Canadian Veterans Research Articles

The relation between adverse childhood experiences and moral injury in the Canadian Armed Forces

ABSTRACT Background: There is increasing evidence that moral injuries (MIs) may affect the mental health of Canadian Armed Forces (CAF) members and veterans. Despite knowledge suggesting that MIs are related to multiple negative mental health outcomes, including the onset of post-traumatic stress disorder (PTSD), it is unknown whether pre-traumatic variables, including the presence of childhood abuse, are related to MIs. Objective: This study seeks to investigate the potential relationship between adverse childhood experiences and later onset MI in military members. Methods: Thirty-three patients newly admitted to an inpatient unit for treatment of trauma-related disorders received a standardized self-assessment package, including the PTSD Checklist for DSM-5 (PCL-5), the Moral Injury Events Scale (MIES; adapted for the Canadian context), and the Adverse Childhood Experiences Questionnaire (ACE-Q), which is a retrospective measure of childhood abuse. Results: Analyses revealed a significant relation between childhood emotional abuse and the presence of MI in adulthood. Specifically, emotional abuse during childhood was correlated with total score on the MIES (p = 0.006) and with its two subscales, perceived betrayals (p = 0.022) and perceived transgressions (p = 0.016). These correlations remained significant when controlling for age and gender. Conclusions: Among CAF members and veterans, childhood events are related to the presence of MI during adulthood. These preliminary data are provocative in suggesting that emotional abuse during childhood may increase the likelihood of endorsing MI during adult military service. Further work is needed to identify pre-traumatic variables that may serve to increase risk or enhance resilience to the development of MI in military members.

A retrospective cohort study comparing non-fatal self-harm emergency department visits between Canadian veterans living in Ontario and matched civilians

This was a retrospective cohort study linking provincial administrative databases to compare rates of non-fatal self-harm between CAF and RCMP veterans living in Ontario and age-matched civilians. This study included male veterans who registered for provincial health insurance between 2002 and 2013. A civilian comparator group was matched 4:1 on age and sex. Self-harm emergency department (ED) visits were identified from provincial ED admission records until death or December 31, 2015. Multivariable Poisson regression compared the risk of self-harm. Analyses adjusted for age, geography, income, rurality, and major physical and mental comorbidities. In total, 9514 male veterans and 38,042 age- and sex-matched civilians were included. Overall, 0.55% of veterans had at least one non-fatal self-harm ED visit, compared with 0.81% of civilians. The rate of ED self-harm visits was 40% lower in the veteran population, compared to the civilian population (RR = 0.60; 95% CI = 0.41–0.87). In both groups, psychosocial and physical comorbidities, and death by suicide were more common in those who self-harmed than those who did not. A better understanding of why veterans have a lower rate of self-harm emergency department visits and how it is related to the number of completed suicides is an important area for future consideration.

The Effect of College Education on Health and Mortality: Evidence from Canada

We investigate the returns to college attendance in Canada in terms of health and mortality reduction. To do so, we first use a dynamic health microsimulation model to document how interventions which incentivize college attendance among high school graduates may impact their health trajectory, health care consumption and life expectancy. We find large returns both in terms of longevity (4.1 years additional years at age 51), reduction in the prevalence of various health conditions (10-15 percentage points reduction in diabetes and 5 percentage points for stroke) and health care consumption (27.3% reduction in lifetime hospital stays, 19.7 for specialists). We find that education impacts mortality mostly by delaying the incidence of health conditions as well as providing a survival advantage conditional on having diseases. Second, we provide quasi-experimental evidence on the impact of college attendance on long-term health outcomes by exploiting the Canadian Veteran's Rehabilitation Act, a program targeted towards returning WW-II veterans and which incentivized college attendance. The impact on mortality are found to be larger than those estimated from the health microsimulation model (hazard ratio of 0.216 compared to 0.6 in the simulation model) which suggests substantial returns to college education in terms of healthy life extension which we estimate to be approximately one million canadian dollars.

"From the darkness to the light": Memoirs of Blind Canadian veterans of the First and Second World Wars

This article is a study of the memoirs of three Canadian ex-servicemen who were blinded during the First and Second World Wars. It inquires autobiographical accounts as a source to understand disability both at an individual and a social level. I argue that autobiographies, as they reflect the individual experience of disability, also reveal concepts and prejudices concerning disability that are inherent to a society at a specific time. The authors hence can either challenge or confirm persistent ideas about disability. This paper is organized in three parts. In the first I present the autobiographies this study is based on, and summarize their main features. In the second I focus on the way blindness impacts individual’s identity. I shall argue that the loss of sight is experienced as life-changing event, a death-rebirth process that deeply affects the veterans as well as their entourage. Blindness enhance hence a process of re-definition of the self which encompasses, on the one hand, blind individuals’ perception of their own ‘exceptionality’ and, on the other, their desire for normality and social integration. In the last section I analyze how the three writers address Canadian society in order to challenge the existing ideas and prejudices about the blind. I argue that they deliberately choose to use autobiographical narratives as a device to point out and challenge common preconceptions about blindness.

Veteran suicide mortality in Canada from 1976 to 2012

Introduction: Suicide prevention for Veterans is a public health priority. However, it has been challenging to study suicide in Canadian Veterans post-release from the military. The Veteran Suicide Mortality Study (VSMS) has assembled data on the risk of death by suicide for Canadian Veterans compared to other Canadians. Methods: This was a record linkage study of Canadian cause of death data from Statistics Canada linked with a cohort of Canadian Veterans from pay data of the Canadian Armed Forces (CAF). The population-based cohort included Veterans released with Regular Force or Reserve Force Class C service for the period 1976–2012. Death by suicide was identified by International Classification of Diseases (ICD) codes. Estimates of relative risk for suicide were calculated using standardized mortality ratios (SMRs) with the Canadian general population (CGP) as the reference. Results: Male Veterans had a higher risk of suicide compared to the CGP (SMR = 1.36 [95% CI, 1.30–1.44]). Female Veterans also had a higher risk (SMR = 1.81 [95% CI, 1.40–2.31]). Suicide risk for Veterans was consistently higher than for the CGP over the 37 years of follow-up. Risk for male Veterans was highest for those under 25 years old and decreased with age, but risk for females was higher than the CGP regardless of age. Discussion: The finding of higher risk of death by suicide for both male and female Veterans compared to the CGP informs the action plans of the recently released suicide prevention strategy. Future studies will identify other characteristics of subgroups of Veterans at higher risk of suicide.

Prioritizing research on cannabis use among Canadian Veterans

Prioritizing research on cannabis use among Canadian Veterans

Contagion versus commemoration: public responses to suicide within Canadian military and Veteran populations

Building on research into historical, public, and institutional perceptions of suicide, this article assesses the role of commemoration and remembrance in government, medical, and military responses to suicide within the Canadian Armed Forces (CAF). It provides an overview of how stakeholders and policy-makers have balanced commemoration with concerns over triggering a contagion effect in certain at-risk populations. The prevailing cultural beliefs of institutions and the public shape how military casualties have been defined and to what extent these deaths have been formally honoured. This article aims to prompt further research in the fields of history, epidemiology, sociology, and psychology into public attitudes toward suicide. Future interdisciplinary studies will provide stakeholders with a nuanced understanding of how the different priorities of the public, government, and the media influence their respective responses to the issue of suicide in military and Veteran populations.

Improving psychiatric–psychological assessment capacity by matching level of care to client outcomes: enhancing discharge planning at an operational stress injury clinic in Canada

Mental health centres that assess and treat Canadian Forces members and Veterans have been experiencing an increasing number of referrals. At an Operational Stress Injury Clinic located in London, Ontario, which is mandated to treat this population, approximately half of clients are discharged within a year and another 12.1% require treatment for 5–9 years. The increasing complexities, such as multiple comorbidities, of these long-term clients reduce clinics’ ability to rapidly assess and treat new clients. This article explores the decision point of whether to continue treatment or to discharge a client to a different level of care as well as how best to provide treatment while keeping care transitions in mind. Enhancing the discharge process could lead to a greater capacity for treating new referrals.

Exploring harm reduction among Canadian Veterans experiencing homelessness

Introduction: In Canada, Veteran homelessness is an increasing concern. It is estimated that approximately 2,950 Veterans experienced homelessness in 2016. Some may also have substance use disorders, which has been linked to loss of housing and homelessness many years after exiting military service. A strategy that facilitates housing stability and reduces the harms of substance use is harm reduction. This study explored how Veterans who have experienced homelessness perceive and experience harm reduction. Methods: This study was a secondary analysis of data collected from the Canadian Model for Housing and Support of Veterans Experiencing Homelessness study that evaluated a Veteran-specific housing model in four Canadian cities. In the primary study, 78 participants received housing and related programming intervention. Focus groups with Veterans occurred at each of the four housing sites from 2012 to 2014. Across all sites, 24 Veterans attended both the 2012 and 2013 focus groups. A total of 39 Veterans attended the final focus groups in 2014. The authors conducted a thematic analysis of Veteran focus group data where data were extracted from transcripts and organized into themes. Results: Various themes emerged from the data including (1) regimented structure, (2) understanding both worlds, (3) congruent recovery journeys, (4) location close enough to services, far enough from harm, and (5) harm reduction is housing stability and housing stability is harm reduction. These themes represent the interface between military culture and homeless culture. Overall, Veterans considered harm reduction as an essential component of housing. Discussion: This study has shown that harm reduction may be part of the solution to ending Veteran homelessness in Canada. The findings of this study may inform how Veteran housing and substance use needs are addressed. Additional research is needed to explore further how harm reduction can be effectively incorporated into Housing First for Veterans.

Depression and the relationship between sleep disturbances, nightmares, and suicidal ideation in treatment-seeking Canadian Armed Forces members and veterans

BackgroundResearch on the relationship between insomnia and nightmares, and suicidal ideation (SI) has produced variable findings, especially with regard to military samples. This study investigates whether depression mediated the relationship between: 1) sleep disturbances and SI, and 2) trauma-related nightmares and SI, in a sample of treatment-seeking Canadian Armed Forces (CAF) personnel and veterans (N = 663).MethodRegression analyses were used to investigate associations between sleep disturbances or trauma-related nightmares and SI while controlling for depressive symptom severity, posttraumatic stress disorder (PTSD) symptom severity, anxiety symptom severity, and alcohol use severity. Bootstrapped resampling analyses were used to investigate the mediating effect of depression.ResultsApproximately two-thirds of the sample (68%; N = 400) endorsed sleep disturbances and 88% (N = 516) reported experiencing trauma-related nightmares. Although sleep disturbances and trauma-related nightmares were both significantly associated with SI on their own, these relationships were no longer significant when other psychiatric conditions were included in the models. Instead, depressive symptom severity emerged as the only variable significantly associated with SI in both equations. Bootstrap resampling analyses confirmed a significant mediating role of depression for sleep disturbances.ConclusionsThe findings suggest that sleep disturbances and trauma-related nightmares are associated with SI as a function of depressive symptoms in treatment-seeking CAF personnel and veterans. Treating depression in patients who present with sleep difficulties may subsequently help mitigate suicide risk.

Factors associated with work satisfaction among Veterans

Introduction: Work satisfaction contributes to the health and well-being of Veterans transitioning to civilian life after service. Therefore, the purpose of this study is to examine the factors contributing to work satisfaction among Canadian Veterans. Methods: We examine multiple factors thought to be associated with work satisfaction using the cross-sectional 2010 survey of the Life After Service Studies (LASS) program of research, which includes a national sample of 3,154 Canadian Veterans released from the regular forces between 1998 and 2007. We performed both unadjusted and adjusted logistic regression models for three rank groupings: privates and cadets, Non-Commissioned Members (NCMs), junior and senior, and officers (junior and senior). Results: In the year after release, 73% of Veterans were satisfied with their work. Officers (89%) were the most satisfied, followed by NCMs (77%), and privates and cadets (52%). Using unadjusted models, factors associated with higher satisfaction rates were: release due to reaching retirement age; being older than 50; reporting no work stress; reporting knowledge, skills, and ability transferability; and similar job tasks between military and civilian occupations; reporting easy adjustment to civilian life; and being satisfied with finances. Using adjusted models, only satisfaction with finances was associated with work satisfaction for NCMs, privates, and cadets. Only involuntary release and years of service were associated with work satisfaction for officers. Discussion: Work satisfaction rates varied considerably according to military rank, and were highest among officers and lowest among privates and cadets. This suggests a need to account for rank when developing strategies to improve work satisfaction rates and reintegration into civilian life among Veterans.

Determinants of successful transition literature review

Introduction: To understand the current Canadian research on transition from military to civilian life, the Office of the Veterans Ombudsman (OVO) initiated a literature review of peer-reviewed work from both academic and government sources, to help identify which factors contribute to a successful transition to civilian life for medically-released Canadian Armed Forces (CAF) Veterans. Methods: A scoping review was conducted by searching Embase, MEDLINE, PsycINFO, Google Scholar and the Veterans Affairs Canada (VAC) Research Directorate website for Canadian articles that described transition facilitators in any of the domains identified by the OVO. Results: In total, 94 relevant studies were identified and most of these focused on all Veterans without identifying a medical or non-medical release. Only 18 addressed the determinants of successful transition and only 2 focused on investigating transition issues for medically-released CAF Veterans compared to their non-medically-released peers. Discussion: The largest limitation found in the literature is the scarcity of articles related to identifying the factors that facilitate a successful transition for medically-released CAF Veterans. A further limitation is that the majority of surveys conducted were based on cohorts that had not experienced transition under the New Veterans Charter (NVC), implemented in 2006, or had only a small number of NVC subjects in their cohort. Given the significant policy and program changes implemented with the NVC, this is a compelling rationale for the requirement of more Canadian research to determine the effectiveness of the NVC policy and programs on transition outcomes for Canadian Veterans.

Canada at Peace and Soldiers at War: Canadian U.N. Soldiers in Korea, Egypt, and Vietnam

In recent years, Canadian peacekeeping and UN involvement has assumed a place of high regard, reverence, and veneration, often at the expense of Canada’s military past. While its glorification is in many ways justified, the mythology surrounding Canada’s peacekeeping role has compelled many Canadians to view Canada solely as a peacekeeping nation. As a result, peacekeeping has become the “touchstone of our identity.” This mythology distorts the reality of Canadian military action to the point where Canadian veterans of NATO conflicts are often forgotten and it ignores the fact that many of the first peacekeepers left Canada “virtually unnoticed,” without the recognition and support of their nation. The mythology of peacekeeping misrepresents Canadian military conflicts and ignores that, in spite of the characterization of peacekeepers as nonviolent and unbiased actors, the majority of them were first and foremost Canadian soldiers, many of whom veterans of World War II. For the soldiers who came of age on the battlefields of Europe, the role of peacekeeping was a frustrating and politically charged experience, whereby they held no power and they felt they made very little positive impact. Despite the virtually universal glorification and celebration of peacekeepers in recent years, investigation of the “Cold War Home Front” demonstrates the difficulties faced by Canadian NATO soldiers, U.N. peacekeepers and their families in a society that wanted to move beyond the years of struggle, pain and sacrifice in war time and had little sympathy for the men and women who ‘chose’ to leave their families to serve in wars their nation was not fighting.

Psychiatric service dogs as a tertiary prevention modality for veterans living with post-traumatic stress disorder

ObjectiveTo document the usability of psychiatric service dogs (PsySDs) as a tertiary prevention modality from the perspective of veterans who have been using a PsySD 2 to 4 years as an assistive aid for post-traumatic stress disorder symptom (PTSD) management. MethodA case series study with PsySD primary users was carried out with 10 Canadian veterans recruited from 4 different dog training schools. Researchers conducted semi-structured telephone interviews and asked questions pertaining to four domains addressing the PsySD’s ‘usability’. A content and thematic analysis were realized using an inductive and deductive approach. ResultsOur conceptual framework proposes four main themes with their associated subthemes:: 1-Service dog’s roles and tasks (8 subthemes, e.g. acting as a socializing agent, maintaining an appropriate free space around the veteran), 2-Personal advantages and Environmental impacts (8 subthemes, e.g. alleviating symptoms; increasing outings and physical activities, enabling social interactions and relationship building), 3-Obstacles (4 subthemes, e.g. high costs of dog maintenance, dog’s presence attracted unwanted public attention, prompting intrusive questions), and 4-Recommendations for PsySD programs (16 subthemes, e.g. creating a national registry for PsySD, encouraging mental health practitioners’ involvement). Conclusions and Implications for PracticeThemes 1 and 2 are positive perceptions, and theme 4 suggests relevant potential improvements. The current study offers insights into how PsySDs concretely assist primary users and can help addressing PTSD chronicity. It presents the roles professionals may play when dealing with patients using PsySDs for PTSD. The proposed conceptual framework can be useful to policy makers, dog trainers and caregivers.

The Effect of College Education on Health and Mortality: Evidence from Canada

We investigate the returns to college attendance in Canada in terms of health and mortality reduction. To do so, we first use a dynamic health microsimulation model to document how interventions which incentivize college attendance among high school graduates may impact their health trajectory, health care consumption and life expectancy. We find large returns both in terms of longevity (4.1 years additional years at age 51), reduction in the prevalence of various health conditions (10-15 percentage points reduction in diabetes and 5 percentage points for stroke) and health care consumption (27.3% reduction in lifetime hospital stays, 19.7 for specialists). We find that education impacts mortality mostly by delaying the incidence of health conditions as well as providing a survival advantage conditional on having diseases. Second, we provide quasi-experimental evidence on the impact of college attendance on long-term health outcomes by exploiting the Canadian Veteran's Rehabilitation Act, a program targeted towards returning WW-II veterans and which incentivized college attendance. The impact on mortality are found to be larger than those estimated from the health microsimulation model (hazard ratio of 0.216 compared to 0.6 in the simulation model) which suggests substantial returns to college education in terms of healthy life extension which we estimate to be approximately one million Canadian dollars.

“The Experience Being My Own”: Identifying Life Writing in Plays by Canadian Veterans of the Great War

“The Experience Being My Own”: Identifying Life Writing in Plays by Canadian Veterans of the Great War

Mental Health Services Use Trends in Canadian Veterans: A Population-Based Retrospective Cohort Study in Ontario.

A substantial evidence base in the peer-reviewed literature exists investigating mental illness in the military, but relatively less is documented about mental illness in veterans. This study uses provincial, administrative data to study the use of mental health services by Canadian veterans in Ontario. This was a retrospective cohort study of Canadian Armed Forces and Royal Canadian Mounted Police veterans who were released between 1990 and 2013 and resided in Ontario. Mental health-related primary care physician, psychiatrist, emergency department (ED) visits, and psychiatric hospitalisations were counted. Repeated measures were presented in 5-year intervals, stratified by age at release. The cohort included 23,818 veterans. In the first 5 years following entry into the health care system, 28.9% of veterans had ≥1 mental health-related primary care physician visit, 5.8% visited a psychiatrist at least once, and 2.4% received acute mental health services at an ED. The use of mental health services was consistent over time. Almost 8% of veterans aged 30 to 39 years saw a psychiatrist in the first 5 years after release, compared to 3.5% of veterans aged ≥50 years at release. The youngest veterans at release (<30 years) were the most frequent users of ED services for a mental health-related reason (5.1% had at least 1 ED visit). Understanding how veterans use the health care system for mental health problems is an important step to ensuring needs are met during the transition to civilian life.

Factors associated with mental health in Canadian Veterans

Introduction: Mental health of Veterans remains a key public policy issue as Veterans with mental health conditions continue to rise in numbers. There is, however, limited information available about specific factors that are associated with mental health in the Veteran population in Canada despite the increasingly perilous nature of military engagements in recent decades. Methods: Regression analysis was conducted on data from a comprehensive self-reported health survey of Canadian Veterans to identify factors associated with mental health, which encompass post-traumatic stress disorders, anxiety disorders, depression, and mood disorders. Results: The findings uncover the role of service-oriented risk factors in the occurrence of mental health conditions notably, overseas deployment (OR=1.55, p≤0.001) and, to a limited extent, land forces (OR=1.34, p≤0.05). The results also show an inverse relationship between income and mental health. Further, lower-educated Veterans have increased odds of mental health conditions. Obesity was found to be a statistically significant factor associated with mental health (OR=1.45, p≤0.001) as well as smoking (OR=1.76, p≤0.001). Home ownership appears to have some protective effect on Veterans' health (OR=1.57, p≤0.001). Discussion: These findings highlight key important factors associated with mental health in Veterans, and they include overseas deployment, land forces enlistment, income, obesity, and smoking. The findings highlight the need for targeted research on the complex causal pathways leading to mental health conditions, especially in deployed Veterans and land forces Veterans so that effective prevention programs can be designed for these groups.

Do DSM-5 changes to PTSD symptom cluster criteria alter the frequency of probable PTSD when screening treatment-seeking Canadian Forces members and Veterans?

Introduction: DSM-5 diagnostic criteria revisions for post-traumatic stress disorder (PTSD) have raised concerns about PTSD prevalence – particularly the new requirement of one avoidance symptom. We examined the frequency of positive screening results for probable PTSD in treatment-seeking Canadian Armed Forces (CAF) personnel and Veterans when both DSM-5 and DSM-IV-TR symptom cluster criteria were applied. Methods: Previously collected data from 382 CAF personnel and Veterans were used to identify the frequency of positive screens using both sets of diagnostic criteria. Results: 71.2% ( n=272) of participants screened positively for probable PTSD using DSM-5 symptom cluster criteria, compared to 77.7% ( n=297) using DSM-IV-TR symptom cluster criteria. Percent agreement analyses found that negative percent agreement was 100.0%, positive percent agreement was 91.6%, and overall percent agreement was 93.5%. Discussion: The number of individuals who screened positively for probable PTSD using DSM-IV-TR criteria was higher than those who screened positively using DSM-5 criteria. The requirement of at least one avoidance symptom appears to have a noticeable impact on the frequency of positive screens for probable PTSD among treatment-seeking military personnel. This has important implications for pension adjudication and treatment entitlement.

A descriptive analysis of medical health services utilization of Veterans living in Ontario: a retrospective cohort study using administrative healthcare data

BackgroundHealth services utilization by Veterans following release may be different than the general population as the result of occupational conditions, requirements and injuries. This study provides the first longitudinal overview of Canadian Veteran healthcare utilization in the Ontario public health system.MethodsThis is a retrospective cohort study designed to use Ontario’s provincial healthcare data to study the demographics and healthcare utilization of Canadian Armed Forces (CAF) & RCMP Veterans living in Ontario. Veterans were eligible for the study if they released between January 1, 1990 and March 31, 2013. Databases at the Institute for Clinical Evaluative Sciences were linked by a unique identifier to study non-mental health related hospitalizations, emergency department visits, and physician visits. Overall and age-stratified descriptive statistics were calculated in five-year intervals following the date of release.ResultsThe cohort is comprised of 23, 818 CAF or RCMP Veterans. Following entry into the provincial healthcare system, 82.6 % (95 % CI 82.1–83.1) of Veterans saw their family physician at least once over the first five years following release, 60.7 % (95 % CI 60.0–61.3) saw a non-mental health specialist, 40.8 % (95 % CI 40.2–41.5) went to the emergency department in that same time period and 9.9 % (9.5–10.3) were hospitalized for non-mental health related complaints. Patterns of non-mental health services utilization appeared to be time and service dependant. Stratifying health services utilization by age of the Veteran at entry into the provincial healthcare system revealed significant differences in service use and intensity.ConclusionThis study provides the first description of health services utilization by Veterans, following release from the CAF or RCMP. This work will inform the planning and delivery of support to Veterans in Ontario.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1596-y) contains supplementary material, which is available to authorized users.