THE SUBCOMMITTEE ON VETERANS AFFAIRS
EVIDENCE
OTTAWA, Wednesday, April 27, 2022
The Subcommittee on Veterans Affairs met with videoconference this day at 12:02 p.m. [ET] to examine and report on issues relating to veterans affairs, including services and benefits provided, commemorative activities, and the continuing implementation of the Veterans Well-being Act.
Senator David Richards (Chair) in the chair.
[English]
The Chair: Honourable senators, welcome to this meeting of the Subcommittee on Veterans Affairs.
I am David Richards, a senator from New Brunswick, chair of the subcommittee. I will introduce my fellow subcommittee members: Senator Boisvenu from Quebec, deputy chair; Senator Anderson from the Northwest Territories will be joining us a little later; Senator Boniface from Ontario; and Senator Yussuff from Ontario.
Those participating virtually are asked to have their microphones muted at all times unless recognized by name by the chair and will be responsible for turning their microphones on and off during the meeting. Before speaking, please wait until you are recognized by name. Should any technical challenges arise, particularly in relation to interpretation, please signal this to the chair or the clerk, and we will work to resolve this issue. Finally, I would like to remind all participants that Zoom screens should not be copied, recorded or photographed. You may use and share official proceedings posted on the SenVu website for that purpose.
Today we begin our study into issues relating to Veterans Affairs, including services and benefits provided, commemorative activities and the continuing implementation of the Veterans Well-being Act. During this meeting, we will examine emerging treatments for Canadian Armed Forces and Royal Canadian Mounted Police veterans suffering from occupational stress injuries.
We welcome, from Veterans Affairs Canada Dr. Alexandra Heber, Chief of Psychiatry, accompanied by Crystal Garrett-Baird, Director General, Policy and Research Division, as well as Dr. Barbara O. Rothbaum, Executive Director, Emory Healthcare Veterans Program and Associate Vice Chair of Clinical Research, Department of Psychiatry, Emory School of Medicine.
Thank you for joining us today by videoconference. We will begin by inviting you to provide your opening remarks, to be followed by questions from our members. We will open with Dr. Alexandra Heber.
The floor is yours, Dr. Heber.
Dr. Alexandra Heber, Chief of Psychiatry, Veterans Affairs Canada: Thank you, Mr. Chair and members of the committee. My name is Dr. Alexandra Heber. I am a Canadian Armed Forces veteran and the Chief of Psychiatry for Veterans Affairs Canada, or VAC. I am here today with my colleague, Crystal Garrett-Baird, who is the Director General of the Policy and Research Division at Veterans Affairs Canada.
It is our pleasure to speak with you about psychedelics and psychedelic-assisted psychotherapy as a treatment for mental disorders, including PTSD, and particularly about the use of psychedelics for treating VAC’s client population.
I am also an associate professor in the Department of Psychiatry and Behavioural Neurosciences at McMaster University, and I am co-chair of the Canadian Military Sexual Trauma Community of Practice, a group of researchers, clinicians, government policy-makers and people with lived experience of military sexual trauma, or MST, who meet regularly to discuss and work together to promote understanding, knowledge mobilization and support for those who have experienced MST as well as to help effect culture change in the Canadian Armed Forces. I tell you this because I see that several of you have listed MST as an interest on your biography, and I would like to expression my appreciation for that.
I also want to acknowledge that I am speaking to you from Ottawa, which is built on the unceded Algonquin Anishinaabe territory. The peoples of the Algonquin Anishinaabe Nation have lived on this territory for millennia. Their culture and presence have nurtured and continue to nurture this land. We who have lived here have a duty to honour and to continue to honour the peoples and land of the Algonquin Anishinaabe Nation.
At Veterans Affairs Canada, our mission is to provide exemplary, client-centred services and benefits that respond to the needs of veterans and their families in recognition of their service to Canada. Under the Canada Health Act, all residents of a province, including veterans, are entitled to receive health services under their provincial or territorial health care plan. But we know that there are a number of mental health care services, such as psychotherapies delivered by non-medical licenced and regulated health care providers, that are not generally covered by the provinces, so for eligible veterans, VAC pays for many services like this that are not covered. However, VAC does not directly deliver health care. Rather, we support our veterans by funding certain services not covered by the regular health care plan.
In 2016, VAC created the Mental Health Treatment Review Committee to provide recommendations to our senior health benefits committees on treatments to support the mental health of our veterans. Guiding principles used to make these recommendations include that the treatment is evidence-based, supported by published peer-reviewed literature and focused, when possible, on veteran health, and that the treatment is approved by Health Canada, is not experimental, has an acceptable safety profile, is cost-effective, aligned with treatments used in the Canadian Armed Forces and the RCMP and, to the extent possible, is gender and culturally sensitive.
In September 2021, the Mental Health Treatment Review Committee addressed the question: What is the current scientific evidence with respect to the use of psychedelic-assisted psychotherapy to treat mental health conditions, including PTSD?
Based on our review of the literature and deliberations, the Mental Health Treatment Review Committee did not recommend the use of psychedelics or psychedelic-assisted psychotherapy at this time. The findings that led to this decision were that although there is emerging evidence that psychedelics may have therapeutic potential, the sample sizes in many of the studies were small, follow-up times were relatively short, and long-term benefits and risks are not yet well established. There is insufficient data on risks to persons with psychotic disorders or those at risk for psychosis, those with dissociative disorders — which are disorders that are often suffered especially by people with very chronic PTSD — and also people who suffer from suicidality or those with a family history of these issues. There isn’t yet good data on the risks to those populations.
In much of the research, the types of psychotherapies used are not standardized or well-described, and there are questions concerning expectancy bias and the lack of blinding or sometimes lack of objectivity of the researchers doing the research. As well, an important number of the published studies have been funded by a single advocacy group. Of note, in Canada, the Canadian Institutes of Health Research, or CIHR, has recently announced plans to fund research into the use of psilocybin-assisted psychotherapy for mental health and substance use disorders.
Ensuring veterans’ health, safety and well-being is our top priority. Once, or if, there is sufficient scientific evidence available to support psychedelics as a safe and effective treatment for our veteran population, we will adjust our benefit grids and formulary accordingly.
Thank you. Ms. Garrett-Baird and I will be happy to answer any questions.
The Chair: Thank you very much, Dr. Heber, and I do apologize for mispronouncing your name earlier. We will go to Dr. Rothbaum so she could give her statement. Thank you.
Dr. Barbara O. Rothbaum, Executive Director, Emory Healthcare Veterans Program and Associate Vice Chair of Clinical Research, Department of Psychiatry, Emory School of Medicine, as an individual: Thank you for inviting me here today. I am going to focus my comments on PTSD and innovative treatments for PTSD, particularly for veterans.
The treatment that has the most evidence of its efficacy for PTSD is prolonged imaginal exposure, or PE. The primary therapeutic technique of PE is imaginal exposure. In imaginal exposure, we ask the patient to go back in their mind’s eye to the time of the traumatic event and recount it out loud, in the present tense, repeatedly. We tape record that recounting and ask the patient to listen to it every day for homework.
We include what’s called in vivo exposure, which just means “in real life.” For in vivo exposure, we help the patient confront real life safe situations that they avoid. Typical examples of in vivo exposure for our veterans include driving in traffic, sitting with their backs to the door or being in crowds.
Other treatments that have been empirically supported for PTSD include Cognitive Processing Therapy, or CPT, and Eye Movement Desensitization and Reprocessing, or EMDR.
New approaches to treating PTSD include the medium of delivery of exposure therapy. Virtual reality is an interactive computer environment in which the user experiences a sense of presence in the environment. It is a 365 degree totally immersive environment. The user wears a head-mounted display that contains a little screen in front of each eye, headphones and a position tracker that tracks head movements and responds accordingly in real time. The immersive nature of VR makes it amenable to using it for exposure therapy. VR exposure therapy has been successful in treating phobias, addictions, fear of public speaking, fear of flying and PTSD, among others. Regarding veterans with PTSD, we have found VR exposure therapy successful in treating Vietnam veterans, survivors of military sexual trauma and post-9/11 veterans.
Another advancement from standard care is enhancing psychotherapy with pharmacological agents. Most of the studies with PTSD patients do not show an advantage of adding SSRI, which is selective serotonin reuptake inhibitors, medication to PE therapy. There has been exploration of combining novel medications to psychotherapy for PTSD, what some have referred to as “rational pharmacotherapy,” in which the medication facilitates the processes of the psychotherapy in a synergistic manner.
This leads us to another area that has received much attention recently, and that is for MDMA-assisted psychotherapy. Many in the field expect MDMA to be the next medication to receive FDA approval for PTSD in the United States. We have been conducting translational research with MDMA and found that MDMA facilitated the extinction of fear in an animal model, and in healthy humans we found significantly more participants in the MDMA group retained extinction learning compared to the placebo group. We believe that extinction is one of the mechanisms underlying the success of PE therapy. Therefore, we believe that MDMA may enhance PE, especially for those who have been treatment resistant. We will be testing MDMA added to PE in veterans who have not responded during our two-week intensive outpatient program in the near future. Just to note, PE is not the therapy that has been used in the MDMA-assisted psychotherapy clinical trials, but we believe it could have advantages in that PE is shorter and more efficient, is an evidence-based therapy that has been disseminated worldwide and the training is shorter and more available.
I’ll now turn to a third innovation, and that is the timing of exposure therapy for PTSD. The majority of patients with PTSD are treated years or decades after the index trauma, at which point PTSD has become chronic and often results in other negative sequelae on physical and mental health. We have conducted studies in the emergency room offering a modified version of exposure therapy immediately following exposure to the traumatic event. Patients who received the early intervention had half the rate of PTSD three months post-trauma as those who were assessed only. The early intervention also appeared to mitigate a genetic risk for PTSD.
The final innovation to standard treatment that I would like to discuss today is massed PE treatment. Most psychotherapy is delivered in weekly sessions. Patients with PTSD drop out of treatment at about a 50% rate.
The Emory Healthcare Veterans Program offers a two-week intensive outpatient program in which we are able to bring in post-9/11 veterans from all over the United States. We transport them, house them, feed them and treat them, all at no cost to the veteran due to our funding from the Wounded Warrior Project to support the Warrior Care Network.
We offer daily individual imaginal exposure therapy with their individual therapist as well as a two-hour in vivo exposure therapy daily. We provide psychotherapy, pharmacotherapy, cognitive rehabilitation for those with mild traumatic brain injury, stress management skills, sleep training and education and sleep tests, wellness such as yoga and acupuncture, family education and counselling and assistance navigating the VA system. During the COVID-19 pandemic, we pivoted to offering this intensive outpatient program via telemedicine. We have specialty tracks for mild traumatic brain injury and substance use disorders.
Overall, we have a 93% completion rate in our intensive outpatient program. I am convinced that this is the best way to treat PTSD. It’s very effective therapy with clinically and statistically significant improvements in PTSD and depression during the two-week period that are maintained up to a year post-treatment. Patients who participated via telemedicine receive similar improvements as patients who are treated on site. We have shown that when we successfully treat the PTSD symptoms, suicidal thoughts decrease.
It has been my honour to present some of the recent innovations in PTSD treatment, and I am happy to participate in any discussion. Thank you.
The Chair: Thank you very much, doctor.
We will now open it to questions. I ask that you keep your questions succinct and that you identify which witness your question is directed to. I will go to our deputy chair, Senator Boisvenu from Quebec.
[Translation]
Senator Boisvenu: I’d like to welcome our witnesses. My first question is for Dr. Heber. You say that you don’t directly provide therapeutic or psychiatric services, but you do fund them. Did I understand correctly?
[English]
Dr. Heber: That is right, yes.
[Translation]
Senator Boisvenu: So that means you have no direct contact with military and veterans affairs clients? Is that my understanding as well?
[English]
Dr. Heber: I am in contact with veterans regularly; however, I am not treating them. They are not my patients. I work with veterans in a number of ways in the community, listening to what they have to say about the services of Veterans Affairs Canada, which is information that I take back to my organization, but we do not provide direct patient care at Veterans Affairs Canada.
[Translation]
Senator Boisvenu: That surprises me. If I understand correctly, you are the Chief of Psychiatry for Veterans Affairs Canada?
[English]
Dr. Heber: That’s correct.
[Translation]
Senator Boisvenu: How can you gauge how effective your treatment is if you have no direct contact with veterans?
[English]
Dr. Heber: Treating veterans directly is, of course, one form of information that is gathered by clinician scientists. However, if you think about it, that is based on one example with one person. For the information we gather, we look at the worldwide research that has been taking place on any treatment, and we also enlist some of our organizations that specialize in conducting reviews for us. At our Mental Health Treatment Review Committee that I was explaining to you, we have clinicians and clinician researchers from across the country who work in our Operational Stress Injury Clinic, so they are both seeing patients who are veterans and they are also conducting research. They are part of our committee.
[Translation]
Senator Boisvenu: If you are chief of psychiatry, how many psychiatrists work with Veterans Affairs Canada?
[English]
Dr. Heber: There are no other psychiatrists at Veterans Affairs. We have a team of mental health professionals, but we don’t have any other psychiatrists.
[Translation]
Senator Boisvenu: So you are the only psychiatrist and you are chief of psychiatry.
Dr. Rothbaum, if we compare the two approaches to treating post-traumatic stress in veterans, that is, the increasing use of psychedelic drugs, and your project — you talk about memory reactivation — which of the two approaches is more successful in treating our veterans with psychological scars?
[English]
Dr. Rothbaum: Thank you. This gives me a chance to clarify.
The psychedelic drugs are not like other medications. They are not like the SSRIs, such as Zoloft, Sertraline or Prozac. The drug does not have the therapeutic benefit by itself; it is MDMA-assisted psychotherapy. It is the drug plus the psychotherapy — the synergistic effect of both together.
The psychotherapy that has been tested has been open-ended, supportive psychotherapy that does not require the patient to talk about the traumatic event. I’ve gone through that training, and we’ve seen the tapes. They say every single time the patient does end up talking about the traumatic event, and they know that’s why they are there, but the therapist doesn’t direct them to talk about it; the patient talks about it when they are ready. The difference is in the type of psychotherapy that we do, which is prolonged exposure. That’s the focus of psychotherapy.
[Translation]
Senator Boisvenu: Do you deal directly with veterans?
[English]
Dr. Rothbaum: Yes, sir.
The Chair: Senator Boisvenu, I will put you on a second round.
Senator Boniface: Thank you to the witnesses for being here. I had some connection issues, so I apologize for missing the early comments by Dr. Heber.
I’m interested in the two-week program you spoke about, Dr. Rothbaum. I’m interested in the timeline. I may have missed in your opening comments how long that has been under way and your early results on the intensiveness. To what do you attribute its success rate? And please provide any other facts you think we should be aware of.
Dr. Rothbaum: Thank you.
Our doors have been open for about seven years — almost eight years — and we have treated about 700 veterans in our two-week intensive outpatient program, or IOP.
I attribute the success of the therapy to using evidence-based psychotherapy. Everything we’re doing for the veterans is evidence-based.
I attribute the retention rate to the intensive outpatient format. PTSD is a disorder of avoidance, and that includes treatment. As I mentioned, it has about a 50% dropout rate from regular therapy. Our veterans have to make the decision to come only once, so they make the one decision to come. Then we have a lot of support. We have a wonderful team of providers, social workers and veteran outreach coordinators. If the veteran doesn’t show up on a particular day to therapy, we send the veteran outreach coordinator to their hotel room to knock on their door and help bring them over.
We have a two-week program, but we start a new cohort of veterans every Monday, so at any given point, people are in their first or second week of treatment. It’s amazing what a difference a week makes in intensive treatment. In that way, the veterans who are in the second week can also be supportive of the veterans in their first week and give them the message that, yes, this is hard but stick it out and it will be worth it.
I think the intensive outpatient model is really what helps the retention. If we retain them, then it adds to the efficacy.
Also, I will add that obviously not 100% of people improve. We’ve seen enough veterans now that we can pretty much tell by the end of the first week if they are on the trajectory to receive the full benefit or not, and we’re offering some augmentation approaches in the second week. For example, we’re offering RTMS, repetitive transcranial magnetic stimulation, and that is where we might be offering the MDMA-assisted PE to those veterans who have not received the full response.
Senator Boniface: Thank you for that.
If I understood your comments correctly, there is a follow-on after the two weeks for up to a year. What does that look like?
Dr. Rothbaum: We assess them at 3, 6 and 12 months once they leave our program. We have just published a longitudinal study, and 85% of the veterans who go through our program achieve large improvements during the two weeks that they maintain in that year, and there are about 15% who don’t.
Senator Boniface: That is great.
Do you know of any other countries that are taking this sort of approach?
Dr. Rothbaum: There are four of our sites, and we’re all a little bit different, within the Warrior Care Network in the United States. In the Netherlands, they have an intensive outpatient program — and we’re colleagues with Dr. Agnes van Minnen’s program — and they also have an excellent retention rate and excellent clinical response rate. Also, in the U.K., Dr. Anke Ehlers has an intensive outpatient program as well.
Senator Boniface: Thank you. That is exactly what I was going to ask.
Senator Yussuff: This question might be more to Dr. Rothbaum in terms of your approach and the work you are doing. Given the longitudinal study that you have done and, of course, the evaluation of your approach, do you believe that this new approach that your clinics are taking holds the best opportunity in how we treat PTSD, from your perspective? That’s given that some of this work is still evolving, but I thought I could get your thoughts.
Dr. Rothbaum: Yes, sir, I do. As I said, I think PTSD is a disorder of avoidance, and these are the best retention rates. I have been studying PTSD since 1986, and these are the best retention rates in therapy, with effective therapy, that I have ever seen. I really do like the intensive outpatient approach. In doing a review of the literature of other intensive outpatient approaches, the retention rates are generally in the high 90s or even 100%, so it’s not just our findings.
Senator Yussuff: If I may, on a follow-up, given what you describe as a success, have other countries that are treating veterans been wanting to know about your research and trying to learn from your experience about how your program could be adopted in other centres around the world? Of course, as you know, it’s not just a U.S. phenomenon. It’s a phenomenon for most developed countries that have veterans who have been in the same kind of theatres as the U.S. veterans over the past couple of decades.
Dr. Rothbaum: Yes, sir. As part of evidence-based medicine, we write and publish treatment manuals so that others can more easily follow our model. We have written treatment manuals for PE, for prolonged exposure therapy, that have been translated into, I think, nine languages. We have also recently written a manual describing the IOP, the intensive outpatient program. That’s available. I work with a number of colleagues around the world, particularly in Australia. I’ll be speaking in Israel in the fall; they are interested in these approaches as well.
Senator Yussuff: I have one quick follow-up. Given the success that you have seen in your approach, what advice would you offer us in terms of a Canadian perspective on how to benefit from your experience? Our committee will conclude this work and put together a report. What advice would you offer us that would be useful for helping our veterans here, especially with the challenges that we have faced, like other countries, in dealing with PTSD? We want to help our veterans in this country’s programs. To some degree, the programs have worked, but we know we have some tremendous work ahead of us. With new areas of research, it is always more helpful to understand how we can better support our veterans to ensure they can get back to a normal life.
Dr. Rothbaum: Yes, sir. I would recommend developing and implementing the intensive treatment programs. I have done several trainings in Canada over the years and decades. I also know you have large numbers of veterans out in less populated regions — as it was referred to me — the wild, wild west. A lot of areas don’t have access to trained providers. Bring them into a central location to treat them and then send them home better, hopefully with support services and now with telemedicine as support and with follow-on services. That would be a great approach. Our VA system in the United States now has some model intensive outpatient programs that they are developing that we have been consulting with as well.
Senator Yussuff: Thank you for your time.
[Translation]
Senator Boisvenu: I have a few questions for our two guests. I’d like to thank them for being here. Dr. Heber, based on your knowledge and research, when a veteran asks for psychological support or services of that kind, approximately how long do they have to wait to obtain those services?
[English]
Dr. Heber: Thank you for that question, Senator Boisvenu.
In Canada, as you may know, at VAC, although we do not provide direct service to veterans, we fund service. When there are new programs that show evidence of being effective, like what Dr. Rothbaum is talking about, we will also finance to bring in experts to train therapists in Canada.
We also have a series of operational stress injury clinics across Canada, which Veterans Affairs Canada fully funds but which are administered by the provincial health authorities. These clinics are staffed by experts in treating veterans with PTSD, major depression and other service-related mental-health injuries.
[Translation]
Senator Boisvenu: Dr. Heber, I’m sorry to interrupt you, but the Subcommittee on Veterans Affairs is doing a study on the quality of services provided to veterans suffering from post-traumatic stress disorder. Here is what I want to know: When a veteran requests psychiatric or psychological services, how long does it take for them to obtain those services? I’m concerned about this, because I want to know if these individuals are left on their own for months. When they use the services of businesses funded by you, how long does it take for them to obtain the services they are requesting?
[English]
Dr. Heber: There is, of course, variability across the country, but I will tell you this as well. What Dr. Rothbaum was talking about reminds me of one of the programs that has been set up. It was originally in the Deer Lodge Centre in Winnipeg. It has been adapted by some of the other OSI clinics. When they have somebody who comes forward and asks for an appointment, there is a delay of a few weeks, so they have set up a program to bring people in, in small groups, to do what we call psychoeducation. They begin to teach people about their symptoms and about some basic ways that they can help themselves to reduce their symptoms before they are actually seen for their full diagnostic assessment and begin their treatment. There are aspects of that that are not the same as what Dr. Rothbaum talked about, but the idea is to bring people in as early as possible and give them, first of all, that collegiality — they are there with other people suffering with the same kinds of issues — and then begin to educate them about these conditions and some of the things that will happen in therapy and also how to help themselves in the meantime.
[Translation]
Senator Boisvenu: Thank you, Dr. Heber. Dr. Rothbaum, you provide services directly to veterans. In your opinion, how much time passes between them obtaining services with you and you being able to treat them?
[English]
Dr. Rothbaum: It’s our policy to return a phone call within 24 hours. We schedule their assessment within one week. We have a three-hour full psychiatric/psychological assessment. We schedule that within one week. Then if we determine that we’re the right place to treat them, we usually get them in anywhere from two to six weeks. Sometimes it depends on the veteran’s schedule and not ours when we’re bringing them in. And fortunately, we’re not full right now. We don’t have a long wait-list, but sometimes veterans will delay it because they need to arrange childcare or get time off from work, if they are working.
Senator Boniface: My question is for Dr. Heber. It’s a follow-up question from some work our subcommittee did a couple of years ago on the use of cannabis and its use for PTSD. One joint study was done by CAF and Veterans Affairs, out of the University of British Columbia; the other study was done by CAMH, in cooperation with the University of Toronto. Can you give us an update on whether those studies have been completed? If so, what were the results?
Dr. Heber: I am sorry, but I do not have the results. I don’t think they have been completed. I don’t have an update for you. However, I can get the information and send it to the committee as soon as possible.
Perhaps you have information, Crystal?
Crystal Garrett-Baird, Director General, Policy and Research Division, Veterans Affairs Canada: Thank you, Alex, and thank you, senator, for the question. There are a couple of things I can note on that.
We are engaged in a number of areas of research on cannabis, given that it’s an evolving area of study and course of treatment. Our goal is to ensure that we fund treatment benefits that have an overall positive impact on veterans. Some of our key areas of research right now, past, present and future-planned, are looking at indications for cannabis for medical use amongst VAC clients; looking at clinical guidelines for cannabis related to the treatment of pain; studying cannabis use disorder among veterans; and developing designs for more controlled trials. We’re working closely on this with academic universities across the country such as Canadian Institutes of Health Research and our Canadian Institute for Military and Veteran Health Research. Our research continues to inform our policy as we move forward.
I would like to make another point on access to mental health services and timeliness. This is not related to cannabis but to access of mental health services. As of April 1, 2022, Veterans Affairs Canada launched a mental health benefits initiative to ensure that veterans coming in with post-traumatic stress disorder, anxiety disorders or depressive disorders are able to have immediate coverage for their treatments, whether it’s prescription medication, access to counselling or a psychologist for a diagnosis or further treatment. That is recognizing the importance of ensuring our veterans have early intervention to treatment because we know that earlier intervention and access to those services gives them a better opportunity at recovery, rehabilitation and stabilization.
Senator Boniface: If I have time, I would like to ask a follow-up on that flowing from Senator Boisvenu’s question.
Let me go to the inquest that took place in Eastern Canada with the deaths of three family members. Have some of these deadlines and changes taken place as a result of what Veterans Affairs has learned through that inquest?
Ms. Garrett-Baird: If you’re referring to the Desmond inquiry, the results of that inquiry have not yet been released. We have been engaged with that, but our priority continues to be ensuring that our veterans have access to the benefits and services they need to ensure their health, safety and well-being.
Senator Boniface: I would hope that you’re monitoring it as you go along and looking at what gaps are being exposed and plugging those gaps along the way as opposed to waiting for the outcome. Would I be correct?
Ms. Garrett-Baird: Yes, very much. We have been monitoring the situation. We have had witnesses appear at the inquiry as well to provide information on how our system works and the supports that are provided. We continue to be engaged in that matter.
Senator Boniface: It’s a very important message.
The Chair: Thank you very much. Senator Anderson is having a bit of a technical problem, so we’ll go to Senator Yussuff.
Senator Yussuff: My question is to Dr. Heber. I want to get more clarity regarding the use of psychedelics. Last December, the Government of Canada, via Health Canada, allowed physicians to request restricted psychedelic drugs for patients as part of their therapy. What discussion, if any, has Veterans Affairs had with Health Canada about their views on the potential of psychedelics for treatment of veterans’ mental health disorders? How do those views differ between what used to be restrictions regarding access to these drugs now that they are making a combination of them to be used?
Dr. Heber: Thank you for the question, Senator Yussuff.
In September 2021, we did our comprehensive review of the topic of psychedelics and psychedelic-assisted psychotherapy to look at whether this was therapy where there was enough evidence at that time so that we could say yes, this would be something that we could support for our veteran population. We found that it is still preliminary. The evidence is promising, but it’s not strong enough yet.
One of the groups that we have spoken to is CIHR. They are putting money into some grants that will be announced shortly to fund psilocybin-assisted psychotherapy specifically. These grants are for three years, I believe, for researchers to study and look at the outcomes and the results.
In terms of Health Canada, a case came to light in March regarding a patient who was being seen in a clinic in British Columbia. This clinic was doing psychotherapy research that was funded by an organization in the United States. As I told you, one organization has been advocating for legalization of psychedelics. This organization has funded a lot of the current research that we have on psychedelics. In and of itself, it’s much better if we have multiple different places and particularly university-funded or, as with CIHR, government-funded research so that all research is not being funded by one organization.
It came to light that what was happening with this patient in B.C. with the psychedelic-assisted psychotherapy she was undergoing was very inappropriate. You can go on the CBC website and find a videotape about it. It’s actually quite shocking. After that came to light, Health Canada decided that they will now investigate psychedelics. They are taking a much more cautious approach, and they have suspended their plans around psilocybin- and MDMA-assisted psychotherapy until they can investigate further what happened in this case and what controls are in place.
In reading the literature, it’s not always clear what is happening in the psychotherapies, unlike what Dr. Rothbaum talked about. With prolonged exposure, which we have had for a long time, it’s very well researched and manualized. People are taught how to do it, and you do it in the same way. It’s very prescriptive. What happens, at least currently, in these psychedelic-assisted psychotherapies is not really clear.
The second thing is that we must remember that we have people who are under the influence of these drugs that really change how they are experiencing their reality. We have an extra responsibility to make sure that they are safe in these situations.
The Chair: Senator Anderson is still not available, so I’m going to jump in with a quick question to Dr. Rothbaum. Is your method of treating PTSD and patients a national program, or is it based out of Emory? How many veterans facilities use or might be using your methods to alleviate PTSD in the United States?
Dr. Rothbaum: Thank you. I assume you’re referring to the intensive outpatient program, our two-week program.
The Chair: Yes, I am.
Dr. Rothbaum: We are part of the Warrior Care Network that is funded by a large grant from the Wounded Warrior Project, so private philanthropy, and there are four sites in the United States. We are geographically located: Us in Atlanta; the Operation Mend Program at UCLA in Los Angeles, California; the Road Home Program at Rush University in Chicago; and the Home Base program Mass General at Harvard in Boston. We’re part of the Warrior Care Network, and there are four of us. Everyone is a little bit different. We are the only one based on prolonged exposure. Two of the programs use CPT, and others use a mixture of therapies.
The Chair: What percentage, in your professional opinion, of veterans are coming back suffering from PTSD? How high is it? What range would you think? The varying degrees of severity would be different, but what would be the range? Would it be 90% or 80%? What would you think?
Dr. Rothbaum: I don’t think it’s that high, luckily, because it’s an awful disorder to have. It disrupts health, well-being and relationships. We estimate that approximately 20% of veterans returning — especially from Iraq and Afghanistan — are suffering from clinically significant PTSD.
The Chair: Okay. Thank you very much.
You said you have a treatment manual. I’m wondering if you could send that to our committee. I would really appreciate it.
Dr. Rothbaum: Yes, sir, I’d be happy to.
I just became aware of and saw the video of the MDMA patient from British Columbia. I would just make a note that it sounds like that therapist was not licenced, so that’s a consideration.
The Chair: Right. Okay. Thank you very much.
Senator Anderson, if you can get a question in, I would be happy.
Ericka Dupont, Clerk of the Committee: Senator Anderson, unfortunately we’re still unable to hear you. Is it possible to perhaps send the question in the chat so we can read it out? If it’s long, that might be unreasonable, but we can try.
I see the question here. Is there a difference in services between the Northwest Territories and the South in terms of access to timely service? Specifically for veterans in the North of Canada.
Ms. Garrett-Baird: I’m happy to respond to that, Dr. Heber, if you would like.
As noted by Dr. Heber, within Veterans Affairs Canada, our responsibility is to ensure we provide coverage for these treatment benefits for veterans, so veterans work with their health care professionals across the country. We know, of course, that in areas like rural and remote areas, Northern Canada, there may be challenges with accessing those providers. There is a network of satellite OSI clinics, and there are approaches to virtual or telehealth that we are also able to support through the department. Is it access that one would necessarily find in Toronto? No, but we do ensure that we work with the registered network of over 12,000 mental health professionals across the country to ensure that veterans have access and can get the treatment that they need.
The Chair: Thank you very much to our witnesses, Ms. Garrett-Baird, Dr. Heber and Dr. Rothbaum. I appreciate your attendance. It was extremely insightful. Thank you to everyone who participated. I see our time is coming to an end, so I will adjourn the meeting for today.
(The committee adjourned.)