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WellWellWellWell----Being of Canadian Armed Being of Canadian Armed Being of Canadian Armed Being of Canadian Armed

Forces (CAF) VeteransForces (CAF) VeteransForces (CAF) VeteransForces (CAF) Veterans

Dr. Cyd Courchesne, OMM, CD, MDDirector General Health ProfessionalsChief Medical Officer, Veterans Affairs Canada

Dr. Jim Thompson MDResearch Medical AdvisorResearch Directorate, Veterans Affairs Canada

OEMAC Annual ConferenceSt. John’s, NewfoundlandJune 2017

1. Describe Canadian military Veteran health

issues.

2. Understand the role of Veterans Affairs Canada

in supporting the well-being of the CAF Veteran

population

3. Clarify your role as an occupational health

specialist in the care of Canadian military

Veterans.

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� Components:◦ Regular Force: full time.◦ Primary Reserve Force: part

time, some with periods of full time service including operational deployments.

� Service Elements:◦ Army, Navy, Air Force.

� Military Service is unique:◦ Unlimited liability: can be

lawfully ordered into harm’s way, 7x24.

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100,000100,000100,000100,000

200,000200,000200,000200,000

300,000300,000300,000300,000

400,000400,000400,000400,000

500,000500,000500,000500,000

600,000600,000600,000600,000

700,000700,000700,000700,000

800,000800,000800,000800,000

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CA

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Pers

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� Living in general population: 697,400.◦ About 3% of Canadian adults, or roughly 1 in 30.

� Operational service:◦ Second World War and Korean War.

◦ More than 70 special duty areas and operations worldwide since then:

� Peacekeeping operations prior to 1990s.

� Increased operational tempo since 1990 including Somalia, Balkans, Persian Gulf, Afghanistan, Libya, Iraq.

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WWII & Korean War Veterans

Modern-Day CAF Veterans

• Homogeneous• 69,700 living• Ages 82 to 100; average 91• Declining numbers• 43% are VAC clients

• 670,100 living• Ages 20 to 90+; average 57• Largest VAC client group &

growing • <20% are VAC clients

CAF Veteran Population

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41,600 2001 to 2013

20%

Released 80% Still Serving

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� Serving Personnel:◦ Canadian Forces Health Services Group.

◦ Reserve personnel: publically funded provincial health care systems when part time in home communities.

◦ Eligible for VAC programs and services.

� Families:◦ Publically funded provincial health care systems.

� Veterans:◦ Publically funded provincial health care systems.

◦ VAC pays for and facilitates access to health care and rehabilitation services.

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WellWellWellWell----BeingBeingBeingBeingDomainDomainDomainDomain

Veterans are…Veterans are…Veterans are…Veterans are…

1. Employment 1. Employment 1. Employment 1. Employment or or or or other meaningful other meaningful other meaningful other meaningful activityactivityactivityactivity

Engaged in activities that are beneficial and meaningful to them

2. Finances2. Finances2. Finances2. Finances Financially secure

3. Health3. Health3. Health3. Health Functioning well physically, mentally, socially and spiritually

4. Life 4. Life 4. Life 4. Life skills skills skills skills & & & & preparednesspreparednesspreparednesspreparedness

Have the skills and knowledge to adapt and live well

5. Social 5. Social 5. Social 5. Social integrationintegrationintegrationintegration In mutually supportive relationships and are engaged in their community

6. Housing & 6. Housing & 6. Housing & 6. Housing & Physical Physical Physical Physical EnvironmentEnvironmentEnvironmentEnvironment

Living in safe, adequate and affordable housing

7. Cultural & Social 7. Cultural & Social 7. Cultural & Social 7. Cultural & Social EnvironmentEnvironmentEnvironmentEnvironment

Understood, valued and supported by Canadians

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Thompson et al. A well-being construct for Veterans’ policy, programming and research. VAC Technical Report. 2016.

� Life course view of Veterans’ well-being.

� Military-civilian transition (red).

� VAC supports well-being throughout life after service.

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MC

T

0

200

400

600

800

1000

1200

1400

1600

serving 5 10 15 20 25 30 35 40 45 50 55 60+

Fir

st

Appro

val of

Dis

abilit

y B

enefi

t

Years after Release

25%25%25%25%

25%25%25%25%

25%25%25%25%

25%

Source:RDB, 2012 12

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� During service:◦ CAF Health Services

manages occupational health

� In life after service:◦ VAC disability

compensation: Is their health condition service-related?

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Causality Evidence:

� Strong statistical association.

� Consistency.

� Biologically plausible.

� Temporality.

� Experimental evidence.

� Dose-response

� Coherent with theory.

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� Hearing loss and tinnitus:◦ Thompson et al. JMVFH. November 2016

� Musculoskeletal disorders.� Mental health problems:◦ Thompson et al. JMVFH. February 2016

� Asbestos on ships.� 1990-91 Persian Gulf War multisymptom illnesses:◦ http://www.healthquality.va.gov/guidelines/MR/cmi/CMISinglePageOpt

31Aug15.pdf

� Herbicides in the Vietnam era:◦ http://www.forces.gc.ca/en/about-reports-pubs/herbicides-

gagetown.page

� Depleted Uranium:◦ http://www.veterans.gc.ca/pdf/Reports/scientific-advisory/2013-du-

veterans.pdf

� Mefloquine.

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� Surveys in 2010, 2013 and 2016 of the well-being of CAF Veterans who released from service since 1998.

� Large samples, nationally representative.

� Not just those participating in VAC programs.

� Regular and Reserve Force.

Veteran = Former CAF member

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1. Most doing well in terms of mental health, employment, income, life satisfaction and adjustment to civilian life.

2. Significant number of Class C (deployed) Reservists and Regular Force Veterans have chronic physical and mental health problems and related disability, double or more the Canadian general population.

3. Reserve Class A/B (non-deployed) Veterans on average not much different from young adults in the Canadian general population.

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0%

10%

20%

30%

40%

Veterans Physical Health

Canadian General Population

Veterans Mental Health

Regular Force

Veterans LASS 2013

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19

0%0%0%0%

5%5%5%5%

10%10%10%10%

15%15%15%15%

20%20%20%20%

25%25%25%25%

20-2420-2420-2420-24 25-2925-2925-2925-29 30-3430-3430-3430-34 35-3935-3935-3935-39 40-4440-4440-4440-44 45-4945-4945-4945-49 50-5450-5450-5450-54 55-5955-5955-5955-59 60-6460-6460-6460-64 65-7065-7065-7065-70

Heari

ng P

roble

m P

revale

nce

Age at Survey

CCHS 2010 General Population, HUI3 module

LASS 2013 Regular Force Veterans, HUI3 module

Hearing problem prevalence by self-report using HUI3 (RedRedRedRed) …

… was considerably smaller than hearing impairment measured by audiometry (BlueBlueBlueBlue)

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0%

5%

10%

15%

20%

25%

30%

35%

40%

HUI3 Self-

Report

Audiometry

Speech

Frequencies

Audiometry

High

Frequencies

Pre

vale

nce

Feder et al. Health Reports. 2015.

Audiometry

HUI3

Health-Related Activity Limitations (blue):

Long-term physical or mental condition or health problem reduces amount or kind of activity in home, work, school, other.

Assistance with Activities of Daily Living (red):

Because of physical or mental health condition or problem, needed assistance with at least one BADL or IADL.

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0%

10%

20%

30%

40%

50%

60%

Pre

vale

nce

Veterans STCL 2010

Canadians CCHS 2008

Compared to General Population:

Thompson et al. Disability correlates in CAF Regular Force Veterans. Dis Rehab. 2014.

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Population Population Population Population EstimateEstimateEstimateEstimate

Odds Ratios ofOdds Ratios ofOdds Ratios ofOdds Ratios ofLimitationsLimitationsLimitationsLimitations§§§§

Diagnosed Chronic Health Condition UnadjustedUnadjustedUnadjustedUnadjusted Adjusted

Pain or DiscomfortPain or DiscomfortPain or DiscomfortPain or Discomfort 65% 27.3*** 10.9***10.9***10.9***10.9***

Mental Health conditionMental Health conditionMental Health conditionMental Health condition 24% 7.9*** 2.7***2.7***2.7***2.7***

Musculoskeletal conditionMusculoskeletal conditionMusculoskeletal conditionMusculoskeletal condition 49% 9.3*** 2.6***2.6***2.6***2.6***

Hearing ProblemHearing ProblemHearing ProblemHearing Problem 28% 2.6*** 2.4***2.4***2.4***2.4***

Cardiovascular conditionCardiovascular conditionCardiovascular conditionCardiovascular condition 21% 2.4*** 1.7**1.7**1.7**1.7**

Gastrointestinal conditionGastrointestinal conditionGastrointestinal conditionGastrointestinal condition 11% 4.6*** 1.5**1.5**1.5**1.5**

Respiratory conditionRespiratory conditionRespiratory conditionRespiratory condition 8% 2.6*** 1.5*1.5*1.5*1.5*

ObesityObesityObesityObesity 28% 1.8*** 1111

DiabetesDiabetesDiabetesDiabetes 6% 2.9*** 1111

CancerCancerCancerCancer 1% 2.2* 1111

22§Compared to those without the condition. *p<0.05, **p<0.01, ***p<0.001

Percent of PopulationPercent of PopulationPercent of PopulationPercent of Population

AAAAdjusted Odds djusted Odds djusted Odds djusted Odds RatioRatioRatioRatio

No No No No LimitationLimitationLimitationLimitation

ssss

Some Some Some Some LimitationLimitationLimitationLimitation

ssss

HighHighHighHighLimitatioLimitatioLimitatioLimitatio

nsnsnsns

No Health ConditionsNo Health ConditionsNo Health ConditionsNo Health ConditionsMental onlyMental onlyMental onlyMental onlyPhysical only Physical only Physical only Physical only Both Physical and MentalBoth Physical and MentalBoth Physical and MentalBoth Physical and Mental

33%2%59%7%

<1%<1%71%28%

17%1%38%23%

1.001.001.001.009*** 9*** 9*** 9*** (3(3(3(3----30)30)30)30)

25*** 25*** 25*** 25*** (12(12(12(12----52)52)52)52)73*** 73*** 73*** 73*** (34(34(34(34----157)157)157)157)

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***p<0.001

Odds of having activity limitations four times higher in those with both physical and mental

health conditions than either one alone.

Thompson et al. Disability correlates in CAF Regular Force Veterans. Dis Rehab. 2014.

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� Increasing age � Women � Non-degree post-secondary

education� Low income� Junior non-commissioned

member rank� Deployment� Low social support� Low mastery� High life stress� Weak sense of community

belonging

Regular Force, LASS 2010, Multivariable regression modelling

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� Historically, suicide rates in serving personnel similar to or less than Canadian population◦ Rates stable over last decade.

◦ Ever having deployed is not a risk factor for suicide.

� Study of suicides in CAF personnel 1972�2006

◦ Male Veteran suicides 1.5 x Canadian males matched for age

and sex.

� Important Public Health problem

◦ Analyzed findings from the Life After Service Studies to

identify characteristics of Veterans with suicidal thinking.

◦ Developed an evidence-based suicide prevention framework

for the Veteran population.

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• Estimated total Veteran population: 697,400

• Total VAC program participants: 202,178

• In receipt of disability benefits for psychiatric diagnoses: 17,323 (13%)

• Clients who are CAF Veterans with service in Afghanistan: 11,080

• In receipt of disability benefits for PTSD: 3,198

• Receiving MH services:

• 2,142 (0.3 % of total population or 1.6 % all Veterans in receipt of benefits)

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• Veterans receiving VAC disability benefits for psyschological diagnoses increased by 50% in past five years.

• Swift access to medical support key to recovery.

• Case management.• OSI clinics.• OSISS peer support.• VAC Assistance Service.• PTSD Coach Canada.

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OSICSainte-Anne

Veterans Affairs Canada Operational Stress Injuries Clinics

Network (OSIC)

Canadian Forces Operational and Trauma Stress Support Centers

(OTSSC)

OTSSCEdmonton

OTSSCOttawa

OTSSCValcartier

OTSSCHalifax

OTSSCPetawawa

OTSSCGagetownOTSSC

Esquimalt

OSIC CHUQ

OSIC Carewest

OSIC Royal Ottawa

OSIC Vancouver

OSIC Edmonton

OSIC Deer Lodge

Horizon HealthOSIC

Fredericton

OSIC Parkwood

OSI Residential Treatment Clinic

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National Operational Stress Injury (OSI) Clinic Network

� Access to specialized treatment centers/facilities

� Arrangement with 7 specialized treatment facilities with in-patient programs

� National network of registered MH professionals

� 4,000 MH professionals

� 300 community clinical care managers

� VAC Assistance services

� Pastoral outreach

� Case managers� 214.4 FTEs

� 100 persons co-located in JPSU/IPSCs (24)

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CROMIS:Client-Reported Outcomes

Management Information System

Presentation to the Deputy MinisterJanuary 27, 2015

David F. Ross, Ph.D.Manager (A) , National OSI Clinic Network Clinical Coordinator

Operational Stress Injury National Network (OSINN)VAC

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Key Elements of Client-Reported Outcomes Management Information System (CROMIS)

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PTSD ChecklistO.Q. 45.2

Assessment for Signal Clients

OQ-Analyst

platform

(DENOMINALIZED SOCIDEMOGRAPHIC INFO)

• Tracking

– ‘real-time’, ‘vital-signs’ outcomes tracking (analogous to blood pressure or EEGs in medicine)

• Reporting

� Reliable Change index

� Selected anxiety and depressive symptoms� Social integration� Vocational integration

� Critical Items...available immediately)

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-25

-20

-15

-10

-5

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Ch

an

ge

in

OQ

-45

Sco

re

• 92 Steadily improved (59%)• 18 Deteriorated early and then improved (12%)• 41 Steadily Deteriorated (26%; )• 5 Improved early and then deteriorated (3%)

Distinct trajectories emerged

Compared to providers NOT USING OQ....

OQ Feedback to Clinicians ONLY

OQ Feedback toClinicians & Consumers

OQ + ASC Feedback to both Clinicians and Consumers

MORE CURE 1.7 X 2.0 X 2.4x more

LESS STAGNATION

1.2x 1.4X less

LESS HARM 2.2X 1.4X 3.7X less

Solid evidence that regular use translates to reliable “real-time” benefits to OSIC clients

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OSI Clinics make a real difference, learn from real outcomes, build better programming

Aggregated Results from first network CROMIS analysis , January 2015)

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Critical 3-Year Window

� VAC Research Directorate, in collaboration with DND, CAF Health Services, Statistics Canada and the Canadian Institute of Military Veteran Health Research◦ Life After Service Studies (LASS) 2016 and 2019.

� Longitudinal followup to LASS 2013.

◦ Mental health in transition to civilian life:

� Five-year longitudinal study of MH in CAF members.

� Two-year study of impact of operational stress injuries on families.

◦ Veteran suicide surveillance.

� CFHS Mental Health Centre of Excellence◦ VAC Psychologist in the CoE.

◦ Research in areas of personalized medicine ( PGMs vs RPGs).

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Magnetic Resonance Imaging (MRI)

for brain structure and function Magnetoencephalography (MEG)

for brain function

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Caudate &

ACC:

Implicated in

amygdala /

autonomic

regulation

Dorsal ACC:

Fear regulation / extinction

Visual cortex:

Co-activation between visual cortex

and amygdala where amygdala

enhances visual processing of salient

stimuli

Orbital frontal cortex:

Implicated in evaluating

salience of stimuli and is

important in decision

making and learning

response

(Todd, et al., Biological Psychiatry, In Revision)

Neuroimaging Neuroimaging Neuroimaging Neuroimaging in PTSDin PTSDin PTSDin PTSD

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� Consolidation of MH under DGHP◦ Mental Health Strategy 2015-2020◦ Establish VAC Mental Health Directorate

� Director + Chief of Psychiatry

� Roll out of CROMIS (1st report March 2015)

� Expansion of:◦ OSI Clinic network◦ OSI Social Support network◦ Case Manager complement

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� Research gives clear picture of nature of the well-being of CAF Veterans.

� VAC works closely with CAF and DND to support the well-being of CAF Veterans.

� Occupational Health physicians have important roles in supporting the well-being of Canadian military Veterans.

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Predict Prevent Dx Treat Outcomes

� CAF/DND website: http://www.forces.gc.ca/en/caf-community-health-services/index.page

� VAC telephone: 1-866-522-2122 (toll-free) Monday to Friday, 8:30 to 4:30, local time

� VAC website: http://www.veterans.gc.ca/eng/

� U.S. Department of Veterans Affairs practice guidelines: http://www.healthquality.va.gov/

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