Proceedings of the Subcommittee on
Veterans Affairs
Issue No. 17 - Evidence - June 6, 2018
OTTAWA, Wednesday, June 6, 2018
The Subcommittee on Veterans Affairs met this day at noon to continue its study on the services and benefits provided to members of the Canadian Forces; to veterans; to members and former members of the Royal Canadian Mounted Police and their families (Topic: study on cannabis use for medical purposes by Canadian veterans).
Senator Jean-Guy Dagenais (Chair) in the chair.
[Translation]
The Chair: Colleagues, we are going to begin our meeting without further delay. I will ask the honourable senators to introduce themselves, starting on my right.
[English]
Senator Boniface: Gwen Boniface from Ontario.
Senator McIntyre: Paul McIntyre, New Brunswick.
Senator Jaffer: Mobina Jaffer from British Columbia.
[Translation]
The Chair: Before we introduce our guest, we must deal with an item of committee business. Is there a motion to nominate a senator as deputy chair of the Subcommittee on Veterans Affairs of the Standing Senate Committee on National Security and Defence?
[English]
Senator Boniface: I would propose Senator Jaffer.
[Translation]
The Chair: Senators, do you accept Senator Jaffer’s nomination?
Hon. Senators: Agreed.
The Chair: Everyone is in agreement. Congratulations to Senator Jaffer, our new deputy chair.
That being said, I will now welcome our witness. Today, we are continuing our study on cannabis use for medical purposes by Canadian veterans. Our witness from the Department of National Defence and Canadian Armed Forces is Colonel Rakesh Jetly, senior psychiatrist and mental health advisor, Canadian Forces Health Services Group.
Colonel Jetly, since we saw each other last Monday, I welcome you again. We are going to listen to your opening statement, and then we will have a question period.
I now invite you to make your presentation.
[English]
Colonel Rakesh Jetly, Senior Psychiatrist and Mental Health Advisor, Canadian Forces Health Services Group, Department of National Defence and Canadian Armed Forces: Thank you very much, chair and senators, for the opportunity to make these brief introductory remarks. I’m Colonel Rakesh Jetly and I am the Senior Psychiatrist for the Canadian Armed Forces. I have various roles within the Canadian Forces Health Services, including the role of mental health advisor to the Surgeon General.
I have served since the late 1980s in various roles, including as a general duty medical officer and a psychiatrist in several deployed settings, including a recent mission in Kandahar. My current role includes being the head of our Canadian Forces Health Services Centre of Excellence, as well as the first occupant of the Canadian Forces Brigadier Jonathan C. Meakin’s Chair in Military Mental Health, which is part of the Institute of Mental Health Research, the IMHR, at the Royal Ottawa Hospital.
These last two positions allow future thinking and research initiatives to become a reality. The current evidence-based treatments for mental health conditions are the best we have ever had, but they do not work for everybody. As well, in the treatment of mental health conditions, not just within the military, there is a trial-and-error approach that can be frustrating to both clinician and patient. We simply cannot predict which treatment will work for a particular patient. This is in contrast to the staging and tissue typing that advises, for example, chemotherapy for breast cancer. Interestingly, recent literature has emerged that suggests the evidence-based treatments that work for civilian PTSD, such as rape and motor vehicle accidents, are less effective in veterans and active duty military. We cannot rely on the simple translation of civilian research.
Our research focuses on three main thrusts. The first is understanding the biological underpinnings of mental illness. We must understand what occurs within the brain and the rest of the body. We know more about brain circuits impacted, electrophysiology, hormones and other blood markers. This understanding will help make the invisible visible. These studies will also potentially give us objective markers of disease and recovery. We have many such ongoing studies.
The second thrust is leveraging technology. Science can, in 2018, analyze billions of data points to predict suicide, illness or resilience. We can develop apps and online treatments, and use video platforms for assessment and treatment. Neuroimaging can aid in objectively demonstrating treatment impact. Several studies are ongoing in this area. We have also developed an app for our Road to Mental Readiness program.
The previous two thrusts will contribute to the third, which is personalized or precision medicine. Using science and predictive analytics, we may be able to suggest treatments more likely to be successful, and thus reducing trial and error. We have two studies underway using genetics and electrophysiology of the brain to predict antidepressant response.
You have asked me here today to discuss the use of cannabis in the treatment of mental illness. The CAF feels there is insufficient evidence currently to suggest marijuana as a treatment for illness such as PTSD. As such, our policies do not permit reimbursement for marijuana, nor do our clinicians recommend its use.
We have evidence of the potential harm of marijuana, including apathy, depression, anxiety and psychosis. There is also an increased risk of cognitive difficulties and accidents. It should be noted that many medications we use also have significant side effects, but also have documented scientific evidence of benefit. Our policies, such as spectrum of care, do not permit us to deviate from evidence-based approaches.
Having said this, I’m compelled by the anecdotes and stories of those doing well using marijuana for a myriad of health conditions. I am excited by the potential benefits that lie undiscovered within the endocannabinoid system. Substances would not affect us if we did not have receptors in the body for them. Much like receptors for opioids and alcohol, there are natural receptors for cannabinoids and natural cannabinoids that the body makes. As an example, neuroimaging of the PTSD brain shows it lighting up like a Christmas tree when we look at the endocannabinoid system. Simply put, the endocannabinoid receptors are found in great concentration in the same region of the brain already well-established as important in PTSD.
Definitive research is needed to better understand this system and its potential. Our own CAF team published an article in 2014 on our small study demonstrating the efficacy of Cesamet, a synthetic endocannabinoid, in reducing PTSD nightmares. We need to establish the safety and efficacy of marijuana in the treatment of mental illness such as PTSD.
All three of our research thrusts should be utilized in such a study. Brain imaging and other biomarkers can measure effective change. There are over 630,000 ways of meeting the criteria for PTSD and that number is multiplied by potential co-occurring illness such as pain, addiction and depression. There clearly will not be one treatment that fits all. Perhaps marijuana helps one subpopulation, but not the others. Research will help us to identify these precise solutions.
I look forward to answering your questions. Thank you.
[Translation]
The Chair: Thank you very much, Colonel Jetly.
Before proceeding to our question period, I would like to note the presence of Senator David Richards from New Brunswick.
I now yield the floor to Senator Jaffer.
[English]
Senator Jaffer: Colonel Jetly, thank you very much for once again coming here. You have made yourself available so many times and we appreciate you working with us. One of the things that we have heard —I don’t know if this is what you see as well — is PTSD affects people differently, not just veterans, and at different times.
For somebody that was part of the Canadian Armed Forces and they leave, and maybe they suffer PTSD two years later, if that happens, what kind of help would a person get? Can they come back and say, “This was when I was in the army?” Do they get help? Is the answer, “No, two years is too long?” I’m just giving an example. Can you explain?
Col. Jetly: Sure. Once somebody has left, they never really leave the family. There are regimental families, and certainly there is caring, but from an administrative point of view, the responsibility then falls into Veterans Affairs. With many of our organizations, we have made many attempts with using the Legion, using Veterans Affairs. We’re trying to educate family doctors across the country. I go to UBC regularly and speak to the graduating medical school class so people have that number and that way to make that contact, the OSISS peer support.
If somebody is struggling, we’re trying to tell the family doctors in the provincial system that if you ask the question of whether they are a veteran, there is a whole suite of services they are eligible for, from treatment to financial support. Then, they would call Veterans Affairs, which would and determine the eligibility.
As the years have gone by, the benefit of the doubt has gone more and more. They will start assessment and treatment prior to the definitive diagnosis and link to service being made, so we’re continuing that journey.
One of the vulnerabilities, of course, is the person we don’t identify when they are still in. When they are still in, the transition can occur more easily. If they have left and gone to a smaller community, then it is a little bit more difficult, but we’re trying to make that easier and easier within government. They can access the health records now because we have been in electronic health records for years. Your file is no longer a big line-up to get photocopied. It’s basically a CD with your health records from the military, so it makes it easier.
Senator Jaffer: That is easily available?
Col. Jetly: They have to request it through some kind of a release. Then it’s available, yes.
Senator Jaffer: One of the things we have heard in our hearings is that, once a person leaves Canadian Armed Forces, they have to do all the testing again. Does that still exist?
Col. Jetly: Again, we can ask our colleagues at Veterans Affairs, but I would say no, they don’t. If we didn’t do the testing, if we didn’t make the diagnosis then, of course, they will have to be diagnosed. This is where I don’t want to mix up the two questions. If we have an established diagnosis of PTSD linked to military on their health records, that’s sufficient for Veterans Affairs to go with.
When they go to a Veterans Affairs clinic and they’re meeting the new clinical team, there will be an assessment. So, if I see a patient for the first time, I can’t necessarily just take the diagnosis from somebody else and run. There will be, again, an intake into a new clinic.
But from a pension eligibility point of view, if the illness was identified, diagnosed and linked to service within the Canadian Armed Forces, Veterans Affairs can use that to adjudicate the file.
Senator Jaffer: Now, I think last time we asked you about the issue of stigma.
Col. Jetly: Yes.
Senator Jaffer: So, if somebody was still in the Canadian Armed Forces and they were suffering from PTSD, does that automatically mean they have to be released?
Col. Jetly: No, absolutely not. What we’re trying to do is introduce the mental health continuum as well — green, yellow, orange and red — and it is getting away from the binary thinking of what healthy is.
Senator Jaffer: Can you explain the colours?
Col. Jetly: Yes. In our Road to Mental Readiness, I spoke yesterday about research and the importance of understanding your population.
When we looked at people’s attitude towards illness, there was a binary thinking where you are either healthy or you’re not. You’re sick or you’re not. Just like physical illness, if my back is sore, there is a difference between “It’s bugging me today” and “I can’t get out of bed.” And it can get worse and better as time goes along.
So we have created what’s called a Mental Health Continuum. We can bring you some pamphlets to explain how it works. You go from green, healthy; yellow, a bit affected — when you come back from deployment, everybody is kind of yellow — to orange and red. We have ways of checking. We have an app where you can actually check how you’re doing today, and it varies. The arrows go back and forth.
We tell people, “When you come back from deployment, you might have a little bit of trouble sleeping for a while. You might be a little sarcastic or irritable, and it should start to get better. If you find it’s not getting better or it starts to go into the other ones, then seek help.”
We’re trying to have people not self-diagnose a disease, but just say, “I feel good” or “I feel shitty” or “I feel this and it’s not getting better.” We are teaching people how to recognize it in each other.
The idea, then, is like we said, one of the biggest barriers to care are people not understanding they have an illness. If you look there and do a self-assessment and say, “Hey, I’m kind of here,” or you say to your colleague, “Hey, you’re kind of” — and I have patients now come and say, “Hey, doc, I think I’m in the orange.”
So we have created this way, which is non-stigmatizing. It’s just looking at how you’re feeling, how you’re sleeping and how you’re interacting with your buddies. If you notice a change in yourself or you notice it in your buddies, then deal with it, and part of dealing with it might be seeking help. We’re trying to work on it that way.
Senator Jaffer: My last question is the gender differences in medical cannabis. Are there gender considerations to take into account with respect to medical cannabis? For example, are there indications that cannabis would affect women differently than men?
Col. Jetly: You’re speaking to exactly the need for more research. Once we start looking at cannabis, we have to start thinking about its role in the menstrual cycle, its role in pregnancy and its role in lactation. Does it get into breast milk? I know it’s fat soluble, so I imagine there is risk of that, but I’ve read that there aren’t pharmaceutical studies per se that have looked at those details. I would say we definitely should be thinking about it. There are different brains, different hormones and different interactions.
In the research we do have to look at that, but I don’t know if we have enough to say what the differences are yet.
Senator Jaffer: Are there barriers between men and women for the use of medical cannabis or are there no barriers?
Col. Jetly: In the forces, neither of them can. But I think in the civilian world, no, not as far as I know.
Senator Jaffer: Thank you.
Senator Boniface: Thank you very much for being here again. I’m very interested in what you see as the potential of looking at how cannabis may be done.
You made some reference here to sort of anecdotal information. Is there any plan in place to collect some of that data or to do some baseline data within the Armed Forces?
Col. Jetly: What we’re hoping to do is not the definitive study, but a definitive study looking at treating people with PTSD and using — again, there are many types of PTSD, there are many types of marijuana, there are different ways of taking it and therein lies the problem. There are over 100 active products in marijuana. The ones that are mostly talked about in the health field, which is a bit of an exaggeration, is THC versus CBD, the two different ones.
In an ideal study, what one would do is take people and give the same person different levels of CBD versus THC and a placebo over time and look at the effect it has.
The ultimate study, though, would not just ask, “Do you feel better?” I think that’s the confounding thing, because just like opiates, there is pain relief and then there is feeling warm and fuzzy. For years, we have struggled with which part of it helps people with dental pain or backache? That warm and fuzzy is actually a good feeling as well, so is the intoxication of marijuana a substitute for feeling better?
When we did the study with Cesamet, which is the synthetic endocannabinoid, we demonstrated that the nightmares went down compared to placebo. People actually reported having fewer nightmares, not just, “I felt better.”
But if we did the ultimate study, we would do neuroimaging. You would show the changes in the brain and if those changes are quieting. We’re doing a study using neurofeedback looking at the brain, and we have demonstrated the amygdala, which is the part of the brain that gets excited in PTSD, actually goes quiet after this treatment.
With marijuana, we can look to see the changes in the brain. We can also look at markers in the body such as inflammation. It has been purported to be good. There is a lot of inflammation in people who have PTSD and mental illness and they have more pain. So we can measure sleep, pain, neuroimaging, quality of life, all of those things to really demonstrate the efficacy but also the safety. We have to look at both things.
That would be the ideal study that we would hope to do in partnership with Veterans Affairs fairly soon.
Senator Boniface: Do you foresee with the legalization that there may be greater openness to this type of a study?
Col. Jetly: I don’t think there is a lack of openness. I really want to separate in my head the whole legalization versus this.
I had a discussion with our previous Surgeon General two years ago. We were driving to Petawawa to visit some troops, and I remember discussing how excited I was about this. We have a policy, but we’re going to participate in research. If science says to me that we use cocaine in ENT, so to me “elicit” versus “illicit” doesn’t matter.
My leadership is completely open to exploring this from a medicinal point of view, because if there is something that can help people that conventional treatments don’t help, we are interested in that.
Senator Boniface: Thank you.
Senator McIntyre: Thank you, Colonel Jetly, for your presentation.
There are mental health programs available at both larger and smaller Canadian Armed Forces bases. In addition, as I understand it, there are Operational and Trauma Stress Support Centres. Could you elaborate a bit on those programs and tell us a little bit about the centres and the operation of those centres?
Col. Jetly: Sure. In a way, thinking about the OTSSCs, those are on our larger bases. When we think about military bases, there are very large bases, intermediate bases and small bases. Technically, if you look at stations versus bases and all of that, there are about 31 across the country and all of them have an element of mental health services. It can range from a couple of social workers to 50 professionals.
The OTSSCs in many ways are on the bases that have the largest populations. Around the late 1990s, after Rwanda, Somalia and the former Yugoslavia, when we started to become more focused on the potential PTSD, we created these operational trauma and stress or PTSD clinics, if you will.
As I mentioned the other day, the only outcome isn’t PTSD after trauma, so that’s why we didn’t call them PTSD clinics because people can be depressed, have substance use problems and all that.
We created five originally, and we added to seven. They are basically the two navy bases in Halifax and Esquimalt, and then our army bases across the country: Gagetown, Quebec City, Valcartier, Petawawa. We have one in Ottawa, as well, because of our large population, and Petawawa and Edmonton.
The Operational Trauma and Stress Support Centres have gathered, over the last almost two decades — I ran the one in Halifax for a number of years — specific expertise in the treatment of psychological trauma and the consequences. We use a team-based approach which separates us from the usual public systems where you have the stovepipe between therapists and doctors, and OHIP pays for some things and not others. We have psychiatry; psychology; mental health nursing; social work; specifically trained padres, chaplains, that have specific mental health training and counselling training; and addiction counsellors. They are all part of the specialized team that works together with a team-based approach.
If we assess someone and diagnose that someone has PTSD, but in discussion with our team, the most important thing for that person right now might actually be couples therapy, as opposed to diving into the treatment of PTSD. We have our social work colleagues that can focus on that, because at some point, whether the spouse is going to stay or not over the next couple of years may trump whether or not we dive into the PTSD treatment.
It’s an evidence-based, team-based approach across the country, and on these larger bases we have that. On the smaller bases, there is the expertise still, depending on the bases you’re at, but the larger centres have the gathered the main expertise.
Senator McIntyre: What about the treatment of PTSD among members of the military? Are those programs and treatments available? What treatments are currently the most successful?
Col. Jetly: The most successful treatments by evidence are the exposure-based therapies, which is the prolonged exposure. It’s a phase-oriented approach. The first phase is to settle people down, maybe treat the drinking, the marital difficulties, and correct sleep or depression. We are teaching them skills to relax.
Once that occurs, most of the treatments involve what is called an exposure-based approached, which is exposing them to the thing that traumatized them in the first place, and then using classical conditioning types of things, such as desensitization and habituation. It lessens the sharpness of those memories that are over-remembered.
One way of thinking about it is if I asked you to watch the scariest movie you have ever seen, you watch it with one eye open. If you watched it 10 days in a row, on the tenth day it would bother you less.
EMDR — Eye Movement Desensitization and Reprocessing — prolonged exposure, the cognitive processing therapy, these are classic therapies. The problem with them is they don’t work for everybody, and there is also a high dropout rate. They are extremely hard.
My colleagues in NATO and some of us are a bit critical of them. They are all based on a fear-based paradigm of PTSD, like an anxiety, and there are limitations to that. We have been talking more and more that maybe people don’t get better because of guilt and shame. Maybe there is a moral injury component or, maybe, “I don’t deserve to get better.”
We see people who have been completely compliant in treatment. We need to listen to our patients and try to figure out what exactly is bothering them. Let’s not assume it’s this thing. It could be seeing that child in the gutter.
We have an international consortium with seven or eight countries that are looking at operationalizing this moral injury, guilt, shame and things.
Senator McIntyre: Some researchers told the subcommittee that PTSD experienced by military members is not the same as PTSD experienced by civilians, and that it does not respond as well to treatment.
Col. Jetly: It responds less, as I said.
Senator McIntyre: What are the major differences? What are the reasons for these differences?
Col. Jetly: Reasons? That’s the million-dollar question. I wish we knew.
As I just touched upon, I think the role of moral injury, shame, guilt, anger — those are humiliation. I think that’s a very unique and compelling part of our story.
Feeling let down by your country, let down by the people of the country, let down by your government, your leadership, sometimes that becomes a swelling piece.
There is a great book by our colleague Charles Hoge, called Once a Warrior —Always a Warrior. He is a retired colonel from the United States.
The other thing is the civilian PTSD literature often talks about “victimhood.” There is a whole language and culture around this. Soldiers in a Western army, a volunteer military that goes to war, don’t consider themselves victims of war. There is a whole different way of thinking about this kind of injury than the victimhood.
There are many differences. That’s why we need to do research on our own population and not necessarily rely on research that has been done on motor vehicle accidents, rape victims, and things like that.
Senator McIntyre: In other words, more research is needed.
Col. Jetly: More research on our own population, absolutely.
Senator Richards: Thank you very much, colonel, for coming. My question was pretty well answered. I was wondering if there was any therapy beyond marijuana medication for people.
People have talked to me about this and said I’m wrong, but my thinking is that it masks the problem rather than cures it. Most of these men and women probably self-medicate before they ever get to see a psychiatrist or someone, because they are in trouble and in pain. Self-medication might not stop with the therapy, and I’m wondering if there were other means of addressing PTSD. You kind of answered it when you answered Senator McIntyre.
Col. Jetly: That’s a very important question. I’m a psychiatrist. I’m a medical doctor. I prescribe medication, but the cornerstone treatment of PTSD is psychotherapy. It’s not medication. That’s really important.
Thank you for bringing that point up. The medication quiets the noise to allow the therapy to occur. What you have is an over-consolidated memory. You remember something too well. Normally, memories go fuzzy. If a woman remembered how painful childbirth was, she would never have a second baby, right?
These memories from trauma are over-consolidated. They are too strong. Making sense of the trauma and connecting the effect and emotions with the memory, so taking it from your desktop into your hard drive, we don’t have a medication yet that can do that, so it’s going to be talk therapy.
What we want to do is try to quiet the noise, try to fix the depression, and get them sleep. Sometimes we need to use medication for that.
Hopefully, there won’t be anyone who works in the trauma field that suggests that medication alone is the treatment for it.
With our own nightmare medications Cesamet and prazosin — we use a few specific elegant little medications — most of the time if people stop taking them, the nightmares come back. So you’re not actually treating the illness, which is okay. You might have a chronic pain condition. The pain meds help you with the pain, but the nightmares will go away once the memory has been consolidated, so psychotherapy is a must.
Senator Richards: Thank you.
[Translation]
The Chair: Before we conclude, Colonel Jetly, I’d like to ask you a question, which I may already have asked when you appeared before the Standing Senate Committee on National Security and Defence. We are talking about treatment for members of the military, but if this also affects family members, will you also provide treatment for family members, spouses and children?
[English]
Col. Jetly: The Canadian Armed Forces and the literature recognize the impact on families in very broad ways. There is the impact from simply having an ill person in the family that can occur, whether it’s psychological, physical or chronic illness. There is also an interesting intergenerational effect of PTSD that is an epigenetic phenomenon.
We are limited by the Canada Health Act in terms of how much direct care we can provide to families in that traditional medical model of care, but we stretch that definition to the absolute maximum that we can.
If someone is suffering from PTSD right from the early assessment phase, we invite the spouse in to get an understanding of the spouse’s experience, the collateral. We can do it under the guise of how we can help the member. Of course, the member’s confidentiality will dictate whether or not the spouse comes in. So couples therapy for the spouse.
Across the country, we run spousal groups. We will have six or seven sessions where we will have an “ask the expert.” One might be talking about medication and one about self-care, to help the spouses that way.
Our Military Family Resource Centres have more and more things in place specifically for this in the sense that they have social workers in place to help families. There is emergency babysitting and all the different programs we have.
Our Road to Mental Readiness has a family module, our resiliency training and specific things aimed for families. There are more and more things being developed with our civilian partners. There is a comic book to help children understand what it is like when Mom and Dad are sick. There is a huge emphasis on trying to help them, short of direct care for mental illness in a spouse. Again, that’s the Canada Health Act which limits that for us.
[Translation]
The Chair: Thank you for your testimony, Colonel Jetly. We have kept you busy this week. You appeared before the Standing Senate Committee on National Security and Defence Monday, and today, you are here before our committee. Your testimony will be very helpful when we prepare our report. Once again, thank you for having made yourself available.
(The committee adjourned.)