Annex A: The Panel's Recommendations

Recommendation 1: The CF should continue to leverage its existing mechanisms for developing, implementing, and evaluating mental health training, specifically the MHEAC and the JSB.

Recommendation 2: Routine suicide awareness and prevention training should be incorporated into the rest of the regular, coordinated mental health training that will occur across each member’s career and deployment cycle.

Recommendation 3: The US Army’s “ACE” program targets the key competencies for suicide prevention and should be strongly considered for the CF’s mental health education efforts.

Recommendation 4: The development of suicide awareness and prevention training should follow sound principles of curriculum development and adult education. Specifically, such training should incorporate opportunities for learners to practice suicide-specific skills, such as asking a friend about suicidal thoughts.

Recommendation 5: The fate of the StF module on suicide prevention should be decided by the Mental Health Education Advisory Committee. Until such time as the full mental health training program has been implemented, the StF suicide prevention program should continue to be available as a training option, particularly for those in gatekeeper roles.

Recommendation 6: For mass education, shorter programs should be favoured over longer ones until such time as there is evidence that longer programs lead to superior outcomes.

Recommendation 7: The Panel does not see the need to mandate that all members receive suicide prevention training by a certain date.

Recommendation 8: The linkage between good leadership, work-related stress, and mental health problems should be covered in the CF’s routine mental health education program, as should the leader’s role in overcoming barriers to mental health care.

Recommendation 9: General leadership skills that form the backbone of leadership training in the CF are probably more important for suicide prevention than specific suicide prevention skills. However, there is enough evidence of potential benefit of suicide prevention training that it should be incorporated into the CF’s mental health education program across a leader’s career cycle. Standalone suicide prevention training may be considered for leaders who will not be receiving suicide prevention training as part of a career course (or other training) over the new few years, but such training should not be considered mandatory. Instead, leaders should prioritize the need for suicide prevention training against other unit and individual training needs.

Recommendation 10: Educational programming for leaders should specifically address ways of managing the disciplinary process in ways that mitigate suicide risk.

Recommendation 11: Those who manage the ongoing education of CF trades that have an increased likelihood of encountering patients at suicide risk (such as MP’s) should consider the need for specific suicide prevention training for their occupational group. The priority of this training should be weighed against the many other educational needs of a given occupational group.

Recommendation 12: Those managing the educational programming for CF health professionals should consider offering educational programming on depression and suicide as part of their regular educational activities (e.g., occupation-specific training at CFB Borden). These individuals should weigh the priority of such training against the many other educational needs of their occupational group.

Recommendation 13: The ability to establish trust and rapport with a potentially suicidal patient is fundamental to the assessment of suicidality. As such, evaluating and, if needed, enhancing these skills should be a focus of suicide prevention education for clinicians.

Recommendation 14: Those supervising clinicians should consider the need to provide targeted education or training on depression and suicide as part of the clinician’s Personal Learning Plan. Again, this needs to be prioritized on an individual basis based on the totality of the individual’s educational needs.

Recommendation 15: Additional mass screening for suicidal ideation in the CF is not recommended, though existing screening during the Periodic Health Assessment and pre- and post-deployment screening may continue as this practice provides useful surveillance data and harm is unlikely.

Recommendation 16: Depression screening during the Periodic Health Assessment and the pre- and post-deployment screening should continue.

Recommendation 17: The CF should consider increasing the frequency of depression screening, but only if it forms part of a systematic approach to primary care management of depression.

Recommendation 18: The CF should follow the emerging literature on the benefits of more frequent PTSD screening in primary care and implement such screening if and when there is sufficient evidence of benefit.

Recommendation 19: The CF should adopt and disseminate the APA guidelines on assessment of suicidality.

Recommendation 20: Assessment of suicidality should of course occur at the first encounter for evaluation of patients with symptoms of mental health problems in both mental health and primary care settings. Suicidality should be reassessed during care for patients who have deteriorated, have developed new symptoms or co-morbidities, have failed to improve as expected, or are experiencing a crisis or significant new stressors. Assessment of suicidality at each and every mental health encounter is not required and in fact may be counterproductive. However, this last finding may not apply to computerized mental health outcomes management systems.

Recommendation 21: In its educational programming on suicide, the CF should emphasize the limited value of risk factors for predicting suicide on a case-by-case basis. Instead, suicide risk assessment hinges on the precise content of an individual’s suicide ideation and plan.

Recommendation 22: Given its central role in suicide prevention, the assessment of suicidality should be a target for quality assurance audits.

Recommendation 23: The CF should empanel a separate group to develop best practices for outpatient management of individuals at high-risk for suicidal behaviour (such as those discharged from an inpatient facility following a serious suicide attempt). The group should specifically address the issue of when a unit “buddy watch” is indicated as well as how precisely the watch is to be carried out. Because resources are likely to vary from region to region, a mixture of both national and regional solutions will be required.

Recommendation 24: A unit “buddy watch” should be reserved for short-term use in truly exceptional circumstances, such as a serious suicide attempt at a remote Forward Operating Base.

Recommendation 25: The CF should follow conventional, evidence-based guidelines for the drug treatment of mental disorders.

Recommendation 26: The CF should follow the guidelines of the American Psychiatric Association with respect to drug therapy for suicidal patients. These guidelines provide instruction on how to mitigate the increased risk of suicidal behaviour that can occur in the first weeks to months after the initiation of antidepressants.

Recommendation 27: Suicidality should be identified and addressed as a separate problem in mental health patients. Patients with suicidal ideation, intent, or behaviour should receive evidence-based psychotherapy specifically targeting the suicidality and the interpersonal problems that are driving it.

Recommendation 28: Cognitive-behavioural approaches targeting impulsivity, emotional dysregulation, and hopelessness/pessimism are particularly appealing for psychotherapy of suicidality because of their strong evidence base and the broad familiarity with CBT among CF clinicians.

Recommendation 29: The decision to augment (or replace) suicidality-specific CBT with interpersonal therapy, purely cognitive therapy, problem-solving therapy, and insight-oriented approaches should be made by the treating clinician, in consideration of the totality of the clinical circumstances.

Recommendation 30: Where clinically appropriate, using manualized approaches of proven benefit should be strongly considered (given that these have the best evidence of efficacy behind them).

Recommendation 31: The CF should consider developing and implementing a single, system-wide process for assuring follow-up for patients receiving care for mental disorders in both primary care and specialty mental health care settings.

Recommendation 32: The CF’s existing Case Management Program can be used as a mechanism to improve follow-up for higher-risk mental health patients.

Recommendation 33: The CF should ensure that suicide surveillance data captures the source of the firearm involved (service vs. personal), as well as enough information to determine whether policies and procedures for firearm access were followed. This surveillance data should inform any needed changes in firearm control policies.

Recommendation 34: The CF should also ensure that suicide surveillance data specifically addresses the agent used in drug suicides, as well as the source of the agent (CF pharmacy, civilian pharmacy using CF Blue Cross card, other), if known. The CF should review existing dispensing/packaging practices for high-risk drugs, with an eye towards identifying any additional opportunities for means reduction.

Recommendation 35: Restriction of access to lethal means at the individual level should be part of the plan for management of suicidal patients in the outpatient setting.

Recommendation 36: The CF should explore opportunities to proactively engage with the local, regional, and national media in order to educate them on suicide and mental health in the CF, with the goal being to encourage responsible reporting of CF member suicides and enhance the confidence that CF members and the public have in the CF’s mental health care.

Recommendation 37: The CF should continue to develop, implement, and evaluate policies and programs designed to mitigate stress and strain in the workplace, with the expectation that these may advance the CF’s suicide prevention agenda, while at the same time offering many other advantages tothe organization.

Recommendation 38: Disciplinary and investigative policies and procedures should be reviewed with an eye towards identifying any additional opportunities for changes that will mitigate stress and lower suicidal risk. Consideration should be given to implementing a version of the US Air Force’s “hands-off” policy for members under investigation. In order to be effective, such a policy would need to be supported by training and development of tools and resources for leaders, investigators, and the rank-and-file.

Recommendation 39: For the purposes of suicide prevention, the Panel does not recommend any additional screening or selection measures be implemented for either potential recruits or members preparing for deployment.

Recommendation 40: The CF should continue to evaluate the resilience training aspects of its mental health training program.

Recommendation 41: The CF should continue to monitor the scientific literature in the area of resilience training, modifying its own programming to reflect best practices.

Recommendation 42: The CF’s Strengthening the Forces programs on anger management, stress management, and healthy relationships likely improve member and family wellbeing and mitigate primary risk factors for suicidal behaviour. For these reasons, they should continue to be offered.

Recommendation 43: The CF should continue to identify the remaining barriers to mental health care (both in garrison and on deployment) and to make any needed changes to address these.

Recommendation 44: Confidentiality with respect to suicidal thoughts and behaviour offers both advantages and disadvantages. CF mental health specialists believe that the effects of the CF’s policy of strong confidentiality protections surrounding suicidality are, in the balance, far more positive than negative. Nevertheless, CF clinicians should engage in meaningful dialogue about medical employment limitations with the operational chain of command. In addition, clinicians should encourage members to disclose details about their mental health problems when doing so can contribute to their recovery.

Recommendation 45: The CF should continue to drive down wait times for mental health services to as low as is feasible.

Recommendation 46: The CF must reinforce its capabilities in clinical quality improvement in mental health care. It must capture enough data on the processes and outcomes of care to permit identification of potential problem areas and to evaluate the effect of any countermeasures.

Recommendation 47: After each suicide, a clinical suicide investigation should take place as soonas possible:

  1. The primary purpose of this investigation should be to explore any opportunities for improved suicide prevention or care in the future, with a focus on health care and communication/collaboration between health professionals and the chain of command;
  2. A secondary purpose should be to feed useful epidemiological data into the CF’s suicide surveillance system;
  3. The investigation should be performed by one or more health professional(s) with special training/experience in suicide investigation;
  4. Investigators should be drawn from a limited pool of qualified investigators for whom performing such investigations would be one of their primary duties;
  5. The investigation should follow a standard protocol—the US’s Department of Defense Suicide Event Report would serve as a useful template;
  6. Psychological autopsy should be reserved for cases in which there is significant uncertainty about the cause of death (e.g., suicide vs. homicide). Those responsible for doing psychological autopsies should have specific training and experience in their execution.
  7. The CF should seek legal counsel to determine the extent to which the information in the clinical suicide investigation can be protected as a quality assurance activity; and
  8. The clinical suicide investigation (or some extract thereof) can serve as a useful reference document for BOI’s.

Recommendation 48: The CF should review the information required for its suicide surveillance activities, making sure that it has a reliable mechanism for capturing the information that is most likely to be helpful for quality assurance. In particular, more detail is required on:

  1. Means;
  2. Triggers;
  3. Mental health care; and
  4. Communication/collaboration with the chain of command

Recommendation 49: The US Department of Defense Suicide Event Report may serve as a useful template for suicide surveillance data.

Recommendation 50: The clinical suicide investigation should be used to capture the data needed for suicide surveillance; investigators should be trained in the use of the suicide event report.

Recommendation 51: For the present, the CF should focus on completed suicides as it fine-tunes its suicide surveillance system. However, in the future, the CF should look towards finding ways of capturing similar information on serious suicide attempts as well.

Recommendation 52: The CF should continue to monitor suicide risk factors (including barriers to mental health care) using its periodic Health and Lifestyle Information Survey.

Recommendation 53: The CF should specifically look at suicide rates in currently serving and former members in its planned cancer and mortality linkage study.

Recommendation 54: The CF should develop a set of performance measures (and ways to capture these) for its suicide prevention program. The completed suicide rate will have limited value as a performance measure because the numbers are expected to be low enough that detecting important changes will be difficult. Thus, other performance measures will be needed (such as the fraction of those with mental health problems who are in care, the prevalence of suicidal ideation, the fraction of mental health patients with a complete suicidality assessment documented in their medical record, etc.).

Recommendation 55: Leader education on available mental health services should be integrated into the CF’s comprehensive mental health education program. The frequency of this training should be guided by demonstrable educational needs rather than any fixed schedule.

Recommendation 56: “Buddy aid” mental health skills should also be integrated into the CF’s comprehensive mental health education program.

Recommendation 57: An implementation plan for all of the Panel’s recommendations should be developed. Because of the resource implications and the complexities involved, the plans for development of a clinical suicide quality assurance investigation system and the overall reinforcement of the CF’s quality improvement capacity for mental health care should be emphasized.

Recommendation 58: A comprehensive communications plan should be developed to educate all stakeholders about the CF’s suicide prevention program. The efforts to engage the media to encourage responsible reporting of suicides should be rolled into this comprehensive plan.

Recommendation 59: The CF’s suicide prevention program has progressed enough that CFAO 19-44 should be repealed and replaced with a suitable policy instrument that sketches out the essential features of the CF’s current approach.

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