Post-Traumatic Stress Disorder
Backgrounder / January 13, 2016 / Project number: BG 16.00X
Post-traumatic stress disorder (PTSD) is a psychiatric disorder that can be best described as an extreme reaction to exposure to trauma.
PTSD may develop following either direct or indirect exposure to actual or threatened death, serious injury or sexual violence. Direct exposure may occur through experiencing a single or multiple traumatic events or through witnessing such an event happen to others. Indirect exposure may occur when learning about a traumatic event that has affected close relatives/friends or when exposed to details about an event through work, much like a police officer. Traumatic experiences may include natural disasters, crimes, accidents, war or conflict, or other threats to life or safety.
The disorder is characterized by a variety of symptoms that can generally be grouped into four categories:
- re-experiencing (nightmares, flashbacks, and other intense or prolonged psychological distress);
- avoidance (avoidance of distressing memories, thoughts, feelings, or external reminders of the traumatic event);
- negative cognitions and mood (represents feelings which may include: persistent and distorted sense of blame of self or others, estrangement from others or markedly diminished interest in activities, and/or inability to remember key aspects of the event); and
- arousal (hypervigilance, reckless or self-destructive behavior, irritability or angry outbursts, and sleep disturbances).
A diagnosis of PTSD requires that a certain proportion of these symptoms be present for more than one month and cause significant distress or impairment of functioning.
As with most mental illnesses, the biological processes involved in PTSD are not fully understood. It cannot be explained why people who experience the same event might either develop PTSD or experience no symptoms.
The understanding of the psychology and biology of PTSD continues to grow. The Canadian Armed Forces (CAF) conducts research into the risk and resiliency factors associated with the illness. Canadian Forces Health Services (CFHS) also uses existing research and evidence to help conduct PTSD-related screening, education, and training.
Treatment of PTSD in CAF members is provided primarily by clinicians within the CAF clinics, in particular at the seven regional Operational Trauma and Stress Support Centres (OTSSC). CAF clinicians are committed to providing evidence-based treatment that includes medication and exposure-based therapy tailored for each individual patient. Most patients diagnosed with PTSD respond to treatment. In cases where complete recovery is not possible, health care providers help patients achieve the best quality of life possible through strategies that help mitigate their symptoms.
PTSD in the CAF
The 2013 Canadian Forces Mental Health Survey provides the best current estimate for the presence of PTSD in serving personnel. Statistics Canada personnel executed in-person interviews with 8200 CAF personnel, assessing symptoms of current and past PTSD. Of those surveyed, 11.1% of Regular Forces personnel met criteria for PTSD at some point in their life, with 5.3% having met the diagnostic criteria in the time of the survey or over the previous year. These estimates are useful because they include those who have sought care and those who have not.
Most CAF members who deploy on operations do not develop PTSD. A 2011 study on the cumulative incidence of PTSD and other mental health disorders estimated that 8% of members had been diagnosed with PTSD. This study, which involved medical record reviews of a stratified random sample of 2014 personnel, provides the most rigorous scientific estimate of CAF personnel diagnosed with PTSD following a deployment in Afghanistan. The study population included all 30 513 personnel who returned from deployment in support of the mission in Afghanistan from October 1, 2001, to December 31, 2008, and was the first study to examine clinical diagnoses made by a mental health professional, rather than self-completed questionnaires.
Afghanistan-related PTSD was more common among those deployed to higher-threat locations, like Kandahar or Kabul, than in lower-threat locations like the Arabian Gulf or Camp Mirage. Army personnel and junior non-commissioned members were shown to have a higher cumulative incidence of PTSD attributed to the mission in Afghanistan.
Many of those diagnosed with PTSD in the CAF return to full duties, while some remain in the CAF with modification to their duties. In cases where symptoms persist, when the medical follow-up requirements preclude certain deployments, or when there is significant risk of recurrence if re-exposed to military-related stressors, a medical release is likely.
The transition from military to civilian life can be a difficult experience for many members; however the CAF has an ongoing partnership and a strong relationship with Veterans Affairs Canada (VAC) to ensure the most seamless transition possible to VAC-delivered care. Before release, each CAF member is assigned a nurse case manager, who works to ensure that all the necessary care to be provided through VAC is in place and that provincial health coverage is arranged.
The leadership at all levels of DND/CAF are committed to ensuring the best possible care for our military members and will continually seek ways to improve mental health services and access to programs.
Screening, surveillance and prevention
CFHS has many programs aimed at preventing or mitigating the effects of stress. Educational programs are delivered to various levels of leadership and cover the full deployment and career cycles. The Strengthening the Forces Health Promotion courses are available to all members. These courses are aimed at increasing mental health literacy and decreasing stigma among CAF members. They also include training in various stress management techniques that can be used before, during, or after stressful events such as combat. Courses cover areas such as anger and stress management, creating a healthy home life, suicide intervention, and addictions awareness.
CAF personnel undergo a mental health screening as part of their pre-deployment health assessment. Deploying personnel also undergo a psychosocial screening by either a mental health chaplain or a mental health professional.
Before deployment, personnel participate in the CAF’s pre-deployment mental health education and training program - The Road to Mental Readiness (R2MR). The program combines classroom and interactive learning to help participants understand:
the relationship between mental health, performance, and military operations;
the physiology of stress and skills that can manage the stress response;
some of the extreme challenges that may be encountered during operations;
the impact of values, beliefs, and meaning on mental readiness;
the role of social support in health and well-being;
strategies to manage stressful demands and mitigate the short and long-term effects of stress; and
family challenges associated with deployment (similar sessions are available for families through the Military Family Resource Centres).
The R2MR website provides military personnel and their families with easy access to information about the challenges of deployment and the resources available to them. This information is intended as a tool to not only provide more concrete information as it pertains to families but also provide them with some general insight on what CAF members are receiving during their own training. For more information, please visit the R2MR website.
Additionally, personnel returning from an international operation of 60 or more days, or select personnel deployed for a shorter period but in a more traumatic environment, undergo the Enhanced Post-Deployment Screening process, normally three to six months after their return to Canada. This screening helps identify those with deployment-related problems, with a particular focus on psychological issues. CAF members complete a detailed health questionnaire and have an in-depth interview with a mental health professional. If required, follow-up care is recommended and arranged.
The mental health of CAF members is also assessed through regular periodic medical check-ups. Screening questions pertaining to PTSD, depression, suicide, and other mental health conditions are routinely asked and responses are recorded as part of regular examinations.
The CAF has a strong mental health program that provides dedicated and responsive care for ill and injured CAF members and emphasizes the elimination of barriers to mental health care. There are 454 mental health professionals in our clinics. A significant amount of mental health care is delivered by primary care providers.
Mental health care in the CAF is guided by evidence-based practices and is delivered through multidisciplinary teams including primary care clinicians, psychiatrists, psychologists, social workers, mental health nurses, addictions counsellors, and mental health chaplains.
CFHS offers comprehensive and individualized treatment to its personnel, which may include psychotherapy (individual, group, and couple) and medication as required. Should in-patient care be necessary, the CAF has long-standing relationships with civilian health care facilities to ensure that personnel get the care they need.
The CAF has a wide variety of mental health services available to its members. These services are delivered through 37 primary care clinics, 31 of which have specialized mental health services, as well as seven OTSSCs at our largest clinics.
OTSSCs are the CAF’s centres of excellence in treating operational stress injuries such as PTSD. The centres, located in Edmonton, Esquimalt, Gagetown, Halifax, Ottawa, Petawawa, and Valcartier, have four mandates: assessment; treatment; outreach (education); and research.
As well as providing direct care to CAF personnel, these centres are community leaders in the area of mental health and have forged partnerships with civilian and academic institutions. CAF professionals are involved in leading-edge research and are continually looking to their colleagues in the civilian sector and other countries for opportunities to build on care provided.
VAC also has Occupational Stress Injury clinics where CAF members can be referred to care providers in the civilian sector.
In addition to determining the incidence of PTSD amongst those CAF members who deployed in support of the mission in Afghanistan from 2001 to 2008, the 2011 Report on Cumulative Incidence of Post-Traumatic Stress Disorder and Other Mental Disorders also examined the proportion of those personnel who utilized specialty mental health services upon their return from deployment. The study found that close to one-third of all deployed personnel received specialty mental healthcare after their return. This is reassuring, as it shows that CAF members are willing to come forward for mental health care.
Beyond the treatment options mentioned above there are a number of programs in place to support those CAF members suffering from PTSD and other conditions. These include:
The CAF Member Assistance Program (1-800-268-7708): This program provides a confidential 24/7 toll-free telephone advisory and referral service to all CAF members and their families. It also provides short-term (up to nine sessions) confidential external (civilian) counselling for those in need.
The Operational Stress Injury Social Support (OSISS) Program: This program provides peer support and family counselling to those suffering from PTSD or other Operational Stress Injuries.
The Military Family Resource Centres (MFRCs) - located at all major CAF bases: Forty MFRCs are located at CAF installations across the country, in the U.S., and in Europe. These centres can provide information on subjects of interest to military families, including mental health. Staff can direct family members in greater need to appropriate service providers. The MFRCs can provide emergency shelter, funding, and child care, as well as psychosocial support through counselling and referral services to complementary programs in the larger community.
Additional crisis intervention through a network of Military Police, medical personnel, social workers and interfaith chaplains.
Full access to civilian community programs, agencies and shelters for members and dependents.
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