The Canadian Armed Forces Suicide Prevention Program. Preventing Military Suicides Tallinn, Estonia June 17, 2013

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1 The Canadian Armed Forces Suicide Prevention Program Preventing Military Suicides Tallinn, Estonia June 17, 2013 LCdr Kenneth J. Cooper CD BA, MD, MBA, MHSc, FRCPC Psychiatrist and Clinical Leader Mental Health Services CF Health Services Centre Atlantic, Halifax

2 CF Suicide Statistics Reg F (M) Reg F (F) Res F (M) Res F (F) 2012

3 Suicide rate, per 100,000 per year Background: Male Suicide Rates in the CF CF Regular Force Male Suicide Rate, (Compared to Canadian Male Suicide Rate) Canadian male suicide rate, standardized to CF age distribution CF Regular Force male suicide rate Male suicide rate is lower in the CF, when adjusted for age Rate has not changed significantly since Afghanistan mission Previously deployed members are no more likely to commit suicide Your health - Our mission Votre santé - Notre mission

4 SMR (%) Comparison of CF Reg. F Male Suicide Rates to Canadian Male Suicide Rates ( ) Time Period Your health - Our mission Votre santé - Notre mission 4

5 Background: Panel Goals 2-day meeting, September 2009 Goals of panel: Review what the CF is doing Evaluate CF s approach against the scientific literature and the practices of its Allies Recommend opportunities to strengthen its program

6 Background: CF/DND Participants LCol R Jetly M Zamorski LCol S Rodrigue Dr. J Whitehead LCdr K Cooper Capt A McDonald Capt A Shugar Ms. L. MacDonald Mental Health Advisor Head, Deployment Health Section National Practice Leader for Social Work Head, Epidemiology Section Psychiatrist Physician Mental Health Nurse Head, Strengthening the Forces Mental Health and Wellbeing Program

7 Background: External Consultants Dr. J Thompson Dr. D Ross Prof. P Links Col E Ritchie LCol M Bell LCol A Cohn LCol L Horstman Medical Advisor, Research Directorate (VAC) National Clinical Coordinator, OSI Clinic Network (VAC) Chair in Suicide Studies, Univ. of Toronto Director, Behavioral Health Proponency Office, Office of the US Army Surgeon General Manager, Behavioral and Social Health Outcomes Program, US Army Psychologist, Mental Health Directorate (Australia) Psychologist, Military Mental Health Service (The Netherlands) Surg Cdr N Greenberg Psychiatrist, Royal Navy (UK); Senior Lecturer, Dr. N Fear Academic Centre for Defence Mental Health (UK) Promote, Protect Senior and Heal Lecturer in Epidemiology, Academic Centre for Promouvoir, protéger Defence et guérir Mental Health (UK)

8 Targets for Targets Suicide for Prevention Suicide Prevention (Mann et in al, the JAMA CF 2005) PREVENTION INTERVENTIONS A Education and Awareness Programs Primary Care Providers Members Gatekeepers Stressful Life Event Mood or Other Psychiatric Disorder A to E B Screening for Individuals at High Risk Treatment Suicidal Ideation B Impulsivity C D F C D E Pharmacotherapy Psychotherapy Follow-up Care for Suicide Attempters/High Risk Pts. Restriction of Access to Lethal Means Hopelessness and/or Pessimism C D G Media Engagement Suicidal Act Access to Lethal Means Imitation F G

9 Potential Targets for Suicide Prevention in the CF Work-related Stressful Life Stressful Life Event Events Barriers to Care H J Leadership and Organizational Factors 90% The Panel of those distinguished committing suicide between have work-related mental health Stressful and other problems, life stressful events life can especially trigger events suicidal depression thoughts These Most Effective All of suicide these lead psychological Mental factors victims Care play suicidal factors have for out suicidal against mental mediate thoughts, a members backdrop illness, intent, suicidal but is of paramount risk less and plans, behaviour than resilience half and are actions in factors care All of these factors contribute to suicidal behaviour Other Work-related Stress Mood or Other Psychiatric Disorder Suicidal Ideation Suicidal Act H A to B Each Chronic of work these stress targets (in I has additional specific to specific preventive events) can contribute strategies to mental health problems E Other Stressful Life Events Delivery of Effective Care -- Impulsivity -- Hopelessness -- Pessimism -- Emotional Dysregulation Access to Lethal Means Imitation K C D F G Individual Risk and Resilience Factors External Environment PREVENTION INTERVENTIONS A B Education and Awareness Programs Primary Care Providers Members Gatekeepers Screening for and Individuals Assessment at High Risk Treatment Treatment C Pharmacotherapy C Pharmacotherapy D Psychotherapy Psychotherapy E D Follow-up Care Follow-up Care for Suicide Restriction E of Access to Lethal F Attempters/High Risk Pts. Means F Restriction of Access to Lethal G Media Engagement Means Organizational Interventions H G Media Engagement to Mitigate Work Stress/Strain H Organizational Interventions Selection/Resilience Training/ I Leader Education/Training Risk Factor Modification Policy The Ease Leadership, (e.g., CF of Screening) has access limited policies, to Interventions to Overcome Barriers to J I Selection/Resilience control lethal and programs means over the Training/ is can Care Risk external important mitigate Selecting Factor Modification work environment the factor right stress Systematic Clinical Quality K J Improvement Suicide people, can enhancing Efforts trigger suicidal their Overcoming resilience, behaviour barriers and in other decreasing to mental suicide-prone health their risk care individuals factors is Quality Additional essential (e.g. of care prevention alcohol needs use) to opportunities be may monitored help in CF

10 Targets CF Suicide for Suicide Prevention Approach in the CF Intervention Current CF Program Recommendations A Mass Education Rolling out mental health training across the career and deployment cycle Integrate suicide awareness and prevention training into mental health training by leveraging existing initiatives B C D Screening Pharmacotherapy Psychotherapy Screening for suicidal thoughts and common mental disorders at Periodic Health Assessment, predeployment, post-deployment CF members have excellent access to these (and to qualified clinicians) Consider increasing frequency of depression screening in primary care Follow conventional guidelines for treatment no CF-specific recommendations

11 Targets CF Suicide for Suicide Prevention Approach in the CF Intervention Current CF Program Recommendations E F G Ensure followup care (i.e. missed appt) Means Reduction Media Engagement Each clinic has its own approach Additional opportunities are likely limited Aggressively communicating CF MH capabilities Surg Gen series of media interviews Standardizing this essential process across the CF Better capture data on means in suicide surveillance system Explore changes in drug packaging/dispensing Include individual means reduction in management plan CFHS to engage media ( such as introduce CDC guidelines for responsible and ethical reporting of suicides) Goals are enhanced confidence and responsible reporting

12 Targets CF Suicide for Suicide Prevention Approach in the CF Intervention Current CF Program Recommendations H I J Mitigation of Work Stress Selection, Resilience Training, Riskfactor Reduction Strong leadership Policies Programs Careful recruitment and selection processes Integration of promising resilience training into MH training Strengthening the Forces (StF) programs Our efforts in this area are Overcome second to none Barriers to Emerging evidence that this is Care Promote, Protect working and Heal Be The Difference Address management of disciplinary process in leader MH education Consider implementation of a hand off policy (similar to USAF) No opportunities for additional medical screening/selection Evaluate resilience training Continue StF programs Use Health and Lifestyle Information Survey to identify current barriers Planned in-theatre mental health needs assessment Strong confidentiality and career protections remain essential

13 Targets CF Suicide for Suicide Prevention Approach in the CF Intervention Current CF Program Recommendations K Quality Improvement in MH Care BOI is a weak and inefficient tool for clinical quality improvement Functional suicide surveillance system, but some key information (e.g., means) is not captured consistently Death and cancer linkage study is progressing Limited inpatient capacity means high-risk patients need to be managed as outpatients QI coordinators at each clinic Some local and national projects Limited electronic data to Promote, Protect support QI and efforts Heal Complete immediate clinical quality assurance investigation after each suicide Use this to enrich surveillance data Consider adding surveillance for serious suicide attempts in future Death and cancer linkage study will fill in gaps for Reservists, Veterans Develop best practices for management of such patients Reinforce QI infrastructure, especially ability to capture data

14 CF Suicide Prevention Panel (September 2009) Key recommendations Confidentiality remains essential; Integrate suicide education into all levels of MH training; Maximize access and quality of MH care; and Conduct Clinical Investigation after every suicide

15 Clinical Suicide Investigation (MPTSR) CDS directed activity (As of April 2010) Two clinicians deploy to event location GDMO and a Military Psychiatrist Review med records and conduct interviews Produce report for Surgeon General Medical Professional Technical Suicide Report (MPTSR)

16 Clinical Suicide Investigation Model Aim is to provide timely, relevant information to the Surgeon General Opportunity for the two clinicians to do some intervention with those affected by the suicide, especially family members

17 What have We Learned? Over 50 completed MPTSRs to date Most suicides were not preventable Suicide is very difficult to predict Knowing does not necessarily prevent event

18 What Have We Learned? Suicides were related to: Presence of mental illness (including substance use disorders) Precipitated by acute stressor such as: Relationship conflict (divorce, separation, etc) Legal or disciplinary problems Financial stress Transition to civilian life

19 What Have We Learned? Suicides were NOT related to: Operational deployment PTSD (no more than any other mental illness) Age or Years of Service

20 Recap of Key Points This Panel has confirmed that the CF has a strong suicide prevention program Canada is recognized within NATO as a leader in reducing stigma related to mental health issues in military members Suicide education should be integrated into MH education Be the Difference initiative Road to Mental Readiness (R2MR) program Explore strategies to engage media

21 Recommended Action Plan Support clinical suicide investigation model Support message that good leadership is one cornerstone of suicide prevention This is more important than specific suicide prevention knowledge and skills

22 Role of the Leadership Continued engagement at all levels Support MH education and awareness Challenge stigma and reduce other barriers to care Respect Confidentiality Communicate, communicate, communicate

23 CF Suicide Prevention The three cornerstones of suicide prevention are: 1. Aware and engaged members 2. Effective leadership; and 3. Excellence in mental health care

24 Questions? Canadian Forces Health Services Services de santé des Forces canadiennes

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