Afghanistan trauma takes a greater toll on military careers than other disorders

Surge of Afghanistan veterans to test Canadian mental-health care resources

LES PERREAUX
MONTREAL — The Globe and Mail
Published Monday, Dec. 12, 2016 5:00AM EST
Last updated Monday, Dec. 12, 2016 5:25AM EST

For the first time since Canada went to war in Afghanistan, the number of soldiers who served there and retired will outnumber those still in the military, a tipping point that will shift a significant mental-health care burden from the army to overstretched provinces and Veterans Affairs.

As of late November, 22,059 of the 40,026 military personnel who served in Afghanistan remained in the Canadian Armed Forces, according to the military. At the recent rate of retirement, the number will slip below half in 2017 and fall rapidly from there.

Veterans Affairs Minister Kent Hehr says his department is ready for the sudden increase in volume of former soldiers with recent combat experience. Advocates and mental-health experts doubt the department’s preparedness, noting civilian patients already face long waits for mental-health treatment.

A Globe and Mail investigation into suicide by men and women who served in the Afghanistan war confirmed 71 cases up until November. Among those people, 15 had been released from the military, but advocates like Mr. Harding say many more than 15 have died this way and gone undocumented. A study of Canadian veterans using data from a 2010 survey found 6 per cent had suicidal thoughts. Other surveys have found 25 per cent have suffered from post-traumatic stress disorder, depression or drug and alcohol abuse.

The Canadian Armed Forces invest heavily in the well-being of its personnel and has made progress screening, tracking and studying mental-health issues in the ranks – particularly suicide rates that seem to be growing among soldiers who fought in Afghanistan. But care shifts to overburdened provincial and territorial health-care providers as people leave the military and are no longer CAF’s responsibility. Meanwhile, Veterans Affairs still has no comprehensive system for monitoring veterans’ health.

“The day a soldier takes off the uniform, they cease to be systematically tracked,” said Brian Harding, a veterans’ advocate who is a member of Mr. Hehr’s mental-health advisory group. For several years, Mr. Harding and others have been pushing Veterans Affairs to produce data on the scope of the suicides. “Canada did not previously have a reckoning of mental-health issues among veterans in any sizable cohort in modern history. We didn’t have Vietnam. We had to deal with this fresh,” Mr. Harding said.

Veterans Affairs officials say they are in contact with 250,000 of Canada’s 600,000 military veterans, most of whom never served in Afghanistan. Under current legislation, veterans must initiate contact with the department. Veterans Affairs is setting up a system to collect statistical data on suicide among veterans from outside agencies. Details have not been released, and the first annual report is not expected until late 2017.

Veterans Affairs’ share of caring for Afghanistan combat veterans has accelerated rapidly in recent years. In 2013, only 21 per cent of soldiers who served in Afghanistan had been released. In 2016, that figure reached 45 per cent, and will pass 50 per cent by the fall of 2017.

Mr. Hehr said his department is ready. “I believe we are,” he said in a recent interview. “We understand that the people who served in Afghanistan will be coming out. We started mapping this out, that many will need mental-health support and physical support when they leave their service.”

While Veterans Affairs cannot force veterans to get help or submit to public-health tracking, he said the department must continue to improve communications. “What we have to do as Veterans Affairs Canada is say we’re open for business,” he said. “We’re here for support. But we can’t force anybody to come through our doors.”

Soldiers have a host of health advantages over veterans and other civilians, Mr. Harding said. “They have easy access to health care, better access to mental-health resources than civilians, and ready access to peer support,” he said. “They get specific training in mental resilience. Leadership is trained to watch for signs of struggle. Sick-leave benefits are excellent.”

Five veteran suicide cases examined in detail in The Globe investigation bolster the point that access to services drops when soldiers retire. The parents of retired private Tyler Hulme described how he overdosed on medication about a month after his release. He had been told it would be a four-month wait for a civilian psychiatrist in Ontario. Retired sergeant Raynald Côté did seek and receive treatment, but fell into isolation and despair with little of the peer support he had in the army.

Retired sergeant Claude Emond had a civilian psychiatrist and massage therapist. “He had services, but when he’d come back from sessions, he felt it was superficial. They didn’t understand his military background and seemed to just be checking boxes,” said his wife, Sylvie Duchesne.

Veterans Affairs provides an array of services from 1-800 crisis hotlines to education funding and mental-health treatment. The department started funding new clinics for operational stress injury in major centres in 2007. They have slowly spread across the country and are operated by provincial health authorities.

Most front-line services are provided by insurance companies, private contractors, service groups and the health ministries and social services of the provinces and territories. The system can be a bewildering tangle for vets.

Alexandra Heber, the newly appointed chief psychiatrist for Veterans Affairs, said untangling that web is one of the keys to planning for the biggest cohort of combat vets since the Korean War in the 1950s. “Over the years, we’ve had one service added on top of something else and something else. We are creating more organization for all of those services,” she said.

But Deborah Harrison, a psychologist and retired professor, has studied the effects of deployment on military families and recently co-wrote a book on military children called Growing up in Armyville. She says Canada is unprepared for the mental-health burden the war will place on provinces already short of psychiatrists, psychologists and other providers.

“We don’t always grasp how historically significant the Afghanistan deployment was,” Dr. Harrison said. “It was the longest military engagement in Canadian history. It was a very dangerous deployment and much more stressful for soldiers and families than previous deployments.

“It was known there would be casualties, but nobody was prepared for the unmeetable demands on Canada’s mental-health care system from that deployment.”

http://www.theglobeandmail.com/news/national/surge-of-afghanistan-vets-to-test-canadian-mental-health-care-providers/article33295082/

Tories’ secret Afghan casualty list reveals intensity of combat

The Star's week-long series tells the stories of Canada's injured troops and highlights the bravery of the young men and women who quietly struggle to rebuild their lives at home.



By BRUCE CAMPION-SMITH AND ALLAN WOODSOttawa Bureau

OTTAWA—Gun shot wounds, buried bombs, vehicle rollovers, rocket attacks and suicide bombers.

For seven months in 2008 — from March to September — those were just a few of the battlefield traumas suffered by Canadian troops as they tangled with insurgents.

They are the very incidents that the military has tried to keep out of the public eye with its decision to keep details on wounded soldiers under wraps.

The policy of releasing the number of injured soldiers only once a year — on Dec. 31 — has obscured the intensity of fight facing Canadian soldiers, as well as the nature of the sometimes life-altering injuries. It has also given Canadians back home a mental buffer against the numbing realities of war — soldiers who fight hard also get hurt.

Over seven months, 52 soldiers were wounded in action and another 24 suffered “non-battle injuries.” Seventeen soldiers died in combat and two others are listed only as “deaths,” language typically used in the case of suicides or when the cause of death is undetermined. The good news in the numbers is that 34 of the 52 soldiers wounded in action were able to return to duty.

The normally secret records, which are produced in Afghanistan and circulated throughout the defence department, show the pace of war is relentless. In just over one week at the end of May 2008, one soldier is injured when a Light Armoured Vehicle rolls over; four are injured when a suicide bomber blows up his car; one soldier takes ill; two others suffered unspecified “non-battle injuries;” three are hurt in a “probable” mine strike and one suffers a gunshot wound.

The deployment, known in military circles as Roto 5, was also a time of rapid change in the political focus and intensity of the Afghan war. In the United States, President Barack Obama was coming to power with a promise to re-engage in America’s then-forgotten war. In Canada, much of the attention was directed toward the capital.

A panel appointed by Prime Minister Stephen Harper had recommended more NATO troops and more helicopters and more focused aid projects if Canada was to extend its mission by two years to 2011. The charismatic chief of defence staff, Gen. Rick Hillier, stepped aside for his successor, Gen. Walter Natynczyk. The nation’s first Red Rally stoked home front support for Canadian troops overseas.

By the end of the summer, though, insurgents had sprung their Taliban brethren from Kandahar’s Sarposa prison in a spectacular truck bombing and Harper began to lay out Canada’s exit strategy from the war ahead of a September election call.

Throughout this period, the records reveal that Canadian troops were taking casualties at least once every three days in life-and-death battles that have rarely been revealed to the public and are almost never acknowledged by defence officials.

A key example was during a visit to Kandahar by Gen. Walter Natynczyk in July 2008, one month after he had assumed the role of chief of defence staff. Wrapping up his five-day visit on July 13, he delivered what one account termed a “cheerful assessment” of the security situation, one that echoed that of ministers in the Conservative government who were running the war.

The Taliban enemy was scared of a face-to-face fight, he said, and security around Canada’s forward operating bases in Kandahar province had shown “significant progress.”

But the days that preceded and followed his visit were some of the most intense of the tour for Canadian soldiers. Thirteen names were entered into the casualty register between July 4 and July 19, the result of 10 separate incidents.

On July 4, Cpl. Brendan Downey was found dead in his sleeping quarters at Camp Mirage, a support base in Dubai.

Pte. Colin Wilmot, a 24-year-old medic, was killed July 5 when he stepped on an IED during an early morning foot patrol. The other was that of Cpl. James Arnal, 25. He was killed on July 19 when he too stepped on a buried bomb.

That blast also injured a corporal with the Royal Westminster Regiment, a reservist from British Columbia, who was treated and returned to duty “complete with a scar in his hindquarters,” according to his regiment.

On July 4, a master corporal and two privates based at CFB Shilo in Manitoba were blown up by an IED. A roadside bomb struck a corporal from Edmonton on July 7. A warrant officer, an experienced senior soldier from Edmonton, was hit by the Taliban’s weapon of choice on July 17. All were treated and returned to duty.

Then, just as Natynczyk was sharing his assessment of the battlefield with reporters, a rocket attack injured a young female soldier. She was a private with the 26th Field Artillery Regiment, a reserve force in Brandon, Man.

The fact that injuries are kept out of the public eye illustrates how unaware Canadians are of the price being paid by soldiers in Afghanistan, said Senator Colin Kenny.

“In death, you hope it’s fast and very little suffering. But the suffering of the wounded goes on and on and on,” said Kenny, the former chair of the Senate defence committee.

“All you have to do is go out to the hospital to meet them. You’re looking at people with half their face gone or their mouth is wired up and their ankles are broken because of the force of the IED,” he said.

In addition, some soldiers complain that hiding the wounded prevents them from being recognized and celebrated for their physical sacrifices on behalf of Canada. In hospitals across the country, they are suffering and recovering alone and in silence, something that can contribute to their frustration, breed resentment and lead to mental health problems.

Defence officials defend the secrecy, saying it’s vital to safeguard operational security and keep insurgents in the dark about the toll their attacks are taking on Canadian troops.

But critics mock that reasoning, noting that allies like Britain and the United States, release their own tallies of wounded troops on a more timely basis — sometimes weekly.

“The lack of transparency here is something that I simply don’t understand,” Kenny said.

He bluntly dismissed the military reasoning as “bulls**t.” He said it’s “not credible” to think that the Taliban don’t have moles inside the coalition base, able to feed out information.

“There are Taliban who are active inside the wire in Kandahar. They bring workers in every day,” Kenny said.

“It’s not credible to say that the Taliban don’t know when someone’s been hurt. They see the helicopters come in and do the medevacs,” he said.

Improvised explosives account for the majority of the incidents and the injuries.

But the records reveal the array of risks that confront a soldier in a war zone, such as gunshot wounds, heat exhaustion, unspecified illness, falls and in one case, a “blow to the head.”

https://www.thestar.com/news/canada/2010/11/05/tories_secret_afghan_casualty_list_reveals_intensity_of_combat.html

Canadians who returned from Afghanistan bearing psychic scars find themselves traumatized and out of the military in far greater numbers than counterparts suffering from mental illnesses unrelated to the Afghan mission.

David Boulos, an epidemiologist with the Mental Health Department of National Defence, tracked thousands of military personnel in the years following their deployment.

Not only are people with Afghanistan-related mental disorders more likely to be professionally sidelined than people who don’t have mental illness, his research shows, they’re “medically released” from the military at more than double the rate of people with mental disorders not deemed to be caused by Afghan deployment.

Boulos’s findings, published in the Canadian Journal of Psychiatry last month, build on previous work underscoring Canada’s failure to treat and reintegrate people whose war wounds aren’t visible.

The extent of those wounds is at the fore again this week, with Prince Harry and Prime Minister Justin Trudeau kicking off the countdown to the 2017 Invictus Games — a sports competition for ill and injured troops.

Auditor General Michael Ferguson highlighted Canada’s struggles to rein in soldiers’ suffering in his latest report, which urged Veterans Affairs to rein in spending on its medical marijuana program.

But if people with diseases of the brain remain marginalized in an environment that prizes toughness, people who owe their diseases to Afghan service are even more marginalized.

INVISIBLE WOUNDS: Crisis in Canada’s military

The cause could be as simple as Afghanistan’s punishing combat environment. Other studies have found correlations between incidence of mental disorders and the danger or stress associated with different Afghan locations, Boulos says: Kandahar tops the list, followed by Kabul.

Boulos and his colleagues tracked personnel from a variety of deployments: Some went to Kandahar; others to Kabul or elsewhere in Afghanistan; others to the United Arab Emirates or the Arabian Gulf or elsewhere in the Middle East or to an “unspecified location.”

It’s extremely difficult to identify a mental disorder’s cause. Boulos used designations the Canadian Forces’ mental health clinicians gave their patients and divided individuals he studied with mental disorders into two groups: the people whose illnesses clinicians deemed “Afghanistan-related,” and everyone else.

“As part of their duties they need to make a judgment as to whether a diagnosis may be related to a deployment or not,” Boulos said in an interview.

Almost four times as many people with Afghanistan-related illnesses had post-traumatic stress disorder: 59.3 per cent, compared to 15.8 per cent of people with unrelated mental disorders.

The Canadian Forces’ “Universality of Service” requirement sets strict benchmarks all its personnel are expected to meet, with the implication being that they can be deployed anywhere at any time to do just about anything.

People with brains sickened thanks to Afghan service are the least likely to meet those expectations.

More than four in 10 (40.9 per cent) of them were found to have a “career-limiting” medical condition, compared to 23.6 per cent of people with other mental disorders.

The first finding that someone’s in violation of “Universality of Service” doesn’t mean you’re out of the military right away, said Boulos, adding it’s “kind of a precursor, a warning.”

People with Afghan-related mental disorders scored dangerously on two of six universality categories in particular, Boulos said: They’re found to be less flexible geographically, less able to move far away with minimal clinical support; and less likely to be found fit under the Canadian Forces’ required occupational skill set.

Sometimes there are accommodations made, occupations found that are better-suited to people who return from combat wounded in a million different ways.

But if you’re continually found not to meet that universality benchmark, you’re out — “medically released” from the Canadian Forces.

And here, too, people with mental illness from their service in Afghanistan are grossly over-represented: 29 per cent of them had been medically released within five years of their diagnosis, compared to 13 per cent of individuals with other mental disorders.

It it inevitable that deployment to a challenging combat zone will derail a military career?

National Defence could be more flexible in its “Universality of Service” requirements — a bit more accommodating of wounded warriors’ limitations.

But that can only go so far, Boulos said.

“The universality of service is kind of to protect the individual as well as to protect those around the individual.”

There are also more steps being taken on the prevention side, Boulos said.

“They have been trying to build up resilience, mental health resilience, in their members, so let’s say they were exposed to a trauma-inducing event, it would be less stress-causing.”

And a lot of it comes back to getting sick people the best possible treatment as soon as possible.

“You’d want to ensure individuals get the quality of care they need.”

http://globalnews.ca/news/2674713/afghanistan-trauma-takes-a-greater-toll-on-military-careers-than-other-disorders/