Suicide Surveillance and the CF Cancer and Mortality Study · Suicide Surveillance and the CF...

Canadian Forces Health Services Group Groupe des Services de santé des Forces canadiennes

Suicide Surveillance and the CF Cancer and Mortality Study

Dr. Elizabeth Rolland-Harris Senior Epidemiologist / Project Lead, CF CAMS II

Military Mental Health Research Symposium

03 May 2016


Faculty/Presenter Disclosure

• Faculty: Elizabeth Rolland-Harris

• Relationships with commercial interests: – None

CFPC CoI Templates: Slide 1


Disclosure of Commercial Support

• No commercial support

• Potential for conflict(s) of interest: – No potential for conflict of interest



Mitigating Potential Bias

• N/A



Overview

• Suicide Surveillance in the CAF – Retrospective epidemiological suicide surveillance portfolio – Canadian Forces Cancer and Mortality Study (CF CAMS I and II)


Retrospective Epidemiological Suicide Surveillance

• Currently includes data from 1995–2014 – Updated annually – 2015 in process

• Includes Regular Force males

7


Number of Suicides by Year Regular Force Males, 1995–2014

0

5

10

15

20

2519

9519

9619

9719

9819

9920

0020

0120

0220

0320

0420

0520

0620

0720

0820

0920

1020

1120

1220

1320

14

Annu

al n

umbe

r of s

uici

des

Year


Problems with crude numbers

• Don’t take into account changes in the population numbers

• Don’t take into account changes in the age/sex distribution of the population


Epidemiologists prefer…

• Standardized rates – In particular, standardized ratios (mortality, incidence)


Why?

• Use a reference/comparison population – May be useful as a yardstick in assessing severity of problem

• Takes into consideration (“controls for”) differences in the age/sex distribution of two different populations


Standardized mortality ratios – a refresher

• Standardized mortality ratio:

Observed # of suicide deaths Expected # of suicide deaths


Comparison of CAF Regular Force Male Suicide Rates to Canadian Male Rates Using Standardized Mortality Ratios

0

20

40

60

80

100

120

140

160

180

200

1995-1999 2000-2004 2005-2009 2010-2011

SMR

Year range


SMRs for Suicide in the CAF Regular Force Male Population by History of Deployment: 1995-2011

0

50

100

150

200

250

1995-1999 2000-2004 2005-2009 2010-2011

SMR

s

Year range

With history No history


Army vs. Non-Army – Significant age-adjusted findings

• Army vs. non-Army – Army: 30.14 per 100,000 population (95% CI: 23.31, 36.97) – Non-Army: 14.95 per 100,000 population (95% CI: 11.34, 18.56)

• Combat Arms vs. non-Combat Arms – CA: 30.35 per 100,000 population (95% CI: 23.03, 39.69) – Non-CA: 18.21 per 100,000 population (95% CI: 14.75, 22.54)


Suicide is multi-factorial…

Suicide is the result of “…complex interrelationships

among a multiplicity of characteristics.”

- E. Durkheim, Suicide: A Study in Sociology (1970)



• So looking at the numbers is only one dimension • Understanding the population and trying to explain what

might contribute to the numbers is also important


MPTSR

• Medical Professional Technical Suicide Report • Policy-mandated investigations of all confirmed suicide

cases – Regular and Reserve Force – Males and Females

• NB. Results presented here are only Regular Force

Males


Demographics

• Marital Status – Never married: 13.3% – Common law: 13.3% – Married: 60.0% – Legally divorced/separated: 13.3%


Demographics (2)

• Highest level of education – Some high school: 20.0% – High school graduate: 46.7% – Some college/technical school: 6.7% – College degree: 6.7% – Bachelor’s degree: 13.3% – Master’s degree or higher: 6.7%


Methods of Suicide

• Hanging: 53.3%* • Firearm/gun (non-military issue): 26.7%* • Asphyxiation: 13.3% • Drugs: 6.7%

* Also most common methods of suicide in Canadian population


Mental Illness Factors

• Mood disorder: 53.3% – Depression: 40.0% – Dysthymia: 6.7%

• Anxiety disorder: 26.7% – Panic disorder: 13.3% – Acute stress disorder: 6.7%

• Both mood and anxiety disorder: 26.7%


Mental Illness Factors (2)

• PTSD: 13.3% • mTBI: 20%


Other Stressors

Factor N (%) Failed/failing spousal/intimate partner relationship

12 (80%)

Failed other relationship (e.g. family, friends) 4 (26.7) Completed spousal, family or friend suicide 5 (33.3) Family or friend death (other than suicide) 1 (6.7) Physical health problem 7 (46.7) Ill family member 3 (20.0) Debt 6 (40.0) Job, supervisor or work performance problems 8 (53.3) Legal problems 6 (40.0)


Non-Mental Health Factors (2)

• >1 stressor at time of death: 80%

• 4-7 concomitant factors: 46.7%

• Legal or disciplinary proceeding or an administrative review process at time of death: 46.7%


26

Canadian Forces Cancer and Mortality Study (CF CAMS)

• Study population included any Regular Force member enrolled between 1972 and 2006, inclusive

• Included both males and females • Cohort looked at in two ways:

– Entire cohort (still serving and released) (n=188,161)

– Released only cohort (n=112,225) • Cohort data linked to:

– Canadian Mortality Database

27

Suicide as Cause of Death Regular Force, 1972-2006

Cohort Males Females

# (%) SMR (95% CI) # (%) SMR

(95% CI) ENTIRE All Causes 3,675

(100.0%) 0.64

(0.62,0.66) 294

(100.0%) 0.67

(0.59,0.75) Suicide 897

(24.4%) 1.01

(0.94,1.07) 37

(12.6%) 0.99

(0.69,1.37) RELEASED All Causes 2,620

(100.0%) 0.77

(0.74,0.80) 204

(100.0%) 0.70

(0.60,0.80) Suicide 696

(26.6%) 1.46

(1.35,4.56) 29

(14.2%) 1.32

(0.88,1.89)


28

Cox Proportional Hazards Model for Suicide – Released Cohort, 1972-2006

• Looked at the factors associated with the likelihood of completing suicide in the released cohort

• Cox Proportional Hazards (PH) Model controls for several risk factors at the same time: – Sex, rank, age at release, reason for release,

years of service, period of military service


29

Cox Proportional Hazards Model for Suicide – Released Cohort, 1972-2006 - Results

• Who is at higher risk of dying by suicide ? – Males – Non-Commissioned members – <10 years of military service – Non-voluntary release – Serving between 1972-1986



Suicide is the result of “…complex interrelationships

among a multiplicity of characteristics.”

- E. Durkheim, Suicide: A Study in Sociology (1970)


Upcoming Research

• CF CAMS II study

CF CAMS I vs II

CF CAMS I • 1972-2006 (35 years) • Cohort built with HRMS

data • Had incomplete reservist

data • Probabilistic linkage • No cancer morbidity

outcomes

CF CAMS II • 1976-2015 (40 years) • Cohort built with pay data • Includes Class C

reservists • Probabilistic linkage but

includes SINs for full cohort

• Will look at mortality in 2017-2018

• Will look at cancer morbidity in 2018-2019


Conclusions

1. Deployment may be a factor in suicides in the CAF, but

– further work is needed to define “deployment” – Looking at other possible (confounding?) factors are necessary to better understanding the true effect of “deployment” as a risk factor for suicide in CAF – as traumatic exposures are not experienced in all deployments


Conclusions

2. Army members have a significantly higher rate of suicide, particularly within the Combat Arms trade


Conclusions

3. In 2014, Regular Force males who took their own lives had psycho-social stressors that may have influenced their actions


Conclusions

4. Released males are a vulnerable sub-population and further research is being conducted on this group

5. Policy- and decision-makers should be encouraged to target suicide prevention priorities outlined in these evidence-based findings.


Conclusions

6. DFHP Epidemiology, in conjunction with its colleagues (DMH, VAC, STC) will continue to conduct surveillance and research into suicide in the CAF (and Veteran) population and will continue to try and better understand the multifactorial nature of the problem


Questions?


For more information

Elizabeth Rolland-Harris MSc PhD Directorate of Force Health Protection,

Department of National Defence

[email protected]

http://www.forces.gc.ca/en/about-reports-pubs-health/report-on-suicide-mortality-caf-2015.page

mailto:[email protected]

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