Canadian Psychiatric Association
Association des psychiatres du Canada
Editorial
Mental Health in the Canadian Armed Forces: New Data, New Answers, and New Questions
The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2016, Vol. 61(Supplement 1) 4S-6S ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0706743715625424 TheCJP.ca | LaRCP.ca
Scott B. Patten, MD, PhD1,2
Keywords mental health, armed forces, Canadian military
This supplement contains 6 papers examining aspects of mental health status and mental health service provision in the Canadian Armed Forces (CAF). Publication of this supplement is partially motivated by a 2013 Canadian Forces Mental Health Survey (CFMHS)—a landmark source of updated information on mental health in the CAF. A prior survey was conducted in 2002, bracketing an eventful 10-year span that most notably included the Afghanistan mission. Mental health in the CAF has attracted a lot of attention in the lay press in Canada and has triggered much public debate, especially around the issue of suicide. This supplement provides a welcome opportunity to examine these important questions through the lens of epidemiological data, providing much needed evidence on this topic. An introductory article by Zamorski et al1 provides context for the CFMHS, summarizing results of the earlier 2002 survey and additional studies conducted by the CAF and Veterans Affairs Canada. Earlier epidemiological data often challenged assumptions about military mental health. For example, the 2002 survey found that failure to recognize a need for care and a lack of trust of the services available were the main reasons for CAF members with mental health issues not seeking help at that time. Surprisingly, stigmatization was found to be less important. Also, deploymentrelated exposures did not appear to be the dominant causes of the burden of mental illness. However, developments since 2002—most notably the mission in Afghanistan but also the CAF’s efforts to improve mental health literacy, service availability, and service effectiveness—all highlight the value of the updated 2012 data. The Zamorski et al1 paper underscores the strong methodology employed in the CFMHS. This was achieved through use of a probability sample, data collection in face-to-face interviews, a high response rate (higher than what is usually achieved in general population surveys) and its use of a contemporary version of the Composite International Diagnostic Interview (CIDI) to assign diagnoses. High quality of
sampling and measurement are required to produce valid estimates in epidemiological studies. Yet, these same concepts of selection and measurement help to frame the limitations of the CFMHS. While the sample is a probability sample, it must be remembered that the target population is subject to selection both pre- and post-recruitment. Because recruitment into the military does not occur randomly, the mental health of this population only partially reflects the effects of the military experience: it also reflects health status at the time of recruitment and the chances of staying in the CAF after recruitment. Again, however, the results challenge assumptions. In the Rusu et al2 paper, childhood physical abuse was found to be more common in the military than the general population. It is therefore not necessarily true that all aspect of mental health are better in military recruits than the general population. Where measurement is concerned, the latest version of the CIDI is an excellent instrument, but it should be acknowledged that it is a fully structured lay (as opposed to clinician) administered interview. The interview is entirely scripted (clarifying questions and [or] responses is not allowed), which limits its accuracy relative to a semi-structured interview conducted by a health professional. Taking this even further, the ability of the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth Edition, diagnostic categories employed to characterize mental health is imperfect. As the authors point out, psychiatric diagnoses can be insensitive (many patients have distress and perceive a need for mental health care
1
2
Departments of Community Health Sciences and Psychiatry, University of Calgary, Calgary, Alberta Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta
Corresponding Author: Scott B. Patten, MD, PhD, University of Calgary, 3rd Floor, TRW Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6. Email: [email protected]
La Revue Canadienne de Psychiatrie 61(Supplement 1)
despite having no apparent diagnosis) and nonspecific (some people with recent disorders do not report dysfunction) when juxtaposed against the broader concepts of mental health and well-being. It has often been assumed that members of the CAF have been selected such that they would be healthier, on average, than members of the general population at their time of recruitment. This healthy warrior assumption mirrors the healthy worker effect that applies to almost any occupational group. In the United States, where some states have opted to include an assessment of adverse childhood experiences in their data collection for the Behavioral Risk Factor Surveillance System surveys, a higher prevalence of each of 11 measured adverse childhood experiences was observed in respondents having a history of military service during the volunteer era, an association that was not observed during the draft era.3 This suggests that members of the military may in some respects be more, as well as potentially in some other respects less, vulnerable to mental disorders. Mental health outcomes have multiple contributing causes. Various combinations of component causes may be sufficient to produce mental health difficulties. Some such component causes are likely to be more prevalent in military populations, others less. Future studies should explore whether adverse childhood experiences interact synergistically with military servicerelated traumas to produce mental disorders, an interaction that has been reported in the Canadian general population.4 It is also important to remember that a survey such as the CFMHS provides cross-sectional data. Such studies provide a snapshot at a point in time in the form of prevalence estimates. Prevalence is not equivalent to risk. Prevalence represents a balance between inflow to a prevalence pool (incidence) and its outflow by mechanisms, such as recovery, leaving the target population, or mortality. A sophisticated discussion of these issues is provided in the supplement.5 An increased prevalence of posttraumatic stress disorder, generalized anxiety disorder, and panic disorder (but not major depressive episodes) when compared with the 2002 data is interpreted as likely being related to increased exposure to combat, resulting in increased incidence of these disorders. The apparently combat-related increase in anxiety disorder prevalence is interpreted as being possibly offset, at least in part, by a primary preventive impact of enhanced health services, such as the Road to Mental Readiness (R2MR) program and perhaps also by a strengthening of health services within the CAF. These enhancements might have resulted in earlier access to care and better treatment. Indeed, such factors could partially offset the expected impact of higher incidence. The small overall increase in prevalence suggests that the negative factors (increasing incidence, negative prognostic determinants) have outweighed positive factors (reduced incidence due to primary prevention, shorter duration due to earlier intervention and better treatment), but of course the details of these complex underlying dynamics remain speculative and are not accessible to cross-sectional analyses. Notably, however,
5S
the authors’ interpretation is supported by an apparently improved capacity within the regular forces to identify mental health care needs.6 Understanding the determinants of mental health involves trying to isolate the effect of one possible determinant from that of other determinants that might otherwise confound the association. Seeking a solution to this problem is the focus of the third paper in the series.2 The issue of confounding is assessed in various papers in the supplement using conventional techniques, such as regression models, matching, and restriction. The Rusu et al2 analysis seeks to apply a series of procedures (restriction followed by an iterative proportional fitting procedure) to create a weighted general population sample much like the CAF sample. The study seeks access to a counterfactual quantity: what would prevalence of mental disorders be in members of the CAF if they were not in the CAF? Through the lens of this procedure, the prevalence of mood and anxiety disorders (and suicide attempts and ideation) are found to be higher in the military sample than in the general population, except for alcohol use disorders, which was higher in the general population. However, as the authors point out, it would be a mistake to conclude that any specific aspect of the military experience in itself causes higher or lower prevalence. The CFMHS sample differs from the general population in many ways, both measured and unmeasured, and causal inference is notoriously difficult from cross-sectional data. For this same reason, reported estimates of the population attributable fraction (PAF) for the Afghanistan deployment7 are qualified by the authors as being tentative as they are valid only to the extent that the adjusted prevalence estimates reflect causal risks. PAF is usually calculated as the difference in risk (risk being usually expressed an incidence proportion) between people exposed to a causal factor and the total population. Prevalence (including an adjusted estimate of prevalence), however, is a function both of risk and duration. Hypothetically, if alcohol use disorders (AUD) result in a sufficiently high rate of exit from the regular forces subsequent to deployment, the estimated PAF for deployment (estimated from prevalence data) might suggest protection even if the risk of developing an AUD after deployment was elevated. This may explain the suggestion of a protective effect of deployment on AUD. The comparison of PAF for childhood abuse with that of the deployment (the estimated PAF for child abuse is larger) should also be interpreted with caution as childhood adversities may interact with adult traumas to cause mental disorders, see comments above. Another paper8 in the supplement examines the performance of the World Health Organization’s Disability Assessment Schedule 2.0 (WHODAS-2) in the CFMHS sample. It reports a factor analysis that provides support for the performance of the 12-item version. An expected association between disorder prevalence and disability ratings is observed with recent disorders having greater impact than remote ones. About one-quarter of respondents with a recent disorder report no disability, another observation
6S
that argues for caution in treating a diagnosis as if it were an adequate assessment of need. A striking finding is a strong magnifying effect of comorbidity on the WHODAS-2 scores. These results are of considerable general interest, as the WHODAS-II has been identified as a possible replacement for the global assessment of functioning (previously Axis V) with elimination of the multi-axial diagnostic system in DSM-5. Within a data-rich environment informed partially by 2 large surveys, the CAF’s mental health care systems have been strengthened. Some of the innovative strategies (such as the literacy enhancing, destigmatizing, and resiliencebuilding R2MR program) are having a widespread influence outside of the CAF, being adapted, for example, for civilian police forces and other workplaces.9 We in the civilian system can learn a lot from the efforts of the CAF, and I hope that this supplement will help us to do so. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and (or) publication of this article.
Funding The author(s) received no financial support for the research, authorship, and (or) publication of this article.
References 1. Zamorski MA, Bennett RE, Boulos D, et al. The 2013 Canadian Forces Mental Health Survey: background and methods. Can J Psychiatry. 2016;61 Suppl 1:10S-25S.
The Canadian Journal of Psychiatry 61(Supplement 1)
2. Rusu C, Zamorski MA, Boulos D, et al. Prevalence comparison of past-year mental disorders and suicidal behaviours in the Canadian Armed Forces and the Canadian general population. Can J Psychiatry. 2016;61 Suppl 1:46S-55S 3. Blosnich JR, Dichter ME, Cerulli C, et al. Disparities in adverse childhood experiences among individuals with a history of military service. JAMA Psychiatry. 2014;71(9):1041-1048. 4. Patten SB. Childhood and adult stressors and major depression risk: interpreting interactions with the sufficient-component cause model. Soc Psychiatry Psychiatr Epidemiol. 2013;48(6): 927-933. 5. Zamorski MA, Bennett RE, Rusu C, et al. Prevalence of pastyear mental disorders in the Canadian Armed Forces, 2002– 2013. Can J Psychiatry. 2016;61 Suppl 1:26S-35S. 6. Fikretoglu D, Liu A, Zamorski M, et al. Perceived need for and perceived sufficiency of mental health care in the Canadian Armed Forces: changes in the past decade and comparisons to the general population. Can J Psychiatry. 2016;61 Suppl 1: 36S-45S. 7. Boulos D, Zamorski MA. Contribution of the mission in Afghanistan to the burden of past-year mental disorders in Canadian Armed Forces personnel, 2013. Can J Psychiatry. 2016;61 Suppl 1: 64S-76S. 8. Weeks M, Garber BG, Zamorski MA. Disability and mental disorders in the Canadian Armed Forces. Can J Psychiatry. 2016;61 Suppl 1:56S-63S. 9. Mental Health Commission of Canada (MHCC). The working mind (Summary) [Internet]. Ottawa (ON): MHCC; 2015 [cited date 2015 Nov 24]. Available from: http://www.mentalhealthcommission.ca/English/initiatives-and-projects/working-mind.
Association des psychiatres du Canada
Editorial
Mental Health in the Canadian Armed Forces: New Data, New Answers, and New Questions
The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2016, Vol. 61(Supplement 1) 4S-6S ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0706743715625424 TheCJP.ca | LaRCP.ca
Scott B. Patten, MD, PhD1,2
Keywords mental health, armed forces, Canadian military
This supplement contains 6 papers examining aspects of mental health status and mental health service provision in the Canadian Armed Forces (CAF). Publication of this supplement is partially motivated by a 2013 Canadian Forces Mental Health Survey (CFMHS)—a landmark source of updated information on mental health in the CAF. A prior survey was conducted in 2002, bracketing an eventful 10-year span that most notably included the Afghanistan mission. Mental health in the CAF has attracted a lot of attention in the lay press in Canada and has triggered much public debate, especially around the issue of suicide. This supplement provides a welcome opportunity to examine these important questions through the lens of epidemiological data, providing much needed evidence on this topic. An introductory article by Zamorski et al1 provides context for the CFMHS, summarizing results of the earlier 2002 survey and additional studies conducted by the CAF and Veterans Affairs Canada. Earlier epidemiological data often challenged assumptions about military mental health. For example, the 2002 survey found that failure to recognize a need for care and a lack of trust of the services available were the main reasons for CAF members with mental health issues not seeking help at that time. Surprisingly, stigmatization was found to be less important. Also, deploymentrelated exposures did not appear to be the dominant causes of the burden of mental illness. However, developments since 2002—most notably the mission in Afghanistan but also the CAF’s efforts to improve mental health literacy, service availability, and service effectiveness—all highlight the value of the updated 2012 data. The Zamorski et al1 paper underscores the strong methodology employed in the CFMHS. This was achieved through use of a probability sample, data collection in face-to-face interviews, a high response rate (higher than what is usually achieved in general population surveys) and its use of a contemporary version of the Composite International Diagnostic Interview (CIDI) to assign diagnoses. High quality of
sampling and measurement are required to produce valid estimates in epidemiological studies. Yet, these same concepts of selection and measurement help to frame the limitations of the CFMHS. While the sample is a probability sample, it must be remembered that the target population is subject to selection both pre- and post-recruitment. Because recruitment into the military does not occur randomly, the mental health of this population only partially reflects the effects of the military experience: it also reflects health status at the time of recruitment and the chances of staying in the CAF after recruitment. Again, however, the results challenge assumptions. In the Rusu et al2 paper, childhood physical abuse was found to be more common in the military than the general population. It is therefore not necessarily true that all aspect of mental health are better in military recruits than the general population. Where measurement is concerned, the latest version of the CIDI is an excellent instrument, but it should be acknowledged that it is a fully structured lay (as opposed to clinician) administered interview. The interview is entirely scripted (clarifying questions and [or] responses is not allowed), which limits its accuracy relative to a semi-structured interview conducted by a health professional. Taking this even further, the ability of the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth Edition, diagnostic categories employed to characterize mental health is imperfect. As the authors point out, psychiatric diagnoses can be insensitive (many patients have distress and perceive a need for mental health care
1
2
Departments of Community Health Sciences and Psychiatry, University of Calgary, Calgary, Alberta Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta
Corresponding Author: Scott B. Patten, MD, PhD, University of Calgary, 3rd Floor, TRW Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6. Email: [email protected]
La Revue Canadienne de Psychiatrie 61(Supplement 1)
despite having no apparent diagnosis) and nonspecific (some people with recent disorders do not report dysfunction) when juxtaposed against the broader concepts of mental health and well-being. It has often been assumed that members of the CAF have been selected such that they would be healthier, on average, than members of the general population at their time of recruitment. This healthy warrior assumption mirrors the healthy worker effect that applies to almost any occupational group. In the United States, where some states have opted to include an assessment of adverse childhood experiences in their data collection for the Behavioral Risk Factor Surveillance System surveys, a higher prevalence of each of 11 measured adverse childhood experiences was observed in respondents having a history of military service during the volunteer era, an association that was not observed during the draft era.3 This suggests that members of the military may in some respects be more, as well as potentially in some other respects less, vulnerable to mental disorders. Mental health outcomes have multiple contributing causes. Various combinations of component causes may be sufficient to produce mental health difficulties. Some such component causes are likely to be more prevalent in military populations, others less. Future studies should explore whether adverse childhood experiences interact synergistically with military servicerelated traumas to produce mental disorders, an interaction that has been reported in the Canadian general population.4 It is also important to remember that a survey such as the CFMHS provides cross-sectional data. Such studies provide a snapshot at a point in time in the form of prevalence estimates. Prevalence is not equivalent to risk. Prevalence represents a balance between inflow to a prevalence pool (incidence) and its outflow by mechanisms, such as recovery, leaving the target population, or mortality. A sophisticated discussion of these issues is provided in the supplement.5 An increased prevalence of posttraumatic stress disorder, generalized anxiety disorder, and panic disorder (but not major depressive episodes) when compared with the 2002 data is interpreted as likely being related to increased exposure to combat, resulting in increased incidence of these disorders. The apparently combat-related increase in anxiety disorder prevalence is interpreted as being possibly offset, at least in part, by a primary preventive impact of enhanced health services, such as the Road to Mental Readiness (R2MR) program and perhaps also by a strengthening of health services within the CAF. These enhancements might have resulted in earlier access to care and better treatment. Indeed, such factors could partially offset the expected impact of higher incidence. The small overall increase in prevalence suggests that the negative factors (increasing incidence, negative prognostic determinants) have outweighed positive factors (reduced incidence due to primary prevention, shorter duration due to earlier intervention and better treatment), but of course the details of these complex underlying dynamics remain speculative and are not accessible to cross-sectional analyses. Notably, however,
5S
the authors’ interpretation is supported by an apparently improved capacity within the regular forces to identify mental health care needs.6 Understanding the determinants of mental health involves trying to isolate the effect of one possible determinant from that of other determinants that might otherwise confound the association. Seeking a solution to this problem is the focus of the third paper in the series.2 The issue of confounding is assessed in various papers in the supplement using conventional techniques, such as regression models, matching, and restriction. The Rusu et al2 analysis seeks to apply a series of procedures (restriction followed by an iterative proportional fitting procedure) to create a weighted general population sample much like the CAF sample. The study seeks access to a counterfactual quantity: what would prevalence of mental disorders be in members of the CAF if they were not in the CAF? Through the lens of this procedure, the prevalence of mood and anxiety disorders (and suicide attempts and ideation) are found to be higher in the military sample than in the general population, except for alcohol use disorders, which was higher in the general population. However, as the authors point out, it would be a mistake to conclude that any specific aspect of the military experience in itself causes higher or lower prevalence. The CFMHS sample differs from the general population in many ways, both measured and unmeasured, and causal inference is notoriously difficult from cross-sectional data. For this same reason, reported estimates of the population attributable fraction (PAF) for the Afghanistan deployment7 are qualified by the authors as being tentative as they are valid only to the extent that the adjusted prevalence estimates reflect causal risks. PAF is usually calculated as the difference in risk (risk being usually expressed an incidence proportion) between people exposed to a causal factor and the total population. Prevalence (including an adjusted estimate of prevalence), however, is a function both of risk and duration. Hypothetically, if alcohol use disorders (AUD) result in a sufficiently high rate of exit from the regular forces subsequent to deployment, the estimated PAF for deployment (estimated from prevalence data) might suggest protection even if the risk of developing an AUD after deployment was elevated. This may explain the suggestion of a protective effect of deployment on AUD. The comparison of PAF for childhood abuse with that of the deployment (the estimated PAF for child abuse is larger) should also be interpreted with caution as childhood adversities may interact with adult traumas to cause mental disorders, see comments above. Another paper8 in the supplement examines the performance of the World Health Organization’s Disability Assessment Schedule 2.0 (WHODAS-2) in the CFMHS sample. It reports a factor analysis that provides support for the performance of the 12-item version. An expected association between disorder prevalence and disability ratings is observed with recent disorders having greater impact than remote ones. About one-quarter of respondents with a recent disorder report no disability, another observation
6S
that argues for caution in treating a diagnosis as if it were an adequate assessment of need. A striking finding is a strong magnifying effect of comorbidity on the WHODAS-2 scores. These results are of considerable general interest, as the WHODAS-II has been identified as a possible replacement for the global assessment of functioning (previously Axis V) with elimination of the multi-axial diagnostic system in DSM-5. Within a data-rich environment informed partially by 2 large surveys, the CAF’s mental health care systems have been strengthened. Some of the innovative strategies (such as the literacy enhancing, destigmatizing, and resiliencebuilding R2MR program) are having a widespread influence outside of the CAF, being adapted, for example, for civilian police forces and other workplaces.9 We in the civilian system can learn a lot from the efforts of the CAF, and I hope that this supplement will help us to do so. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and (or) publication of this article.
Funding The author(s) received no financial support for the research, authorship, and (or) publication of this article.
References 1. Zamorski MA, Bennett RE, Boulos D, et al. The 2013 Canadian Forces Mental Health Survey: background and methods. Can J Psychiatry. 2016;61 Suppl 1:10S-25S.
The Canadian Journal of Psychiatry 61(Supplement 1)
2. Rusu C, Zamorski MA, Boulos D, et al. Prevalence comparison of past-year mental disorders and suicidal behaviours in the Canadian Armed Forces and the Canadian general population. Can J Psychiatry. 2016;61 Suppl 1:46S-55S 3. Blosnich JR, Dichter ME, Cerulli C, et al. Disparities in adverse childhood experiences among individuals with a history of military service. JAMA Psychiatry. 2014;71(9):1041-1048. 4. Patten SB. Childhood and adult stressors and major depression risk: interpreting interactions with the sufficient-component cause model. Soc Psychiatry Psychiatr Epidemiol. 2013;48(6): 927-933. 5. Zamorski MA, Bennett RE, Rusu C, et al. Prevalence of pastyear mental disorders in the Canadian Armed Forces, 2002– 2013. Can J Psychiatry. 2016;61 Suppl 1:26S-35S. 6. Fikretoglu D, Liu A, Zamorski M, et al. Perceived need for and perceived sufficiency of mental health care in the Canadian Armed Forces: changes in the past decade and comparisons to the general population. Can J Psychiatry. 2016;61 Suppl 1: 36S-45S. 7. Boulos D, Zamorski MA. Contribution of the mission in Afghanistan to the burden of past-year mental disorders in Canadian Armed Forces personnel, 2013. Can J Psychiatry. 2016;61 Suppl 1: 64S-76S. 8. Weeks M, Garber BG, Zamorski MA. Disability and mental disorders in the Canadian Armed Forces. Can J Psychiatry. 2016;61 Suppl 1:56S-63S. 9. Mental Health Commission of Canada (MHCC). The working mind (Summary) [Internet]. Ottawa (ON): MHCC; 2015 [cited date 2015 Nov 24]. Available from: http://www.mentalhealthcommission.ca/English/initiatives-and-projects/working-mind.
