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BACKGROUND The earliest days of the COVID-19 pandemic in Canada were marked by a significant surge in COVID cases and COVID-related deaths among residents of long-term care facilities (LTCF; also known as centres d’hébergement et de soins de longue durée [CHSLD] in Québec). As part of Canada’s response to the COVID-19 pandemic, Canadian Armed Forces (CAF) personnel were mobilized for an initial emergency domestic deployment to the hardest-hit LTCFs (Operation LASER LTCF) to support the remaining civilian staff in ensuring the continued delivery of care to residents. Akin to what was observed following past CAF international humanitarian missions, there was an expected increased risk of exposure to multiple stressors that may be psychologically traumatic and potentially morally injurious in nature (i.e., related to important values; e.g., witnessing human suffering). Emerging data from healthcare workers exposed to the unprecedented medical challenges and dilemmas of the early pandemic stages was also pointing to such experiences being associated with increased risk of adverse mental health outcomes. OBJECTIVE To identify and quantify the individual-, group-, and organizational-level risk and resilience factors associated with moral distress, moral injury and traditional mental health and well-being outcomes of Operation (Op) LASER LTCF CAF personnel. METHODS A multimethod research initiative was conducted, consisting of two primary data collection studies (a quantitative survey and qualitative interviews). The quantitative arm was a complete enumeration survey with online self-report questionnaires administered at three timepoints (3, 6, and 12 months post-deployment). The qualitative arm consisted of individual interviews conducted virtually, with a focus on understanding the nuanced lived experiences of individuals taking part in the Op LASER LTCF deployment. RESULTS CAF personnel deployed to Op LASER LTCF (n = 2,595) were invited to participate in the study. Overall, 1,088, 582, and 497 individuals responded to the survey at Time 1 (3 months), Time 2 (6 months), and Time 3 (12 months) post-deployment, providing a participation rate of 41.9%, 22.4%, and 19.2% for Time 1, Time 2, and Time 3, respectively. Data for all three timepoints was obtained from 212 participants (representing 19.5% of all Time 1 responses). The target sample size for qualitative interviews was set at approximately 50, with considerations for resourcing and data saturation. Interest in participating in qualitative interviews surpassed expectations with over 200 individuals expressing interest; this allowed for purposive sampling across key characteristics, including gender, rank, Op LASER LTCF role, and province. In total, 53 interviews were conducted. CONCLUSIONS The data generated by this research is being used to inform and better understand the well-being and mental health of Op LASER LTCF personnel over time, identify general and Op LASER LTCF-specific risk and protective factors, provide necessary supports to the military personnel who served in this mission, and to inform preparation and interventions for future missions, especially those more of a domestic and humanitarian nature.

The scientific literature on workplace interventions that target individual-level determinants of mental health for primary or secondary prevention is mixed, with many studies failing to show stati...

BackgroundDifferences in healthcare delivery systems and pathways to mental healthcare for Canadian Armed Forces (CAF) members and Veterans may contribute to variations in mental health services use (MHSU) and the factors associated with it. We: (1) estimated the prevalence of past 12-month MHSU (≥1 visit with a medical or mental health professional); and (2) identified sociodemographic, military-, trauma-, and health-related variables associated with MHSU among CAF members and Veterans.MethodsThe current study used data from the 2018 CAF Members and Veterans Mental Health Follow-Up Survey (CAFVMHS). Model variables were selected a priori, and their respective associations with MHSU were estimated among (1) CAF members and (2) Veterans using separate multivariable logistic regression models.ResultsSimilar proportions of CAF members and Veterans reported past 12-month MHSU (26.9 vs. 27.5%, respectively). For both CAF members and Veterans, meeting criteria for at least one past 12-month MH disorder was associated with past 12-month MHSU [adjusted odds ratio (AOR) = 7.80, 95% confidence interval (CI) = 7.18–8.46; and AOR = 11.82, 95% CI: 11.07–12.61, respectively). Past-year suicide ideation, a history of sexual trauma, and endorsement of adverse childhood experiences were also significantly associated with MHSU among CAF members and Veterans.SignificanceSimilar to previous research, meeting screening criteria for a past 12-month MH disorder was strongly associated with MHSU among both samples. This study extends our existing knowledge about factors associated with MHSU among CAF members and Veterans, and offers direction for future research to increase MHSU.

The relationship between adverse experiences and later development has been explored by many researchers, leading to the conceptualization of resilience as a factor explaining the normal or optimal development of some individuals exposed to adversity. Today many different interventions exist aiming to improve the ability of individuals to respond to adversity. In this narrative literature review, we evaluate the literature surrounding resilience and resilience training, discussing the quality of the evidence supporting resilience training, theoretical and practical differences between types of training, and the impact of resilience and psychological training on outcome measures across a variety of settings. The results of our review show that the quality of the literature is mixed, resilience training is not well differentiated from other forms of training, and that the impact of psychological training on later functioning depends heavily on the type of outcome measured and the setting of the training. Further research must be conducted prior to the implementation of resilience training programs in order to assure their efficacy and effectiveness in proposed contexts.

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.

The aim of this study was to assess the validity of a 14-item mental health self-efficacy scale developed to assess the effectiveness of the Road to Mental Readiness (R2MR) – a program aimed at improving the well-being and mental health of Canadian Armed Forces (CAF) personnel. The validity of the scale was assessed through an analysis of data collected as part of a pilot study and a larger group randomized control trial (GRCT) on the effectiveness of R2MR administered to CAF noncommissioned member recruits during basic training. Using data collected for the pilot study (N = 276), an initial review of items indicated a need to eliminate two redundant items and two items that were weakly correlated with other scale items. A parallel analysis and exploratory factor analysis (EFA) conducted on the resulting 10-item scale pointed to a one-factor model with all items loading satisfactorily. Using data from the GRCT (N = 1962), a confirmatory factor analysis (CFA) was conducted to further assess the revised scale. This CFA suggested good model fit (Root Mean Square Error of Approximation of .07 and Standardized Root Mean Square Residual of .06). The revised scale had an alpha of .88, was very strongly correlated with the full scale (r = .97, p < .001), and significantly predicted perceived control and self-efficacy regarding accessing mental health care and intention to access care.

Objective: Potentially morally injurious experiences (PMIE) (events that transgress an individual’s subjective moral standards) have been associated with psychologically distressing moral emotions such as shame and guilt. Military leaders and clinicians have feared that those with PMIEs may be less likely to seek help due to the withdrawing nature of shame/guilt; however, to date, help-seeking patterns of military personnel with PMIEs has not been explored. Our objective is to address this research gap. Method: Data from a nationally-representative mental health survey of active Canadian military personnel were analysed. To assess the association between exposure to three PMIEs and past-year help-seeking across different provider categories (i.e. professionals, para-professionals (those delegated with mental health advisory tasks but are not licenced to practice as medical professionals), non-professionals), a series of logistic regressions were conducted, controlling for exposure to other deployment and non-deployment-related psychological trauma, psychiatric variables, military factors, and sociodemographic variables. Analytical data frame included only personnel with a history of Afghanistan deployment (N = 4854). Results: Deployed members exposed to PMIEs were more likely to seek help from their family doctor/general practitioner (OR = 1.72; 95%CI = 1.25–2.36), paraprofessionals (OR = 1.72; 95%CI = 1.25–2.36), and non-professionals (OR = 1.44; 95%CI = 1.06–1.95) in comparison to members not exposed to PMIEs. Those exposed to PMIEs were also more likely to seek professional care from the civilian health care system (OR = 1.94; 95%CI = 1.27–2.96). Conclusion: Contrary to long-held, but untested, assumptions regarding the impact of PMIEs on help-seeking, we found those with PMIEs are more likely to seek help from gatekeeper professionals (i.e. general practitioners), para-professionals, and non-professionals rather than specialized mental health professionals (e.g. psychologists). Increased utilization of civilian professionals raises concerns that active military members may be avoiding military health services. Clinically, this highlights the need to increase awareness of moral injury to ensure that actively serving military members are provided with appropriate advice and treatment.

ObjectiveThe primary objective was to explore differences in perceived need for care (PNC), mental health services use (MHSU) and perceived sufficiency of care (PSC) between Canadian Armed Forces Regular Force (RegF) and Reserve Force (ResF) personnel with an objective need for mental health services.DesignData came from the 2013 Canadian Armed Forces Mental Health Survey, a cross-sectional survey of serving personnel (n=72 629). Analyses were among those with an Afghanistan deployment and an identified mental disorder (population n=6160; sampled n=868). Logistic regression compared PNC, MHSU and PSC between RegF and ResF. Covariate-adjusted marginal prevalence difference estimates were computed.Primary outcome measureThe primary outcomes were PNC, MHSU and PSC. Each had three service categories, including an aggregate ‘any’ of the three: (1) information about problems, treatments or services; (2) medication and (3) counselling.ResultsResF had an 10.5% (95% CI −16.7% to −4.4%) lower perceived need for medication services but PNC differences were not significant for other service categories. MHSU tended to be lower for ResF; 9.1% (95%CI −15.5% to −2.6%) lower for medication, 5.4% (95% CI −11.5% to 0.7%) lower, with marginal significance, for counselling and 11.3% (95% CI −17.3% to −5.2%) lower for the ‘any’ service category. Additionally, ResF tended to have a lower fully met need for care; 13.4% (95% CI −22.1% to −4.6%) lower for information, 15.3% (95% CI −22.9% to −7.6%) lower for counselling and 14.6% (95% CI −22.4% to −6.8%) lower for the ‘any’ service category.ConclusionsOur findings suggest MHSU and PSC differences between Canadian RegF and ResF personnel that are not fully accounted for by PNC differences. Deficits in ResF members’ perceptions of the sufficiency of information services and counselling services suggest perceived, or experienced, barriers to care beyond any PNC barriers. Additional research assessing barriers to mental healthcare is warranted.

We examined the psychometric properties of a quality of life measure, the WHOQOL-BREF, in male treatment-seeking veterans. A sample of 131 veterans at an outpatient clinic completed a mail-in survey that included the WHOQOL-BREF as well as measures of posttraumatic stress, depression, anxiety symptoms, and functional health status. The WHOQOL-BREF showed evidence of good internal consistency and strong test-retest reliability. In addition, analysis of results demonstrated evidence of construct, convergent, and discriminant validity. The results suggest that the WHOQOL-BREF is a reliable and valid measure that can be used in the planning of psychological services provided to veterans with mental health problems.

Identifying the factors associated with mental health services use (MHSU) is an important step in developing strategies to improve services access and delivery. The aims of the present study were t...

Background: In the context of the Canadian mission in Afghanistan, substantial media attention has been placed on mental health and lack of access to treatment among Canadian Forces personnel. We compared trends in the prevalence of suicidal behaviour and the use of mental health services between Canadian military personnel and the general population from 2002 to 2012/13. Methods: We obtained data for respondents aged 18–60 years who participated in 4 nationally representative surveys by Statistics Canada designed to permit comparisons between populations and trends over time. Surveys of the general population were conducted in 2002 ( n = 25 643) and 2012 ( n = 15 981); those of military personnel were conducted in 2002 ( n = 5153) and 2013 ( n = 6700). We assessed the lifetime and past-year prevalence of suicidal ideation, plans and attempts, as well as use of mental health services. Results: In 2012/13, but not in 2002, military personnel had significantly higher odds of both lifetime and past-year suicidal ideation than the civilian population (lifetime: adjusted odds ratio [OR] 1.32, 95% confidence interval [CI] 1.17–1.50; past year: adjusted OR 1.34, 95% CI 1.09–1.66). The same was true for suicidal plans (lifetime: adjusted OR 1.64, 95% CI 1.35–1.99; past year: adjusted OR 1.66, 95% CI 1.18–2.33). Among respondents who reported past-year suicidal ideation, those in the military had a significantly higher past-year utilization rate of mental health services than those in the civilian population in both 2002 (adjusted OR 2.02, 95% CI 1.31–3.13) and 2012/13 (adjusted OR 3.14, 95% CI 1.86–5.28). Interpretation: Canadian Forces personnel had a higher prevalence of suicidal ideation and plans in 2012/13 and a higher use of mental health services in 2002 and 2012/13 than the civilian population.

Objectives: Failure to perceive need for care (PNC) is the leading barrier to accessing mental health care. After accessing care, many individuals perceive that their needs were unmet or only partially met, an additional problem related to perceived sufficiency of care (PSC). The Canadian Armed Forces (CAF) invested heavily in workplace mental health in the past decade to improve PNC/PSC; yet, the impact of these investments remains unknown. To assess the impact of these investments, this study 1) captures changes in PNC/PSC over the past decade in the CAF and 2) compares current PNC/PSC between the CAF and civilians. Methods: Data were drawn from the 2013 and 2002 CAF surveys and the 2012 civilian mental health survey (total N = ∼40 000), conducted by Statistics Canada using similar methodology. Exclusions were applied to the civilian sample to make them comparable to the military sample. Prevalence rates for No need, Need met, Need partially met, and Need unmet categories across service types (Information, Medication, Counselling and therapy, Any services) were calculated and compared between 1) the 2 CAF surveys and 2) the 2013 CAF and 2012 civilian surveys after sample matching. Results: Reports of Any need and Need met were higher in the CAF in 2013 than in 2002 by approximately 6% to 8% and 2% to 8%, respectively, and higher in the CAF than in civilians by 3% to 10% and 2% to 8%, respectively. Conclusions: These results suggest that investments in workplace mental health, such as those implemented in the CAF, can lead to improvements in recognizing the need for care (PNC) and subsequently getting those needs met (PSC).

ObjectiveThe primary objective was to explore differences in mental health problems (MHP) between serving Canadian Armed Forces (CAF) components (Regular Force (RegF); Reserve Force (ResF)) with an Afghanistan deployment and to assess the contribution of both component and deployment experiences to MHP using covariate-adjusted prevalence difference estimates. Additionally, mental health services use (MHSU) was descriptively assessed among those with a mental disorder.DesignData came from the 2013 CAF Mental Health Survey, a cross-sectional survey of serving personnel (n=72 629). Analyses were limited to those with an Afghanistan deployment (population n=35 311; sampled n=4854). Logistic regression compared MHP between RegF and ResF members. Covariate-adjusted prevalence differences were computed.Primary outcome measureThe primary outcomes were MHP, past-year mental disorders, identified using the WHO’s Composite International Diagnostic Interview, and past-year suicide ideation.ResultsResF personnel were less likely to be identified with a past-year anxiety disorder (adjusted OR (AOR)=0.72 (95% CI 0.58 to 0.90)), specifically both generalised anxiety disorder and panic disorder, but more likely to be identified with a past-year alcohol abuse disorder (AOR=1.63 (95% CI 1.04 to 2.58)). The magnitude of the covariate-adjusted disorder prevalence differences for component was highest for the any anxiety disorder outcome, 2.8% (95% CI 1.0 to 4.6); lower for ResF. All but one deployment-related experience variable had some association with MHP. The ‘ever felt responsible for the death of a Canadian or ally personnel’ experience had the strongest association with MHP; its estimated covariate-adjusted disorder prevalence difference was highest for the any (of the six measured) mental disorder outcome (11.2% (95% CI 6.6 to 15.9)). Additionally, ResF reported less past-year MHSU and more past-year civilian MHSU.ConclusionsPast-year MHP differences were identified between components. Our findings suggest that although deployment-related experiences were highly associated with MHP, these only partially accounted for MHP differences between components. Additional research is needed to further investigate MHSU differences between components.

Background: Mental disorders constitute a significant public health problem worldwide. Ensuring that those who need mental health services access them in an appropriate and timely manner is thus an important public health priority. We used data from 4 cross-sectional, nationally representative population health surveys that employed nearly identical methods to compare MHSU trends in the Canadian military versus comparable civilians. Method: The surveys were all conducted by Statistics Canada, approximately a decade apart (Military-2002, Military-2013, Civilian-2002, and Civilian-2012). The sample size for the pooled data across the surveys was 35,984. Comparisons across the 4 surveys were adjusted for differences in need in the 2 populations at the 2 time points. Results: Our findings suggested that first, in the Canadian military, there was a clear and consistent pattern of improvement (i.e., increase) in MHSU over the past decade across a variety of provider types. The magnitudes of the changes were large, representing an absolute increase of 7.15% in those seeking any professional care, corresponding to an 84% relative increase. Second, in comparable Canadian civilians, MHSU remained either unchanged or increased only slightly. Third, the increases in MHSU over time were consistently greater in the military than in the comparable civilian sample. Conclusions: Our findings point to advantages with respect to MHSU of the military mental health system over the civilian system in Canada; these advantages have widened substantially over time. These findings speak strongly to the potential impact of analogous changes in other health systems, both military and civilian.

Background A link between moral injury (i.e., the psychological distress caused by perceived moral transgressions) and adverse mental health outcomes (AMHO) has been recently proposed. However, the prevalence of exposure to morally injurious events and the associated risk of experiencing AMHO remains understudied. Method The impact of exposure to potentially morally injurious experiences (PMIEs) was explored in relation to past-year PTSD and MDD, using the 2013 Canadian Armed Forces Mental Health Survey dataset of Afghanistan mission deployed regular force and reserve personnel. A series of logistic regressions were conducted, controlling for relevant sociodemographic, military, deployment, and trauma-related variables. Results Over half of the deployed personnel endorsed at least one PMIE. Several demographic and military variables were associated with exposure to PMIEs. Those exposed to PMIEs demonstrated a greater likelihood of having past-year PTSD and MDD; feeling responsible for the death of Canadian or ally personnel demonstrated the strongest association with PTSD and MDD. Mental health training was not a moderator for PMIE exposure and AMHO. Conclusions Exposure to PMIEs during deployments is common and represents an independent risk factor for past-year PTSD and MDD. Improved training that targets moral-ethical dilemmas and treatment interventions that address moral injury expressions is warranted.

BackgroundSome veterans, and especially those with mental disorders, have difficulty reintegrating into the civilian workforce.PurposeThe objectives of this study were to describe the scope of the existing literature on mental disorders and unemployment and to identify factors potentially associated with reintegration of workers with mental disorders into the workforce.Data SourcesThe following databases were searched from their respective inception dates: MEDLINE, EMBASE, Cumulative Index Nursing Allied Health (CINAHL), and PsycINFO.Study SelectionIn-scope studies had quantitative measures of employment and study populations with well-described mental disorders (eg, anxiety, depression, posttraumatic stress disorder, substance-use disorders).Data ExtractionA systematic and comprehensive search of the relevant published literature up to July 2009 was conducted that identified a total of 5,195 articles. From that list, 81 in-scope studies were identified. An update to July 2012 identified 1,267 new articles, resulting in an additional 16 in-scope articles.Data SynthesisThree major categories emerged from the in-scope articles: return to work, supported employment, and reintegration. The literature on return to work and supported employment is well summarized by existing reviews. The reintegration literature included 32 in-scope articles; only 10 of these were conducted in populations of veterans.LimitationsStudies of reintegration to work were not similar enough to synthesize, and it was inappropriate to pool results for this category of literature.ConclusionsComprehensive literature review found limited knowledge about how to integrate people with mental disorders into a new workplace after a prolonged absence (>1 year). Even more limited knowledge was found for veterans. The results informed the next steps for our research team to enhance successful reintegration of veterans with mental disorders into the civilian workplace.

Introduction. The mental health of Canadian Armed Forces (CAF) populations emerged as an important concern in the wake of difficult CAF deployments in the 1990s. This article is the first comprehensive summary of findings from subsequent surveys of mental health and well-being in CAF Veterans, undertaken to inform mental health service renewals by CAF Health Services and Veterans Affairs Canada (VAC). Methods. Epidemiological findings in journal publications and government reports were summarized from four cross-sectional national surveys: a survey of Veterans participating in VAC programs in 1999 and three surveys of health and well-being representative of whole populations of Veterans in 2003, 2010, and 2013. Results. Although most Veterans had good mental health, many had mental health problems that affected functioning, well-being, and service utilization. Recent Veterans had a higher prevalence of mental health problems than the general Canadian population, earlier-era Veterans, and possibly the serving population. There were associations between mental health conditions and difficult adjustment to civilian life, physical health, and multiple socio-demographic factors. Mental health problems were key drivers of disability. Comparisons with other studies were complicated by methodological, era, and cultural differences. Discussion. The survey findings support ongoing multifactorial approaches to optimizing mental health and well-being in CAF Veterans, including strong military-to-civilian transition support and access to effective mental and physical health services. Studies underway of transitioning members and families in the peri-release period of the military-to-civilian transition and longitudinal studies of mental health in Veterans will address important knowledge gaps. (Article in English) Introduction : La santé mentale de la population des Forces armées canadiennes est devenue une préoccupation importante à la suite des déploiements difficiles des années 1990. Ceci est le premier résumé compréhensif des sondages qui ont suivi sur la santé mentale et le bien-être des vétérans des Forces armées canadiennes tenus par le groupe des services de santé des FAC et des Anciens Combattants Canada. Méthodologie : Les résultats épidémiologiques publiés dans les revues scientifiques et les rapports gouvernementaux sont les résumés de quatre enquêtes nationales transversales: un sondage des vétérans participant dans les programmes des Anciens Combattants Canada en 1999 et trois sondages sur la santé et le bien-être des vétérans en 2003, 2010 et 2013. Résultats: La majorité des vétérans présentaient une bonne santé mentale, mais un certain nombre de vétérans avaient des problèmes de santé qui affectaient leur bien-être, leur fonctionnement et leur utilisation des services. Les vétérans des années plus récentes ont une prévalence plus élevée de problèmes de santé mentale que la population canadienne en générale, que des vétérans plus âgés et possiblement que la population militaire. Les résultats montrent une association entre la condition de la santé mentale et une transition à la vie civile difficile, la santé physique, et plusieurs autres facteurs sociodémographiques. Les problèmes de santé mentale sont directement liés aux incapacités. Une comparaison à d'autres enquêtes étudiées serait difficile pour des raisons de méthodologie, d'ère et de différences culturelles. Conclusion : Les constatations de l'enquête supportent une approche multifonctionnelle pour optimiser la santé mentale et le-bien-être des vétérans des FAC, y compris un appui de taille et un accès à des traitements efficaces lors de la période de transition de la vie militaire à la vie civile. Des études longitudinales sur la santé mentale des vétérans aborderaient les lacunes.

In the past 15 years in Canada, as in other nations, the mental health of veterans has emerged as a key concern for both government and the public. As mental health service enhancement unfolded, the need for wider population studies became apparent. This paper describes the renewal of services and key findings from national surveys of serving personnel and veterans.

Although mental disorders constitute a significant public health problem in military populations, little is known about whether military members seek mental health treatment in a timely manner.The objective of this study was to examine delays in making the initial treatment contact for various mental disorders in a military population.A cross-sectional analysis was conducted using data from the Canadian Community Health Survey-Canadian Forces Supplement.Participants (N = 8441) were assessed for mood and anxiety disorders, using the World Health Organization's Composite International Diagnostic Interview. Those meeting criteria for at least 1 disorder in their lifetime were included in the analyses.:The majority (82%-100%) of military members with a DSM-IV disorder eventually seek treatment. However, there are significant delays in seeking treatment. Median delays for major depressive disorder, generalized anxiety disorder, posttraumatic stress disorder, panic disorder, and social phobia are 3, 3, 7, 8, and 26 years, respectively. For deployment related posttraumatic stress disorder, longer delays are associated with being in an older age cohort, being male, not having comorbid panic disorder, and shorter military service duration. Across all disorders, longer delays are associated with being in an older age cohort, shorter military service duration, and earlier age of onset.Failure to initiate treatment in a timely manner is a major mental health service access issue in the military context. Interventions that aim to shorten treatment delays are needed and should target military members most at risk for delaying treatment.

Background: Mental disorders constitute a significant public health problem in active military populations. However, very little is known about patterns of mental health service use in these populations. Objectives: The primary objective of this study was to examine the patterns and predictors of mental health service use in active Canadian Force members. Additional objectives included identification of barriers to service use. Design: A cross-sectional analysis was conducted using data from the Canadian Community Health Survey-Canadian Forces Supplement. Subjects and Measures: Participants were assessed for mood, anxiety, and substance use disorders using the World Health Organization's Composite International Diagnostic Interview. Those who met criteria for at least 1 disorder in the past year (n = 1220) were included in the analyses. Results: Of military members with a 12-month diagnosis, 42.6% used services in the past year. Predictors of service use included mental health indicators, gender, marital status, and military rank. Of military members who failed to use services, only a small percentage (3.5–16.0%) acknowledged a need for services. These members perceived a number of barriers to services, foremost among which was lack of trust in military health, administrative, and social services. Conclusions: Despite recent efforts to de-stigmatize mental health problems and treatments, unmet need for mental health services remains a significant problem in active militaries. Our findings indicate that military institutions should continue public education campaigns to de-stigmatize mental health problems and should make necessary changes in health delivery systems to gain the trust of military members.

Although pain is a significant clinical problem in individuals suffering from post-traumatic stress disorder (PTSD), reliable and valid measures of pain for this population are lacking. The goal of this study was to validate the Brief Pain Inventory (BPI) in French-speaking veterans suffering from PTSD (n=130). We administered the BPI, as well as measures of PTSD, health status, quality of life, and social desirability, to veterans being assessed or treated for PTSD at a Veterans Affairs Canada clinic. The BPI showed strong internal consistency, as evidenced by Cronbach's alphas of 0.90 and 0.92 for the severity and interference subscales, respectively. Similar to previous findings, a two-factor structure (pain severity and pain interference) was found using an exploratory factor analysis. The two factors explained nearly 73% of the variance of the instrument. The BPI was also strongly correlated with health status and quality of life in the physical domain. In this veteran sample, nearly 87% of the veterans suffered from significant current pain. Veterans in our sample reported rates of pain severity that were similar to or higher than most of those reported by cancer patients and others with significant physical disability/illness. Overall, the French version of the BPI is a reliable, valid measure of pain in PTSD-suffering populations. Pain is a major issue in veterans with PTSD, and should be screened for with instruments such as the BPI.

The goal of this study was to examine whether panic mediates the relationship between fear, helplessness, and horror (PTSD criterion A2) and dissociation at the time of trauma. The study sample included 709 police officers and 317 peer-nominated civilians who had been exposed to a variety of critical incidents. Participants filled out measures of critical incident exposure, PTSD criterion A2, panic, and dissociation. Results indicate that together, physical and cognitive symptoms of panic completely mediate the relationship between criterion A2 and dissociation in civilians, and partially mediate that relationship in police. These results provide support for the idea that panic mediates the relationship between fear, helplessness, and horror (criterion A2) and dissociation at the time of trauma. The results also raise the possibility, however, that the mediational role of panic may be further moderated by additional variables.

Objective: To estimate the lifetime prevalence of trauma exposure and posttraumatic stress disorder (PTSD) among a representative, active military sample, and to identify demographic and military variables that modulate rates of trauma exposure as well as PTSD rates and duration. Method: A cross-sectional weighted sample of 5155 regular members and 3957 reservists ( n = 8441) of the Canadian Armed Forces (CAF) was face-to-face interviewed using a lay-administered structured interview that generates Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, psychiatric diagnoses. Results: Within this sample, 85.6% reported 1 or more trauma exposure, with a median number of 3 or more exposures. Compared with males, females were less likely ( P < 0.05) to be exposed to warlike trauma (adjusted odds ratio [AOR] 0.40), disasters (AOR 0.43), assaultive violence (AOR 0.52), and witnessing trauma (AOR 0.75). However, they were more likely to report sexual assault (AOR 7.36). The lifetime prevalence of PTSD was 6.6% and the conditional rate was 7.7%. Both lifetime and conditional PTSD rates were higher among female soldiers, but lower among the reserve forces, both male and female. Finally, the median duration of PTSD was negatively influenced by younger age of onset, but not influenced by whether the event occurred during deployment. Conclusions: Active members of the CAF report a high degree of trauma exposure but a moderate rate of lifetime PTSD.

Although recent studies suggest that posttraumatic stress disorder (PTSD) symptoms and pain may be related, the possible mediational role of depression in this relationship has not been examined. This study sought to examine this question in a sample of 130 male veterans seeking assessment or treatment for deployment-related PTSD. Results suggest that PTSD and pain are moderately related (r = .29) but that this relationship is fully mediated by depression. Our findings have important clinical implications: Treatment of PTSD and pain in veteran populations should include careful assessment and regular monitoring of depression.

This study validates a survey for community violence exposure, provides details of exposure in young adults, and determines psychological effects. 518 university students completed the Survey of Exposure to Community Violence (SECV) and questionnaires regarding trauma and socioemotional outcomes. Participants were divided into high, moderate, or low witnessing and victimization groups. Results showed SECV validity, with violent trauma more frequently reported in moderate/high victimization groups. 93.2% of respondents reported witnessing and 76.4% being victimized by violence. The most frequent events involved being hit, threatened, or seeing a gun/knife used as a weapon. The most frequent perpetrators were non-family members, except for domestic violence. The most frequent location was near home, although school was noted for peer victimization. High-exposure groups reported greater depression, aggression, interpersonal problems, and post-traumatic stress disorder symptoms. This replicates and extends previous findings on the prevalence of violence exposure and its negative effects in today's young adults.

Despite the availability of efficacious treatments, few individuals with a new-onset mental disorder access treatment in a timely manner. While barriers to mental health treatment have been studied among prevalent cases, few studies have focused specifically on incident cases. The purpose of the current study was to examine the prevalence and correlates of perceived barriers to mental health treatment among incident cases. Data came from the Canadian Community Health Survey, cycle 1.2 (CCHS 1.2), which represents a nationally representative sample of 36,984 Canadians. We used descriptive analyses to estimate the prevalence of different types of perceived barriers to treatment and logistic regression analyses to estimate the association between potential correlates and the probability of endorsing each type of barrier. The most frequently reported type of barrier was acceptability. Coping efficacy and psychological well-being were negatively associated with the likelihood of reporting accessibility barriers. Education was negatively associated with reporting acceptability barriers but positively associated with reporting availability barriers. Among individuals with a recent disorder onset, acceptability barriers are the most frequently reported. Perceived accessibility barriers may be open to influence from current clinical functioning and current perceptions of internal coping resources. These findings contribute to an important discussion about the complexity of pathways to care and point to the need for comprehensive approaches to overcoming barriers to care.

Research has shown a relationship between community violence exposure and heightened aggression in young adults (Scarpa, in press). This study tests the role of psychophysiological functioning in mediating this relationship. Fifty-four university students (mean age = 20.25) were selected from a screening sample (N= 476) based upon high- and low-violence exposure. Salivary cortisol, heart rate (HR), and heart rate variability (HRV) were obtained before and after two stressor tasks. Aggression was reported before the tasks. Aggression was significantly correlated with reduced baseline HR, increased baseline HRV, and increased poststressor cortisol. However, exposed groups did not differ psychophysiologically, suggesting that psychophysiological functioning does not serve as a mediator. Instead, violence exposure and psychophysiological functioning have independenteffects on aggressive behavior. © 2000 John Wiley & Sons, Inc.

Although researchers have examined the 6–12 month period after which service members return home from an overseas deployment, their studies often focus on members’ mental and physical health (e.g., whether or not the member is displaying symptoms of post-traumatic stress disorder or a minor traumatic brain injury). In this chapter, we take a different approach to the post-deployment reintegration period, focusing instead on the positive and negative experiences and perceptions associated with three domains that returning service members have told us are important: reintegrating back into a garrison work environment, reintegrating back into one’s family, and integrating the deployment experiences into one’s personal identity. In addition, the chapter describes the development and validation of the Post-Deployment Reintegration Scale (PDRS), which we created to support our research, as well as the construction and use of norms for the PDRS. Finally, we focus on single service members, looking at the degree to which marital status and whether or not someone has dependents influence the post-deployment reintegration experiences and perceptions captured by the PDRS.

Since its inclusion in the Diagnostic and Statistical Manual of Mental Disorders, there has been skepticism over the validity of delayed-onset posttraumatic stress disorder (PTSD). Paucity of research on the correlates and the clinical consequences of delayed-onset PTSD have historically added to this skepticism. The objective of this study was to address an important gap in the literature by examining the prevalence, the correlates, and the clinical consequences of delayed-onset PTSD using data from a large epidemiological survey. Data were drawn from the Canadian Community Health Survey-Canadian Forces Supplement (N = 8,441), a cross-sectional epidemiological survey of mental health in the Canadian Forces. Logistic regressions were used to identify correlates of delayed onset. Cox regressions were used to examine the impact of delayed onset on symptom duration. The prevalence of delayed-onset PTSD in this Canadian population was less than 1%. Delayed-onset cases accounted for 8.5% of all PTSD cases. Experiencing trauma in early childhood, experiencing a repeated trauma, and serving in the land troops were all associated with greater likelihood of developing delayed-onset PTSD. Delayed onset, after controlling for important sociodemographic, military, and clinical variables, was associated with greater symptom duration. The phenomenon of delayed-onset PTSD, albeit uncommon, does exist. Certain trauma characteristics may increase the risk for developing delayed-onset PTSD. Delayed onset may be associated with more chronic forms of this disorder.

Objective: This study examined associations between sociodemographic, military, and psychiatric need variables and past-year mental health service use among active Canadian military members. The likelihood and intensity of services were examined across two provider types— mental health providers and medical providers. Methods: Data were drawn from the first epidemiological survey of mental health in the Canadian Forces, conducted by Statistics Canada in 2002. Survey instruments included the Composite International Diagnostic Interview, which was used to assess mental health and service use. Results: Of the 8,441 military members who participated in the survey, 14.5% (N=1,220) met criteria for having a mental disorder in the past year. However, of the 8,441 only 9.1% (N=767) contacted a mental health provider in the past year for mental health problems; even fewer (N=539, 6.4%) contacted a medical provider. Across the two provider types, the majority of those seeing a provider reported five or fewer mental health visits in the past year. In univariate and multivariate analyses across the two provider types, psychiatric need variables were consistently associated with both greater service use likelihood and intensity. In multivariate analyses, lower military rank was consistently associated with both greater service use likelihood and intensity. Conclusions: Of the entire military sample, only a small percentage used mental health services. The observed associations between military and psychiatric need variables and mental health service use in this study should be used by military health care providers and administrators to increase mental health service use among those most at risk of not using services. (Psychiatric Services 60:358–366, 2009)

Objective: The goal of this study was to identify rates, characteristics, and predictors of mental health treatment seeking by military members with posttraumatic stress disorder (PTSD). Method: Our sample was drawn from the 2002 Canadian Community Health Survey–Canadian Forces Supplement (CCHS-CF) dataset. The CCHS-CF is the first epidemiologic survey of PTSD and other mental health conditions in the Canadian military and includes 8441 nationally representative Canadian Forces (CF) members. Of those, 549 who met the criteria for lifetime PTSD were included in our analyses. To identify treatment rates and characteristics, we examined frequency of treatment contact by professional and facility type. To identify predictors of treatment seeking, we conducted a binary logistic regression with lifetime treatment seeking as the outcome variable. Results: About two-thirds of those with PTSD consulted with a professional regarding mental health problems. The most frequently consulted professionals, during both the last year and lifetime, included social workers and counsellors, medical doctors and general practitioners, and psychiatrists. Consultations during the last year most often took place in a CF facility. Treatment seeking was predicted by cumulative lifetime trauma exposure, index traumatic event type, PTSD symptom interference, and comorbid major depressive disorder. Those with comorbid depression were 3.75 times more likely to have sought treatment than those without. Conclusions: Although a significant portion of military members with PTSD sought mental health treatment, 1 in 3 never did. Trauma-related and illness and (or) need factors predicted treatment seeking. Of all the predictors of treatment seeking, comorbid depression most increased the likelihood of seeking treatment.

This study aimed to identify predictors of treatment seeking in military members with posttraumatic stress disorder (PTSD) using data from the 2002 Canadian Community Health Survey-Canadian Forces Supplement (Statistics Canada, 2003). To identify predictors, two complementary analyses (binary logistic regression and recursive partitioning of independent variables) were conducted in military members with PTSD (N = 509). Results indicate that trauma-related (index traumatic event type, cumulative trauma exposure), demographic (marital status), enabling (income), and need (PTSD interference) factors predict treatment seeking in military members with PTSD, and that treatment seekers and nontreatment seekers are both comprised of distinct subgroups. Interventions aimed at increasing treatment-seeking behaviors should be tailored to the specific needs of various subgroups of nontreatment seekers.

Objectives: This study had a twofold purpose: to validate the French-Canadian version of a measure of deployment risk and resilience factors and to examine the relation between deployment risk and resilience factors and postdeployment functioning. Method: Canadian veterans at an outpatient clinic (n = 131) completed a mail-in survey that included a measure on deployment risk and resilience factors, the Deployment Risk and Resilience Inventory (DRRI) (1), as well as measures on psychological and physical health. Results: Internal consistency and test-retest reliability coefficients for the DRRI scales were very good. As expected, DRRI risk factors were negatively associated with psychological and physical functioning, and DRRI resilience factors were positively associated with psychological and physical functioning. Low- as well as high-magnitude deployment risk factors were associated with functioning. Conclusions: The French-Canadian version of the DRRI is a reliable and valid measure of deployment risk and resilience factors. Deployment risk and resilience factors are associated with a host of problems in physical and psychological functioning for veterans. (Can J Psychiatry 2006;51:755-763) Information on funding and support and author affiliations appears at the end of the article. Clinical Implications * Risk and resilience factors operating during and soon after a deployment can have an impact on physical and psychological health. * The use of the reliable and valid DRRI is indicated for the assessment of deployment risk and resilience factors. * Low- as well as high-impact deployment risk factors should be assessed. Study Limitations * The small, male sample limits generalizability. * Cross-sectional data cannot imply causality. * Additional risk factors specific to peacekeeping need to be identified and assessed in future studies. Key Words: posttraumatic stress disorder, deployment, risk factor Abbreviations used in this article BAI Beck Anxiety Inventory BDI Beck Depression Inventory DRRI Deployment Risk and Resilience Inventory MC Marlowe-Crowne MC-Form C Form C of the Marlowe-Crowne Social Desirability Scale PCL-S PTSD Symptom Checklist PTSD posttraumatic stress disorder SD standard deviation SF 12 Short Form Health Survey Over the past 5 decades, Canadian military troops have been deployed to numerous operational missions. Recent deployments have included such conflict-ridden places as Croatia, Bosnia-Herzegovina, Rwanda, and Afghanistan. In the course of operational missions, military personnel are routinely exposed to deployment-related experiences that are stressful or potentially traumatic. There is growing evidence that objective and subjective aspects of various deployment experiences can have a long-term negative impact on physical and psychological functioning (2). Among the most studied high-magnitude objective deployment risk factors, combat exposure is associated with numerous psychological problems, including PTSD (3), depression (4), and substance abuse (5), as well as physical problems such as pain (6). Although low-magnitude factors such as deployed soldiers' concerns about family and relationship disruptions have not traditionally received much attention in the field, recent studies (2,7) suggest that they may also have a negative impact on mental health, especially for women. Beyond objective aspects of deployment experiences, there is also considerable evidence that subjective aspects of deployment experiences, most notably perceived threat, are associated with PTSD symptom severity (8). Finally, important experiences that occur before and soon after deployment are also associated with postdeployment functioning. Among predeployment risk factors, early childhood family environment (9) and exposure to stressful events (9) are both associated with negative mental health outcomes. …

This study examined whether peritraumatic dissociation serves to protect trauma-exposed individuals from experiencing high levels of peritraumatic distress or is an epiphenomenon of high levels of peritraumatic distress. The sample was comprised of 709 police officers and 317 peer-nominated civilians exposed to a variety of critical incidents. Participants filled out measures of trauma exposure, traumatic stress, peritraumatic distress, and peritraumatic dissociation. There was an overall moderate-to-strong linear relationship between peritraumatic distress and dissociation. Among those with high levels of dissociation, very few reported low levels of distress. Among those with high levels of distress, a significant number--but not all--reported high levels of dissociation. Our results do not provide support for the idea that dissociation protects individuals from experiencing high levels of distress at the time of the trauma but rather suggest that dissociation is an epiphenomenon of high levels of distress observed in a subset of individuals.

Background In this chart review, we attempted to evaluate the benefits of adding aripiprazole in veterans with military-related PTSD and comorbid depression, who had been minimally or partially responsive to their existing medications. Methods A retrospective chart review of patients who received an open-label, flexible-dose, 12- week course of adjunctive aripiprazole was conducted in 27 military veterans meeting DSM-IV criteria for PTSD and comorbid major depression. Concomitant psychiatric medications continued unchanged, except for other antipsychotics which were discontinued prior to initiating aripiprazole. The primary outcome variable was a change from baseline in the PTSD checklist-military version (PCL-M) and the Beck Depression Inventory (BDI-II). Results PTSD severity (Total PCL scores) decreased from 56.11 at baseline to 46.85 at 12-weeks (p < 0.0001 from Wilcoxon signed rank test) and the depression severity decreased from 30.44 at baseline to 20.67 at 12-weeks (p < 0.0001 from Wilcoxon signed rank test). Thirty seven percent (10/27) were considered responders, as defined by a decrease in total PCL scores of at least 20 percent and 19% (5/27) were considered as responders as defined by a decrease in total BDI score of at least 50%. Conclusions The addition of aripiprazole contributed to a reduction in both PTSD and depression symptomatology in a population that has traditionally demonstrated poor pharmacological response. Further investigations, including double-blind, placebo-controlled studies, are essential to confirm and further demonstrate the benefit of aripiprazole augmentation in the treatment of military related PTSD.