Post-traumatic stress disorder (PTSD) is a psychiatric disorder that can be best described as an extreme reaction to stress. It is categorized as an anxiety disorder, along with other conditions such as panic disorder, phobias, and obsessive-compulsive disorder.
PTSD may develop in response to an extremely traumatic experience that involves a real or perceived threat to the safety or life of either the individual suffering or someone else. As a result, the individual evokes feelings of intense fear, horror, or hopelessness.
The disorder is characterized by a variety of symptoms that can generally be grouped into three categories:
- re-experiencing (nightmares, flashbacks and intrusive thoughts);
- avoidance (avoidance of people, places, or circumstances that remind the individual of the traumatic event); and
- hyperarousal (hypervigilince, exaggerated startle response, mood swings and/or irritability, and disturbed sleep).
A diagnosis of PTSD requires that these symptoms be present for at least one month and be severe enough to interfere with the individual’s ability to function at work, home, or in social situations.
As with most psychiatric conditions, the exact cause of PTSD is not fully understood. It cannot be explained why people who experience the same event might either develop PTSD or experience no symptoms.
The understanding of the psychology and biology of PTSD continues to grow. The Canadian Forces (CF) conduct significant research into the risk and resiliency factors associated with the illness. CF Health Services also uses existing research and evidence to help conduct PTSD-related screening, education, and training.
Treatment of PTSD is provided primarily by clinicians within the CF clinics, led by seven regional Operational Trauma and Stress Support Centres. CF clinicians are committed to providing evidence-based treatment that includes medication and exposure-based therapy tailored for each individual patient. Most patients diagnosed with PTSD respond to treatment. In cases where complete recovery is not possible, health care providers help patients achieve the best quality of life possible through strategies that help mitigate their symptoms.
PTSD in the CF
The vast majority of CF members who deploy do not develop PTSD. A 2011 study on the cumulative incidence of PTSD and other mental health disorders estimated that eight-per-cent (8%) had been diagnosed with PTSD. This study, which involved medical record reviews of a stratified random sample of 2,045 personnel, provides the most rigorous scientific estimate of CF personnel diagnosed with PTSD following their deployment in Afghanistan. The study population included all 30,518 personnel who returned from deployment in support of the mission in Afghanistan from October 1, 2001 to December 31, 2008 and was the first study to examine clinical diagnoses made by a mental health professional, rather than self-completed questionnaires.
Afghanistan-related PTSD was more common among those deployed to higher-threat locations, like Kandahar or Kabul, than in lower-threat locations like the Arabian Gulf or Camp Mirage. Army personnel and junior non-commissioned members were shown to have a higher cumulative incidence of PTSD attributed to the mission in Afghanistan.
Many of those diagnosed with PTSD in the CF return to full duties, while some remain in the CF with some modification to their duties. Some are also medically released and transitioned to Veterans Affairs Canada (VAC).
CF Health Services has an ongoing partnership and a strong relationship with VAC to ensure a seamless transition to VAC-delivered care. Before release, each CF member is assigned a nurse case manager, who ensures that all the necessary care to be provided through VAC is in place and that provincial health coverage is arranged.
Screening, surveillance and prevention
CF personnel undergo a mental health screening as part of their pre-deployment health assessment. Deploying personnel also undergo a psychosocial screening by either a mental health chaplain or a mental health professional.
Before deployment, personnel participate in the CF’s pre-deployment mental health education and training program – The Road to Mental Readiness (R2MR). The program combines classroom and interactive learning to help participants understand:
- the impact of mental health on deployment;
- the physiological reaction to stress and how to mitigate it;
- the importance and application of goal setting, visualization, self talk and arousal management;
- the challenges that may be encountered while deployed and their potential impact;
- the impact of values, beliefs and meaning in mental readiness;
- the importance of a social support system;
- how to prevent and manage stress; and
- family stressors associated with deployment (family members are invited to attend).
The R2MR website provides deploying soldiers and their families with easy access to information about the deployment process. This information is intended as a tool to not only provide more concrete information as it pertains to families but also provide them with some general insight on what the Canadian Forces members are receiving as training as well. For more information, please visit the R2MR website.
Soldiers returning to Canada after a lengthy deployment also participate in the CF’s five-day Third Location Decompression (TLD) program. Throughout the program, personnel are also educated about PTSD and operational stress injuries. To help ease the transition to life back home, the mental health team also provides information about home, work and community life. During TLD, each deployed personnel has the opportunity to speak to a mental health professional and to raise concerns.
Additionally, personnel returning from an international operation of 60 or more days also undergo the Enhanced Post-Deployment Screening process, normally three to six months after their return to Canada. This screening helps identify those with deployment-related problems, with a particular focus on psychological issues. Throughout the screening, CF members complete a detailed health questionnaire and have an in-depth interview with a mental health professional. If required, follow-up care is recommended and arranged.
Results from this post-deployment screening (occurring three to six months after deployment) have shown that approximately four-per-cent (4%) of personnel report symptoms of PTSD at the time of their screening.
The mental health of CF members is also continually assessed through regular periodic medical check-ups. Screening questions pertaining to PTSD, depression, suicide and other mental health conditions are routinely asked and responses are recorded as part of regular examinations.
Mental health awareness programs are also a significant part of the mental health continuum at CF Health Services because they encourage personnel to recognize the signs of stress and to seek or promote early treatment.
CF Health Services has many programs aimed at preventing or mitigating the effects of stress. Educational programs are delivered to various levels of leadership and cover the full deployment and career cycles. These courses are aimed at increasing mental health literacy and decreasing stigma among CF members. They also include training in various stress management techniques that can be used before, during, or after stressful events such as combat. Courses cover areas such as anger and stress management, creating a healthy home life, suicide intervention, and addictions awareness.
CF Health Services has a strong mental health program that provides dedicated and responsive care for ill and injured CF members and emphasizes the elimination of the barriers to mental health care. The CF programs are currently delivered by approximately 380 military and civilian mental health providers plus additional support staff. As well, a significant amount of mental health care is delivered by primary care providers.
Mental health care in the CF is guided by evidence-based practices and is delivered through multidisciplinary teams including primary care clinicians, psychiatrists, psychologists, social workers, mental health nurses, addictions counsellors, and chaplains.
CF Health Services offers comprehensive treatment to its personnel that is individualized and may include psychotherapy (individual, group, couple) and medication as required. Should in-patient care be necessary, the CF have long-standing relationships with civilian health care facilities to ensure that personnel get the care they need.
The CF have a wide variety of mental health services available to its members. These services are delivered through:
- Twenty-six mental health clinics at bases across Canada. These clinics vary in size depending on the size of the base they support. The smallest would provide psycho-social services through a social worker.
- The five largest mental health clinics are the regional clinics (Halifax, Valcartier, Ottawa, Edmonton, and Esquimalt). These clinics provide a full range of care, including general mental health care, operational trauma and stress support, psycho-social services, and addictions counselling.
Operational Trauma and Stress Support Centres (OTSSCs) are the CF’s centres of excellence in areas such as PTSD. The centres have four mandates —assessment, treatment, outreach (education), and research. These centres are located in Edmonton, Esquimalt, Gagetown, Halifax, Ottawa, Petawawa and Valcartier.
As well as providing direct care to CF personnel, these centres are also community leaders in the area of mental health and have forged partnerships with civilian and academic institutions. CF professionals are involved in leading edge research and are continually looking to their colleagues in the civilian sector and other countries for opportunities to build on care provided.
In addition to determining the incidence of PTSD amongst those CF members who deployed in support of the mission in Afghanistan from 2001 to 2008, the 2011 PTSD and other mental health disorders cumulative incidence study also examined the proportion of those personnel who utilized specialty mental health services upon their return from deployment. The study found that close to one third of all deployed personnel received specialty mental healthcare after their return. This figure is reassuring as it shows that CF members are seeking care for potential operational stress injuries without fear of being stigmatised or out of fear of career impact.
Beyond the treatment options mentioned above there are a number of programs in place to support those CF members suffering from PTSD and other conditions. These include:
- The CF Member Assistance Program: This program provides a confidential 24/7 toll-free telephone advisory and referral service to all CF members and their families. It also provides short-term (up to nine sessions) confidential external (civilian) counselling for those in need.
- The Operational Stress Injury Social Support (OSISS) Program: This program provides peer support and family counselling to those suffering from PTSD or other Operational Stress Injuries.
- The Road to Mental Readiness (R2MR) Program: The R2MR program and website provide deploying soldiers, their families and service providers with easy access to information about the deployment process.
- The Military Family Resource Centres (located at all major CF bases): Forty Military Family Resource Centres (MFRCs) are located at CF installations across the country, in the U.S., and in Europe. These centres can provide information on subjects of interest to military families, including mental health. Staff can direct family members in greater need to appropriate service providers. The MFRCs can provide emergency shelter, funding, and child care, as well as psychosocial support through counselling and referral services to complementary programs in the larger community.
- Additional crisis intervention through a network of Military Police, medical personnel, social workers and interfaith chaplains.
- Full access to civilian community programs, agencies and shelters for members and dependants.
Department of National Defence, Canada
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