Proceedings of the Subcommittee on
Veterans Affairs
Issue 9 - Evidence - February 4, 2015
OTTAWA, Wednesday, February 4, 2015
The Subcommittee on Veterans Affairs of the Standing Senate Committee on National Security and Defence met this day at 12:03 p.m. to continue its study on 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.
[Translation]
The Chair: Honourable senators, today we are continuing our study on operational stress injuries and other mental health issues affecting veterans.
[English]
Our witnesses today are from the Department of National Defence and the Canadian Armed Forces. We are very pleased to welcome Lieutenant-General David Millar, Chief of Military Personnel; Colonel Hugh MacKay, Deputy Surgeon General, Canadian Forces Health Services Group; Colonel Andrew Downes, Director of Mental Health, Canadian Forces Health Services Group; and Colonel Rakesh Jetly, Mental Health Advisor, Directorate of Mental Health, Canadian Forces Health Services Group.
We have a fairly large panel. I'm hoping each of you will be participating in the discussions. Lieutenant-General Millar, would you have some opening remarks?
[Translation]
Lieutenant-General David Millar, Chief of Military Personnel, National Defence and the Canadian Armed Forces: Honourable senators and members of the committee, my fellow officers and I are very pleased to have the opportunity to talk to you about the mental health issues affecting serving members of the Canadian Armed Forces, as well as the services, treatments and programs provided to Canadian Armed Forces personnel, and to their families.
Joining me today are Colonel Hugh MacKay, Deputy Surgeon General;; Colonel Andrew Downes, Director of Mental Health; and Colonel Rakesh Jetly, Chief Psychiatrist for the Canadian Armed Forces.
[English]
The provision of care and services to Canadian Armed Forces members with mental illness is a significant priority within our Canadian Forces.
Through our mental health programs we provide comprehensive medical care, and the Integrated Personnel Support Centres that we have across our country provide critical support to meet the needs of our ill and injured personnel. In partnership with Veterans Affairs, the Operational Stress Injury Social Support Program offers a national peer support network to help those suffering from stress injuries and their families. Military Family Resource Centres at each of our bases and wings provide a range of programs and services that support military families, including mental health education, short-term counselling and bereavement services.
Within our 44 medical clinics across the country — 30 of which are integrated specialized mental health services along with seven operational trauma stress support centres — we have 455 established positions. As of mid-January of this year, 94 of those positions are filled with clinicians experienced in the treatment of mental illness. Efforts are continuing to fill the remaining positions, but as we know, this is a dynamic situation, and as mental illness and reduced stigma become more prevalent throughout Canada, the competition for clinicians is a continual effort.
However, there are also over 3,000 civilian mental health professionals registered as service providers to the Canadian Armed Forces that we can refer our patients to in order to ensure timely access to service.
[Translation]
For Canadian Armed Forces personnel who access mental health care, the recent acquisition of the client-reported outcome management information system will allow for rapid treatment outcome assessment that will guide modification and optimization of individualized care.
The direct entry of mental health information into military electronic health records in a secure and confidential manner will enhance communications between primary care clinicians and mental health professionals, strengthening collaborative care.
[English]
Other technology that will directly enhance care is being installed in our clinic. This includes virtual reality systems for exposure therapy and high-definition video telecommunication terminals that will allow mental health specialists to assess and treat patients in more remote locations in Canada, thereby reducing the need for patients to travel and reducing wait times.
The recently announced expansion — I believe you received handouts from us — of the Road to Mental Readiness mental health education program will provide the resources to enhance both the development and the delivery of the program. This will ensure continued delivery of mission specific and pre- and post-deployment training for military personnel and families, tailored developmental career training and occupation specific content to meet the unique demands of specialized professions within the military and the environments all aimed at reducing stigma, and it is working.
[Translation]
We have seen evidence of significant improvement in mental health knowledge and attitudes, and steady decreases in stigma and other barriers to care. These outcomes are encouraging, and more than 200 Canadian Armed Forces members volunteered to participate in last year's mental health video. The video entitled You are Not Alone addresses stigma and demonstrates that we are making steady progress toward the goal of eliminating the stigma associated with mental illness.
[English]
The most recent showcase was last week's Bell Let's Talk event at National Defence Headquarters, which many of you may have seen, where our Major Réjean Richard said he wished he had taken that step 20 years ago and is able to do so now because mental health is becoming normalized. Sergeant Major Pichard expressed how good the care and services are, as long as you reach out.
In the coming year, the Surgeon General will convene another expert panel on suicide prevention to review our current practices in this area. This will build on the strong program currently in place, which was guided by the previous expert panel from 2009.
Finally, the Canadian Armed Forces is committed to providing leading-edge, evidence-based care. The recently announced Canadian Military and Veterans Mental Health Centre of Excellence, the co-chair is sitting to my left, Colonel Rakesh Jetly, will have a forward-looking perspective in research, education and clinical care. The centre will conduct research on unique aspects of military and veteran's mental health and will collaborate with scientific experts in academia, government, private sector, research consortia and with NATO and our Allies to ensure that the knowledge gained from leading-edge clinical research translates rapidly into clinical care.
The CAF is committed to ensuring that personnel suffering from mental illness have access to medical care and support services necessary to return them to duty because we want to normalize mental health — it's all right not to feel good some days — or assist their transition to civilian life and to invest in research in order to enhance our ability to care for and support them.
Mr. Chair, thank you very much. We would very much like to respond to any questions you may have.
The Chair: Thank you very much, general, for your introductory remarks. Would anyone else like to add anything to the general's comments at this stage?
Lt.-Gen. Millar: Mr. Chair, if I could, Colin pointed out an error that I made in my speaking points. I indicated 455 positions for mental health, and I said 94 and I meant 94 per cent are filled.
The Chair: Thank you for pointing that out. We are interested in knowing what is happening within the Department of National Defence at the present time with respect to operational stress injury — the clinical approach and what various offices you have. We are also interested in the future — how we're improving that treatment, what clinical improvements you are making and what other fundamental changes you are hearing or learning about. We are also interested in the stigma aspect of this and the cultural change that is necessary. So you could have that in mind with your answers to the honourable senators.
Was a video made of the recent Bell Let's Talk even? Will we be able to learn, after the fact, a little more about this?
Lt.-Gen. Millar: Yes, it was recorded, and we can get you the excerpts from that.
The Chair: That will be helpful to us. At another time, maybe when you do the suicide round table, we might be able to have some direct participation because these are areas of serious concern to us in an ongoing study.
Lt.-Gen. Millar: Certainly.
Senator Stewart Olsen: Thank you, gentlemen, for coming. We are honoured to have you here. My first question is to allow you to give us a bit of background on how far you have come in the last few years at changing the operational procedures in the military to recognize PTSD and OSISS.
Lt.-Gen. Millar: Thank you very much.
Like Canada and like Canadians writ large, in the forces, mental illness was not well understood or discussed. Certainly if we go back to World War I and World War II, shell shock — today's PTSD — was not then and is not today a new phenomenon. Certainly we did not understand it well. Canadian Forces prides itself on training, education, development and preparing troops for war because indeed that is our mandate.
But we didn't understand the impact of mental illness, trauma and post-traumatic stress disorder back then. I believe the trauma and the experiences from Afghanistan have once again opened our eyes to the need to prepare, train and educate ourselves and to make us more resilient in preparation for the types of trauma and hardships we will see when we deploy.
As a result of that, to answer your question, senator, we now have introduced an education and training program that is focused on making our men and women of the Canadian Armed Forces more resilient, more aware and understanding of the symptoms and signs of mental illness, and more willing to seek treatment much earlier in the program.
This training and education program starts when you are a brand new recruit coming into the Canadian Forces and continues throughout your career. It is a focus prior to deployment and also after deployment when you decompress from a major operation. Yet we still have the issue of stigma because, like all of us, we are very proud and don't want to show weakness. It is important to us, as part of our stigma reduction campaign and as part of our training and education campaign, that members of the Canadian Armed Forces understand that a mental injury is not unlike a physical injury. We have treatments and programs to fix physical and mental injuries and therefore it's all right not to feel well and to seek help. The focus of our strategy has been through the training, education and reduction of stigma.
Colonel Hugh Colin MacKay, Deputy Surgeon General, Canadian Forces Health Services Group, National Defence and the Canadian Armed Forces: I would like to add a couple of points from the perspective of health services. One has to do with the research we have been able to enhance. We have undertaken a considerable amount of research in the last several years to make sure that we have a better understanding of just what the implications are for our soldiers on operations with respect to mental illness. Our most recent and probably the largest study that we have done is a mental health survey conducted for us in 2013 by Statistics Canada. We have been able to identify, through that study, that we basically had stable rates of depression within the Canadian Armed Forces. We did see post-traumatic stress disorder almost double, if you will, probably as a result of operations in Afghanistan, which contributed to that increase since our last survey done in 2002.
We're looking at much more information within this survey. We haven't had the opportunity to complete the analysis, but we are looking at all of the factors that may be contributing to what is happening on operation that causes mental illness. We have looked recently at the significant factors. One aspect that has popped up is that 33 per cent of mental illnesses as a result of operations are due to a sense of being in a dangerous environment. About a quarter of the mental illnesses are attributed to seeing dead bodies and body parts. Only a very small part was attributed to actually engaging in combat — only about 5 per cent.
Because we are starting to understand these things, we are able to target the educational programs to help people understand what they may face and what the impact may be on them.
The other thing is that we have screening programs in place. We programmatically screen people coming out of theatre in order to identify that mental illness as soon as possible, so that we can help to direct them into care. That along with the educational programs that help people understand what is happening to them has also contributed to what we've seen as an increase in access to our services over the last 10 years, which is quite heartening for us. The survey data is telling us they are coming forward at a higher rate to seek mental health care. Those are the some of the things I would add.
Senator Stewart Olsen: Thank you. I would like to follow that up with the transition.
When it has been decided by physicians that a serving member can no longer serve because of PTSD or OSIs, is there an effort by the military and the Department of Veterans Affairs to follow up on the care? We've heard there may be a gap in care and the records. Where are we on that, because a continuation of treatment is vital for people who are severely injured?
Lt.-Gen. Millar: We are actively working with Veterans Affairs because both of us have the same interest: our military members. It is critical to us that the care we provide within the Canadian Armed Forces, medical, social and family, continues as our members transition beyond the uniform. That transition program is something that the new minister and the new deputy minister have really taken up with great energy. We will be meeting in the coming week to develop the transition strategy. Even before that, and under our current program, we have had a military employment transition program that looks at our Canadian Forces members from a family perspective, a health perspective and an employment perspective.
Our objective is to ensure that as members transition, their family is taken care of, they have job placement and, on the medical side, that we have brought members to a point where they are stable and, therefore, can be either taken care of if necessary because of PTSD, by the Operational Stress Injury clinics of Veterans Affairs or by our provincial health care system for those cases that are not PTSD-related.
Colonel Andrew Downes, Director of Mental Health, Canadian Forces Health Services Group, National Defence and the Canadian Armed Forces: The care provided to individuals going through transition can be a complicated matter in some cases because when some people leave the forces, they go to remote areas where there may not necessarily be the range of services that we would like them to receive. That's one thing I want to highlight.
Overall, things work this way: When we know that somebody is about to release through the case management process, we ensure that care is transferred to a receiving clinician depending on the needs of the individual. We really do try to ensure that there is no gap in care during transition.
Senator Stewart Olsen: Do their records go with them as you arrange that transfer?
Col. Downes: There are a couple of different issues related to the transfer of records. One that has been discussed quite a bit is the provision of the entire medical file such that Veterans Affairs determine eligibility for benefits and services.
Typically when we refer people to another clinician for care or services, the relevant parts of the file would be transferred for that purpose. This standard procedure is done when we refer people to any other health care provider so that the relevant information is passed on. The same is done when transferring to Veterans Affairs or to a civilian clinician.
Lt.-Gen. Millar: I will add that we are digitizing all the records now. If you can imagine, traditionally all our medical records are hard copy kept at bases, operational headquarters or even at medical facilities at national headquarters. When a member retires, we have to bring those papers together and transfer the file to another agent, such as Veterans Affairs. It makes it difficult because of the accumulation of paper, so we are digitizing the records. There was a recent decision to enhance our capabilities to allow us to transfer those documents readily.
I mentioned earlier about working closely with Veterans Affairs to integrate our capabilities. We do not want a step function whereby a member gets to release and there's a handshake with Veterans Affairs as they take over. We are in the process of integrating VAC adjudicators and employees within the deputy surgeon general's organization so that they can have access to those records as we start the medical release process. Therefore, six months to one year in advance, Veterans Affairs can commence its administrative paperwork so that benefits are available and they are aware of what care is required for our members well in advance to make it a seamless transition.
My last point is the crux of the issue around the availability of records. Only about 25 per cent of veterans that release from the military will present to Veteran Affairs to access their care and benefits. Usually after they have released for some time, about 75 per cent subsequently come back. By that time, medical records have gone into archive, so you have to pull those records and have an independent doctor look at them. In the Canadian Forces, we are giving a copy of the medical record to our members upon release so they can have it.
Senator Stewart Olsen: That's very helpful.
The Chair: As a follow-up, because of the closure of eight to ten offices of Veterans Affairs across Canada, we understand that Service Canada is helping to provide information, which is not case management. You said that you transfer to Veterans Affairs. Are you transferring in a different manner now than you were doing a year and a half ago?
Lt.-Gen. Millar: Within our Integrated Personnel Support Centres, we have a centre on each of our bases and wings that is the focal point for the administration of all medical, social, financial and family care. The centres are manned by military and Department of National Defence public servants. We also have Veterans Affairs embedded within the centres. As our members come in to be assisted through their care or through their transition, the case managers from Veterans Affairs, which were referred to by Andrew, are there to take care of our members.
Senator, the issue you also talked about is for those veterans already out of the military and accessing. Our area of focus is our military members becoming veterans and how we affect that transition.
The Chair: That's a helpful distinction.
Senator White: Out of interest, you talked about the research piece, which I agree is extremely important. I've been trying to figure out whether we are seeing a higher percentage per capita of our soldiers coming back with mental health challenges compared to other theatres we have been involved in. If so, do you know why? Is it the type of combat role or the support when they return?
Colonel Rakesh Jetly, Mental Health Advisor, Directorate of Mental Health, Canadian Forces Health Services Group, National Defence and the Canadian Armed Forces: That's a great question. Unfortunately, we don't have the data from prior wars. We know that many people after wars have had difficulties. World War I figures show that the peak of World War I pensions in the U.S., the U.K. and Canada continued to rise until the beginning of World War II. We've known that war has been unhealthy for people, physically and mentally, for many, many years. There is some work on the old peacekeeping kind of paradigm of soldiers being unable to act and unable to do things because of very tight rules of engagement. Some of us thought that in a combat-type mission, where they are able to act, we might see fewer difficulties. However, because of things like the loss of colleagues, et cetera, the rates are just as high.
I don't think we have a clear comparator. We know that since people have been sending people into harm's way, a significant minority have come back with difficulties. For the folks in the battle group that was in Gagetown in 2007, the PTSD rate four years out was about 25 per cent. We have not seen numbers like that for the people outside the wire in previous studies.
There is always an impact, whether you're doing peacekeeping or humanitarian work.
I was in Rwanda years ago.
Senator White: Yes, 1988.
Col. Jetly: Witnessing those things is very difficult as well, so I think there are different types of traumas, whether you're a passive witness or an active participant. I think the psychological consequences are thorough.
Senator White: Thank you very much for that.
I guess the second piece around research talks about who handles it best. Are there certain units or segments of the military that seem to have less prevalence, although they are as active as other units in the military? I'm not talking about air force, navy, army. I'm talking about specific units within the force itself.
Col. MacKay: Senator, I don't think we have been able to parse out that kind of detail within the survey data that we have done to date that we would be able to identify specific types of units. We have seen, though, that all types of units are impacted by the effects of going away on operations like Afghanistan, whether they're sitting at our Camp Mirage facility doing the logistical support or they're sitting running UAVs.
We have seen, I believe, that, within the combat arms units, there's some elevated risk of mental illness. We've also seen, with the data we've been able to look at so far, some elevated risk of mental illness in health care providers, but infantry versus armoured and that type of detail we don't have.
Senator White: A small question, I promise. I don't ask it to suggest that one unit is better at it. I ask it because I have heard members of certain units talk about the fact that they believe everyone has PTSD. Whether or not it becomes an illness is what's important, and the manner in which they handle people coming home is important. I guess that's why I was looking at whether or not you've seen that.
Is there a best practice out there that maybe we can engage more fully?
Col. Jetly: I can speak to that briefly. There is some very compelling American data looking at perceived leadership in terms of the incidence of PTSD within certain fighting units. Our approach with education and cultural change is to create leaders without trying to tell people how to suck eggs, authentic genuine leaders that know their people well and that will notice the subtle changes and those kinds of things and create the climate of help seeking, health seeking and those kinds of things. There are many factors in terms of the health care that is provided but also the example that the leaders set and that peers set. So we're targeting all of those aspects in our cultural change.
Senator White: Thank you very much. Thanks again, each of you, for being here.
Senator Mitchell: Thanks, gentlemen, very much. I was actually going to ask about leadership. I think we are all extremely impressed by the quality of leadership in the military and the way it's developed and so on, but just to emphasize the fact that there might be subtle differences in the way that one leader leads and another leader leads that could prevent somebody from catching a problem or not.
My other question is this: Almost all of the discussion about PTSD ranges around the condition as it arises out of deployment somewhere, but there are PTSD issues in the RCMP, for example. They do deploy sometimes, but we find it certainly amongst those people who don't deploy and who haven't ever used their weapon or haven't ever been shot at. There's some discussion now, maybe just in the popularized media — and this is in no way a criticism because there's been a great effort to integrate women into the military here — of sexual harassment and harassment generally. Do you focus on that type of PTSD, and is there a different kind of stigma associated with that that needs to be addressed?
Lt.-Gen. Millar: Absolutely. Today, we tend to associate PTSD with traumatic events during deployments and operations. That's very true. As we decrease stigma and start to normalize the conversation around mental illness, we see more and more people coming forward that aren't necessarily Afghanistan veterans, to Senator White's earlier question, but were in Bosnia, Kosovo, Somalia. Post-traumatic stress will develop over time and present itself perhaps four to seven years after an event. Our initial cadre of members coming in were the non-Afghanistan veterans. Now, Afghanistan certainly is prevalent in terms of PTSD.
But outside of that, yes, you can experience trauma in your day-to-day life, whether it's a car accident or a significant emotional event affecting family. That, a number of other biomarkers and, perhaps, a tendency to be more susceptible to the other mental illnesses, such as depression and anxiety, all create a chain of events that can lead to exacerbating mental illness to the point that post-traumatic stress disorder presents itself in other ways. So as you mentioned, senator, sexual harassment or sexual misconduct can create a post-traumatic stress issue that results in mental illness.
So, yes, in our training, education and development, we are not differentiating or not just focusing on combat and the trauma experienced in combat, as Colin said. We are addressing it right across the spectrum within the Canadian Forces, and, indeed, our cases, as Andrew will mention, are other than the operational type. Again, it's not that on deployments and operations everyone who participates encounters PTSD or develops mental illness. It's what happens there. What was the traumatic issue? Those traumatic issues can happen here at home as well.
Col. Downes: As General Millar has mentioned, we focus our stigma reduction on general mental illness. We do not focus it on just those who have mental illness related to operations. It's the broad public health aspect of mental illness that we're looking at.
The second thing I would like to highlight is that when we get patients with PTSD, sometimes it can be very complex in terms of whether it was the deployment or some event prior to the deployment that actually caused this. We sometimes see that the deployment unmasks the symptoms that existed before the deployment. So it can be very challenging sometimes to sort of tease the two apart, but, nonetheless, we still treat patients the same way. We reduce stigma for all mental illness. In our recent survey, we did find — and I don't remember the number off the top of my head — a measurable number of people who had not deployed but who had PTSD.
Senator Mitchell: Thank you. I visited the Military Family Resource Centre in Calgary several years ago. You referenced that program in your comments, general. I think it's an excellent program. The point was made to me that the funding to these centres is based upon Regular Force numbers in their area of jurisdiction, but, in a place like Calgary, where a lot of military reserves were deployed and where they don't have a Regular Force base in the same way that we do in northern Alberta or outside of Edmonton in Wainwright, that causes a funding problem. They have the volume of issues because they have reservists who went and fought, but they're not getting funding based upon the per capita reservists. They get funding based upon Regular Forces.
Is that an issue? Are you aware of it? Can you address it?
Lt.-Gen. Millar: Yes, senator. Thank you. Interestingly, from our reserve and our surveys that we've conducted, when you're speaking about mental illness, our reservists are more resilient than our Regular Force members. Very interesting. I found that most eye-opening when I reviewed the Life After Service Studies and when I looked at various reserve studies. I attribute that to our Reserve Forces being more resilient — and this is my personal opinion — simply because a reservist will grow up outside of the military environment — professionally, family-wise — and will be exposed to a much broader experiential baseline, whereas in the military we're all cut from the same cloth; we just look the same. That civilian experience, combined with their military experience, seems to make them more resilient, adaptable, flexible and adjustable.
So we're not seeing that family dependency as much, or even the member dependency. That's primarily because they've already made those connections within their communities because they live and work in those communities as civilians. Then they come and deploy, or they'll come to their unit, and that's where they'll avail themselves of MFRCs and our Integrated Personnel Support Centres and everything the military has to offer. But then, once they're not working in uniform and they're back in their civilian environment, they're already connected into those services.
Having said that, and recognizing that that is a gap, 85 per cent of military members live off the base; they live in their communities. Our Military Family Resource Centres are on the base. So there's a natural disconnect. What we are doing now is integrating our family resource centres with the provinces and with the services that the provinces provide to families, and making that link so that we can make a referral to our reservists or our members living off base to the civilian service that's available, whether it's mental health counselling, child welfare, daycare, all of those, because we are sponsoring it through our Military Family Resource Centres. We are evolving that capability so that it is more available.
Senator Mitchell: I have another question that I wanted to ask. There's a good deal of evidence — and certainly the minister and the Commissioner of the RCMP have both acknowledged this; it's quite widely known, and I alluded to it earlier — for harassment in the RCMP, and PTSD related to that, and other reasons. To some extent the argument has been made that resources are an issue there, but there's also experience and learning there.
Is there any possibility of synergies between the military and the RCMP? Have you explored those? Are there ways to coordinate the centres and get economies of scale?
Lt.-Gen. Millar: I'll start off and then ask Andrew to comment.
We are working extremely closely with the RCMP. We have shared with them our Mental Health Strategy for the Canadian Armed Forces. As a matter of fact, they are replicating it. We participate with them in research as well, and they sit on the steering committee between the Department of National Defence, Veterans Affairs and the RCMP in terms of how we're managing our veterans — because RCMP has veterans too — and we're sharing all of those best practices, the research and programs.
In terms of our peer support programs, the Operational Stress Injury Social Support Program, we open that to the RCMP as well as to their family members. So, yes, there is a significant amount of synergy going on.
Andrew?
Col. Downes: Thank you, sir.
Not perhaps closely related to the family resource centre issue, but just to highlight some of the things we are working on with the RCMP. This includes the Road to Mental Readiness program. This has been implemented in some police forces, including some parts of the RCMP. We also have a joint MOU with the RCMP and Veterans Affairs to share our resources in our operational stress support centres and the OSI network of Veterans Affairs. We could be treating RCMP members, for example, with post-traumatic stress disorder in our centres.
The Chair: I think it would be helpful for the record if you could clarify last year's quote, "You're not alone," the mental health video we talked about earlier on stigma and cultural change. Could you elaborate on that a little bit? What has been the result of that? Did you disseminate the video around the countryside?
Lt.-Gen. Millar: Yes, chair, we did. Our very first video, prior to "You're not alone," was about stigma reduction, where we put out a call to military members, recognizing that mental illness is a personal issue, recognizing that we want to make it a normalized issue. At that time we put out a call to military members, hoping that they would come forward and be willing to be taped on a video and to tell their story. Within a short period of time we had 200 members of the Canadian Armed Forces wanting to be videotaped telling their story. That ranged from private to Vice-Admiral Norman, the Commander of the Navy. The message in that video, which was broadcast across the Canadian Forces on our defence-wide network and on our website at forces.gc.ca, said that it's all right not to feel good; it's all right to seek help; come in and seek help.
That was the first of many videos. "You're not alone" was a further complement to that video to say these are the services out there that are available. We treat mental illness as something that can be addressed and fixed. You're not alone, because there are other military members and there are family members.
So it was to appeal also to the family and spouses. That video was broadcast throughout the Canadian Forces and on our external web page.
The Chair: So we can assume that a lot of military personnel and families have seen this video?
Lt.-Gen. Millar: Yes, senator.
The Chair: The recent Bell Let's Talk event, could you describe that a little bit? What's the outcome of that event?
Lt.-Gen. Millar: Bell Let's Talk, led by Clara Hughes, our famous Olympian —
The Chair: Speed skater and cyclist.
Lt.-Gen. Millar: Yes. She has really been the face of talking about mental illness across Canada. We climbed on board with Bell right away. If Bell is talking about it, then we can support and be a role model. I believe that if Canadians see combat warriors that have been in Afghanistan tell their story about post-traumatic stress disorder, then they lead by example and Canadians writ large should feel comfortable with talking about mental illness. So we have twinned with Bell Let's Talk, along with many others, to be able to talk about mental health.
Just a week ago, in the concourse of National Defence headquarters, Bell kicked off one of their Bell Let's Talk campaigns and invited the Canadian Forces to sit on a panel. We had two panel members, Master Warrant Officer Pickard, and Major Richard, along with one of our PGA golfers. They sat in front of a large audience — and it was televised — to tell their stories about post-traumatic stress disorder and living with it. Their message was that the help is there; reach out and talk.
That was the event that we held. That particular day, Bell's arrangement was that based on the number of tweets and texts, a percentage of the funding will go to mental illness. They raised $6 million that day from that campaign kickoff, five cents at a time.
Col. Jetly: It's a tremendous initiative that we have been involved in for the third year now. It's just the idea of "let's talk." In our job, every day is "let's talk," because this is our thing, but this is to have one day.
The Chair: This is an interview. Is this on social media only, or is it on traditional media, for those of us who are older?
Col. Jetly: I don't do any of this stuff either. It's tweeting, it's Facebook, all of these types of things. If you look online, you will see celebrities, athletes, politicians, the Prime Minister himself, everybody forwarding this. It really is the idea, and Bell is in a unique position because of the global medium they own, such as TV, radio, newspapers, that kind of thing. It has become a huge event, and we were approached a few years ago. A lot of their spokespeople are athletes, people like Clara Hughes and Michael Landsberg. Last year when Clara did her big ride around the country, she stopped at several bases.
The Chair: I recall that. That was part of that program.
Col. Jetly: That's part of the whole idea, and she stopped specifically at some of our bases and had an event at Valcartier where our soldiers did a ride-a-thon alongside her. It's partnering and the idea that mental illness is a Canadian issue, not just a Canadian Armed Forces issue. It's a population-based approach.
The Chair: So it's partially therapeutic for those that see it —
Col. Jetly: Absolutely.
The Chair: — and it's also a fundraiser.
Col. Jetly: It's everything. Absolutely.
The Chair: Very interesting. You referred in your opening remarks, general — and I think Colonel Jetly is the designated one for this. This is a client-reported outcome management information system. Thanks for not using a lot of acronyms. We can get through the long terminology. It tells us a bit about what you're doing.
You said it allowed for rapid treatment outcome assessment. Can you describe that in a little more detail? What do you hope to get from this particular initiative?
Col. Jetly: Absolutely. It's an outcome management system. Lots of times when you have the patient-clinician dyad, we can think about it as two people. Evidence shows that when you ask the patient how they're doing, they often just say "fine" because that's what Canadians say. How they are really feeling we're not sure, so it's hard to predict how they're doing.
This computerized system would allow the clinician and the patient at every session to fill out a few questionnaires, and you can track how people are doing that way, such as if they are responding as they should to the treatment, and it allows you to tweak the treatment as you go along.
For example, if someone has depression and they choose early on to say, "Let's just have therapy; I'd rather not have medication," five or six sessions down the road, if they fall off the expected treatment response, then you can revisit it. You can rapidly revisit the treatment approach, and this will be helpful for the individual patient and doctor but also at a clinic level and national level. It will gives us a clear idea of how well we're treating the illnesses and identifying training needs, but it will also allow the individual patient care to be tweaked.
Veterans Affairs has rolled this out as well, so it will also be part of that transition where the same data can be passed back and forth among all of our clinics.
The Chair: This is a software program and package?
Col. Jetly: Absolutely.
The Chair: Did you purchase that from another country? Who developed this?
Col. Downes: The software was developed in the United States, and it uses standard mental health survey instruments. As Colonel Jetly mentioned, this has already been rolled out to the OSISS clinics in Veterans Affairs, and we're doing the same, working with the same partners. In fact, we have Veterans Affairs representatives involved in helping to train our staff.
The Chair: If we were to visit the United States, where would we find the hub of a lot of research going on and work in the particular area that's helpful to you here in Canada?
Col. Jetly: They have many hubs. The National Center for PTSD is one of the places.
The Chair: In Washington?
Col. Jetly: No, I think it's in Virginia, in the area.
The Chair: Pretty close to Washington.
Col. Jetly: But they have many hubs. Some of their veterans' hospitals have 90,000 patient catchments, so it's kind of an interesting thing, certainly in the Washington area. Their military and VA systems have different approaches. The electronic health records of the U.S. Department of Veterans Affairs is a good program to look at.
The Chair: So you could take an observation like the general referred to in terms of reservists not suffering from post-traumatic stress to the same level or degree, you could take that fact that you might have observed here and compare that to some of the U.S. findings and maybe develop some new clinical information as a result?
Col. Jetly: Yes, and we're constantly communicating with our colleagues on those.
To go back to one of the earlier points, our evolution is a little different from the Australians and Americans because we didn't have Vietnam, so we didn't blow the dust off of stuff from 20 years ago.
In retrospect, we have the ability to sort of react. The head of the National Center for PTSD said if you want to look at how to treat PTSD, just go north of the border to see what they're doing in Canada. Because we have had a fresh start to a lot of these things, things like third location decompression are not being done in the U.S. but they are being done here, and the U.S. wants to emulate us. There is a sharing back and forth among certainly Australia, the U.S. and Canada, and the Netherlands is also very involved with us. We're sharing best practices on a regular basis.
The Chair: Before I go to second round, with respect to other sharing of best practices, do you do anything with first responders, such as police forces other than the RCMP, which we've talked about?
Col. Jetly: When we first began with the Road to Mental Readiness, it became such a hit that we were getting calls from every community to help. So we actually partnered with the Mental Health Commission of Canada, and the Mental Health Commission is taking the lead. They're taking our product and civilianizing it, if you will, so now they're in the process of rolling it out nationally.
We are still involved, as well as the Calgary police department and New Brunswick RCMP. We handled it, but really, every single community's firefighters and police are playing a part. We just received a call in Alberta for us to help there; they have had a few recent suicides amongst emergency responders. So we're partnering as much as possible and leveraging our relationship with the Mental Health Commission, mental health associations and academia to try to roll out and share some of these things.
The Chair: That's very helpful. It shows the road to the future and a lot of initiatives that are in progress, some of which will bear better results than others, but we'll keep in touch with you just to hear how things are developing there.
Senator Stewart Olsen: I have more of a clinical question than anything. PTSD itself, I know it's had different inceptions and different names, but it probably goes back to the beginning of time, I'm not sure.
Has the illness itself — I'm uncomfortable calling it an illness because I think it's a human condition. Has it changed? Has it evolved? Or are we just hearing more about it? Has our attitude changed?
Col. Jetly: It has changed. That's a great question. If we look at videos from World War I, there are some fantastic videos of people that had somatic responses, such as facial tics. To some extent, they might have represented going over the top and maybe bayoneting someone in the face. Later on, people developed these odd behaviours and movements, and they were treated with hypnosis and things like that.
As time has gone along, the flashback has become common, reliving things, and maybe that reflects media and movies and things like that. So it's a different kind of idea. Nightmares seem to have persisted throughout, so there has been an evolution. I think disease often reflects what's happening in the culture.
A major thing that has occurred just with this last DSM, the DSM-5, since 1980, PTSD has fallen under anxiety disorders. It was considered like an anxiety. Now they've created a trauma-specific category, so it's kind of like anxiety but it's actually something unique and related to trauma. We'll see an evolution as we go forward or look at other aspects.
The most common illness after trauma is actually depression. Depression is more common than PTSD, so looking at it through the lens of trauma is going to change things. It has been evolving as we start to understand the illness, and each iteration of the Diagnostic and Statistical Manual of Mental Disorders tweaks the diagnostic criteria quite significantly, actually.
Senator White: Thanks again for your comments and your responses. I appreciate the fact that there's a lot of sharing going on with best and current practices.
Is there a formal think tank out there being developed to try and drive some of this? I appreciate the commentary around research because if it's only happening as a result of gravity, we may not be drawing it down fast enough. Some of the think tanks developed around the world on other issues have been very successful in developing other strategies, aside from the ones you happen upon.
Is that formal think tank being looked at from an international perspective, and if so, who is driving it? If not, why?
Lt.-Gen. Millar: Our version of that think tank may not be exactly that, but it is the Canadian Institute for Military and Veteran Health Research. It is a consortium led by Queen's University, Alice Aiken, in combination with the Royal Military College of Canada. It has now grown to a force of 36 universities, and therefore that consortium — which is conducting the majority of the think tank activity, the research and support of our clinical practices the doctors have been talking about — is now reaching an international level because of its notoriety, and it is connecting with its equivalent in academia over in Europe. That is bearing out the very surgical look at what is behind mental illness, behind the condition, behind PTSD not just as it pertains to military members but as it pertains to families as well. They are broadening the research.
From a family perspective, we also have a think tank called the Vanier Institute, and you are familiar with the creation of that model after the hardships associated with military life from a family perspective. There is a body of research going on in family resilience and incorporating provincial authorities to be able to study how best, if the military is devising practices to take care of families, to expose that to families in high-tempo occupations around Canada.
A think tank is the Canadian Institute for Military and Veteran Health Research, but as Colonel Jetly alluded to, within our expertise as chief psychiatrist and director of mental health, we also plug into our Five Eyes allies — New Zealand, Australia, United States, the U.K. — and through their respective think tanks, that's where we identify best practices.
Col. MacKay: Senator, part of our intention in creating the Research Chair in Military Mental Health, which is going to be working very closely with the Royal Ottawa and also having that outreach to those international partners, is to try and bring together the expertise that exists internationally to address the issues that we all face.
CIMVHR does have a very broad focus. Having our research chair with one of the institutes that is a member of CIMVHR helps us to focus within that organization, bringing together the thoughts around the issues we face to help develop better studies to answer our questions. But it is also to give that opportunity for Colonel Jetly to have those contacts. He is very well-connected internationally with our allies and the experts on military mental illness.
Senator White: Thank you very much.
The Chair: We probably have been skirting around this. We are aware of Ms. Alice Aiken's work, and the tremendous growth in the past few years with the Royal Military College, Queen's and all the other universities and groups that have joined on that effort. There is great hope that some good work is coming from that and will continue.
General, in your introductory remarks you refer to "recently announced," and as another example, the Queen's RMC initiative is only three or four years old, and it has grown exponentially. Many of the programs you talked about today are very new in their implementation and announcement. You said "recently announced Canadian Military and Veterans Mental Health Centre of Excellence." Is that an overseeing body that puts its arms around the different programs you are doing?
Lt.-Gen. Millar: It is, senator. We are very proud to have twinned with the Royal Ottawa. Indeed, there is an operational stress injury clinic in the Royal Ottawa that we refer our military veterans to, and we have a close relationship. That relationship was solidified recently with the announcement that Colonel Jetly would be the co-chair, along with the head psychiatrist of the Royal Ottawa. Together, the two of them will be the overarching subject matter experts that will bring the best practices and research together to further develop our clinical practices.
Col. Jetly: The centre of excellence will essentially be housed within headquarters, VAC, and a lot of leveraging. The three main thrusts will be research to better understand the biological underpinnings of disease to make the treatments better.
One of the issues and one of the great limiters is the limiting of care itself, so we need to understand the illnesses better and improve treatment. We will look at education. Part of it is the knowledge translation. There is a lot of great knowledge in the minds of a few people. How do we get that to all the practitioners out there? And there is the clinical care itself. The people in the centre of excellence will be involved and looking at psychiatry. A Veterans Affairs psychologist, a family physician, social worker and a bio-scientist will be part of this centre and try to have it be strategic looking, not to be distracted by the day-to-day and look a couple of years out. We are putting the pieces together right now, and it's going to allow us to look three or four years out, not at the day-to-day things that are ongoing. We are quite excited about looking at how we educate practitioners to the approach and translate some of that knowledge.
The Chair: With the centre of excellence, DND and Veterans Affairs, what relationship will you have with the Queen's University and Royal Military College initiative?
Col. Jetly: It will be part of the hub and housed within part of our headquarters, but in the relationship with CIMVHR, academia and the allies, the centre will have multiple relationships. We have a fantastic relationship with CIMVHR, but if King's College in the U.K. or the Israeli IDF wants to work on something, our centre of excellence will certainly engage with them. The idea is to bring the best science and knowledge, translate the best knowledge and get it out there to the front line to the soldiers, sailors and airmen that need it as quickly as possible.
The Chair: The centre of excellence will primarily be handling information and dissemination —
Col. Jetly: No, doing the work itself, doing the research. We have projects on the go as well, conducting the research itself.
The Chair: When do you expect it to be up and running?
Col. Jetly: It's already started.
The Chair: In fact, we are keeping you away from your work.
Col. Jetly: Almost literally.
The Chair: Thank you all very much for being here. This was very helpful to us, and we will be following this issue. We've got quite a work program because we're moving from what is happening now to what we see possibly happening in the future, and you will be a critical part of that.
We want you to know, from the Subcommittee on Veterans Affairs and the Senate generally, how much we appreciate the work that you are doing for the members of the Canadian Armed Forces and their families.
Thank you for that.
Lt.-Gen. Millar: Thank you very much, senator. As you and I discussed, the more we talk about it, the more we normalize it, the more that Canadians and Canadian Forces feel comfortable talking about the condition of mental health. Therefore people will lower the barriers and lower the stigma, come out and come forward for help.
As Major Richard said, if he had made that bold step 20 years ago, he would not have got to the point of post-traumatic stress disorder completely consuming his life. Again, the more we talk, the more people come into care, the more we can do to help. Thank you very much for this.
The Chair: Keep working at that. This meeting is now concluded.
(The committee adjourned.)