Canadian Armed Forces Veterans: Mental Health Findings from the 2013 Life After Service Survey
Citation: Thompson JM, VanTil L, Sweet J, Poirier A, McKinnon K, Dursun S, Sudom K, Zamorski M, Sareen J, Ross D, Hoskins C, Pedlar D. Canadian Armed Forces Veterans: Mental Health Findings from the 2013 Life After Service Survey. Charlottetown PE: Research Directorate, Veterans Affairs Canada. Research Directorate Technical Report. Charlottetown. 19 March 2015.
This document reports analysis of the mental health findings from the 2013 Life After Service Survey of Canadian Armed Forces Veterans. The goal was to produce a comprehensive reference document to inform policies, programs, services and research intended to support the mental health and well-being of CAF Veterans after leaving service. The objectives were to describe need in terms of the prevalence and severity of mental health problems, identify characteristics of subgroups with and without mental health problems, describe service utilization by Veterans with mental health problems and identify possible implications of the findings for policies, programs and services. This first phase of the mental health analysis lays the foundation for part two: more precise estimates of the extent of mental health problems and multivariable modelling to identify factors that identify potentially vulnerable subgroups and potentially protective factors in CAF Veterans.
The 2013 survey (LASS 2013) extended the LASS 2010 survey by including Primary Reserve Force Veterans for the first time, and by including Regular Force Veterans who had released from 1998 to 2012. LASS 2010 surveyed Regular Force Veterans who released from 1998-2007. Like LASS 2010, LASS 2013 was a computer-assisted telephone interview survey, conducted by Statistics Canada for Veterans Affairs Canada (VAC) and the Department of National Defence (DND) in February-March 2013. The survey sampled former Primary Reserve Force personnel with Class A/B and C service who released from service 01 January 2003 to 31 August 2012 and Regular Force personnel who released 01 January 1998 to 31 August 2012:
- Reserve Force Class A/B. Veteran who was a Primary Reserve Force member with any Class B temporary full-time service in addition to Class A serviceFootnote 1.
- Reserve Force Reserve Class C: Veteran who was a Primary Reserve Force member with any Reserve Class C service in addition to Class A and possibly Class B service. Since 2002, Reserve Class C service was only authorized for those deployed on operations, domestically or internationally.
- Regular Force. Veteran who was a member of the Regular Force. Some in this category also had service in the Reserve Force.
ES1. Overview of Findings
Most Were Doing Well. Most CAF Veterans who released from service since 1998 had good mental health. The majority had very good to excellent self-rated mental health, did not have significant psychological distress, did not have diagnosed mental health conditions, and were not experiencing significant life stress.
Some had Mental Health Problems. The findings support ongoing enhancements of mental health services for CAF Veterans. Mental health conditions were much more prevalent in Regular Force and deployed Reserve Veterans than in the Canadian general population matched for age and sex. Non-deployed Reserve Veterans were like other young adult Canadians. The prevalence of diagnosed mental conditions was 24% in Regular Force Veterans, 17% in deployed (Class C) Reserve Veterans, and 9% in non-deployed (Class A/B) Reserve Veterans. The survey also included three measures of current mental health: 16% of Regular Force Veterans had fair/poor self-rated mental health, 13% had moderate or severe psychological distress, and 17% had markedly diminished mental health-related quality of life using the SF-12 mental component summary (MCS).
Impacts and Determinants of Mental Health Problems. These findings support VAC’s approach to supporting good mental well-being by providing access to services across a variety of determinants of health. Mental health problems in these Veterans were associated with multiple biopsychosocial factors including socioeconomic characteristics, military characteristics, measures of stress, coping and satisfaction, physical health status and comorbidity, and disability. Most Veterans with diagnosed mental health conditions had co-occurring chronic physical conditions.
Characteristics of Subgroups with Higher Prevalence of Mental Health Problems. The findings identified characteristics of subgroups more likely to have mental health problems. The likelihood of having a diagnosed mental health condition was highest in middle-aged versus younger and older Veterans; women; the widowed, separated and divorced; education other than post-secondary degree; unemployed and not working/not looking; those with lower income; and those who felt they had a difficult adjustment to civilian life. In Regular Force Veterans, the odds of having diagnosed mental health conditions were significantly elevated and highest in junior followed by senior non-commissioned members, 10-19 years of service (interrupted careers), and involuntary followed by medical release. About half of Veterans with diagnosed mental conditions had two or more mental conditions. Disability measured as activity limitations was more prevalent in Veterans with diagnosed mental health conditions than in those without. Mental health conditions were associated with low mastery, weak sense of community belonging, life stress, work stress, dissatisfaction and low social support.
Suicide Prevention. The findings support suicide prevention activities and identify subgroups more likely to be on suicidal pathways. Suicidal ideation was most prevalent in those with diagnosed mental health conditions and so was particularly prevalent among VAC clients. Suicidal ideation was also prevalent in those aged 40-49; women; education other than university degree; unemployed and unable to work; low income; medical release; junior NCMs including privates; physical and mental health conditions particularly those with both and with higher degrees of comorbidity; disability; not satisfied with life; home care and unmet needs for either type of health care. Suicidal ideation was more prevalent in VAC clients, consistent with the higher prevalence of health conditions in Veterans participating in VAC programs.
Transition to Civilian Life. The findings support provision of services for Veterans with mental health problems in transition to civilian life. Difficult adjustment to civilian life was much more prevalent in those with mental health conditions at the time of the survey than in those without (Regular Force 62% vs. 26%, Reserve Class C 59% vs. 17%). Of those with difficult adjustment, more than half (59%) of Regular Force Veterans had mental health conditions, as did nearly half (43%) of Reserve Class C Veterans. There is a gap in research on mental health influences at the time of transition.
Veterans Participating in VAC Programs. VAC staff serve Veterans with the most complex health problems. The majority (71%) of Regular Force Veterans with mental health conditions were participating in VAC programs, as were about half (49%) of Reserve Class C Veterans with mental health conditions. The majority with comorbid mental and physical health conditions, a measure of case complexity, were participating in VAC programs.
ES2. Extent of Mental Health Problems
Measures of Mental Health Problems. In this report, the phrase "mental health problem" is broadly inclusive of (1) any of the three diagnosed mental health conditions asked about in this survey, (2) other diagnosed psychological conditions not asked about in the survey, and (3) symptoms but no diagnoses. Five brief measures of mental health problems were used to capture dimensions of mental health: self-reported health conditions diagnosed by a health professional lasting 6 months or more, the Kessler K10 measure of psychological distress, a question on self-rated mental health, the SF-12 mental component summary (MCS) and the PC-PTSD (Primary Care – Posttraumatic Stress Disorder) screener. The latter four measures captured past month or current mental health status. Of the four stages in the CAF continuum of mental health -- healthy, reacting, injured and ill – these five indicators measure the latter three stagesFootnote 2.
Most are Doing Well. The majority of Veterans in all three groups had good mental health. Most did not have any of the common diagnosed mental conditions: 76% of Regular Force, 83% of Reserve Class C (deployed) and 91% of Reserve Class A/B (non-deployed) Veterans. The majority had very good/excellent self-rated mental health: 62% of Regular Force, 67% of Reserve Class C and 74% of Reserve Class A/B Veterans.
Prevalence of Diagnosed Conditions. The prevalence of diagnosed conditions (mood disorders, anxiety disorders or PTSD) was 24% in Regular Force, 17% in Reserve Class C (deployed) Reserve Force and 9% in Reserve Class A/B (non-deployed) Reserve Force Veterans. Regular Force and Reserve Class C Veterans had much higher prevalences of mood disorders, anxiety disorder and particularly PTSD than age-gender matched general Canadian population, and the prevalences were higher than reported for serving CAF personnel. Reserve Class A/B Veterans had much lower prevalences of mental health problems and so were much like similarly aged Canadians (39% had released as recruits). Prevalences of mental health problems were so low that further analysis was limited to Regular Force and Class C Reservists.
Prevalence of Current Mental Health Problems. Prevalences of each of the measures of current mental health status were lower than the prevalences of diagnosed conditions using cutoffs reflecting severe mental health states: 16% of Regular Force Veterans had fair/poor self-rated mental health, 13% had moderate or severe psychological distress using the K10 measure, and 17% had markedly diminished mental health-related quality of life using the SF-12 mental component summary (MCS). Using broader cutoffs to include less severe recent mental health status, the prevalence of good/fair/poor self-rated health was 39%, of mild, moderate and severe mental disorders using the K10 was 21%, and of below-norm mental health-related quality of life (SF-12 MCS < 50) was 33%.
Prevalence of Combinations of Diagnosed Mental Conditions and Current Mental Health Problems. Prior civilian and military population studies have established that there is a burden of impactful mental health problems larger than captured by mental health diagnoses alone. Measures of current or past month mental health problems did not fully overlap with diagnosed mental conditions. Those who did not report one of the diagnosed conditions but had mental health problems by the other four measures might have had one of the diagnosed conditions but did not report it on the survey, or had other diagnosed mental health conditions, or had undiagnosed or subthreshold symptoms.
Estimates of the prevalence of mental health problems using combinations of diagnosed conditions and other measures ranged 25-29% using cutoffs designed to capture more significant mental health states and 38-41% using cutoffs including Veterans with less severe mental health problems. For example, the proportion with diagnosed conditions or fair/poor SRMH (self-rated mental health) was 26%, while the proportion with diagnosed conditions and good/fair/poor SRMH was 41%.
Severity of Mental Health Problems. Mental health problems range in severity. Of those with diagnosed mental conditions:
- 30% had severe degrees of psychological distress using the K10 measure (7% of the population), while 34% had low K10 psychological distress scores meeting the "likely well" category (K10 score < 10).
- About half (55%) had very low mental health-related quality of life (MCS < 40) (13% of the population), while 45% had better HRQoL (> 40).
- About half (55%) had fair/poor self-rated health (13% of the population), while 13% were in the excellent/very good category.
ES3. Determinants and Impacts of Mental Health Conditions
Mental health problems in these Veterans were associated with a variety of biopsychosocial factors including socioeconomic characteristics; military characteristics; measures of stress, coping and satisfaction; physical health status and comorbidity; and disability. However LASS 2013, like all surveys of CAF serving personnel and Veterans, was a point in time snapshot (cross-sectional survey). So while it is possible to identify statistical associations between mental health problems and various factors, conclusions cannot be drawn about whether a causal relationship existed. Mental health problems can impact Veterans and families in a variety of ways, including ease of adjustment to civilian life, social relationships, employment, income, quality of life, disability, suicidality and resource utilization. However the same factors can also act as determinants of mental health, for example by contributing to the onset or chronicity of mental health problems.
Socioeconomic Characteristics. The likelihood of having a mental health condition was highest in middle aged versus younger and older Veterans; women; the widowed, separated and divorced; education other than post-secondary degree; unemployed and not working/not looking; and those with lower income.
Military Characteristics. In Regular Force Veterans, the odds of having diagnosed mental health conditions were significantly elevated and highest in junior followed by senior non-commissioned members, 10-19 years of service (interrupted careers), and involuntary followed by medical release. There did not appear to be an association with service branch.
Drinking and Smoking. The survey contained no data on substance use disorders and addiction, but two well-established health risks were assessed: alcohol drinking and smoking. Prevalence of mental health conditions was above average for daily smokers but not for heavy drinkers. The odds of having any of the three diagnosed mental health conditions was 2 times higher for daily smokers with mental health conditions compared to non-smokers but was not elevated for heavy drinkers with mental health conditions compared to those were not heavy drinkers. Heavy drinking is not a direct measure of addiction.
Physical Health. Comorbidity is the co-occurrence of two or more health problems in the same person. Comorbidity and especially multimorbidity (3 or more conditions) is correlated with poorer quality of life, more disability, greater case complexity and greater use of health services. About half of Veterans with diagnosed mental conditions had two or more mental conditions: 55% of Regular Force and 47% of Reserve Class C. Most Veterans with mental conditions had co-occurring physical conditions: 90% in Regular Force, 92% in Reserve Class C and 63% in Reserve Class A/B Veterans. Conversely, 30% of Regular Force Veterans with physical conditions had mental conditions, as did 24% of Reserve Class C and 12% of Reserve Class A/B Veterans.
Disability. All four types of activity limitations measured in LASS 2013 were more prevalent in Veterans with diagnosed mental health conditions than in those without. The odds of having mental health conditions were considerably higher in those with activity limitations, ranging from 4 and 5 (Reserve Class C and Regular Force) times higher in those with activities limited by pain and discomfort; to 8 times higher for activity restriction in life domains; to 11 and 9 times higher for needing assistance with at least one ADL; and to 12 and 20 times higher for those with psychological distress that interfered with life. In interpreting these numbers it is important to recall that chronic physical health conditions co-occurred in the great majority of those with mental health conditions.
Stress, Coping and Satisfaction. All six measures of stress, coping and satisfaction were, not surprisingly, significantly correlated with the presence of diagnosed mental health conditions: higher odds of mental conditions in those with weak sense of community belonging, low mastery, dissatisfaction with life, high life stress, work stress past year in those at work in the past year, and dissatisfaction with main activity in the past year. Odds ratios for having mental disorders were highest for low mastery, dissatisfaction with life and having extreme/quite a bit of life stress.
Social Support. Veterans with diagnosed mental health conditions had lower mean perceived social support.
Suicidal Ideation. Past-year ideation was present in 5% (95% C.I. 4-7%) of Reserve Class C and 7% (6-8%) of Regular Force Veterans and was more prevalent in those participating in VAC programs. Suicidal ideation was most prevalent in those with diagnosed mental health conditions; and also prevalent in those aged 40-49; women; education other than university degree; unemployed and unable to work; low income; medical release; junior NCMs including privates; physical and mental health conditions particularly those with both and with higher degrees of comorbidity; disability; not satisfied with life; home care and unmet needs for either type of health care.
Service Utilization. Most Reserve Class C and Regular Force Veterans had extended health insurance (prescription drugs, dental care, eye glasses). Differences between those with and without mental health care conditions were slight. Most Reserve Class C and Regular Force Veterans had a regular medical doctor. Home care utilization was significantly more prevalent in those with mental health conditions than in those without. Mental health problems are common among Veterans using VAC services: 47% of Regular Force clients had one of the three diagnosed mental health conditions asked about in the surveyFootnote 3 as did 50% of Reserve C clients.
VAC Program Participation. The majority (71%) of Regular Force Veterans with mental health conditions were participating in VAC programs, as were about half (49%) of Reserve Class C Veterans with mental health conditions. VAC staff work with Veterans who have the most complex health problems, measured as comorbidity of mental and physical health conditions. A significant proportion of clients in three key VAC programs had one of the three diagnosed mental conditions: 47% in the disability benefit program, 84% in the rehabilitation program and 60% in the Veterans Independence Program.
Much of the health status of VAC clients is not represented by administrative data: of those with any of the three diagnosed mental health conditions, about two thirds (65%) had VAC disability benefits for a psychiatric diagnosis while more than a third (35%) did not. About two-thirds of Regular Force Veterans with mental health problems identified in transition interviews prior to release had mental conditions in the survey; 63% of Regular Force personnel who released during 2006-12 had a transition interview, as did 12% of Reserve Class C Veterans.
Adjustment to Civilian Life. Of those with difficult adjustment, more than half (59%) of Regular Force Veterans had mental health conditions, as did nearly half (43%) of Reserve Class C Veterans. Difficult adjustment was much more prevalent in those with mental health conditions at the time of the survey than in those without (Regular Force 62% vs. 26%, Reserve Class C 59% vs. 17%).
The table below summarizes implications in two areas: policy, programs and services on the one hand, and further research on the other. There are implications for both population health and individual care. The findings in this report inform further analysis of the LASS 2013 survey data to provide greater insight into the mental health and well-being of CAF Veterans and inform researchers planning new studies to close gaps in knowledge of mental health in Veterans.
|Finding||Implications for Policy, Programs, Services||Implications for Research|
|Most Regular Force and Reserve Force Veterans were doing well in terms of employment, income, life satisfaction and mental health.||The majority of Veterans are well, countering the public misperception that most are not. Many with chronic health problems are living well.||Identify factors that promote good mental health in CAF Veterans.|
|The prevalence of mental health problems in Veterans was larger than in the general population.||Further supports the provision and enhancement of effective mental health care and rehabilitation services and social determinants of mental health.||Continued need for research into the determinants of mental health in military Veterans.|
|Reserve Class C (deployed) Veterans were more like Regular Force Veterans than non-deployed Reserve Veterans or the general population.||Deployed Reserve Veterans appear to require support services to the same extent as Regular Force Veterans.||The two groups could be combined for some analyses.|
|Reserve Class A/B Veterans on the whole were young and healthy with a relatively low burden of mental health problems. They had very low utilization of VAC services. More than a third (39%) released as recruits.||Class A/B Reservists generally require mental health supports to the same degree as similarly aged young adult Canadians in the general population.||Further studies could concentrate resources on deployed Reserve (Reserve Class C) and Regular Force Veterans.|
|Many with diagnosed conditions did not have significant current mental health problems (psychological distress, self-rated poor mental health or poor mental health-related quality of life).||Not all with diagnosed conditions require high levels of support services.||Use measures of current mental health status in conjunction with diagnosed conditions (mental illness) to measure population mental health problems.|
|Many with current mental health problems (psychological distress, self-rated poor mental health or poor mental health-related quality of life) did not have diagnosed conditions.||Some might have had unrecognized and undiagnosed conditions, others might have had subthreshold symptom states that nevertheless impact quality of life and could evolve into mental illness.||Further analysis using combinations of measures of mental health status will better clarify mental health service needs in CAF Veterans.|
|Since this was a cross-sectional study, fluctuations of mental health problem severity within individual life courses is unknown.||Difficult to target the provision of supports across the life course after service; importance of individualized services.||Longitudinal studies being planned will clarify the natural history of Veterans’ mental health problems over their life courses.|
|Multiple socioeconomic characteristics and physical health conditions were associated with mental health problems in the Veterans in analyses.||Identifies CAF Veteran subgroups with higher rates of mental disorders. Supports programs and services that enhance Veterans' well-being by addressing multiple determinants of health, including both physical and mental health services and the social determinants (education, employment, income and social support).||Determine relative effectiveness of providing supports for socioeconomic determinants of health in managing mental health in Veterans. Multivariable analyses accounting for confounding would clarify the relative role of potential determinants and impacts of mental health problems in CAF Veterans.|
|Prevalences of mental health problems were higher in middle age groups than in younger or older Veterans.||Identifies age groups for targeting resources.||Longitudinal studies being planned will clarify changes in Veterans’ mental health needs over their life courses.|
|Regular Force female Veterans were 1.6 times more likely than men to have one or more of the diagnosed mental conditions and more likely to have fair/poor self-rated mental health.||Identifies female Veterans as a group for targeted programming and attention in service delivery.||Samples sizes of women are low in military Veteran surveys, limiting conclusions that can be drawn about determinants of mental health in women Veterans.|
|Odds of having diagnosed mental conditions were highest in those with other than university degree education, not employed and low income.||Evidence for programs that enhance well-being through education, employment and income supports.||In studies of employment and income in CAF Veterans, consider mental health status and mental health-related activity limitations.|
|The odds of having mental health conditions were higher in non-commissioned members than officers.||There might be important differences in the types of supports required by NCMs as they transition to civilian life.||Better understand why mental health problems are more prevalent in CAF Veterans who released with non-commissioned ranks.|
|The odds of reporting a difficult adjustment to civilian life were ten times higher in Regular Force Veterans with diagnosed mental conditions at the time of the survey, and eight times higher in deployed Reserve Veterans.||Suggests the importance of promoting mental well-being in transition in promoting good mental health later in life.||Clarify the life course influences of mental health in CAF Veterans from transition to later in life.|
|There is a gap in research on mental health influences at the time of transition.||Evidence for transition supports is largely anecdotal.||Need for research in mental health during transition.|
|Of the three-quarters of Regular Force Veterans who were employed in the civilian workforce, one in six had a diagnosed mental condition, one four had below average mental health-related quality of life, one in twelve had moderate to severe psychological distress and one in ten had fair/poor self-rated mental health.||People with mental health problems engage in productive employment. Consider supports for employed Veterans with mental health problems who are having difficulty finding or retaining employment.||Assess workforce attachment in CAF Veterans with mental health problems.|
|Mental health problems were increasingly more prevalent in Veterans who were unemployed, not working and not looking for work, and unable to work.||While poor mental health is related to not having a work role, incentives and supports promoting mental health likely play a role in returning Veterans to employment.||Identify effective strategies for optimizing mental health around employment.|
|Diagnosed physical health conditions were very common in those with mental health conditions: 90% in Regular Force, 92% in deployed Reserve and 63% in non-deployed Reserve Veterans.||Mental health promotion requires attention to both physical and mental health in policies, programs and services. Points to the importance of primary and collaborative multidisciplinary care.||Consider physical health when studying the determinants, impacts and management of mental health problems in CAF Veterans.|
|The likelihood of having mental conditions was much higher in those with measures of high stress, difficulty coping, low perceived social support, and various measures of dissatisfaction.||This finding supports the importance of relieving stress, enhancing mastery and coping skills, and improving satisfaction through social support, counselling, rehabilitation and support for the social determinants of health.||Important confounders to consider in multivariable analyses. Further research needed to understand causality and identify effective means of addressing these factors to promote mental well-being.|
|The odds of having mental conditions were 8-11 times higher in those with activity restriction in major life domains and needing for assistance with activities of daily living than in those without these measures of disability.||Mandates attention to mental as well as physical health conditions in mitigating disability.||Consider mental health in studies of disability in military Veterans.|
|One in five Regular Force and Reserve Class C Veterans with diagnosed mental health conditions had past-year suicidal ideation.||Reinforces importance of providing effective mental health care.||Identify factors influencing suicide in CAF Veterans.|
|One in eight CAF Veterans participating in VAC programs had past-year suicidal ideation.||Not surprising since Veterans seek VAC assistance with chronic health problems but reinforces importance of engaging in effective suicide prevention activities.||Evaluate effectiveness of suicide prevention activities for Veterans with chronic health problems and disability.|
|Veterans had significant rates of attributing their mental health conditions to military service.||Assess program reach and provide effective communications about relationship of mental health problems to prior military service versus post-service factors.||Determine relationship between military service and post-service mental health.|
|Veterans participating in VAC programs have mental health conditions beyond those identified in VAC disability benefit administrative data.||Benefit administrative data does not give a full picture of mental health status of VAC clients.||Reinforces importance of conducting whole-population studies.|
|In VAC clients, there was an association between presence of a mental health problem in the transition interview prior to release and presence of a diagnosed mental health condition in the survey after release.||Survey findings can be used to inform screening for risk of poor transition outcomes.||Suggests potential role for transition interview findings in further research. Longitudinal research required to clarify the life course natural history of mental disorders in CAF Veterans.|
|Most Regular Force and Class C Reservists with diagnosed mental health conditions had regular medical doctors.||Importance of including family physicians and general practitioners in VAC services and informing them about Veterans’ health issues.||Linkage to provincial databases would provide insights into health care provided in the provincial healthcare systems.|
|Most Regular Force and Class C Reservists with diagnosed mental health conditions had health insurance.||Those without insurance might require alternative supports.||Could be of value in assessing outcomes of VAC programs.|
ES4. Interpretation Guidance
The findings in this report describe the health and well-being of the three subgroups of CAF Veterans.
- This descriptive study had limited controls for chance and confounding, so be cautious about concluding that there are differences or similarities between groups when there is no adjustment for differences in age, gender and other characteristics and statistical test results are not reported.
- LASS 2013 was a point-in-time, cross-sectional survey, therefore causal conclusions cannot be drawn from this study alone, including the effects of military service or DND/CAF/VAC programs on Veterans' later life courses.
- Be cautious about drawing conclusions about the presence of "risk" and "protective" factors. Inferential statistical methodology such as regression modeling will be required to control for confounding, meaning the joint effects of characteristics and indicators on each other, and since this was a cross-sectional analysis then causality cannot be inferred.
- Findings cannot be generalized to all Veterans because the survey included only those who released in 1998-2012 (Regular Force) and 2003-2012 (Reserve Force).
ES5. Next Steps
This descriptive analysis of the mental health findings in LASS 2013 yielded valuable insights into the extent, determinants and impacts of mental health in CAF Primary Reserve and Regular Force Veterans who released from service since 1998. Further analyses in progress will deepen understanding of the mental health and well-being of these Veterans to inform policy, programs and services to support CAF Veterans.
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