THE SUBCOMMITTEE ON VETERANS AFFAIRS
EVIDENCE
OTTAWA, Wednesday, March 22, 2023
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 Veteran’s 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, senator from New Brunswick, chair of the subcommittee. I’m joined today by my fellow subcommittee members, Senator Boisvenu, deputy chair from Quebec; and Senator Yussuff from Ontario. We’re also joined by Senator Patterson from Ontario, and we expect Senator Deacon from Ontario.
Today, we continue our study into emerging treatments for veterans suffering from occupational stress injuries. We have the pleasure of welcoming, from the Canadian Psychiatric Association, Dr. J. Don Richardson, Co-Chair, Section on Military and Veterans. Thank you for joining us today. We will begin by inviting you to provide your opening remarks, to be followed by questions from our members.
Before asking and answering questions, I would like to ask the participants in the room to please refrain from leaning in too close to the microphone or to remove your earpiece when doing so. This will avoid any sound feedback that could negatively impact the committee staff in the room.
Dr. Richardson, when you’re ready, the floor is yours.
Dr. J. Don Richardson, Co-Chair, Section on Military and Veterans, Canadian Psychiatric Association: Thank you. I’m pleased to appear before this group in Ottawa, and to start off on unceded Algonquin Anishinaabe territory.
My name is Dr. Richardson and I’m here to testify on behalf of the Canadian Psychiatric Association as chair of the military and veterans section, specifically on emerging treatments on operational stress injuries for veterans.
I have multiple roles, just to clarify. I am also the consultant psychiatrist and medical director of St. Joseph’s Operational Stress Injury Clinic in London, and the scientific director of the MacDonald Franklin OSI Research Centre, which is also in London. I also serve as a medical advisor to Atlas Institute for Veterans and Families here in Ottawa.
I was told I had seven minutes, so if I go over seven minutes, please interrupt me. I will try to keep it as short as possible, especially since it might be more fruitful to have a conversation.
Prior to focusing on emerging treatments for operational stress injuries, or OSIs, it is important to look at the definition. Because often when we think of OSIs, the first thing that comes to many people’s minds is PTSD. However, major depressive disorder is as common as PTSD, and OSIs also include other psychiatric conditions. Therefore, when we look at emerging treatments, we need to take a broad view on other treatments or emerging treatments for other conditions, specifically major depressive disorder, substance use disorder and other psychiatric conditions that impact veterans’ overall functioning.
It is also important to acknowledge that many veterans continue to struggle with accessing first-line, evidence-based care, including pharmacotherapy — or medication treatments — and psychotherapy. And dropouts — veterans who start treatment and end prematurely — continue to be an issue.
This might have already been reviewed, but a lot of research has shown that military-related or combat-related PTSD does not respond as well to treatments, including medication treatments or psychotherapy, when compared to civilian-related PTSD.
Many reasons have been hypothesized why this is. We do know that the military population is predominantly male, and that there might be a difference between response to treatment when comparing women to men. In the military population with specifically PTSD, it frequently occurs with other mental health conditions, what we call comorbidity — so PTSD plus something else — especially major depressive disorder and substance use disorder. PTSD in the military context tends to be more severe and tends to be related to repeated traumatic events.
I assume you have already heard about other emerging treatments specifically for PTSD and major depressive disorder. I will review a little bit about esketamine and ketamine, which you might have heard of; repeated transcranial magnetic stimulation, or rTMS; and then, of course, psychedelic-facilitated psychotherapy, which gets a lot of media attention.
First, the use of esketamine through nasal spray and the off‑label use of ketamine infusion is currently indicated for treatment-resistant depression. It has also been demonstrated to assist with suicidal ideation that occurs frequently in veterans with PTSD and major depressive disorder. There is also emerging evidence on combining ketamine with psychotherapy to assist with PTSD.
Across Canada, veterans still face significant challenges when trying to access this type of treatment, especially if they live outside of major urban centres where these treatments are often located.
There have been some trials for at-home oral ketamine treatment, which has been shown to be not as effective as infusions or intranasal ketamine. However, it might allow for more access for individuals who do not live within major urban centres.
Repeated transcranial stimulation, or rTMS for short, is also indicated for treatment-resistant depression. There is some emerging evidence on its benefits, specifically for PTSD.
What the research also needs to look at is: Does it help PTSD without also helping major depressive disorder? Individuals who are receiving rTMS often have co-morbid — or the primary condition they are focusing on is depression.
There has been some evidence for bilateral sequential theta burst stimulation. I’m not an expert in that, but in that area, it’s predominantly if there is a way to provide rTMS more frequently in order to have a quicker response but also make it easier for veterans to access treatment. Rather than having treatments over an entire month, they might be able to have treatments within one week or two weeks.
Most of the efficacy and safety tend to be unfortunately in smaller samples, and most of them are really focused on treatment-resistant depression with co-morbid PTSD.
Psychedelic-assisted psychotherapy, and here, psilocybin, MDMA or ketamine, shows promise in assisting those with treatment-resistant PTSD and major depressive disorder. Unfortunately, the study sample sizes are small, short follow-up, and the long-term benefits and potential risk are not well established.
There are also many questions about whether this type of treatment is scalable, meaning is it scalable to the sense across Canada and for veterans that might be living in more remote areas? Could it ever be offered as first line? What we don’t know is who should be referred for these newer emerging treatments and if they should be reserved if they did not respond to other types of first-line treatments.
There are also many innovations with regard to improving treatment outcomes from current evidence-based treatment. For example, most trauma-focused psychotherapy — this is psychotherapy where people talking about the traumatic event — is traditionally offered on a weekly basis. There have been some studies that have shown some promise in doing this type of trauma-focused psychotherapy daily, and therefore it can decrease the time for response. Rather than having 12 sessions over 12 weeks, having 12 sessions done over 12 days, for example. This is called massed prolonged exposure treatment, or massed PE. You might have heard of that from other individuals.
There is also some emerging evidence on pharmacogenetics, that is using our understanding how different genetic make-ups of a person might determine how they might respond to different —
The Chair: Dr. Richardson, could you —
Dr. Richardson: Am I near the —
The Chair: Yes. A few more seconds, please, and then we will go to questions.
Dr. Richardson: Thank you for that; I’ll cut it quickly. The other emerging is pharmacogenetics, and the other area that needs to be looked at is treatment guidelines, which tend to focus only on first-line treatments. And then how can we personalize treatments? There is emerging evidence for the use of AI or machine learning in order to better help clinicians determine which individuals might respond better to one treatment or another.
The Chair: Thank you very much. We’ll go to questions now. We will begin with our deputy chair, Senator Boisvenu.
[Translation]
Senator Boisvenu: I think we should have you back again, because you’re really very interesting.
First, I understand that your association is in favour of employing psychedelic substances. Therefore, am I right to think you’ve already come out in favour of treatment with psychedelic substances?
[English]
Dr. Richardson: If you look at the Canadian Psychiatric Association at this time with regard to recommendation for psychedelic-assisted psychotherapy, I would look at it as the research phase. More research is needed, and should be reserved for treatment resistance, meaning they have tried other treatments and have not responded.
Senator Boisvenu: So it’s wait and see? Okay.
[Translation]
My second question has to do with the current capacity in the health care system to treat patients using conventional treatments like psychotherapy. We know that in Canada, and especially in Quebec, the wait times to access these services are very long. You’ve also told us that the drop-out rate is high. Are those two things interrelated? Are the long wait times to get services and the high drop-out rate related?
[English]
Dr. Richardson: I will answer the last one first. We do know that there are high drop-out rates among veterans who seek treatments, meaning that often when they start doing the trauma‑focused psychotherapy, they will drop out for many reasons. One is that nobody wants to talk about traumatic events. The other area is accessing treatments and delays in accessing treatments. They are not necessarily related in that way.
We do know that not everybody needs long-term trauma‑focused psychotherapy, and what we need to also look at is whether we should move to more of what is called a step‑care approach, meaning first getting a better understanding of what it is that the veteran is looking for, and then matching it to their specific needs. Some individuals might need one or two sessions. They might need some assistance with either financing, housing or might need some psycho education on what their condition is; others might need more in-depth treatment, for example, talking therapy.
The challenge now is sometimes a veteran might go through all kinds of extensive assessments and then wait for the treatment. How can we match it so that some people might need other types of treatments, whether it is, for example, internet‑based psychotherapy or virtual treatment or even in the area of peer support, and then others might need a lot more? It’s trying to match the needs to exactly what might benefit them the most.
Senator M. Deacon: Thank you for being with us here this afternoon and for the work that you’re continuing to do in London. It’s very impressive.
I’m trying to dig down first into the potential risks and side effects of the psychedelic-assisted psychotherapy. What kind of medication is prescribed now to deal with the PTSD, and how do its side effects potentially compare with the MDMA that we are talking about quite continuously?
Dr. Richardson: That’s a very good question. I’m not an expert on MDMA because I don’t prescribe it. However, when we look at some of the current treatments or medication treatments for PTSD, almost any medication has the potential to have adverse effects, and each individual might respond differently to each medication, for example, whether the potential side effects are higher for psychedelics than they are for other medication has to do primarily that we know a lot more about the medications currently used than the psychedelics.
Senator M. Deacon: Thank you. I understand it’s not your wheelhouse or your direct area of expertise. Generally speaking, we talk about access and how difficult some treatments might be. If you could share, when an individual goes on to psychedelic-assisted therapy, do they have to go through a time when any existing medications are out and cleared from their system? Is there an additional challenge with this, that they have to go off all the meds they might already be on?
Dr. Richardson: That’s a very good question. I don’t know the answer to that, whether they need to come off their other medication. That would have to go with regard to their current protocols.
Senator M. Deacon: Okay. All right. What I’ll take is absolutely something that was part of your direct conversation at the end of your statement. You started to talk about the importance of treatment guidelines and personalized treatments. I would just like you to elaborate a little bit more on the tease you gave us around personalized treatments and a little more about that area, because we don’t hear too much about it.
Dr. Richardson: Okay. Thank you. I apologize because I hear my echo so loud behind me that it’s —
Senator M. Deacon: It is loud.
Dr. Richardson: When we look at personalized treatments, when somebody comes in for treatment, what we do now is try this medication, and then we need to wait anywhere from two to four weeks to see if they respond. If they don’t respond, and about a third to almost 50% will not respond to the first med, then we’ll try another medication. Then we’re waiting. Each time you try a new medication, it’s sometimes harder for you to respond, so there is a long delay.
Sometimes you might start an antidepressant or mood stabilizer, and they have significant side effects, so then we’re starting again with a new med.
One of the benefits of personalized treatment is, for example, your genetics never change, so if you did a cheek swab and you’re doing pharmacogenetics, we would know at the beginning whether you would respond well or not, whether you’re a fast or slow metabolizer, and whether you would tolerate one medication compared to another. That’s one way of personalizing it, so if the veteran came in, I would be able to say, “Well, based on your pharmacogenetics, I don’t think we’re going to try drug XYZ, but we will try this one because you’re more likely to tolerate it.” Hopefully, we’ll be able to respond to it. That’s one small aspect.
With regard to the other area, using advanced analytics or machine learning, an individual would come in based on their signs and symptoms, either from questionnaires, based on their pharmacogenetics, based on co-morbidity. It would look at all of the data that we currently have, and say, “You’re more likely to respond to an antidepressant, and this is the one that you would tolerate the best.” Or it might come up with an algorithm to say, “Based on your signs and symptoms, I would not suggest starting with medication. I would suggest starting first with psychotherapy. If you do not respond, then try this.” It’s a way of personalizing it just for you, rather than a veteran coming in and getting treatment based on who they see.
Senator M. Deacon: Thank you.
Senator Yussuff: Thank you to Dr. Richardson for being here. Listening to you, assessing a veteran’s needs with regard to what their specific ailment might be seems very complex because it’s not a straight path. It may be true that they are depressed, but there are other issues that may be compounding that reality.
How accessible is it for veterans to get the proper assessment in order to get the proper treatment? This is a big dilemma we see. We can all relate to the fact that veterans suffer from PTSD, but there are other underlying challenges and causes that may be contributing to much deeper paralysis of the individual. How do we do that?
Is there a standardized way in which all veterans have the same access to assessment so we don’t misdiagnose but don’t also miss the opportunity to help them more specifically, given this complex world we are dealing with?
Dr. Richardson: I think you’re raising a very important part in terms of assessing and ensuring that the individual is more of a holistic assessment so we don’t focus only on, for example, PTSD, but also on how they are relating or the supports they might have in their life. So it is looking at more of a psychosocial and biological model, meaning the environment that they live in, other stressors that might contribute to their condition, but also challenges in their recovery, their social supports in terms of what is happening at home, and, of course, financial stressors that might also be contributing.
I’m a psychiatrist, so I focus on the mental health psychiatric aspect, but many veterans also have, as you probably are aware, musculoskeletal issues, chronic pain or other physical conditions that impact their overall lives, which also have an impact, obviously, on their brain and mind. It’s working collaboratively not just on the mental health side but also working with their other clinicians. The challenge is finding primary care, but if they have a family doctor, working collaboratively to make sure other areas of their lives are also being addressed, so it’s not just focused on one condition. And then there is providing those other supports if they are available with regard to working with Veterans Affairs Canada to ensure that they have the financial resources and supports, retraining and that whole area.
Senator Yussuff: Do we have a standardized way across systems to assess a veteran when they seek help for their problems? They may be lucky to have an experienced physician like yourself, and based on your knowledge and understanding of the whole individual, you may take a particular approach. Is that a norm in the system in how we are able to assess veterans? Mixed diagnosis or misdiagnosis are equally as important because we might not get to the root cause of symptoms that are creating other problems and not really assist the veterans or their deterioration might be much more prevalent if we don’t get to some other things that might lead to chronic depression and recurrence of their PTSD challenges.
Dr. Richardson: If we look at what happens in the civilian world, for example, if you have an anxiety attack and your heart is pounding and you go to any of your local emergencies, the treatment you receive might be a little different. If you go to different walk-in clinics, the treatment you receive might be a little bit different. It’s not the same as if you had chest pain and you go to the emergency room because you think you have a heart attack; almost everywhere you go in Canada, the treatment will be the same.
Unfortunately, on mental health, standardized assessments for mental health conditions are not as standardized as they should be. That answers that part.
The other area is cultural competence. Do the clinicians have knowledge about military stressors and military culture? That is important in developing the trust of people disclosing stressful events that might have occurred during their military service, so there are two areas.
In our network of clinics across Canada, we have standardized assessments and follow standardized protocols for treatments. What is available within the general community, and being mindful that most veterans do not seek treatment at our centre, most are receiving treatments in the community, that’s where I do agree with you that the assessments might not be standardized, and, of course, the treatment then is not as standardized as it probably should be.
Senator R. Patterson: Thank you very much. This is a very important topic because we know that the veteran population is exponentially growing because veterans are living longer. There are some estimates that over 600,000 people are veterans, almost the size of Ottawa, from a population base spread across the country and the world. The work you’re doing is absolutely critical partly because we know that symptoms of PTSD may be completely ignored and not manifest until later in their lives when it becomes untenable.
I’m very impressed with the work that has been done by the Canadian Psychiatric Association in terms of guidelines on PTSD, occupational and operational stress injuries, so I have a couple of questions related to that.
Because of things such as military sexual trauma, the impact of service on women — that’s the approach I’m going to come at this with — we know that the needs are not necessarily the same. How are you defining occupation versus operational stress injuries, and how do you see us getting some standardization in thinking about these intersections that make up veterans now in terms of treatment guidelines?
Dr. Richardson: Thank you for raising that. That’s a very important topic, and the approach with regard to how we would view occupational and comparing it to operational.
Occupational injuries or occupational stress is often used outside of the military or veteran context, and operational stress injuries have evolved more as a Canadian term that was established by former Lieutenant-Colonel Grenier, primarily to destigmatize mental illness, that individuals could be deployed on operation, and instead of coming back with a physical injury, could they have a stress injury.
For most clinicians within the network of veteran health, we would view military sexual trauma as an operational stress injury as opposed to specifically occupational. But when we describe it to most people, a work-related injury would be the same on the civilian side.
Senator R. Patterson: As a follow-up question on that, as we’re looking at sex and gender as an intersection in terms of the research that’s being done in the realm of post-traumatic stress disorder — breaking it down, “moral injury” — knowing you have a very strong research background, how are you including sex and gender in terms of how you follow along with your research? Because the population of women is growing.
Dr. Richardson: That’s a very critical question. Also now, if you’re applying for grants, you need to answer that question.
In the past, for example, even in work I had published, there are fewer women in the military or in the veteran population. You might not have a large enough sample size of women, so often they were excluded from the studies. That was something that would have occurred in the past, meaning the numbers were too small. And if you started doing research, you would risk identifying individuals if you talked about where they’re deployed, because Canada is small. Also, the numbers for statistical power were too small.
However, now, to get something published, you can’t exclude someone because of that. When you’re doing studies, you need to over-sample individuals. The numbers would be smaller, meaning you make sure that you do all that you can do in the research study to recruit more women so that you have a sufficient number and you do not exclude them.
That would be an area that would now be consistent in research. That would be one area that’s a major advance.
We also need to ensure that when we’re asking questions, we are looking at that whole area and saying, “Is this question meaningful to you?” Because the question itself might be different. We don’t want to make assumptions of old questions or studies that might not have looked at that to that degree. So first is asking and ensuring that you’re sampling and then making sure that you’re not making interpretations based on very small numbers.
[Translation]
Senator Boisvenu: That’s very interesting. Thanks again for being here, it’s very helpful. You say there are a lot of drop-outs. Knowing this, is there a strategy to help keep veterans in therapy?
[English]
Dr. Richardson: One of the things that is starting to be used with regard to dropouts, one that I have described, is can we condense treatment? In asking someone to commit to 12 or 20 sessions for very focused treatments, you’re almost creating the situation where you might have higher dropouts. Is there a way to condense the treatment? That’s being done for the psychotherapies.
One of the advances or one of the positives, if there are any, with the pandemic is that it forced innovation and a lot of clinicians, like myself, to virtual care.
A big challenge for veterans is that they don’t live in the city. Driving an hour or an hour and a half, paying for parking, waiting in the waiting room to see me for 45 minutes, that’s a challenge. It would be for anyone. So is there a way we can condense it? What we’re doing is giving the choice to veterans so that they can access care virtually, as a way to decrease dropouts.
There are current strategies with regard to shortening treatments for psychotherapy, some of the repetitive transmagnetic stimulation, and also doing measurement-based care to ensure we are using ways to better determine if this individual is likely to drop out. There are certain things with regard to whether they have a trusting relationship with me or their clinician. There might be warning signs, and then we can intervene earlier to encourage individuals. The other thing we’ve found is engaging family members in the treatment.
[Translation]
Senator Boisvenu: Can a connection be made between the drop-out rate among veterans and rising homelessness in our cities?
[English]
Dr. Richardson: That I don’t know. It’s a very interesting question. Are you asking about homeless veterans or homelessness in general within Canadian society?
[Translation]
Senator Boisvenu: An estimated 5,000 to 6,000 veterans in this country today are homeless, and therefore without housing or a fixed address. Is it fair to say that these individuals end up homeless due to lack of treatment or because they drop out of treatment?
[English]
Dr. Richardson: That I do not know, but I think it’s something that should be looked at. I’m not an expert in homeless veterans. However, I would imagine that for some of these veterans, especially if they have difficulties with mental illness, drugs or alcohol, accessing care is a challenge. Trusting organizations and getting them into treatment would be very similar to what we see on the civilian side.
What we don’t know — and I will look into that, because I never thought of that — is if these individuals have accessed care before, dropped out and are now homeless, or are they veterans who have never sought treatment and never had a diagnosis?
I have treated veterans who were homeless. They self‑disclosed that, while they came back from deployment and were released, they were struggling and homeless. They were not in treatment. They eventually got into treatment. I don’t know if those who are dropping out of treatment become homeless. I do not know.
It’s a good question. Thank you.
Senator Yussuff: Again, thank you very much for the work you’re doing. Equally, I know wanting to do the right thing sometimes needs to be properly analyzed so you don’t do the wrong thing in the process.
On some of the experience that we are gaining with regard to what other jurisdictions are doing in treating veterans, the U.S. government, through their VA as well, states like Texas are undertaking psychedelic-assisted psychotherapy studies specifically with veterans to determine their potential benefit.
You mentioned that controversial treatments for mental health disorders, such as PTSD or depression, are less effective with veterans compared to the general public.
Do you believe that the Canadian government should fund clinical psychedelic-assisted psychotherapy trials, specifically for veterans, as the U.S. are doing?
Obviously, the U.S. is very focused on trying to get studies that specifically focus on veterans, not just the general population, to try to assess whether these things are effective — whether or not they are effective, we’ll find out with the trials they’re doing and the studies they’re funding — if it can be utilized to help veterans deal with the challenges that they are faced with.
Dr. Richardson: That’s a very good question. At a minimum — and that’s what I try to encourage my colleagues that are doing research — it is having a veteran identifier, meaning that, in these studies, sometimes there’s a challenge recruiting. They might not know that an individual has self-identified that they’re a veteran.
If we ensure through those processes that you have a veteran identifier, then they can look to see, okay, out of the 20 who have done this study, 5 were veterans. Did they respond differently compared to civilian trauma? That would be a way of looking at it in that way.
Senator Yussuff: Based on your experience and the work you’re doing, if you had one or two things to recommend that we, as a committee, could give some thought to and that we could put in our recommendations to government, what would that be specifically around the challenges that veterans face in services across the country but, more importantly, dealing with the fact that PTSD has been identified as a serious problem for veterans more specifically?
I know the public, in general, has issues with this. What would you say would be of value that we could try to encourage our government to look at this as a way of helping to deal with the challenges veterans are faced with?
Dr. Richardson: Very globally, number one is to improve and ensure access. It was already mentioned, long delays in accessing assessments and treatments; there are a lot of areas in that.
Also, encouraging and promoting virtual care, which is another way for accessing. I’m mindful. Patients who come in are travelling large distances. That would be an area.
One of the areas that was already discussed here is in terms of looking to ensure people are getting evidence-based treatments. Then also providing resources and research to look at the emerging treatments.
Not everyone is going to respond to first-line treatments. They will need treatments for treatment-resistant depression or PTSD, including ketamine and some of the emerging evidence with regard to the psychedelics, all of those areas.
One of the benefits — I know this is focused only on veterans — in the teaching that I do, is that if you can treat a veteran, you can probably treat a civilian. It is transferable to the general population.
Knowing if a veteran can respond well to psychedelic-facilitated psychotherapy would also assist informing the civilian first responders, public safety personnel that also suffer from PTSD.
Senator Yussuff: Thank you very much, doctor. Thank you for coming. Thank you for the work you do and for what you’re doing on behalf of veterans.
Dr. Richardson: Thank you.
Senator M. Deacon: Thank you, again, as we continue to delve into this. In your earlier statement, you talked about three strategies, three levels. One started with a nasal spray, I believe. The second one was said quickly, but I think it was rTMS.
Generally speaking, what percentage of success does one have with the nasal spray? And with the second treatment, it wasn’t convulsive therapy, but it sounded like it. Could you define those again for me, please?
Dr. Richardson: Sure. I was focusing on treatments that are currently available for treatment-resistant depression, and that it’s currently also being investigated to benefit PTSD. One is the area of ketamine infusion, which is IV, or esketamine, which is intranasal ketamine. It’s also available orally as a tablet. I don’t have the exact percentages, but I can provide that to this group, in terms of its treatment response rate for those who are treatment-resistant. Treatment-resistant means they did not respond to conventional, first-line treatments like an antidepressant and/or psychotherapy.
And rTMS is repetitive transcranial magnetic stimulation, so it is using a high-powered magnet to focus areas of your brain to stimulate it, and that’s been shown to be helpful for treatment-resistant PTSD.
Senator M. Deacon: Thank you, that is great.
Dr. Richardson: Thank you.
Senator R. Patterson: Going back to recommendations that we can make in terms of improving access for women veterans, do you have any recommendations, whether it be research topics, recommendations for Veterans Affairs, who really control all of this, which you think would be useful?
Dr. Richardson: As was brought up earlier, having standardized assessments, it’s important to specifically ask about military trauma, and then specifically ask about military sexual trauma because individuals might not self-disclose.
It is also to ensure that the environment — meaning coming in — is welcoming for women that might have experienced military sexual trauma. In the same way that you might go to hospitals and they have a rainbow triangle that says this is a safe place, it is to ensure that in the environment for women — when they are coming in — the images they’re seeing around them are representative of them; that would be another area, so ask, sensitize individuals, both of those things.
Then getting individuals who have lived experience to co‑create some of these programs so that it has the look and feel from their perspective.
The Chair: Thank you very much. I have a quick question. Senator Yussuff also skirted this question.
Standardized treatment can’t be one-size-fits-all in psychedelic treatment. It would be absurd to think that psychedelic treatment would help everyone in the same way or to the same degree.
I’m wondering, in a controlled study, what do you do? Do you go with the percentages of success as an indicator? How does this work within a controlled study with psychedelic treatment of patients with PTSD? How broad should this study be? How successful can it be?
Dr. Richardson: Those are very important questions. I’m not sure I can answer all of them, because you’re asking questions that we also struggle with.
However, in terms of standardized treatments, it is true that a one-size-fits-all approach probably will not be helpful for everyone, simply because there are many variables, as was discussed. Military sexual trauma, moral distress or moral injury respond differently to different types of treatment compared to stress or fear-based trauma; something happens that was overwhelming.
When we look at general protocols, what are the things that you should start first, what are the things that you should start second, and then what are the things that, if those don’t work, would have you go to the third line, which would be a standardized way and looking at standardized assessments and standardized treatments. And then it is looking at treatment response, when they’re doing studies, comparing to see if it is better than standardized treatments and whether it is cost‑effective, which is something else that needs to be looked at. It might be better, but in terms of how long it takes or the number of people, is it scalable across an entire nation or all areas that look at research?
The Chair: I agree with that. I think that’s true.
And going back to the idea that — not so much psychedelic at the moment — cannabis can help relieve PTSD or whatever, there is a concern on my part that this also masks a deeper problem, and I’m wondering if psychedelic therapy might do that, too? I’m not saying it would; I’m just asking the question.
Dr. Richardson: That’s a good research question to look at in terms of whether it’s treating a condition, and once you stop it, sometimes, to see if the symptoms come back, or does it create other issues in terms of potential addictions or dependence on it?
The Chair: Doctor, we’re still a long way from a conclusion in these studies, aren’t we?
Dr. Richardson: For some. Going back to your other question, I think if we can personalize treatments to a greater degree, then it’s probably going to be less of “one-size-fits-all.” I think that’s probably an area that we’re closer to than determining some of the other questions with regard to emerging treatments.
The Chair: Thank you.
Senator Boisvenu: Doctor, you said that you don’t have any data about the relation between homeless and people who will let down their therapy, and we didn’t receive any people working with the homeless. Should we have those people, so they can bring some data about who are those homeless?
The Chair: Absolutely, right. Yes, of course.
Dr. Richardson: I might suggest Cheryl Forchuk at the University of Western Ontario. She has done work on homeless veterans, so there might be data there that I’m not aware of. That might be an individual you could contact.
Senator Boisvenu: We can get in contact with them. Good.
Senator R. Patterson: A very tight question goes to the standards that the Canadian Psychiatric Association has around PTSD and military veterans. The U.K. and the U.S. certify medical care providers so that they actually have the understanding, and they are the ones who treat veterans.
Can you see a place for that type of system in Canada, and what role would the Canadian Psychiatric Association have? Do you see a value there?
Dr. Richardson: That’s probably something that I’d have to ask the Canadian Psychiatric Association whether they would endorse that, but I would definitely see that as looking at accreditation in terms of value, especially for military culture, to ensure that individuals know enough about the stressors in the military. Because you might have heard from veterans that they don’t want to be sharing or explaining what the work life was like.
It definitely would be a benefit to ensure that, if it’s not mandatory, at least veterans could ask, “Have you completed this course?” And that itself might be helpful.
The Chair: Thank you very much.
(The committee adjourned.)