The State and Impact of Mental Illness in the CAF and Canadian Society

Core Determinants of Health

According to the Public Health Agency of Canada, there are 12 core determinants of health: employment and working conditions; education and literacy; physical environments; social support networks; personal health practices and coping skills; social environments; healthy child development; biology and genetic endowment; culture; financial and social status; gender; and health services.

Aside from healthy child development, biology and genetics, gender and culture, the CAF can, and does, influence most other determinants of health in one way or another. All who serve are employed; they have a support network with their peers, families and chain of command; there is continued education through the professional development program; and although they must often work in austere and dangerous environments, that work is done with high quality equipment, training and leadership. Rarely does an organization have this level of influence. It is evident that the CAF impact on mental health goes far beyond the mandate of the CF H Svcs Gp.

The leadership of the CAF is committed to improving the mental health of its members. It has been well recognized that mentally and physically fit armed forces are stronger and more effective. The Chief of Defence Staff (CDS) Guidance to Commanding Officers (Chapter 1901.4) lists expectations for senior leaders to support and promote health among their subordinates. It states:

  • Take responsibility for the promotion of health and physical fitness in your unit;
  • Lead by example—embrace a healthy and active lifestyle and facilitate the achievement of optimum health and fitness in your personnel. Create and reinforce a culture of healthy lifestyle through local policy initiatives, and support for programs that educate, motivate and facilitate personnel to make positive health choices;
  • Support your personnel’s access to health promotion programs offered at your unit or Base/Wing and provide support to your local health promotion program’s operations and maintenance budget;
  • Work with the Health Services staff to identify and address significant health issues facing your personnel;
  • Scrupulously respect employment restrictions recommended by medical officers. Wherever safe, prudent, and possible, accommodations in the workplace will be made to allow ill and injured members to continue to function in a capacity compatible with their limitations; and
  • Create, to the greatest extent possible, a climate of information, trust and understanding around health care issues. CAF members must know that the privacy of their health information is absolute and will be vigorously defended. They must also know that the chain of command will support them to the greatest extent possible, to maximize their chances of recovery from illness and injury.

These fundamental principles cannot be understated in the maintenance of a physically and mentally fit military force.

Mental Health

"Mental health is a state of well-being in which the individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her own community."

World Health Organization (2007). What is mental health?
Retrieved on January 12, 2013
http://www.who.int/features/qa/62/en/index.html

Mental Illness

A mental illness has strict criteria for diagnosis that are found in the Diagnostic and Statistical Manual of Mental Disorders. The outcome for each diagnosis depends on the degree of severity and other factors. As with every diagnosis, mental or physical, there is never a guarantee of full recovery to a person’s pre-existing state and some may not fully recover even with the best available treatment.

Although the normal expectation is that recovery means a return to a pre-existing state, many people can end up better than they were in many ways. That may simply consist of recognizing vulnerability to illness and a need to better look after one’s self.

The most common mental health diagnosis in Canada and the CAF is major depression, while the most common mental illness related to operations is post-traumatic stress disorder (PTSD).

Mental Injury

It is recognized that a person can be injured both physically and mentally during operations. The term “Operational Stress Injury” (OSI) is not a diagnosis; rather it is a grouping of diagnoses that are related to injuries that occur as a result of operations. The most common OSIs are PTSD, major depression and generalized anxiety. This term has helped break down several barriers to care and reduce the stigma surrounding mental illness.

This type of description should not, however, create a stigma that other mental illnesses are not as important. Stress in the workplace can have an effect on mental health and can contribute to mental illness.

Need for Care

The CAF is a subset of Canadian society and its members’ mental health is reflective of the mental health status of Canadians in general. We are different, however, in that we screen out serious mental illness such as schizophrenia. Conversely, we have a higher incidence of stress injuries as a result of the dangerous environments we operate in.

Mental illness in Canadian society poses a greater burden of disease on the health care system than all cancers combined, and one in five Canadians will develop a mental illness in their lifetime. According to the Mental Health Commission of Canada, every day 500,000 Canadians are absent from work due to mental illness. It is reasonable to conclude that the incidence of poor mental health and mental illness would be similar in the CAF and have the same impact on our organization.

The most consistent finding in all CAF mental health research is that most individuals are free of mental illness during any given year. A significant minority will, however, have problems during a year, and a much larger group will suffer from a mental illness at some point in their lives. The 2002 CAF Mental Health Survey showed that 15 percent of all CAF personnel experienced symptoms of one of five common mental disorders in the previous 12 months (major depression, social phobia, post-traumatic stress disorder (PTSD), panic disorder, and generalized anxiety disorder).

Studies have demonstrated that the overall prevalence of one or more mental illnesses in the CAF is similar to that in the general population, including the level of alcohol dependence. For reasons that are not yet fully understood, however, CAF Regular Force personnel have almost twice the risk of depression as their civilian counterparts.

The need for support extends beyond those who have an overt mental illness. There is a small, but important, group who do not have a formal diagnosis of a mental illness, but whose levels of distress may be having an impact on their daily lives, whether at home or at work.  Of the 12 percent of CAF members on deployment in Afghanistan who reported some job interference due to mental health, more than half did not have a diagnosis of mental disorder.

Impact of Operations

Deployment has proven to be a risk factor for mental health problems. The CF H Svcs Gp Operational Stress Injury (OSI) Cumulative Incidence Study, published in 2011, showed that 13 percent of personnel who deployed in support of the mission in Afghanistan up to 2008 were diagnosed with a deployment-related mental illness after more than four years of follow-up. Combat exposure and exposure to atrocities are risk factors for post-deployment mental illness. Deployment, however, accounts for relatively little of the overall burden of mental disorders in the CAF. Military personnel experience nearly all the non-operational risks and vulnerabilities to mental illness as their civilian counterparts.

There is no evidence of increased risk of deployment related mental health problems in CAF Reservists compared to Regular Force members; three large, population-based studies have failed to demonstrate a higher risk of post-deployment mental health problems in Reservists. In fact, the research suggests that CAF Reservists appeared to have slightly better mental health, on average, than Regular Force personnel.

Data from the 2002 CAF Mental Health Survey, the 2010 Operational Mental Health Assessment and the 2011 Operational Stress Injury Cumulative Incidence Study all showed a small increased risk of mental illness with each additional deployment.

Periods of transition may also be stressful for military personnel and may affect mental health status. Transitions occur before and after missions, with changing rank and jobs, as well as during each posting season. For anyone who has deployed on a combat, peacekeeping or humanitarian assistance mission, each is a life-changing event and the transition home may be difficult for some. At the end of a CAF career, there is the transition from military to civilian life. This period can be more difficult for those who are released from the armed forces because of a physical or mental illness or injury.

Report of the Canadian Forces Expert Panel on Suicide Prevention

Suicide

Suicide is an important public health problem linked to mental health. It is the second leading cause of death among persons aged 15 to 34 in Canada. Due to the relatively small number of suicides among CAF members each year, it is not possible to identify statistically significant changes from year to year. Rates must therefore be assessed over five-year periods.

The United States Army’s suicide rate has doubled over the past decade and there has been considerable attention to the rate of suicide in the CAF. Suicide rates have, in contrast, remained stable in the CAF over the last 10 years. Suicide rates in the CAF are no higher, and are in fact lower, than those in the general population of the same age and sex. There is no increased rate of suicide among those who have deployed versus those who have not.

Use of Services

Approximately 15 percent of CAF Regular Force personnel access mental health services each year. Care-seeking is also common post-deployment— approximately 30 percent of those deployed in support of the mission in Afghanistan sought specialty mental health care through CF H Svcs Gp within four years of their deployment. While these numbers show that CAF mental health services are accessible and acceptable to many CAF members, less than half of those with an apparent mental disorder will seek care in any given year. This unmet need for care is not a problem that is unique to the CAF. Studies show that CAF Regular Force members with mental health problems are more likely to seek care than their civilian counterparts.

Although CAF efforts have drastically reduced the time our members wait before seeking care, this remains a problem in the CAF and in the general population. While most with persistent problems do eventually seek care, some wait years or even decades to do so. During this period, they suffer unnecessarily, are not as productive as they could be, and their condition may become more difficult to treat successfully.

Stigma and Barriers to Care

The CAF Expert Panel on Suicide Prevention (2010) found that CAF personnel report a broad range of barriers to mental health care. The most prevalent barrier is their own lack of recognition that they have a problem. The next most prevalent barrier is the desire to manage one’s problems alone. Other common barriers include negative attitudes towards mental health care (e.g., that it is ineffective or harmful) and concern about the career impact of seeking care. Barriers to care that typically exist in the civilian population, such as inability to pay for care, language barriers or wait times, are not prevalent in the CAF.

Stigma remains a problem that can never be fully overcome, but most CAF members now hold largely forward-thinking attitudes about mental health and mental health care. For example, only six percent of CAF personnel returning from deployment in support of the mission in Afghanistan indicated that they would think less of someone who was receiving mental health care. In contrast, the Canadian Centre for Addiction and Mental Health statistics indicate that only 49 percent of the general population would socialize with a friend who has a serious mental illness. Concerns among CAF members about how they would be perceived are, however, more prevalent, with 15 percent reporting that they would be concerned about what others might think if they were to receive care. With the ever-changing composition of the CAF, and the fact that members are a part of and influenced by Canadian society, there must be a continued CAF and national effort to address this problem.

Occupational Impact of Mental Illness

Mental disorders are prevalent in all working populations and contribute to impaired productivity, short- and long-term sick leave, unwanted turnover and use of disability and health benefits. Impaired mental health that falls short of an overt mental illness can also have an impact on the vitality, creativity, motivation and commitment of workers, with predictable consequences on the organization’s ability to deliver high quality products and services. Mental illness and impaired mental health exert a powerful effect on the workplace and on the ultimate success of an organization.

In summary, the state and impact of mental illness in CAF is complex and difficult to measure. The last 10 years have given us the best understanding of the mental health of CAF members that we have ever had. We are at risk of the same illnesses as other Canadians and we serve in dangerous environments around the world. We have a much better understanding of the impact of these operations, now hold very forward thinking views of mental illness and have one of the lowest rates of stigma in NATO.

The mental health of CAF members is influenced by many factors, both within the control of the CAF and outside its influence. The next section describes our comprehensive mental health system that aims to improve mental health, reduce risk of illness, deliver high-quality health care and enhance our understanding of all aspects of mental illness.

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