that program, and I'm aware of the post-deployment screening that went on during that process to try to identify health problems that might have arisen prior to coming back to Canada. I know my colleagues have worked on that and have done the analysis of that program, but I'm not very familiar with the findings.
The Chair: It's a policy decision to do that, and there must have been some work to lead to that policy decision. Was the work to make that decision done within National Defence, and they would have done a study afterwards to determine whether it was worthwhile?
Dr. Thompson: Because that's all done at DND and the Canadian Forces, I'm not very familiar with that work.
Mr. Pedlar: My understanding is that Dr. Mark Zamorski, Department of National Defence, was lead on that work for a number of years. That's the connection that I'm familiar with in terms of who was the most knowledgeable and responsible.
The Chair: Thank you.
I'm looking at "determinants of veterans' mental health, life cycle perspective," that slide that you gave us, which I think is very instructive. You're into block number 3 where you want to go, and that's determinants in transition to civilian life, but the pre-service determinants is the first block.
We would be interested in knowing if any work is being done in Canada or elsewhere that helps in the selection process for who should be in the Armed Forces and who is best suited to be deployed. Are there some factors that would indicate this person is likely to have mental challenges later on or is likely to be able to handle the stress and trauma that is inevitable in a war situation?
Dr. Thompson: Again, I would have to defer to my colleagues in the Department of National Defence and the Canadian Forces who are studying that very issue. They're part of a long line of researchers who have looked at this, right back to prior to the Second World War, and especially during the Second World War, when there had been a well-published experiment of trying to screen out those individuals, later finding that as the war went on, they ended up recruiting some of them. There are difficulties trying to come up with those sorts of screening tools.
What they've worked hard on is resilience in the Canadian Forces. They have programs where they develop psychological resilience in their service members to prevent the onset of mental health problems.
Mr. Pedlar: If I may add to that, Dr. Jitender Sareen, at the University of Manitoba, has done work on some of these pre-service determinants, probably not from the perspective of policy decisions on when to deploy or not — that's more within the realm of the Canadian Armed Forces — but rather in the context of whether people have a higher likelihood of developing mental health disorders. So he's done work on early childhood trauma and its impacts later. He's a very capable individual and would probably make a good witness.
The Chair: We're aware of his work, but I do thank you for that. If you have any other thoughts of ongoing studies, don't hesitate to let us know later on because it's all very helpful.
Senator Stewart Olsen: I'm going to go back to the area of deployment because I wish we had a bit more on that. Especially with mental health problems, it may be a bit easier. I am wondering about our peacekeepers. If you know the areas of deployment, you know you had peacekeepers somewhere, and the whole concept of a "veteran is a veteran" is very important to our veterans. It's not always active theatres of war; injuries and mental health problems develop within our peacekeeping groups as well. I'm wondering if you might consider putting a bit more into that kind of a study in your next go around.
I look at your stats on the prevalence of chronic conditions. Oddly enough, though, I've heard it mentioned several times that musculoskeletal injuries are chronic. I don't see them here, and I'm wondering if they are included in arthritis, back problems and chronic pain. You see a lot of knee and shoulder injuries in veterans from all types of deployments. I'm wondering where that might be included.
Dr. Thompson: I'll answer the two questions, number one about deployment.
As I mentioned, in 2010 we had deployment data on whether they had deployed outside Canada for 30 days or not. We certainly used that as a factor in all of our analyses — the work we did on suicidal ideation and the work we did on disability, for example. What was interesting was that deployment fell out as a factor when we were adjusting for health conditions, which was a signal to us. We're seeing this in the research now that's coming out of the U.S., in particular, and the U.K. It's not necessarily about having deployed. It's about having health problems. Military personnel who haven't deployed, as you said, can certainly have health problems.
On the other hand, we know that deployment brings increased risk. The Canadian Forces did a very good study looking at mental health problems related to those who deployed in support of the mission in Afghanistan. For example, they found out that the cumulative incidence of developing mental health disorders that the clinicians felt were due to the deployment was much higher in those who deployed to high-threat locations than in those who deployed to low-threat locations, but they occurred in both. They occur also in those who don't deploy.
So the overall finding is that it's not about deployment, per se; it's about whether a person developed mental health problems. That's the more fundamental issue, but there is no question that certain kinds of deployment experiences are associated with a higher likelihood of having mental health problems.
The second question, your point about musculoskeletal —
Senator Stewart Olsen: Sorry to interrupt you, but if I could just get some clarification: It's not about deployment, but then you go on to say well, yes, it is about deployment. Are you saying that your study wasn't about deployment or that your findings weren't?
Dr. Thompson: What's important is that seeing a service member or a veteran who has been in service and, for example, thinking that just because they haven't deployed, they might not have mental health problems, isn't correct thinking from a clinician's perspective. They may well have mental health problems like anybody can get them.
It's a tangled response. The other way of looking at it is that, yes, those who deploy to high-threat locations are more likely to get health problems, including mental health problems, but even those who have not deployed can also have mental health problems.
Does that clarify it for you?
Senator Stewart Olsen: Yes, there's no question there, but I think where I was trying to go is that in transitioning out of active service into, say, VAC, I think it may be important to look at the area of deployment so that you may be able to pre-empt or predict some types of injuries that may not show at the time of transition. That's more where I'm going as I think that it could be important. I don't know, but I think that could be important.
Dr. Thompson: Just to clarify that a bit more, the type of service somebody had may be one of the determinants for a person's mental health issues, but mental health issues are caused by a complex of things. In fact, researchers in that area talk about the causal pie. There are many slices of the pie that go into causing mental health problems, such as a person's early childhood experience, genetic makeup, whether they deployed, what current stresses they are under at the time, post-service, social problems, relationship problems or economic problems. All of those factors add together in this causal pie for developing a mental health problem.
Mr. Pedlar: In terms of our priority around deployments, our biggest focus right now is on Afghanistan moving forward, and that's because we're able to do the right things moving forward. It's harder to go back and look at deployments in the 1990s, when stuff wasn't collected necessarily as well at that time. So my priority as director is to make sure that when we move forward with Afghanistan, really over the rest of this century, with people coming forward, we'll have mastery of that deployment and others moving forward.
Senator Stewart Olsen: I see. Thank you. I do understand about the pie. That goes to Senator Day's position on pre- screening, too. If you pre-screen, you make pick up some things as well.
Sorry, go on to the second.
Dr. Thompson: With regard to the second question, back problems and arthritis are markers of musculoskeletal disorders in these population surveys. They've been there for many years in this checklist that's used in surveys around the world because they are two of the most common and two that have the biggest impact in terms of numbers in the population. As you rightly said, though, there are many other physical health conditions that people can have, and, in Veterans Affairs, that association has been found for eligibility for benefits for all sorts of other musculoskeletal disorders, too. It's just that these are two common markers used in surveys.
Senator Stewart Olsen: I see.
Dr. Thompson: We can't ask about all the questions, for example, and you're right that chronic pain includes musculoskeletal issues, as well as other chronically painful conditions.
Senator Stewart Olsen: Thank you very much.
Senator Lang: I'd like to go back to your opening comments again, and I want to get a clarification. You'd said, in a general sense, that the myth that the veterans have been all adversely affected in one manner or another was strictly a myth, and you referred to the narrative of that. I just wanted to see exactly what you were saying there. It sounds to me like you're saying the issues that are facing us are real but not as significant as perhaps others are saying they are. Is that what you said?
Mr. Pedlar: Jim will reply to this as well.
I think it's really a case of keeping it in perspective, which is that in the work that we do, despite challenges that this population faces, most say that they're doing well and that they had an easy or not difficult transition to civilian life. So that's on the one hand.
It's important, though, to keep that perspective because if you're reading the media all the time, one might come to the conclusion that that's not true, that in fact veterans are broken. That kind of a "broken veteran" brand is not helpful to veterans who are looking for jobs and the many veterans who transition successfully and do well.
On the other hand, this work does clearly show that veterans have higher levels of mental and physical health conditions than other Canadians. At the same time, that is also true.
Senator Lang: Following up on that, I think that's a very important message and narrative that should be out there. I agree in part with what you've said because it's not helpful to those veterans who have been able to adapt and transition successfully to have everyone under the same brand, so to speak. At the same time, we need to recognize that there are quite a number that have been affected.
Roughly, what is the percentage? Is it 80 per cent who have been successful versus 20 per cent? Do you have any idea on the statistics?
Mr. Pedlar: We ask a question in both surveys about adjustment to civilian life. The findings across both surveys were very similar, which is that about a quarter find transition from military service to civilian life difficult or very difficult. Around 60 to 65 per cent find it not difficult, relatively easy, and then there's another group that are in between, so somewhat difficult. About a quarter, though, find it very difficult or difficult. That's consistent across two studies now.
Senator Lang: The other area that I'm wondering if you're looking at, or perhaps will in the future, is the question of the success rates of these programs that have been put in place. In your surveys and talking to those who have access to these surveys, at the end did we get an outcome and how successful was that outcome?
Dr. Thompson: These surveys are cross-sectional, point-in-time snapshots, so they don't allow us to draw conclusions about causal relationships among factors. That's one issue.
They also weren't designed specifically to look at programs. Dave might want to expand on that.
Mr. Pedlar: There are two points there. One is that in the first survey we looked at the Regular Force; in the second survey we looked at the Regular Force and the Reserve Force; and in the next version of the survey we will follow people over time. It will become what's call the longitudinal study. That will allow us to look at people and it will give us more opportunity to look at what happened to people between time A and time B. There is more potential to look at those kinds of questions, but we don't have a design for those kinds of questions yet.
The Chair: Doctors, before we sign off, I would appreciate your background information in relation to the announcement made in December 2014. It was a DND announcement that the Canadian Armed Forces would establish, within the Canadian health services group, a national Canadian military and veterans mental health centre of excellence. Are you aware as to whether this Canadian military and veterans mental health centre of excellence has in fact been established and do you play any role in that?
Mr. Pedlar: I do not know if it has been established yet. The answer is yes, we do play a role in it. The deputy director or deputy chair of the centre is expected to be a Veterans Affairs employee. We will be involved in some way around the governance of the centre, although I do not know the details of that at this time. However, I have been in discussions with the Canadian Armed Forces on this before and after Christmas.
The Chair: Could you follow up for us and let us know what the timeline is on when Veterans Affairs and the Canadian Armed Forces will be cooperating with respect to this centre of excellence?
Mr. Pedlar: Yes, sir, we will do that.
The Chair: It indicates that there will be collaboration with scientific experts and academia to ensure that knowledge gained from leading-edge clinical research translates rapidly into clinical care. It seems to me that a lot of the work you are doing is anticipated as part of the input to the centre of excellence. We would be interested in knowing when you expect that to get up and running.
Mr. Pedlar: We will be delighted to answer that question, sir.
The Chair: That concludes our allotted time for the meeting today.
Dr. Pedlar and Dr. Thompson, thank you very much for being with us and explaining the research work you're doing. We thank you as well for the work and the results of that that will help veterans here in Canada.
Mr. Pedlar: Thank you, sir.
(The committee adjourned.)