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Abstract 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.

Objectives: The literature presents complex inter-relationships among individual-factors and organisational-factors and barriers to seeking mental health support after deployment. This study aims to quantify longitudinal associations between such factors and barriers to mental health support., Design: A longitudinal online survey of Canadian Armed Forces (CAF) personnel collected data at 3 months post-deployment (T1), 6 months post-deployment (T2) and 1 year post-deployment (T3)., Setting: In 2020, as part of Canada's response to the COVID-19 pandemic, 2595 CAF personnel deployed on Operation LASER to support civilian long-term care facilities in Québec and Ontario., Participants: All Operation LASER personnel were invited to participate: 1088, 582 and 497 responded at T1, T2 and T3, respectively. Most respondents were young, male, non-commissioned members., Main Outcome Measures: Barriers to mental health support were measured using 25 self-reported items and grouped into theory-based factors, including eight factors exploring care-seeking capabilities, opportunities and motivations; and two factors exploring moral issues. Logistic regressions estimated the crude and adjusted associations of individual and organisational characteristics (T1) with barriers (T2 and T3)., Results: When adjusting for sex, military rank and mental health status, increased meaningfulness of deployment was associated with lower probability of endorsing barriers related to conflicts with career goals and moral discomfort in accessing support at T2. Higher scores in trust in leadership were associated with lower probability of endorsing four barriers at T2, and five barriers at T3., Conclusions: We identified several modifiable organisational-level characteristics that may help reduce perceived barriers to mental health support in military and other high-risk occupational populations. Results suggest that promoting individuals' sense of purpose, instilling trust in leadership and promoting relatedness among team members may improve perceptions of access to mental health supports in the months following a domestic deployment or comparable occupational exposure., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Moral injury is a relatively new, but increasingly studied, construct in the field of mental health, particularly in relation to current and ex-serving military personnel. Moral injury refers to the enduring psychosocial, spiritual or ethical harms that can result from exposure to high-stakes events that strongly clash with one's moral beliefs. There is a pressing need for further research to advance understanding of the nature of moral injury; its relationship to mental disorders such as posttraumatic stress disorder and depression; triggering events and underpinning mechanisms; and prevalence, prevention and treatment. In the meantime, military leaders have an immediate need for guidance on how moral injury should be addressed and, where possible, prevented. Such guidance should be theoretically sound, evidence-informed and ethically responsible. Further, the implementation of any practice change based on the guidance should contribute to the advancement of science through robust evaluation. This paper draws together current research on moral injury, best-practice approaches in the adjacent field of psychological resilience, and principles of effective implementation and evaluation. This research is combined with the military and veteran mental health expertise of the authors to provide guidance on the design, implementation and evaluation of moral injury interventions in the military. The paper discusses relevant training in military ethical practice, as well as the key roles leaders have in creating cohesive teams and having frank discussions about the moral and ethical challenges that military personnel face., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The earliest days of the COVID-19 pandemic in Canada were marked by a significant surge in COVID-19 cases and COVID-19-related deaths among residents of long-term care facilities (LTCFs). 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 (ie, related to core values, eg, witnessing human suffering). Emerging data from health care workers exposed to the unprecedented medical challenges and dilemmas of the early pandemic stages also indicated that such experiences were associated with increased risk of adverse mental health outcomes., Objective: This study aims 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 LASER LTCF CAF personnel. This paper aimed to document the methodology, implementation procedures, and participation metrics., Methods: A multimethod research initiative was conducted consisting of 2 primary data collection studies (a quantitative survey and qualitative interviews). The quantitative arm was a complete enumeration survey with web-based, self-report questionnaires administered at 3 time points (3, 6, and 12 mo after deployment). The qualitative arm consisted of individual, web-based interviews with a focus on understanding the nuanced lived experiences of individuals participating in the Operation LASER LTCF deployment., Results: CAF personnel deployed to Operation LASER LTCF (N=2595) were invited to participate in the study. Data collection is now complete. Overall, of the 2595 deployed personnel, 1088 (41.93%), 582 (22.43%), and 497 (19.15%) responded to the survey at time point 1 (3 mo), time point 2 (6 mo), and time point 3 (12 mo) after deployment, respectively. The target sample size for the qualitative interviews was set at approximately 50 considering resourcing and data saturation. Interest in participating in qualitative interviews surpassed expectations, with >200 individuals expressing interest; this allowed for purposive sampling across key characteristics, including gender, rank, Operation LASER LTCF role, and province. In total, 53 interviews were conducted., Conclusions: The data generated through this research have the potential to inform and promote better understanding of the well-being and mental health of Operation LASER LTCF personnel over time; identify general and Operation LASER LTCF-specific risk and protective factors; provide necessary support to the military personnel who served in this mission; and inform preparation and interventions for future missions, especially those more domestic and humanitarian in nature., International Registered Report Identifier (irrid): DERR1-10.2196/44299., (©Anthony Nazarov, Deniz Fikretoglu, Aihua Liu, Jennifer Born, Kathy Michaud, Tonya Hendriks, Stéphanie AH Bélanger, Minh T Do, Quan Lam, Brenda Brooks, Kristen King, Kerry Sudom, Rakesh Jetly, Bryan Garber, Megan Thompson. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 06.11.2023.)

Introduction: First responders and other public safety personnel (PSP; e.g. correctional workers, firefighters, paramedics, police, public safety communicators) are often exposed to events that have the potential to be psychologically traumatizing. Such exposures may contribute to poor mental health outcomes and a greater need to seek mental health care. However, a theoretically driven, structured qualitative study of barriers and facilitators of help-seeking behaviours has not yet been undertaken in this population. This study used the Theoretical Domains Framework (TDF) to identify and better understand critical barriers and facilitators of help-seeking and accessing mental health care for a planned First Responder Operational Stress Injury (OSI) clinic., Methods: We conducted face-to-face, one-on-one semistructured interviews with 24 first responders (11 firefighters, five paramedics, and eight police officers), recruited using purposive and snowball sampling. Interviews were analyzed using deductive content analysis. The TDF guided study design, interview content, data collection, and analysis., Results: The most reported barriers included concerns regarding confidentiality, lack of trust, cultural competency of clinicians, lack of clarity about the availability and accessibility of services, and stigma within first responder organizations. Key themes influencing help-seeking were classified into six of the TDF's 14 theoretical domains: environmental context and resources; knowledge; social influences; social/professional role and identity; emotion; and beliefs about consequences., Conclusion: The results identified key actions that can be utilized to tailor interventions to encourage attendance at a First Responder OSI Clinic. Such approaches include providing transparency around confidentiality, policies to ensure greater cultural competency in all clinic staff, and clear descriptions of how to access care; routinely involving families; and addressing stigma., Competing Interests: The authors declare that they have no conflicts of interest to report with respect to the research, authorship, and publication of this article.

Background: Differences 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., Methods: The 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., Results: Similar 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., Significance: Similar 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., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Kate St. Cyr, Aihua Liu, Rachel A. Plouffe, Maede S. Nouri, Callista A. Forchuk, Sonya G. Wanklyn, Brian M. Bird, Alyson L. Mahar Anthony Nazarov, J. Don Richar and Her Majesty the Queen in Right of Canada, as represented by Defence Research and Development Canada for the contribution of Deniz Fikretoglu.)

The Canadian Armed Forces (CAF) deployed 2595 regular and reserve force personnel on Operation (Op) LASER, the CAF's mission to provide support to civilian staff at longterm care facilities in Ontario and in the Centres d'hébergement de soins de longue durée in Quebec. An online longitudinal survey and in-depth virtual discussions were conducted by a multidisciplinary team of researchers with complementary expertise. This paper highlights the challenges encountered in conducting this research and their impact on the design and implementation of the study, and provides lessons learned that may be useful to researchers responding to similar public health crises in the future., Competing Interests: The authors have no conflicts of interest to declare.

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., (Crown Copyright © 2021. Published by Elsevier Ltd. All rights reserved.)

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., Competing Interests: No potential conflict of interest was reported by the authors., (© 2021 Society for Military Psychology, Division 19 of the American Psychological Association.)

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., (© 2020 Her Majesty the Queen in Right of Canada. Published by Informa UK Limited, trading as Taylor & Francis Group.)

Background: Despite increased interest in workplace mental health interventions, the evidence for beneficial effects is mixed. Furthermore, many existing studies lack methodological rigor. We report results from a group randomized control trial to test the efficacy of a vastly popular intervention in Canada, the Road to Mental Readiness (R2MR) program, which has been widely disseminated in military, first responder, and civilian settings., Methods: The trial took place among Canadian Armed Forces military recruits completing their basic military qualification (BMQ) training, and randomized 65 platoons (N = 2831) into either (a) an Intervention (R2MR at week 2 of BMQ), or (b) a delayed Intervention Control (R2MR at week 9 of BMQ) condition. The principal investigator, participants, and data collection staff were blinded to platoon condition. Individual-level psychological functioning, resilience, mental health service use attitudes, intentions, and behaviours, and additional covariates were assessed with questionnaires around week 2 (a day or two before Intervention platoons received R2MR), at week 5, and at week 9 (a day or two before the Control platoons received R2MR). Military performance outcomes were obtained from administrative databases., Results: The full trial results were mixed; for some outcomes (psychological functioning, resilience, and military performance), we saw no evidence of beneficial effects; where we did see benefits (mental health service use attitudes, intentions, behaviours), the effects were very small, or disappeared over time. Analyses among two subsamples (Group 1: Intervention platoons with a Fidelity Check and their Controls, and Group 2: Intervention platoons without Fidelity Check and their Controls) indicated that for some outcomes (attitudes and help-seeking), under high fidelity conditions, the beneficial effects of R2MR were increased and better sustained; Conversely, under poor fidelity conditions, decreased beneficial effects or even iatrogenic effects were observed. Analyses across three training divisions indicated the larger organizational climate further influences efficacy., Conclusions: Our findings paint a very complex picture in which it is made evident that sensible, evidence-informed workplace mental health interventions such as R2MR may work under high fidelity conditions, but may yield no discernable benefit or even inadvertent iatrogenic effects if implemented poorly or without sufficient consideration to the larger organizational context., Trial Registration: ISRCTN 52557050 Registered 13 October 2016.

Objective: The 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., Design: Data 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 Measure: The 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., Results: ResF 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., Conclusions: Our 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., Competing Interests: Competing interests: Both DB and DF report that they are employees of the Canadian Department of National Defence and funding for this research came via this federal government department., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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.

Objective: The 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., Design: Data 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 Measure: The primary outcomes were MHP, past-year mental disorders, identified using the WHO's Composite International Diagnostic Interview, and past-year suicide ideation., Results: ResF 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., Conclusions: Past-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., Competing Interests: Competing interests: Both DB and DF report that they are employees of the Canadian Department of National Defence and funding for this research came via this federal government department., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

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., (© 2016 Canadian Medical Association or its licensors.)

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)., (© The Author(s) 2016.)

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.

Purpose: 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., Methods: 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., Results: 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., Conclusions: 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.

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.

Background: Some veterans, and especially those with mental disorders, have difficulty reintegrating into the civilian workforce., Purpose: The 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 Sources: The following databases were searched from their respective inception dates: MEDLINE, EMBASE, Cumulative Index Nursing Allied Health (CINAHL), and PsycINFO., Study Selection: In-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 Extraction: A 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 Synthesis: Three 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., Limitations: Studies of reintegration to work were not similar enough to synthesize, and it was inappropriate to pool results for this category of literature., Conclusions: Comprehensive 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.

Purpose: 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., Methods: 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., Results: 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., Conclusions: 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.

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.

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.

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.

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.

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.

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.

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.

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.