Suicide and suicide prevention in the Canadian Armed Forces

Backgrounder / September 12, 2013 / Project number: BG - 13.041

Every suicide is a tragedy. Indeed, the loss of any of our soldiers is painful and heartbreaking. As such, the health care needs of military personnel are a priority for the Government of Canada and the Canadian Armed Forces (CAF). The CAF recognizes the sacrifices military personnel and their families make in the service of their country. Senior leaders are committed to ensuring personnel receive the highest standard of care and support available.

The CAF’s spectrum of health programs and initiatives includes an extensive suicide prevention program consisting of primary prevention, clinical and non-clinical interventions, mental health education and suicide awareness training. Great efforts are made to identify people at risk for mental health problems and to provide them with the assistance that they require.

In 2012, the Government identified and announced an additional $11.4 million investment to enhance the CAF’s extensive mental health system in order to reduce wait times through innovative recruitment campaigns for health care professionals and enhance treatment approaches for patients. This investment will supplement the $38.6 million spent annually to provide mental health care to CAF personnel.

In addition, from 2003 to 2009, $98 million was committed under the Mental Health Initiative to permit the hiring of additional mental health practitioners, and to increase the number of mental health professionals within the Department of National Defence (DND) and the CAF. The CAF have several initiatives underway to achieve their goal.

Suicide is a concern for all Canadians. According to Statistics Canada, suicide is the second leading cause of death for those aged 15 to 34. Suicide rates among currently serving CAF personnel are lower than those among the overall Canadian population and there has been no statistically significant change observed in the suicide rates in the CAF since 1995. This is not surprising, given that CAF personnel are a screened workforce and have access to comprehensive, high quality health programs and services.

Suicide rates

The CAF collect information on sudden death, which includes suicide, through the Director Casualty Support Management, the Military Police and the Administrative Investigation Support Centre.

In tabulating suicide rates among CAF personnel, the CAF do not include the deaths of civilians on DND property, DND employees, or Canadian Rangers. Information on these occurrences is, however, collected by the Military Police. The figures in Table A originate with the Directorate of Force Health Protection, and are based on the information collected by the Administrative Investigation Support Centre. These figures include male Regular Force personnel only, as the low number of suicides amongst female CAF members makes the statistical analysis of female rates unreliable. The values in Table A are calculated as a rate per 100,000, like those provided by Statistics Canada. Consistent with accepted research methodology, in order to determine whether numbers have varied by random fluctuation (low numbers are particularly subject to random fluctuation) or if they indicate the beginning of a trend, the CAF compare and monitor the numbers over a five-year period.

 

Table A

Suicide rates among male Regular Force personnel:1995-2012

YearNumber of male Reg Force personnelNumber of suicides among male Reg Force personnelMale Reg Force suicide rate per 100,000
2012 58 135 10  
2011 58 622 211  
2010 58 723 12  
5 year period(2005-09) 275 606 50 18
2009 56 813 11  
2008 55 704 13  
2007 55 140 9  
2006 54 301 7  
2005 53 648 10  
5 year period(2000-04) 263 323 50 19
2004 53 873 10  
2003 54 137 9  
2002 52 747 9  
2001 51 029 10  
2000 51 537 12  
5 year period(1995-99) 281 533 56 20
1999 52 689 10  
1998 54 284 13  
1997 54 982 13  
1996 57 323 8  
1995 62 255 12  

 

1. In 2011, there were 21 suicide deaths in male Regular Force personnel. While this number is higher than previous years, it is important to note that suicide numbers vary from year to year and as is the case for any statistic, a variation can either be due to random patterns or indicate the beginning of a trend.

As previously stated, the low rate of suicide among female CAF personnel makes the numbers statistically insignificant and difficult to compare as a rate per 100 000 over time. It is more useful to report the following numbers: there were no suicides among Regular Force female personnel from 1995 to 2002, there were two in 2003, there were none in 2004 and in 2005, there was one in 2006, there was one in 2007, there was one in 2008, and there were two in 2009, none in 2010, one in 2011 and three in 2012.

Each suicide death in the CAF is investigated. A Board of Inquiry is normally convened in cases where the cause of death is determined to be from self inflicted means. Normally, the motivating factors that led to the event are among the issues examined during this process.

In April 2010, the CAF also initiated a Medical Professional/Technical Suicide Review process. This review process does not replace Boards of Inquiry and is conducted by a team of health professionals as soon as possible following a suicide. The objectives of the suicide review process are to identify potential opportunities for enhanced suicide prevention and to provide more detailed and reliable information for the CAF’s suicide surveillance system. To date, over 40 such reviews have been completed and the findings have provided greater insight into suicide in the CAF and insight into how to enhance the already high quality of mental health care the CAF provide.

Reserve Force suicides are also tracked and are investigated. However, due to the nature of Reservists, who are often embedded in local communities where they receive their health care and sometimes make limited contact with their unit, the CAF cannot be certain that all suicide deaths are reported to CAF officials. Therefore, Regular Force male suicides are the most accurate to report and provide the best insight into the impact of suicide on the CAF population.

Deployed personnel

No consistent relationship has been established between deployment and the risk of suicide in the CAF at this time. All military personnel undergo a mental health screening as part of their pre-deployment medical assessment. Deploying personnel also undergo a psychosocial screening by either a chaplain or a mental health professional.

Before deployment, all personnel participate in the CAF’s pre-deployment mental health training program ─ The Road to Mental Readiness (R2MR). The program combines classroom and interactive learning to help participants understand:

  • the impact of deployment on mental health;
  • the physiological reaction to stress and how to mitigate it;
  • the importance and application of goal setting, visualization, self talk, and stress management;
  • the challenges that may be encountered while deployed and their potential impact;
  • the impact of values, beliefs, and meaning in mental readiness;
  • the importance of a social support system;
  • the role of leaders in managing stress in their subordinates; and
  • family stressors associated with deployment (family members are provided an educational briefing as well to assist them in managing the stress associated with deployment).

For more information, please visit the Road to Mental Readiness (R2MR) website.

Throughout deployment, CAF personnel can consult mental health care providers in-theatre.

Soldiers returning from deployment participate in the CAF’s five-day Third Location Decompression program. During decompression, each deployed person is encouraged to speak to a mental health professional and to raise any concerns that they may have. Throughout the program, personnel are also provided with information about post-traumatic stress disorder and other operational stress injuries. To help ease the transition to life back home, the mental health teams also provide information about what may await soldiers at home, work, and community life as they re-connect with life in Canada.

Upon their return to Canada, CAF personnel continue to have access to a full range of mental health services and programs.

In addition, CAF personnel returning from an international operation of 60 or more days duration undergo an Enhanced Post-Deployment Screening Process within three to six months after their return to Canada. The post-deployment screening is meant to better identify those that may experience deployment-related problems, with a particular focus on psychological issues. During the screening process, CAF members complete a detailed health questionnaire and have an in-depth interview with a mental health professional. If there are concerns regarding a member, he or she is referred to a physician for further assessment and treatment.

It is important to note that individuals are encouraged to seek help at any point prior to and throughout their screening process. In fact, the CAF are finding that one-half of those who require follow-up based on the results of their post-deployment screening are already in treatment. Referrals can also be made directly from Third-Location Decompression.

Mental health screening of all CAF members is conducted regularly through carefully structured periodic health assessments. During these assessments, screening questions pertaining to post-traumatic stress disorder, depression, addiction, suicide, and other mental health conditions are routinely assessed.

Prevention and Care

Mental health, including suicide prevention, is a shared responsibility. Along with excellence in health care, mental health programs in the CAF are supported by a strong and engaged leadership and mental health literate personnel. Both CAF leadership and personnel help create a stigma-and barrier-free environment, encourage the early recognition of the signs of stress and promote early treatment.

Canadian Forces Expert Panel on Suicide Prevention

The Canadian Forces Expert Panel on Suicide Prevention, held in Halifax in September 2009, found that the CAF have a strong suicide prevention program in place that compares most favourably to those of its North Atlantic Treaty Organization (NATO) partners and closest allies.

The panel also found that the CAF have implemented, or are in the process of implementing, nearly all of the suicide prevention strategies most consistently identified in civilian scientific literature. In addition, the panel expressed agreement that the CAF’s approach also targets additional factors that are more specific to military organizations.

Since the panel, the CAF have established the Medical Professional/Technical Suicide Review process that is conducted by a team of health professionals following a suspected suicide. The CAF have also implemented a patient follow-up protocol for missed mental health appointments as another tangible way to help prevent suicide, which is consistent with mental health best practices.

As well, the CAF have become involved in initiatives that promote responsible media reporting of suicides. CAF mental health experts have shared guidelines on responsible reporting and have been made available to discuss the complexities of suicide.

As a next step, the CAF are planning to evaluate the outcomes of its suicide prevention program, which will involve assessing the program’s impact on CAF families and barriers to care (stigma, geographical, structural, and other).

Education Programs

The Canadian Forces Health Services Group has several programs aimed at preventing or mitigating the effects of stress. Educational programs are delivered to various levels of leadership and cover all aspects of a member’s career. The Directorate of Mental Health Training and Education Section has developed evidenced-based mental health curriculum that has been integrated in CAF career courses. To date, over 56,000 CAF members have received some form of mental health training and education.

These courses are aimed at increasing mental health fitness and literacy, decreasing stigma among CAF members and increasing leadership engagement and social support. 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.

The CAF health promotion program, Strengthening the Forces, offers suicide awareness and education training based on the A.C.E. (Ask, Care, Escort) model. At the leadership level, a one-day course called Mental Fitness and Suicide Awareness helps prepare supervisors to promote mental fitness and to mitigate the incidence of mental health injuries including deliberate self-harm and suicide within the military community. In addition to the supervisor’s course, a Mental Fitness and Suicide Awareness full-day course is available to all CAF personnel and their families.

Half-day suicide awareness sessions and briefings are also available on all bases and wings. This training takes place under the CAF’s larger health promotion umbrella responsible for promoting healthy living and an addiction-free lifestyle and preventing injury and illness through education and skill building activities which includes stress management, anger management, and effective communication.

For more information, please visit the Strengthening the Forces website.

Care

The CAF have a strong mental health program that provides dedicated and responsive care for ill and injured CAF members and emphasizes the elimination of the barriers to mental health care. 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 chaplains.

The CAF offer comprehensive treatment to their personnel including fully covered psychotherapy and access to medication as required. CAF personnel have daily access to a general duty medical officer at the base medical clinic. When in-patient care is necessary, the CAF have long-standing relationships with civilian healthcare facilities to ensure that personnel get the care they need.

In the case of an emergency, CAF personnel in crisis can also see a primary care physician on a 'walk-in' basis, without an appointment at one of the CAF Medical Clinics. All primary care physicians have been trained in suicide assessment, management and prevention. They may also go to a civilian healthcare centre during quiet hours or they may call 1-800-268-7708 to reach the Member Assistance Program, 24 hours a day, from anywhere in the world, and receive a confidential referral for help.

Personnel or the friends and family of someone in need of help can also call the military police or 911, who will respond on an emergency basis, and either bring the suicidal member to the base clinic during working hours, or to the local hospital emergency department after hours. Military and civilian police, as well as emergency services personnel, are trained in mental health crises and in helping and managing the suicidal person.

Anyone who is assessed by primary care, psychosocial services or mental health clinicians as at risk for suicide is seen immediately by a physician. If hospitalization is necessary, patients are escorted to one of the local civilian hospital emergency rooms, where the psychiatrist on-call will be briefed by the DND physician (general duty medical officer or psychiatrist) on the member's condition. The on-call psychiatrist will then assess the CAF member and if needed, will admit the CAF member to hospital for safety and for treatment until their acute suicidal state has resolved and the member is safe to return to their outpatient CAF mental health and primary care team for follow-up treatment.

Operational Trauma Stress Support Centres

Operational Trauma and Stress Support Centres (OTSSCs) are the CAF’s centres of excellence in areas such as post-traumatic stress disorder. The centres have four mandates — assessment, treatment, outreach (education), and research. These centres are located in Esquimalt, B.C.; Edmonton, Alta.; Ottawa and Petawawa, Ont.; Valcartier, Que.; Gagetown, N.B.; and Halifax, N.S.

As well as providing direct care to CAF personnel, these centres are also 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.

For more information, please visit the OTSSC website.

Veterans Affairs Canada operates nine operational stress injury clinics primarily to serve veterans and former RCMP officers who have suffered operational stress injuries as a result of their service. These clinics can also assist currently serving CAF personnel. The clinics are located in Fredericton, N.B.; Montréal and Quebec City, Que.; Ottawa and London, Ont.; Winnipeg, Man.; Edmonton and Calgary, Alta.; and Vancouver, B.C. A residential treatment (live-in) clinic is now open at Ste. Anne’s Hospital in Sainte-Anne-de-Bellevue, in Quebec.

Support

CAF personnel and families can call 1-800-268-7708 to reach the Member Assistance Program, 24 hours a day, from anywhere in the world, and receive a confidential referral for mental health support. The program provides external short-term counselling to CAF members seeking assistance outside of typical military health services. Reserve Force personnel and their families also have access. The program is civilian-based in that it uses professional counsellors provided by the Employee Assistance Services of Health Canada.

The Operational Stress Injury Social Support network provides peer support and social support for families and to the bereaved across the country. The network is accessible through an interactive map located on the OSSIS website. A joint venture of the CAF and Veterans Affairs Canada, this very successful initiative was started by a group of military veterans.

Families of personnel with mental health concerns currently have access to a range of CAF and Veterans Affairs Canada services and programs including counselling under the Member Assistance Program, peer support through the Operational Stress Injury Social Support network; crisis intervention through the Veterans Pastoral Outreach Program; and the guidance of the more than 40 Military Family Resource Centres located at CAF installations across the country, in the U.S., and in Europe.

Awareness programs

Mental health awareness programs are a significant part of the CAF mental health continuum of care because they encourage personnel to recognize the signs of mental illness, including post-traumatic stress disorder, and to seek or promote early treatment.

In June 2009, the Chief of the Defence Staff launched the Canadian Forces Mental Health Awareness Campaign, which has the dual aim of educating CAF personnel on mental health issues, and building a culture of understanding. The campaign’s theme of “Be the Difference” communicates the idea that all personnel can make a difference to those affected by mental health issues.

On February 12, 2013, the Canadian Armed Forces joined politicians, entertainers, sports teams, Olympic athletes and others affected by mental illness in the national conversation on mental health as part of the third annual Bell “Let’s Talk Day.” This is the first year the CAF has participated in this event, which resulted in Bell donating $4,813,313.30 in additional funding for Canadian mental health programs –  a 23 percent increase over the 2012 Bell “Let’s Talk Day” total.

Research

Over the past 10 years, the CAF has put significant effort into conducting research and enhancing the care provided to personnel. As part of the CAF leadership’s commitment to improve and enhance the care and support services currently available to members, the CAF will continue to monitor suicide rates and conduct research on mental health issues.

Canadian Forces Cancer and Mortality Study

The Canadian Forces Cancer and Mortality Study was announced in October 2010 as a collaborative effort between the CF Health Services Group, Veterans Affairs Canada and Statistics Canada. All CAF personnel who joined the Regular Force from January 1, 1972 to December 31, 2006 were included in this study. The initial mortality results released in spring 2011 looked at both serving and former CAF members together and the results showed the risk of suicide was comparable to the Canadian population. However, when considering the population of former CAF personnel alone, men in this group had a higher risk of suicide compared to the Canadian population. Further analysis identified the following associated risk factors: service before 1986, shorter period of service (less than 10 years), former Non‑Commissioned Member rank, and release for involuntary or medical reasons.

For more information and initial mortality results, please visit Canadian Forces Cancer and Mortality Study.

Cumulative Incidence of Post-Traumatic Stress Disorder and Other Mental Disorders

The Cumulative Incidence of Post-Traumatic Stress Disorder and Other Mental Health Disorders study provides a reliable estimate of deployed personnel who have been formally diagnosed with conditions related to deployment such as post-traumatic stress disorder, over an average of almost five years of follow-up. It allows the CAF to better understand the overall psychological impact of the mission in Afghanistan on the CAF and its personnel.

The study group included all CAF members enrolled in the Regular or Primary Reserve Force, who returned from deployment of any duration in support of the mission in Afghanistan between October 1, 2001 and December 31, 2008. The CAF identified 30,518 such personnel and examined the medical records of a random sample group of 2,045 personnel.

The initial findings of the cumulative incidence study estimates that 8 percent of personnel who deployed in support of the mission in Afghanistan were diagnosed with mission-related post-traumatic stress disorder. An additional 5.2 percent or personnel were diagnosed with Afghanistan-related mental health disorders other than post-traumatic stress disorder (for example, depression).

For more information on the cumulative incidence, please visit Cumulative Incidence of Post-Traumatic Stress Disorder and Other Mental Disorders.

2013 Canadian Armed Forces Mental Health Survey

In March 2013, the Government announced the allocation of $4.6 million towards the 2013 Canadian Armed Forces Mental Health Survey. Statistics Canada representatives initiated this survey in March 2013 and are contacting randomly‑selected Regular and Reserve Force personnel to participate in an hour-long interview. Participation in the survey is voluntary, and responses are confidential. The results of the 2013 Canadian Armed Forces Mental Health Survey will be available in 2014 and will be compared to the state of mental health in the general Canadian population. The last survey of this nature was conducted in 2002 prior to the mission in Afghanistan to help inform the renewal of the CAF mental health system.

The results of this survey will help ensure that CAF mental health resources are targeted and allocated appropriately and that programs and services are meeting the unique needs of personnel. In particular, through comparison with the 2002 survey results, this survey will help measure the impact of the mission in Afghanistan and will provide insight about those who have not accessed care.

For more information, please consult the 2013 Canadian Armed Forces Mental Health Survey website.

The way forward

Suicide is a tragedy and an important public health concern. Significant investment and commitment has been made to ensure the CAF have the health, education and awareness programs required to help identify people at risk for mental health problems and to provide them with assistance.

When a suicide death occurs, it is thoroughly reviewed. Each suicide death in the CAF is investigated in order to identify potential opportunities for enhanced suicide prevention and to provide more detailed and reliable information for the CAF’s suicide surveillance system.

While no consistent relationship has been established between deployment and the risk of suicide in the CAF at this time, the CAF acknowledge that there is a link between deployment and mental health conditions. Accordingly, the CAF remain vigilant and have a robust pre- and post- deployment mental health screening and education program. To date, over 56, 000 CAF members have received some form of mental health training and education. Screening for mental health conditions is conducted prior to and following deployment and as part of periodic health assessments. Over the past 10 years, the CAF have put significant effort into conducting research in order to further enhance the care provided to personnel.

Caring for CAF members and their families will remain a priority. The CAF have provided leadership in the area of mental health and remain committed to working with its partners to ensure that our personnel, with their families, who are called to sacrifice so much in service to their country, receive quality care and support. The CAF continue to assess its capabilities and adjust its resources to assure they are meeting the increasing complexities and demands associated with caring for our own. 

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