Annex I: Suicide Surveillance in the CF

Suicide surveillance practices in the CF have changed over the past 9 years and there will be further improvement in the near future. This will be discussed in 3 sections: suicide surveillance up to the present time, deficiencies in current suicide surveillance, and finally plans for the future. Suicide surveillance will be further divided into completed suicide, suicide attempts, and suicide ideation.

Suicide Surveillance, Past and Present

A. Completed Suicide

Suicide surveillance was not well organized prior to 2000 due to lack of staff. There was no calculation of rates and only irregular review of causes of mortality among CF personnel. Following concerns about a cluster of suicides in Quebec, a study by Sakinofsky and colleagues in 1996 investigated the suicides of CF personnel between January 1990 and June 1995. The Sakinofsky study also found that deployment was not a risk factor for suicide.

Since 2000 there has been a more rigorous approach to suicide surveillance. Crude CF male suicide rates have been calculated from 1995 to the most recent complete calendar year. This has been done for male Regular Forces personnel only. Due to the low numbers of suicides annually, five year averaged rates are usually calculated, and confidence intervals tend to be quite wide. Canadian rates for suicide in females are typically 1/3 to 1/5 of those for males. In conjunction with the low proportion of females in the CF, there are quite often no female suicides in any given year. There were no suicides in females from 1995 to 2001, there was one in 2002, 2 in 2003, one each in 2006, 2007, and 2008. These analyses only include Regular Force suicides as Reserve Force records are incomplete for both suicides and those at risk. There is a high turnover for Class A Reservists and suicides among this group are probably reported and investigated outside the military system unless they are specifically brought to the attention of DND.

Information on the number of suicides in the past has been obtained from the Directorate of Casualty Support Management (DCSM). Since 2004 all CF deaths have been reviewed by epidemiologists through review of Summary Investigations, Boards of Inquiry, and medical charts to confirm which deaths are in fact suicides. Disagreement with DCSM findings has been rare. Demographic information (i.e. age, sex, and deployment history) originates from the main CF personnel database (the Human Resource Management System or HRMS). History of deployment is based on deployment Unit Identification Codes (UIC) from HRMS. Canadian suicide rates by age and sex are obtained from Statistics Canada using death certificate data. Codes utilized have been ICD-9 E950-E959 in the past and currently ICD-10 codes X60-X84, both cover suicide and self-inflicted injury. Injury deaths of uncertain intent (E980-E989 and Y10-Y34) have not been included due to the concern that CF deaths are probably more intensively investigated than deaths among the general Canadian population, excluding these deaths gives a more conservative SMR result. Canadian population denominators are taken from Statistics Canada publications.

Since 2000 the following basic analyses have been completed on a regular basis:

  1. Calculation of crude CF male suicide rates. The male Regular Force suicide rate is in the range of 17-20/100,000 per year. These rates appear to be slowly decreasing as is the rate in the general Canadian population. Means of suicide have only been recorded since 2004. The most common means of suicide is by hanging, strangulation, or suffocation.
  2. To compare CF male rates with general Canadian male population rates, standardization by age using the indirect method is used to provide standardized mortality ratios (SMR) for suicide. This controls for the age difference between the CF male and general Canadian male populations. The limitation to this approach is that there is currently a lag time of 3 years before Statistics Canada releases mortality data for all of Canada. The male Regular Force SMR is about 80% for suicide.
  3. SMRs are calculated separately for those with and without a history of deployment. Concern has been expressed that those with a history of deployment may have a higher risk of suicide. The SMR for those with a history of deployment is in the 60 to 80% range.
  4. As SMRs of those with and without a history of deployment cannot be compared directly to each other as they are standardized to different population distributions, direct standardization is done using the total male population of the CF as the standard. Age-adjusted suicide rates for those with and without a history of deployment are compared using rate ratios. The suicide rate ratio is approximately equal to one, mean that there appears to be no increased suicide risk among those with a history of deployment.

B. Suicide Attempts

Information on suicide attempts is available from anonymous surveys such as the Health and Lifestyle Information Survey (HLIS). The HLIS is a mail survey which has been conducted every 4 years up to 2008. The HLIS 2004 found that less than 1% of Regular Force respondents reported ever attempting suicide.

The 2002 CF Supplement to the Canadian Community Health Survey—Cycle 1.2 was a population-based survey done by Statistics Canada on CF Regular and Reserve Force members. At the time of the survey, 2.2% of CF men and 5.6% of CF women reported a suicide attempt at some point in their life. The reason for the difference between this rate and the CCHS rate is unknown—significant underreporting of suicide attempts has been shown in some contexts. Methodological differences may also account for some of this difference.

Military police may keep some type of suicide attempt records; however they are almost certainly incomplete. CF members who do attempt suicide and seek medical treatment will in the vast majority of cases receive treatment at civilian medical facilities. It is unknown if the severity of the intent is recorded.

C. Suicide Ideation

Information on suicide ideation is available from both the HLIS 2004 and from the CCHS DND Supplement 2002; the latter provided the figures that follow. Approximately 16% of CF Regular Force personnel have seriously considered suicide at some time during their life, 4% of CF personnel had those thoughts within the last 12 months. These numbers are comparable to the general Canadian population rates. A question on suicide ideation in the past 12 months has been added recently to the Periodic Health Assessment (PHA). The PHA is required every 5 years for CF personnel up to age 40 and then every 2 years thereafter.

Deficiencies in Current Suicide Surveillance

A. Completed Suicide

Risk factors for completed suicide are not recorded in a systematic fashion on all Summary Investigations and Boards of Inquiry. For example, it is unknown what proportion of CF members who completed suicide had financial problems. Knowledge of this type would help to steer suicide prevention efforts. Information about the means of suicides is not complete. Although death from firearms is the second most common means of suicide among CF personnel, it is unknown how many of these firearms were CF weapons.

Rates of suicide among Reserve Force personnel and released CF personnel are unknown. The latter are recorded in the provincial/territorial vital statistics systems while the former are captured incompletely by CF suicide records maintained by DCSM.

B. Suicide Attempts

There is no surveillance for attempted suicide at the present time. The military police do some type of tracking, it is unknown if severity of intent is recorded. It is important to record the severity of intent as the epidemiology of suicide attempts and completed suicides tend to be very different. Surveillance of suicide attempts is difficult in any population. However, some tracking would be possible through a combination of military police and medical records.

C. Suicide Ideation

A repeated personal interview mental health survey would provide higher quality and more comparative information than that obtained from the HLIS.

Plans for the Future

A. Completed Suicide

Improved recording of risk factors and means of suicide is required. This can be achieved through an improved Summary Investigation or Board of Inquiry process but the long delays (often 3 or 4 years) in completing these administrative investigations would argue for a new approach. A detailed yet succinct investigation by medical staff could meet this objective.

The lack of information on Reserve Force and released personnel suicides will be corrected through a linkage to Statistics Canada’s mortality database as part of the CF Cancer and Mortality Study. This linkage is one component of a larger joint Veterans Affairs Canada – DND project known as the Transitional Outcomes Study, the linkage being Phase 3.

B. Suicide Attempts

There are currently no plans to institute surveillance of suicide attempts. If initiated, it should combine both military police and medical records and severity of intent should be measured where possible.

C. Suicide Ideation

Suicide ideation will continue to be measured on the HLIS and during the PHA. A repeat of the CCHS DND Supplement survey would add to the knowledge base in this area but would require agreement as well from Statistics Canada to conduct the survey among the general Canadian population to provide comparative data.

 


This Annex was provided by Jeff Whitehead, Head, Epidemiology Section, Directorate of Force Health Protection

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