Trends in suicidal behaviour and use of mental health services in Canadian military and civilian populations

A Canadian national study of provincial and territorial correctional workers' suicidal ideation, plans, and attempts

Correctional workers (CWs) endure several operational stressors (e.g., exposures to potentially psychologically traumatic events) and organisational stressors (e.g., shift work, staff shortages), which are associated with positive screens for mental disorders and self-reports of suicidal behaviours and thus urgently warrant further inquiry. The Canadian Provincial and Territorial Correctional Worker Mental Health and Well-Being Study (CWMH) used an online survey to collect data from Canadian correctional service organisations across all 13 provinces and territories. This national Canadian study investigates suicidal behaviours among CWs across diverse occupational roles and provincial and territorial jurisdictions (n = 3740, 50.1% female). The results estimated prevalence proportions for self-reported past-year and lifetime suicidal thoughts, planning, and attempts across the 13 Canadian provincial and territorial correctional systems, with the exceptions of past-year suicidal planning in Alberta, Newfoundland and Labrador, New Brunswick, and Yukon where jurisdictional considerations and requests precluded the inclusion of select questions. Substantial proportions of participants reported past-year or lifetime suicidal ideation (i.e., 9.1%, 29.2%, respectively), planning (i.e., 4.1%, 14.7%, respectively), or attempts (i.e., 0.8%, 7.2%, respectively). Sociodemographic variables (i.e., sex, age, marital status, total years of service, occupational category) were associated with past-year and lifetime suicidal behaviours. Findings provide opportunities for future research and can inform tailored efforts by clinicians, service providers, and organisational leaders to support proactive interventions and treatments, including supporting the partners and families of CWs, fostering social support networks, and improving access to timely mental health treatment.

Coping style as a risk factor for future alcohol use disorder: A 16-year longitudinal study in a Canadian military sample

BACKGROUND

Coping strategies used in response to stress have the potential to influence the development of mental health disorders, including alcohol use disorders. The current study investigated whether coping strategies placed an individual at greater likelihood for developing a future alcohol use disorder.

METHODS

This study used data from the Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey; a nationally representative 16-year follow-up survey, with initial data collected in the 2002 Canadian Community Health Survey - Canadian Forces Supplement. The total sample from the two datasets included 2941 individuals who were Regular Force members in 2002. Coping styles included problem-focused, avoidant, and self-medication. Adjusted logistic regression analyses examined relationships between coping style (in 2002) and alcohol use disorders (developed between 2002 and 2018).

RESULTS

Self-medication coping in 2002 was associated with any alcohol disorder since last interview (i.e., 2002-2018) (AOR 1.26; 95 % CI, 1.02-1.57) and during the past year (adjusted odds ratios [AOR 1.26; 95 % CI, 1.08-1.47]), as well as past-year binge drinking (AOR 1.19; 95 % CI, 1.09-1.29). Problem-focused coping was protective against past-year alcohol abuse (AOR 0.84; 95 % CI, 0.71-1.00) and any alcohol use disorder (AOR 0.87; 95 % CI 0.76-1.00).

CONCLUSION

Coping styles were strongly associated with future alcohol use disorders. Notably, results show the risk extended over a 16-year period. Findings suggest the use of self-medicating coping strategies places an individual at increased risk of developing alcohol use disorders, while problem-focused coping may decrease future risk of alcohol use disorders.

Suicidal Ideation, Planning, and Attempts Among new Royal Canadian Mounted Police Cadets

BACKGROUND

Royal Canadian Mounted Police (RCMP) report diverse occupational stressors and repeated exposures to potentially psychologically traumatic events, which may increase the odds of screening positive for a mental disorder, and increase the risk of death by suicide. The current study was designed to provide prevalence information regarding suicidal behaviours (i.e., ideation, planning, attempts) and assess for sociodemographic differences among cadets at the start of the RCMP Cadet Training Program (CTP).

METHOD

Cadets (n = 736, 74.0% male) were administered the structured Mini International Neuropsychiatric Interview by a mental health clinician or a supervised clinical psychologist trainee. The interview includes an assessment of past month suicidal ideation, planning, attempts and lifetime suicide attempts.

RESULTS

Within 1 month of starting the CTP, a small percentage of cadets reported past month suicidal ideation (1.6%) and no cadets reported any suicidal planning (0%) or attempts (0%). Lifetime suicide attempts were reported by (1.5%) of cadets.

CONCLUSIONS

The current results provide the first information describing the prevalence of suicidal ideation, planning, and attempts among RCMP cadets starting the CTP. The estimates of suicidal behaviours appear lower than the general population and lower than reports from serving RCMP. Higher prevalence estimates of suicidal behaviours reported by serving RCMP, relative to lower estimates among cadets starting the CTP in the current study, may be related to age, cumulative experiences or protracted exposures to operational and organizational stressors, rather than insufficient screening of recruits.

Associations among child abuse history, deployment-related traumatic events, mental disorders, and suicidal behaviors in Canadian Regular Force personnel

Increasing attention has been focused on suicidal behavior among military personnel. Exposure to deployment-related traumatic events (DRTEs) and child abuse (CA) both have been associated with mental disorders and suicidal behaviors among military personnel. Thus, the primary objectives of this study were to examine (a) sex differences in CA history and DRTEs, past-year mental disorders, and past-year suicide-related outcomes and (b) independent, cumulative, and interactive effects of CA history and DRTEs on past-year mental disorders and suicide outcomes among Canadian military personnel. Data were from the representative Canadian Forces Mental Health Survey collected in 2013 (N = 8,161; response rate = 79.8%). The results indicated a high prevalence of trauma exposure, with sex differences noted for specific trauma types. Both CA history and DRTEs were strongly associated with mental disorders, CA history: aORs = 1.60-2.44; DRTEs; aORs = 1.67-3.88. Cumulative, but not interactive, effects were noted for the effects of CA history and DRTEs on most mental disorders. Associations between CA history and DRTEs on suicide outcomes were largely indirect via their impact on mental disorders. Information regarding the role of specific types of predeployment trauma on mental disorders and suicidal behavior can be used to develop more targeted prevention and intervention strategies aimed at improving the mental health of military personnel.

Mental Health Disorders and Suicidal Behaviors Among Provincial Correctional Workers

OBJECTIVE

We examined the prevalence ofmental health disorders and suicidal behaviors (ideation, planning, and attempts) among a sample of provincial correctional workers in Manitoba.

METHODS

Self-reported mental health data from a survey on correctional worker mental health and well-being were analyzed for 491 correctional workers.

RESULTS

Over half (57%) of respondents screened positive for mental health disorder, most commonly major depressive disorder, and over one-third of respondents (37%) screened positive for more than one disorder. Positive mental health screens for all mental health disorders were associated with statistically significantly increased odds of lifetime suicidal ideation, and positive screens for most disorders were associated with past year suicidal ideation.

CONCLUSIONS

Relative to other public safety personnel and the general public, correctional workers appear have a higher prevalence of mental health disorders and suicidal behaviors. The association between positive screens for mental health disorders and suicidal behaviors highlights the vulnerability of correctional workers in regards to mental well-being.

The gap between perceived mental health needs and actual service utilization in Australian adolescents

Despite being highly prevalent, adolescent mental health problems are undertreated. To better understand the mental health treatment gap, we assessed the prevalence and correlates of help-seeking, including perceived need for care and access to that care. Data were drawn from Young Minds Matter (YMM) survey-the second Australian child and adolescents survey of mental health and wellbeing. Parent-reported data and self-reported child data were combined into one dataset to analyse 2464 Australian adolescents aged 13-17 years. We employed bivariate and multivariate logistic regression models to assess the correlation between independent variables (professionally assessed with mental disorders only, self-reported self-harm/suicidality only and both) and their distribution over outcome variables (perceived need and service use). Mental disorders include depression, anxiety, ADHD and conduct disorder. Our study revealed 15.0%, 4.6% and 7.7% had professionally assessed with mental disorders only, self-reported self-harm/suicidality only and both, respectively. Overall, 47.4% and 27.5% of adolescents respectively perceived need for care and used services in the past-12-months. While among those only who perceived the need, only 53% of adolescents used any services. Professionally assessed with mental disorders only, self-reported self-harm/suicidality only and both were associated with higher likelihood of perceived need and service use (p < 0.001 for all). However, adolescents who self-reported self-harm/suicidality only were not found to be significantly associated with service use among those who perceived the need for care. Adolescents who perceived the need for mental health care but did not seek care represent a treatment gap. Our results suggest the importance of reducing the wide treatment gap that exists between need and care.

Sex Differences in Determinants of Suicide Risk Preceding Psychiatric Admission: An Electronic Medical Record Study

BACKGROUND

Individuals requiring inpatient psychiatric care represent a group at higher risk of progressing toward suicide attempt. Using electronic medical record (EMR) data collected from psychiatric inpatient admissions, the objective of this study was to identify sex differences in risk factors for suicide plans and/or attempts within the 30 days preceding hospital admission.

METHODS

Resident Assessment Instrument for Mental Health (RAI-MH) intake data were obtained for patients admitted to a Canadian tertiary-care hospital deemed a "threat or danger to self" during a 10-year period (2008-2018). Data was extracted for individuals categorized into three groups: non-suicidal (N = 568), presence of suicide plan (N = 178), and presence of suspected suicide attempt (N = 124) in the 30 days prior to hospital admission. Multivariate logistic regression models were used to examine determinants of suicide risk.

RESULTS

Across all models, diagnosis of depression was the strongest predictor of suicide plan and/or attempt (OR = 5.54, 95% CI = 3.71-8.27, p < 0.001). Comparing clinical symptoms between suicidal and non-suicidal groups at the time of admission, the largest effect sizes were found for hopelessness (p < 0.001, η² = 0.11), and guilt or shame (p < 0.001, η² = 0.09). Female sex was identified as a significant factor for elevated suicidal risk (OR = 1.56, 95% CI = 1.01-2.21, p = 0.01), thus we stratified the regression model by sex to identify specific risk factors for suicide plan and/or attempt for males and females. Among males, having no confidant (OR = 2.13, 95% CI = 1.19-3.80, p = 0.01), presence of recent stressors (OR = 1.95, 95% CI = 1.16-3.29, p = 0.01), and participation in social activities (OR = 1.67, 95% CI = 1.02-2.71, p = 0.04) were important predictors, while among females, younger age (OR = 0.96, 95% CI = 0.94-0.97, p < 0.001) increased odds of suicide plan and/or attempt.

CONCLUSION

EMR-derived findings highlight different psychosocial and clinical determinants for males and females associated with suicide plan or attempt prior to psychiatric admission. Identifying precipitating factors that elevate imminent suicide risk may inform suicide prevention efforts for psychiatric inpatients.

Pathways to mental health care in active military populations across the Five-Eyes nations: An integrated perspective

Military service is associated with increased risk of mental health problems. Previous reviews have pointed to under-utilization of mental health services in military populations. Building on the most recent systematic review, our narrative, critical review takes a complementary approach and considers research across the Five-Eyes nations from the past six years to update and broaden the discussion on pathways to mental healthcare in military populations. We find that at a broad population level, there is improvement in several indicators of mental health care access, with greater gains in initial engagement, time to first treatment contact, and subjective satisfaction with care, and smaller gains in objective indicators of adequacy of care. Among individual-level barriers to care-seeking, there is progress in improving recognition of need for care and reducing stigma concerns. Among organizational-level barriers, there are advances in availability of services and cultural acceptance of care-seeking. Other barriers, such as concerns around confidentiality, career impact, and deployability persist, however, and may account for some remaining unmet need. To address these barriers, new initiatives that are more evidence-based, theoretically-driven, and culturally-sensitive, are therefore needed, and must be rigorously evaluated to ensure they bring about additional improvements in pathways to care.

Lifetime Prevalence and Comorbidity of Mental Disorders in the Two-wave 2002-2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS): Prévalence et Comorbidité de Durée de vie Des Troubles Mentaux Dans l'Enquête de Suivi Sur la Santé Mentale Auprès des Membres des Forces Armées Canadiennes et Des ex-Militaires (ESSMFACM) en Deux Cycles de 2002 à 2018

OBJECTIVE

The current study used the Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS) to (1) examine the incidence and prevalence of mental disorders and (2) estimate the comorbidity of mental disorders over the follow-up period.

METHOD

The CAFVMHS (2018) is a longitudinal study with two time points of assessment. The sample is comprised of 2,941 Canadian Forces members and veterans who participated in the 2002 Canadian Community Health Survey: Canadian Forces Supplement. The World Health Organization Composite International Diagnostic Interview (WHO-CIDI) was utilized to diagnose Diagnostic and Statistical Manual-IV post-traumatic stress disorder (PTSD), major depressive episode (MDE), generalized anxiety disorder, social anxiety disorder (SAD), and alcohol abuse and dependence. Self-report health professional diagnoses were assessed for attention deficit hyperactivity disorder (ADHD), mania, obsessive compulsive disorder (OCD), and personality disorder. We established weighted prevalence of mental disorders and examined the association between mental disorders using logistic regression.

RESULTS

In 2018, lifetime prevalence of any WHO-CIDI-based or self-reported mental disorder was 58.1%. Lifetime prevalence of any mood or anxiety disorder or PTSD was 54.0% in 2018. MDE (39.9%), SAD (25.7%), and PTSD (21.4%) were the most common mental disorders. There was a substantial increase in new onset or recurrence/persistence of mental disorders between the two measurement points (16-year assessment gap); 2002-2018 period prevalences were 43.5% for mood and anxiety disorder and 16.8% for alcohol abuse or dependence. The prevalence of self-reported ADHD, OCD, any personality disorder, and mania were 3.3%, 3.0%, 0.8%, and 0.8%, respectively. Comorbidity between mental disorders increased over the follow-up.

CONCLUSIONS

This study demonstrates a high burden of mental disorders among a large Canadian military and veteran cohort. These findings underscore the importance of prevention and intervention strategies to reduce the burden of mental disorders and alcohol use disorders in these populations.

Rationale and Methodology of the 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS): A 16-year Follow-up Survey: Raison D'être Et Méthodologie De L'enquête De Suivi Sur La Santé Mentale Des Membres Des Forces Armées Canadiennes Et Des Anciens Combattants, 2018 (ESSMFACM)

OBJECTIVE

Knowledge is limited regarding the longitudinal course and predictors of mental health problems, suicide, and physical health outcomes among military and veterans. Statistics Canada, in collaboration with researchers at the University of Manitoba and an international team, conducted the Canadian Armed Forces Members and Veterans Mental Health Follow-Up Survey (CAFVMHS). Herein, we describe the rationale and methods of this important survey.

METHOD

The CAFVMHS is a longitudinal survey design with 2 time points (2002 and 2018). Regular Force military personnel who participated in the first Canadian Community Health Survey Cycle 1.2-Mental Health and Well-Being, Canadian Forces Supplement (CCHS-CFS) in 2002 (N = 5,155) were reinterviewed in 2018 (n = 2,941). The World Mental Health Survey-Composite International Diagnostic Interview was used with the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria.

RESULTS

The CAFVMHS includes 2,941 respondents (66% veterans; 34% active duty) and includes data on mental disorder diagnoses, physical health conditions, substance use, medication use, general health, mental health services, perceived need for care, social support, moral injury, deployment experiences, stress, physical activity, military-related sexual assault, childhood experiences, and military and sociodemographic information.

CONCLUSIONS

The CAFVMHS provides a unique opportunity to further understand the health and well-being of military personnel in Canada over time to inform intervention and prevention strategies and improve outcomes. The data are available through the Statistics Canada Research Data Centres across Canada and can be used cross-sectionally or be longitudinally linked to the 2002 CCHS-CFS data.

Segmenting or Summing the Parts? A Scoping Review of Male Suicide Research in Canada

OBJECTIVE

Suicide in Canadian men is high and rising. Research consistently indicates increased suicide risk in male subgroups including sexual minority, Indigenous, middle-aged, and military men. The current scoping review addresses the research question: Among male subgroups featured in Canadian suicide research, what are the key findings to inform suicide prevention efforts?.

METHOD

A scoping review was undertaken in accord with PRISMA-ScR guidelines. Structured searches were conducted in CIHAHL, Medline, PsychInfo, and Web of Science to identify studies reporting suicidality (suicidal ideation, plans and/or attempts) and suicide among men in Canada. Inclusion criteria comprised primary empirical studies featuring Canadian male subgroups published in English from 2009 to 2020 inclusive.

RESULTS

Sixty-eight articles met the inclusion criteria, highlighting significant rates of male suicidality and/or suicide in 3 categories: (1) health inequities (n = 29); (2) age-specific (n = 30); and (3) occupation (n = 9). The health inequities category included sexual minority men, Indigenous, and other marginalized males (i.e., homeless, immigrant men, and men who use opiates). Age-specific men focused on adolescents and youth, and middle-aged and older males. Active military, veterans, and first responders featured in the occupation category. Studies compared at risk male subgroups to females, general male populations, and/or other marginalized groups in emphasizing mental health disparities and increased suicide risk. Some men's suboptimal connections to existing mental health care services were also highlighted.

CONCLUSION

While male subgroups who are vulnerable to suicidality and suicide were consistently described, these insights have not translated to tailored upstream suicide prevention services for Canadian boys and men. There may be some important gains through integrating social and mental health care services for marginalized men, implementing school-based masculinity programs for adolescent males, orientating clinicians to the potential for men's mid-life suicide risks (i.e., separation, bereavement, retirement) and lobbying employers to norm help-seeking among activate military, veterans, and first responder males.

Suicide and suicidality in contemporary serving and ex-serving Australian Defence Force personnel

OBJECTIVE

The risk of suicide in contemporary serving and ex-serving Australian Defence Force personnel is an area of significant concern, driving government-directed inquiries, community campaigns and most recently, the establishment of a permanent National Commissioner for Defence and Veteran Suicide Prevention. This concern is mirrored in international militaries and despite investment in prevention programmes, suicide is a leading cause of death in military populations. This review seeks to summarise recent findings from Australian research regarding the magnitude and factors associated with suicide and suicidality in contemporary serving and ex-serving Australian Defence Force populations and discusses research findings, implications and future opportunities.

METHODS

Initial review of the prevalence of suicide and suicidality in the general community and military populations is presented, followed by review of recent research findings pertaining to suicides and suicidal thoughts, plans and attempts in contemporary serving and ex-serving Australian Defence Force personnel. Key findings are presented from the 2010 Australian Defence Force Mental Health and Wellbeing Prevalence Study and the 2015 Transition and Wellbeing Research Programme.

RESULTS

Differences between serving and ex-serving Australian Defence Force cohorts were observed, with rates of completed suicide in ex-serving Australian Defence Force males more than double that of serving Australian Defence Force males, and increased risk for suicidality observed among those who had recently transitioned out of full-time Australian Defence Force service. Risk for increased suicidality and completed suicide is particularly evident for younger males of lower ranks, and those who have been medically discharged.

CONCLUSIONS

The findings provide insight into career phases and groups that should be followed-up and targeted for prevention and early intervention programmes, including prior to and several years following transition out of full-time military service. Further research to better understand the factors that influence those who develop suicidal ideation, and those who progress to plans and attempts, will inform a more sophisticated approach to suicide prevention programmes.

Evaluating the quality of resilience apps for military members and public safety personnel

LAY SUMMARY

A growing number of smartphone apps are being recommended to help build resilience. It is important to test whether these apps are of good quality and evidence-based. This study systematically evaluated 12 popular resilience-related apps for military and public service personnel and found that the majority were of high quality.

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Objectives:

Research suggests a high prevalence of problematic alcohol use among military personnel relative to civilians. Our primary objectives were to compare the prevalence, correlates, help-seeking behaviors, perceived need for care, and barriers to care for alcohol use disorders (AUDs) in the Canadian Armed Forces (CAF) and the Canadian general population (CGP).

Methods:

Data were from 2 nationally representative surveys collected by Statistics Canada: (1) the Canadian Community Health Survey on Mental Health collected in 2012 (N = 25,113; response rate = 68.9%) and (2) the Canadian Forces Mental Health Survey collected in 2013 (N = 8,161; response rate = 79.8%). Descriptive statistics and logistic regression were used to examine differences in outcomes of interest associated with AUDs in the CAF and CGP.

Results:

The prevalence of lifetime AUDs was significantly higher in the CAF (32.0%) than the CGP (20.3%; adjusted odds ratio [AOR] = 1.14, 95% confidence interval [CI, 1.02 to 1.27]) after adjustment for sociodemographic covariates. In contrast, the past-year prevalence of AUDs was significantly lower among CAF personnel (4.5%) than civilians (3.8%; AOR = 0.78, 95% CI [0.61 to 0.99]) after adjustment for sociodemographic covariates. Child abuse history and comorbid mental disorders were strongly associated with past-year AUDs in both populations. CAF personnel compared to the CGP were more likely to perceive a need for care (AOR = 4.15, 95% CI [2.56 to 6.72]) and engage in help-seeking behaviors (significant AORs ranged from 1.85 to 5.54). CAF personnel and civilians with past-year AUDs reported different barriers to care.

Conclusions:

Findings argue for the value of different approaches to address unmet need for AUD care in the CAF and CGP.

Temporal Changes in the Cross-Sectional Associations between Cannabis Use, Suicidal Ideation, and Depression in a Nationally Representative Sample of Canadian Adults in 2012 Compared to 2002

BACKGROUND

With the recent legalization of nonmedical cannabis in Canada, it is important to document previous associations between cannabis use and major depressive episode and suicidal ideation, as well as the extent to which these associations have changed over time.

METHODS

This study uses pooled data from the 2002 and 2012 Canadian Community Health Survey's Mental Health Component, which are repeated cross-sectional surveys of nationally representative samples of Canadians 15 to 60 years of age (n = 43,466). Binary logistic regression was performed, applying weighting and bootstrapping, to examine the association between at least monthly use of cannabis and past 12-month suicidal ideation and major depressive episode (MDE).

RESULTS

At least monthly nonmedical cannabis use was associated with an increased odds of MDE and suicidal ideation, and both associations strengthened in 2012 compared to 2002. Canadians using cannabis at least once a month in 2012 had 1.59 (95% confidence interval [CI], 1.11 to 2.27) times the odds of experiencing suicidal ideation and 1.55 (95% CI, 1.12 to 2.13) times the odds of experiencing MDE compared to those who used cannabis at least once a month in 2002. This temporal change remained after controlling for other substance use.

CONCLUSIONS

Monthly cannabis use was consistently related to both suicidal ideation and MDE, and these associations were stronger in 2012 compared to 2002. The findings of this study provide a baseline for the association between cannabis use and suicide and depression in the Canadian population that should be reevaluated now that nonmedical cannabis has been legalized.

Suicide in Canadian veterans living in Ontario: a retrospective cohort study linking routinely collected data

OBJECTIVES

To compare the risk of death by suicide in male veterans with age-matched civilians.

DESIGN

Retrospective cohort study linking provincial administrative databases between 1990 and 2013 with follow-up complete until death or December 31, 2015.

SETTING

Population-based study in Ontario, Canada.

PARTICIPANTS

Ex-serving Canadian Armed Forces and Royal Canadian Mounted Police veterans living in Ontario who registered for provincial health insurance were included. A civilian comparator group was matched 4:1 on age and sex.

MAIN OUTCOME

Death by suicide was classified using standard cause of death diagnosis codes from a provincial registry of mandatory data collected from death certificates. Fine and Gray sub-distribution hazards regression compared the risk of death by suicide between veterans and civilians. Analyses were adjusted for age, residential region, income, rurality and major physical comorbidities.

RESULTS

20 397 male veterans released to Ontario between 1990 and 2013 and 81 559 age-sex matched civilians were included. 4.2% of veterans died during the study time frame, compared with 6.5% of the civilian cohort. Death by suicide was rare in both cohorts, accounting for 4.6% and 3.6% of veteran and civilian deaths, respectively. After adjustment for confounders, veterans had an 18% lower risk of dying from causes other than suicide (HR 0.82, 95% CI 0.76 to 0.89) and a similar risk of dying by suicide (HR 1.01, 95% CI 0.71 to 1.43), compared with civilians.

CONCLUSIONS

Deaths by suicide were rare in male veterans residing in Ontario. Our findings demonstrate that veterans had a similar risk of suicide-related mortality as an age-matched civilian population. A better understanding of effective suicide prevention as well as clarifying pathways to seeking and receiving mental health supports and services are important areas for future consideration.

Comparison of past-year mental health services use in Canadian Army, Navy, and Air Force personnel

Introduction: What causes the excess burden of mental disorders and related outcomes in the Army remains unclear. Deployment-related trauma has been one intuitive explanation. However, there may be other factors at play – for example, lower mental health services use (MHSU) in Army personnel. This study compares MHSU across the Canadian Army, Navy, and Air Force. Methods: Data were drawn from the 2013 Canadian Forces Mental Health Survey. The sample consisted of Regular Force members ( N = 6,696). The primary outcomes for past-year MHSU were: (1) any past-year MHSU; (2) intensity of care (total clinical contact hours), and (3) perceived helpfulness of care (PHC). ­Modified Poisson regression and analysis of covariance (ANCOVA) were used to assess the relationship between the elements (Army, Navy, Air Force) and each outcome, adjusting for sociodemographic and military characteristics, as well as clinical variables such as the presence of five past-year mental disorders. Results: In unadjusted analyses, Army personnel had significantly greater past-year MHSU and intensity of care relative to Air Force personnel. No significant relationship was found between the element and any of the MHSU parameters after adjustment. Discussion: Differences in past-year MHSU are an unlikely contributing factor to the higher risk of mental disorders and related outcomes among Army personnel; the true explanation must lie elsewhere. Findings argue for a system-wide, and not element-specific, approach to improving Canadian Armed Forces (CAF) programs and services.

More Than Just Counting Deaths: The Evolution of Suicide Surveillance in the Canadian Armed Forces

Suicide prevention and surveillance are of primary concern to the Canadian Armed Forces (CAF) and to the CAF Health Services (CFHS). Suicide surveillance has been conducted on behalf of the CFHS by the Directorate of Force Health Protection for nearly 30 years. Over time, multiple changes have occurred within CAF: changes in its military role (from a primarily peacekeeping role to one also involving active combat), changes in operational tempo, temporal changes in at-risk subpopulations, as well as increased awareness and concern with suicide and suicide prevention. This has resulted in the annual reporting of CAF suicide rates and the evolution of the report's content to respond to the needs of its end users. More recently, Regular Force Army and Combat Arms males have been identified as being at significantly higher risk of suicide, relative to their counterparts, as well as to the Canadian general population. However, this trend has been fairly stable. To optimize the use of limited epidemiologic resources and to shift the focus from the rates themselves towards a better understanding of what they represent and how they can be modified, the suicide surveillance portfolio is evolving to include complementary data sources and elements. This paper describes the different data sources that constitute the CAF's enhanced suicide surveillance portfolio, the value-added evidence generated by the use of complementary data collection methods and sources, and how this evidence is used by CAF leadership in their efforts to prevent suicide amongst those who serve.

A retrospective cohort study comparing non-fatal self-harm emergency department visits between Canadian veterans living in Ontario and matched civilians

This was a retrospective cohort study linking provincial administrative databases to compare rates of non-fatal self-harm between CAF and RCMP veterans living in Ontario and age-matched civilians. This study included male veterans who registered for provincial health insurance between 2002 and 2013. A civilian comparator group was matched 4:1 on age and sex. Self-harm emergency department (ED) visits were identified from provincial ED admission records until death or December 31, 2015. Multivariable Poisson regression compared the risk of self-harm. Analyses adjusted for age, geography, income, rurality, and major physical and mental comorbidities. In total, 9514 male veterans and 38,042 age- and sex-matched civilians were included. Overall, 0.55% of veterans had at least one non-fatal self-harm ED visit, compared with 0.81% of civilians. The rate of ED self-harm visits was 40% lower in the veteran population, compared to the civilian population (RR = 0.60; 95% CI = 0.41-0.87). In both groups, psychosocial and physical comorbidities, and death by suicide were more common in those who self-harmed than those who did not. A better understanding of why veterans have a lower rate of self-harm emergency department visits and how it is related to the number of completed suicides is an important area for future consideration.

Association between a history of child abuse and suicidal ideation, plans and attempts among Canadian public safety personnel: a cross-sectional survey

BACKGROUND

A history of child abuse has been identified as a risk factor for suicidal behaviour in general population samples; however, it remains unknown how a history of child abuse and career-related trauma together are related to suicidal behaviour. This cross-sectional survey was designed to 1) estimate the prevalence of a history of child abuse among Canadian public safety personnel, 2) examine the associations between child abuse and suicidal behaviour, 3) examine the associations between career-related trauma and suicidal behaviour and 4) examine the cumulative and interactive effects of child abuse and career-related trauma on suicidal behaviour.

METHODS

Data were drawn from a Web-based survey collected by the Canadian Institute for Public Safety Research and Treatment Team. Child abuse included physical abuse, sexual abuse and exposure to intimate partner violence in childhood. Suicidal behaviour included lifetime ideation, plans and attempt(s). We used logistic regression models to examine the associations between child abuse and suicidal behaviours, and cumulative and interaction models to test the relations between a history of child abuse and career-related trauma on suicidal behaviours.

RESULTS

The survey completion rate was 49.3% (n = 4199). A total of 2275/4073 respondents (55.9%) reported experiencing 1 or more types of abuse as a child. All types of child abuse and career-related trauma were significantly associated with suicidal behaviour (adjusted odds ratio 1.57-3.25). No cumulative or interaction effects were noted.

INTERPRETATION

Both a history of child abuse and career-related trauma were significantly associated with suicidal behaviours; however, stronger relations were seen for the former. This finding may help the development of effective treatment and intervention strategies aimed at reducing suicidal behaviour among public safety personnel.

Mental Health Services Use Trends in Canadian Veterans: A Population-Based Retrospective Cohort Study in Ontario

OBJECTIVE

A substantial evidence base in the peer-reviewed literature exists investigating mental illness in the military, but relatively less is documented about mental illness in veterans. This study uses provincial, administrative data to study the use of mental health services by Canadian veterans in Ontario.

METHOD

This was a retrospective cohort study of Canadian Armed Forces and Royal Canadian Mounted Police veterans who were released between 1990 and 2013 and resided in Ontario. Mental health-related primary care physician, psychiatrist, emergency department (ED) visits, and psychiatric hospitalisations were counted. Repeated measures were presented in 5-year intervals, stratified by age at release.

RESULTS

The cohort included 23,818 veterans. In the first 5 years following entry into the health care system, 28.9% of veterans had ≥1 mental health-related primary care physician visit, 5.8% visited a psychiatrist at least once, and 2.4% received acute mental health services at an ED. The use of mental health services was consistent over time. Almost 8% of veterans aged 30 to 39 years saw a psychiatrist in the first 5 years after release, compared to 3.5% of veterans aged ≥50 years at release. The youngest veterans at release (<30 years) were the most frequent users of ED services for a mental health-related reason (5.1% had at least 1 ED visit).

CONCLUSION

Understanding how veterans use the health care system for mental health problems is an important step to ensuring needs are met during the transition to civilian life.

Mental Disorder Symptoms among Public Safety Personnel in Canada

BACKGROUND

Canadian public safety personnel (PSP; e.g., correctional workers, dispatchers, firefighters, paramedics, police officers) are exposed to potentially traumatic events as a function of their work. Such exposures contribute to the risk of developing clinically significant symptoms related to mental disorders. The current study was designed to provide estimates of mental disorder symptom frequencies and severities for Canadian PSP.

METHODS

An online survey was made available in English or French from September 2016 to January 2017. The survey assessed current symptoms, and participation was solicited from national PSP agencies and advocacy groups. Estimates were derived using well-validated screening measures.

RESULTS

There were 5813 participants (32.5% women) who were grouped into 6 categories (i.e., call center operators/dispatchers, correctional workers, firefighters, municipal/provincial police, paramedics, Royal Canadian Mounted Police). Substantial proportions of participants reported current symptoms consistent with 1 (i.e., 15.1%) or more (i.e., 26.7%) mental disorders based on the screening measures. There were significant differences across PSP categories with respect to proportions screening positive based on each measure.

INTERPRETATION

The estimated proportion of PSP reporting current symptom clusters consistent with 1 or more mental disorders appears higher than previously published estimates for the general population; however, direct comparisons are impossible because of methodological differences. The available data suggest that Canadian PSP experience substantial and heterogeneous difficulties with mental health and underscore the need for a rigorous epidemiologic study and category-specific solutions.

Deployment-Related Traumatic Events and Suicidal Behaviours in a Nationally Representative Sample of Canadian Armed Forces Personnel

OBJECTIVE

Worldwide, there has been substantial controversy with respect to whether military deployment is a risk factor for suicidal behaviour. The present study examined the relationship between lifetime exposure to deployment and deployment-related traumatic events (DRTEs) and past-year suicidal ideation (SI), suicidal plans (SP), and suicidal attempts (SA).

METHOD

Data were analysed from the 2013 Canadian Forces Mental Health Survey (8161 respondents; response rate, 79.8%; aged 18-60 years). A total of 12 individual items assessed exposure to DRTEs (e.g., combat, witnessing human atrocities, feeling responsible for the death of Canadian or ally personnel, knowing someone who was injured or killed). We examined each individual DRTE type as well as the number of types of DRTEs in relation to suicidal behaviour.

RESULTS

Lifetime deployment was not significantly associated with suicidal behaviour. In models adjusted for sociodemographic variables, most of the individual DRTE items and the DRTE count variable were significantly associated with suicidal behaviours (adjusted odds ratio ranged between 1.10 and 5.32). When further adjusting for child abuse exposure, these associations were minimally attenuated, and some became nonsignificant. In models adjusting for mental disorders and child abuse, most DRTEs and number of types of DRTEs became nonsignificant in relation to SI, SP, and SA.

CONCLUSIONS

Active military personnel exposed to increasing number of DRTEs are at increased risk for SI, SP, and SA. However, most of the association between DRTEs and suicidal behaviour is accounted for by child abuse exposure and mental disorders.