2021 Report on Suicide Mortality in the Canadian Armed Forces (1995 to 2020)
List of Figures
List of Tables
- Table 1: Mental Health Factors
- Table 2: Prevalence of Documented Work and Life Stressors Prior to Suicide
- Table 3: CAF Regular Force Male Multiyear Suicide Rates (1995 – 2020)
- Table 4: Comparison of CAF Regular Force Male Suicide Rates to Canadian Male Rates Using Standardized Mortality Ratios (SMRs) (1995 – 2019)
- Table 5: Standardized Mortality Ratios for Suicide in the CAF Regular Force Male Population by History of Deployment (1995 – 2019)
- Table 6: Comparison of CAF Regular Force Male 5-Year Suicide Rates by Deployment History Using Direct Standardization (1995 – 2020)
- Table 7: Standardized Mortality Ratios for Suicide in CAF Regular Force Males by Environmental Command (2002 – 2019)
Abstract
Introduction: Each death from suicide is tragic. Suicide prevention is an important public health concern and is a top priority for the Canadian Armed Forces (CAF). In order to better understand suicide in the CAF and refine ongoing suicide prevention efforts, the Canadian Forces Health Services annually examine suicide rates and the relationship between suicide, deployment and other potential suicide risk factors. This analysis, conducted by the Directorate of Mental Health (DMH), is an update covering the period from 1995 to 2020.
Methods: This report describes crude suicide rates from 1995 to 2020, comparisons between the Canadian population and the CAF using Standardized Mortality Ratios (SMRs), and suicide rates by deployment history using SMRs and direct standardization. It also examines variation in suicide rate by environmental command, and uses data from Medical Professional Technical Suicide Reviews (MPTSR) to examine the prevalence of other suicide risk factors for suicide deaths that occurred in 2020.
Results: There were no statistically significant increases in the overall suicide rates that were calculated for each incremental time segment over 1995 to 2020. The number of Regular Force males that died by suicide was not statistically higher than that expected based on male suicide rates in the Canadian General Population (CGP) for each time period that was evaluated.
Rate ratios comparing Regular Force males with a history of deployment to those without this history did not establish a statistically significant link between deployment and increased suicide risk. The findings for the 2015 – 2019 period suggest that the suicide rate in those with a history of deployment was slightly higher but not statistically different when compared to those with no history of deployment (age-standardized suicide rate ratio: 1.04 [95% CI: 0.55, 1.94]). This is concordant with the 10-year (2005 – 2014) pattern which indicated that those with a history of deployment were possibly at a higher risk of suicide than those with no such history (age-adjusted suicide rate ratio: 1.45 [95% CI: 0.97, 2.16]); an elevated rate that was also statistically non-significant.
These rate ratios also highlighted that, since 2006 and up to and including 2020, being part of the Army command was associated with a higher risk of suicide relative to those who were part of the other environmental commands (age-standardized suicide rate ratio: 2.09 [95% CI: 1.60, 2.72]). The 3-year suicide rate moving average suggested that the gap between Army and non-Army command suicide rates appears to be narrowing. Regular Force males in the Army combat arms occupations had a statistically significant higher suicide rate (31.62/100,000 [95% CI: 25.44, 39.34]) compared to Regular Force males in other occupations (18.13/100,000 [95% CI: 15.32, 21.44]).
Results from the 2020 MPTSRs continue to support a multifactorial causal pathway (this includes biological, psychological, interpersonal, and socio-economic factors) for suicide rather than a direct link between single risk factors (such as Post-Traumatic Stress Disorder (PTSD) or deployment) and suicide. This was consistent with MPTSR findings from previous years. While all CAF members experienced the COVID-19 pandemic, its contribution to stressors and suicide risk were not able to be assessed.
Conclusions: Suicide rates in the CAF did not increase with any statistical significance over the period of observation described in these findings, and after age standardization they were also not statistically higher than those in the Canadian general population. Despite the added stressors associated with the COVID-19 pandemic, the observations in 2020 were comparable to those from previous years. However, small numbers do limit the ability, or power, of statistical assessments to detect differences with statistical significance when they are real and not chance occurrences. The increased risk in Regular Force males under Army command compared to those under non-Army commands, although decreasing, is a finding that continues to be under observation by the CAF.
Keywords: Age-adjusted rate; Canadian Armed Forces; Canadian population; deployment; rate ratio; rates; standardized mortality ratio; suicide.
Executive Summary
The tragic loss of life of Canadian Armed Forces (CAF) members due to suicide requires ongoing focus to understand these difficult events and to refine CAF suicide prevention efforts. This report describes the suicide experience in the CAF and the descriptive characteristics of Regular Force males that died by suicide between 1995 and 2020, with additional information on the risk factors associated with Regular Force males that died by suicide in 2020.
Methods
Data described in Section 3.1 [Results from the Medical Professional Technical Suicide Review (MPTSR) Reports, Regular Force Males, 2020 Results Only] are drawn from the 2020 MPTSRs. The MPTSR is one of the investigations that follows each CAF suicide. The MPTSR is a quality assurance tool for Canadian Forces Health Services (CFHS) that is requested immediately following the confirmation of all Regular Force and Primary Reserve Force suicides. Each MPTSR is typically conducted by a team consisting of a mental health professional and a primary care physician.
Epidemiological data described in Section 3.2 (Epidemiology of Suicide in Regular Force Males, 1995 – 2020, inclusive) and 3.3 (Epidemiology of Suicide in Regular Force Males, by environmental command, 2002 – 2020, inclusive) was obtained from the Directorate of Casualty Support Management up until 2012. As of September 2012, the number of suicides was tracked by DMH. Information on deployment history and CAF population data originated from the Directorate of Human Resources Information Management (DHRIM). Finally, Canadian general population data and suicide counts, by age and sex, were obtained from Statistics Canada.
Frequencies, crude rates, standardized mortality ratios (SMRs) (ratio of observed number of CAF suicides to expected number of CAF suicides, if the CAF were to have the same age and sex-specific rates as the Canadian general population) and directly standardized rates were calculated. SMRs were calculated until 2019 in this report because Statistics Canada has released data for the Canadian general population only up to that year.
This report, as in the past, analyses only Regular Force males who have died by suicide. The annual female Regular Force and Reserve force suicide deaths were insufficient to conduct trend analyses comparable to what has been completed for male Regular Force members, as detailed reporting poses a potential privacy concern. Additionally, there is a lack of access to data for Reservists as they receive much of their health care in the provincial system and the associated information tends to be unavailable during the MPTSR process.
Results
Mental Health Diagnosis of Those Who Died by Suicide in 2020
The mental disorders that were identified among the Regular Force males at the time of their suicide death in 2020 included depressive disorders (63.6%), anxiety disorders (27.3%), post-traumatic stress disorder (27.3%), or other trauma and stress-related disorders (36.4%). A documented addiction or substance use disorder was reported in (63.6%) of these suicide deaths. It was common (63.6%) for these members to have at least two active mental health problems at the time of death (i.e., a combination that could include: depressive disorders, trauma and stress-related disorders, anxiety disorders, addictions or substance-use disorders, traumatic brain injury or personality disorders).
Work/Life Stressors of Those Who Died by Suicide in 2020
At the time of death, 90.9% of the Regular Force males that died by suicide in 2020 were reported to have had at least one prominent work and/or life stressor (such as failing relationship(s), friend/family suicide, family/friend death, family and/or personal illness, debt, professional problems or legal problems); just over half (56.5%) had two or more concomitant stressors prior to their death. Additionally, all CAF members were exposed to the COVID-19 pandemic and as such, this was a common stressor among all subsets of this population. However, while some individuals may have had unique stressors that were amplified during, or possibly attributable to, the Covid-19 pandemic, this was not something that was able to be assessed among those who died by suicide as this data was not systematically collected.
Crude Suicide Rates, 1995 – 2020
The 2015 – 2019 5-year crude suicide rate for Regular Force males was 24.5 per 100,000 population (95% CI: 19.2, 31.2); the 2020 single year crude suicide rate was 21.0 per 100,000 population (95% CI: 10.8, 36.7). This 5-year rate was consistent with the earlier 2010-2014 crude rate (24.3/ 100,000 [95% CI: 19.0, 31.0]). Additionally, the suicide rate confidence intervals for all measured 5-year periods had some degree of overlap, suggesting a low likelihood of statistically significant differences among the crude rates over time.
Annual suicide numbers among Regular Force Females have, to-date, been low; they typically range between zero and two events per year, but as high as three in one year. This relatively low number of annual female suicides poses reporting challenges, both in protecting privacy and maintaining confidentiality of the deceased as well as in drawing any meaningful statistical inferences due to lack of statistical power. However, over the course of the coming year, work will be done to explore this further and determine what meaningful patterns and trends can be confidently discerned about female suicides from the available data.
Comparison of CAF Regular Force Male Suicide Rates to Canadian Rates Using Standardized Mortality Ratios, 1995 – 2019
The SMR for 2010 – 2014 (126% [95% CI: 99, 159]) and for 2015 – 2019 (122% [95%CI: 96, 155]) both appear to be statistically non-significant, suggesting that, for both time periods, the observed number of Regular Force male suicides was similar to what would be expected in the Canadian male general population if it had the same age distribution. However, the SMR for the 2010 – 2014 period was very close to being statistically significant and warrants some hesitancy in identifying this as statistically non-significant.
Impact of Deployment on CAF Regular Force Male Suicide Rates
SMRs were calculated separately for those with a history of deployment (96% [95%CI: 78, 117]) and those without this history (93% [95%CI: 76, 114]) for the 1995 – 2019 period. These did not identify a statistically significant difference in suicide rates relative to the male Canadian general population when age was taken into account.
Impact of Environmental Command on CAF Regular Force Male Suicide Rates
An age-standardized suicide rate ratio was calculated to compare Army to non-Army commands for the 2002 – 2020 period. This was statistically significant (2.09 [95% CI: 1.60, 2.72]), indicating a higher suicide rate among Regular Force males in the Army command. This finding was supported by a statistically significant higher Army command SMR in the 2007 – 2011 period (182% [95% CI: 129, 249]) and the 2012 – 2016 period (199% [95% CI: 143, 269]), indicating that suicide rates were higher than what would be expected among the male Canadian population when age was taken into account.
The crude suicide rate among the Regular Force male population who were in an Army combat arms occupation was also calculated. For the 2002 – 2020 period this crude suicide rate was found to be higher than the overall rate among Regular Force males in other occupations (i.e., 31.62/ 100,000 [95% CI: 25.44, 39.34] for Army combat arms occupations versus 18.13/ 100,000 [95% CI: 15.32, 21.44] among others).
Conclusion
Suicide rates in the CAF did not increase with any statistical significance over the period of observation described in these findings, and after age standardization they were also not statistically higher than those in the Canadian general population. Additionally, despite the added stressors associated with the COVID-19 pandemic, the suicide rate and its related characteristics in 2020 were comparable to observations from previous years. However, small numbers do limit the ability, or power, of statistical assessments to detect differences with statistical significance when they are real and not chance occurrences. The increased risk in Regular Force males under Army command compared to those under non-Army commands is a finding that, although decreasing, continues to be under observation by the CAF.
1. Introduction
Each death from suicide can have a tragic impact on families, friends, and colleagues. Suicide prevention is an important public health concern in Canada and is a top priority for the Canadian Armed Forces (CAF). The CAF Suicide Prevention Action Plan reflects the CAF’s commitment to ensuring that everything that can be done is done to mitigate the risk of suicide. The investigation and analysis of deaths from suicide by CAF members provides valuable information that can assist in guiding and refining ongoing suicide prevention efforts. This annual report is one method used to ensure that clinical and prevention programmes are optimised.
There has been concern since the early 1990s about the rate of suicide in the CAF and its possible relationship to deployment. In response to these concerns, the CAF began a suicide mortality surveillance program to determine the rate of suicide among CAF personnel in comparison to the Canadian general population (CGP), as well as the rate of suicide in those personnel with a history of deployment compared to those without such a history.
Historically the reports have focused on the surveillance and epidemiology of suicide within the CAF. Since 2015, the report has expanded its scope to describe additional information related to suicide in the CAF including an in-depth analysis of the variation of suicide rates by environmental command. This report also provides information on the underlying risk factors that may have contributed to the Regular Force male suicides that took place in 2020 based on an assessment of the Medical Professional Technical Suicide Reviews (MPTSRs).
This report, as in the past, analyses only Regular Force males who have died by suicide. MPTSRs are completed for all CAF deaths from suicide, including Reserve and female members; however, data from those investigations are not included in this analysis for the following reasons:
- Female suicide numbers are small (range between 0 and 2 events per year), which precludes the ability to conduct trend analyses. In addition, reporting separately on their characteristics would contravene the privacy of the involved individuals (“identity” and “attribute” disclosureFootnote 1).
- For Reserve Force data there are issues associated with completeness, in addition to concerns with possible identity and attribute disclosure as discussed above. Since many Reserve Force members receive their health care in the provincial health care system, Reserve member reporting and their available records may be incomplete.
- Since data on suicide attempts is often incomplete, due to differences in its definition and inconsistent reporting by members, and in keeping with other occupational health studies, this report evaluates only deaths from suicide, not attempts. Furthermore, the data used for this analysis include only those who have died of suicide while active in the Regular Forces, and do not include those who have died of suicide after retirement from the military. For more information on Veterans see the 2019 Veteran Suicide Mortality Study [2].
2. Data Sources and Methods
2.1 Data Sources
2.1.1 Medical Professional Technical Suicide Review
Data on suicide risk factors (mental health and psycho-social factors) are collated from the Medical Professional Technical Suicide Reviews (MPTSR). MPTSRs are requested by the Canadian Forces Health Services (CFHS) when a death is deemed to have been due to suicide, and are conducted by military medical professionals. This team reviews all pertinent health records and conducts interviews with family members, health care providers, and colleagues who worked with the member and who may be knowledgeable about the circumstances of the death. MPTSRs began in 2010 as a Quality Assurance tool within the CFHS to provide the Surgeon General with observations and recommendations for optimising suicide prevention efforts within CFHS. All MPTSR information is collected and managed by the Directorate of Mental Health (DMH).
Six mental health factor categories and nine work and life stressor categories were enumerated. Each was identified as present if it was considered to be an active issue around the time of death. It should be noted that all members were exposed to stressors associated with the COVID-19 pandemic during 2020. For some, this added stressor may have increased the risk of suicide, either directly or indirectly through its influence on other stressors; however, the contribution of the pandemic to suicide deaths was not captured in the MPTSR investigations and as such, no valid conclusion can be drawn about its influence. The mental health factor categories included:
- depressive disorders: i) disruptive mood dysregulation disorder; ii) major depressive disorder, single and recurrent episodes; iii) persistent depressive disorder (dysthymia); iv) premenstrual dysphoric disorder; v) substance/medication-induced depressive disorder; vi) depressive disorder due to another medical condition; vii) other specified depressive disorder; and, viii) unspecified depressive disorder.
- trauma and stressor-related disorders: i) reactive attachment disorder; ii) disinhibited social engagement disorder; iii) posttraumatic stress disorder; iv) acute stress disorder; v) adjustment disorders; vi) other specified trauma- and stressor-related disorder; and, vii) unspecified trauma- and stressor-related disorder.
- anxiety disorders: i) separation anxiety disorder; ii) selective mutism; iii) specific phobia; iv) social anxiety disorder (social phobia); v) panic disorder; vi) panic attack; vii) agoraphobia; viii) generalized anxiety disorder; ix) substance/medication-induced anxiety disorder; x) anxiety disorder due to another medical condition; xi) other specified anxiety disorder; and xii) unspecified anxiety disorder.
- addictions or substance-use disorders;
- traumatic brain injury: considered to be an active issue if it occurred at any time in an individual’s past; and
- personality disorders: considered an active issue if it was identified at any time in an individual’s past
The work and life stressor categories included:
- failed or failing spousal or intimate partner relationship;
- failed or failing other relationship (e.g. family, friends);
- completed spousal, family or friend suicide (considered to be an active issue if it had occurred at any time in an individual’s past);
- family or friend death (other than suicide);
- physical health problem;
- chronic illness in spouse or family member;
- excessive debt, bankruptcy or financial strain;
- job, supervisor or work performance problem; and
- legal problems (e.g. child custody dispute, litigation).
2.1.2 Epidemiological Surveillance
Information on the number of suicides and demographic information was obtained from the Directorate of Casualty Support Management (DCSM) up to 2012. As of September 2012, suicides were tracked and data provided by DMH. DMH cross-references their results with those collected by the Administrative Investigation Support Centre (AISC), which is part of the Directorate Special Examinations and Injuries (DSEI).
Information on deployment history and CAF population data (i.e., age, sex, unit, command, Military Occupational Structure ID/Military Occupation code (MOSID/MOC) and deployment history) for active members, as of July 1st of a given year, originated from the Directorate of Human Resources Information Management (DHRIM). History of deployment was based on data from DHRIM; deployments included all international assignments with a location outside of Canada and the U.S. and, when determinable, excluded training, exercises, and meetings with international partners. It should be noted that the number of active personnel in a given year and those with a history of deployment occasionally changes from previous reports due to updating of DHRIM records. Additionally, command was categorized into one of four environmental command groupings (Army, Air, Navy, or other command) based on individuals’ last specified command or in some cases, unit information.
Canadian suicide counts by age and sex were obtained from Statistics Canada. Data were available up to 2019 at the time of preparation of this report. Canadian suicide rates are derived from death certificate data collected by the provinces and territories and collated by Statistics Canada. Codes utilized for this report were ICD-9 E950-E959 (suicide and self-inflicted injury) in the Shelf Tables produced by Statistics Canada from 1995 to 1999. For 2000 to 2019 the number of suicide deaths was based on ICD-10 codes X60-X84 and Y87.0 utilizing Table 13-10-0392-01 ‘Deaths and age-specific mortality rates, by selected grouped causes’ from Statistics Canada. During Statistics Canada’s production of each year's death statistics, data from previous years may have been revised to reflect any updates or changes that had been received from the provincial and territorial vital statistics registrars. Open verdict cases (ICD-9: E980-E989; ICD-10: Y10-Y34, Y87.2) are excluded by Statistics CanadaFootnote 2, although they are routinely included in suicide statistics reported elsewhere (e.g., UK – both in civilian and military contexts). To ensure valid comparisons, the Statistics Canada exclusions were followed for these analyses. CGP denominators up to 2000 were taken from Statistics Canada CANSIM Table 051-0001; from 2000 onwards, they were taken from Table 17-10-0005-01 ‘Population estimates on July 1st, by age and sex’. Denominator numbers, up to and including 2015, were final inter-censal estimates; however, while the denominator numbers were final post-censal estimates for 2016 to 2018, for 2019 the estimates were updated post-censal ones.
For the CAF members who died from suicide, information on component, environment, MOSID/MOC, last known department description and last known location were obtained through a request to the Directorate of Human Resources Information Management (DHRIM) or from MPTSR data, with preference given to the MPTSR information when it was present.
Command was ascertained by one of three possible methods:
- If command was explicitly stated in the MPTSR or in the Suicide Event Report for an individual (2011 – 2020 cases), that command information was used.
- When information as to which CAF command an individual belonged was not available in the MPTSR or the DCSM/AISC database, individuals were assigned into Army or Non-Army command categories based on their home unit information.
- In some cases, MOSID and rank were also used to classify individuals if the home unit information was not clear. This subjective method may have led to misclassification of some suicides into an incorrect command, affecting the validity of the results.
MOSID information for the analysis involving the combat arms Army occupations was obtained directly from DHRIM. Individuals were considered to be employed in combat arms Army occupation if they had the following MOSIDs: 00005 (CRMN), 00008 (ARTYMN-FD), 00009 (ARTYMN-AD), 00010 (INFMN), 000178 (ARMD), 000179 (ARTY), 000180 (INF), 000181 (ENGR), 00339 (CBT ENGR) and 00368 (ARTYMN) (since 2012).Footnote 3
2.2 Methods
Crude CAF Regular Force male suicide rates were calculated from 1995 to 2020. Suicide rates prior to 1995 have not been calculated as the historical method of ascertainment of suicides within the CAF was not well defined.
To compare CAF Regular Force male suicide rates with the male CGP rates, standardization by age using the indirect method was used to provide Standardized Mortality Ratios (SMRs) for suicide up to 2019. This method controls for the difference in age distribution when comparing between the CAF Regular Force male and general Canadian male populations. An SMR is the observed number of cases divided by the number of cases that would be expected in the population at risk based on the age and sex-specific rates of a standard population (the CGP in this case) expressed as a percentage. Therefore, an SMR less than 100% indicates that the population in question has a lower rate than the CGP, while an SMR greater than 100% indicates a higher rate.
SMRs were calculated separately for Regular Force males with and those without a history of deployment, as well as for those in the four environmental command groupings (i.e., Army, Air, and Navy or ’Other’).
The calculation of confidence intervals (CIs) for statistics from population data are provided in this report for those who may want to generalize or compare the results between years or to other defined populations. Confidence intervals were calculated for the CAF Regular Force male suicide rates and SMRs directly with Poisson distribution 95% confidence limits using the exact method described by Breslow and Day [3].
Confidence intervals are typically used as a measure of uncertainty around a statistical estimate (e.g., a sample mean or mortality rate) when working with samples from a defined population. However, when statistics such as suicide rates are computed from a completely enumerated population, questions of statistical stability are less relevant to these calculated rates, as everybody in the population is counted. Errors associated with the process of data collection, the coding of cause of death, or in the estimation of the population denominators are usually of greater concern. In such situations, the calculated suicide rate and its confidence intervals simply represent a characterisation of the rate’s population distribution and this is based on the assumption that it is distributed according to a known theoretical distribution (e.g., Poisson distribution) around the calculated rate (i.e., some individuals who did not die had a non-zero probability of death from suicide). This permits a comparison of one population’s rates, and distribution, to those of another population (e.g., populations characterized by year); confidence intervals provide some guidance as to whether the two population estimates are comparable (i.e., when confidence intervals overlap) or different (i.e., when confidence intervals do not overlap) with a certain level of statistical probability. The p=0.05 level is used to determine whether two population distributions are different with statistical significance.
Direct standardization, standardized to the age structure of the total male Regular Force population, was also used for two comparisons. In order to further compare suicide risk between Regular force males with a history of deployment versus those without such a history and between members in the Army command versus those in non-Army commands, standardized rate ratios with 95% confidence intervals were computed as outlined in Rothman and Greenland [4].
Because the annual suicide numbers for the Canadian Armed Forces are small, they are influenced by random annual variability. Moving averages, which take an average of the year of interest as well as the previous and following yearFootnote 4, have been used by others in a similar military suicide context [5]. This method attempts to control the aforementioned annual variability caused by small numbers and provides a snapshot of potential temporal trends in the data.
3. Results
3.1 Results from the Medical Professional Technical Suicide Review Reports, Regular Force Males, 2020 Results Only
3.1.1 Mental Health Factors
MPTSRs were completed on 11 of the 12 2020 CAF Regular Force male suicides;Footnote 5 and a trial dual-purpose Board of Inquiry (BOI) review was completed for one individual. Among the CAF members for whom data was collected, 10 (90.9%) had at least one of the mental health factors in Table 1 identified as an active issue. The mental health factor categories of addictions or a substance use disorder, depressive disorders and trauma and stress-related disorders were equally the most frequent factors, each was identified in seven (63.6%) individuals. Among individuals with a trauma and stress-related disorder identified as an active issue at the time of death, three (27.3%) had PTSD and four (36.4%) had other disorders in this category. Four (36.4%) individuals had a traumatic brain injury in the past, three (27.3%) had an anxiety disorder identified as an active issue at the time of death and two (18.2%) had been identified with a personality disorder in the past.
Documented evidence of prior suicidal ideation and/or prior suicide attempts was noted for 10 (90.9%) individuals (not shown). Overall, seven (63.6%) individuals had at least two of the mental health factors listed in Table 1 at the time of death.
The MPTSR does not provide an indication as to whether these mental health concerns were related to operational stressFootnote 6; however, it does attempt to provide an indication as to whether the suicide was related to a deployment and for this query, ‘no’ or ‘unknown’ was recorded for all 11 individuals with a completed MPTSR.
a The total does not equal 100% as not all individuals were diagnosed with a mental health factor at time of death, and some individuals had more than one of the mental health factors listed.
3.1.2 Work and Life Stressors
Work and life stressors identified for the Regular Force male suicide deaths in 2020 are listed in Table 2. Ten (90.9%) individuals had at least one reported stressor and six (54.5%) individuals had two or more. The most prevalent stressor was a failed or failing spousal or intimate partner relationship, identified in seven (63.6%) individuals. Additionally, all Regular Force males were exposed to the COVID-19 pandemic and as such, this was a common stressor in this population. While some individuals may have had unique stressors that were amplified during, or possibly attributable to, the Covid-19 pandemic, this was not something that was able to be assessed among those who died by suicide as this data was not systematically collected.
a The total does not equal 100% as one individual had none of the reported stressors and six individuals had more than one.
b Determined to be an active concern if it occurred during an individual’s life history.
In addition to these stressors, four (36.4%) individuals had a documented history of being a victim of physical, sexual and/or emotional abuse or assault during their lifetime. There were three (27.3%) individuals who had been experiencing some sort of legal, disciplinary or ‘other’ proceedings prior to their death. There were three (27.3%) individuals who were in the process of being released from the CAF and all three were medical releases.
3.2 Epidemiology of Suicide in Regular Force Males, 1995 – 2020, Inclusive
The annual number of male Regular Force suicides between 1995 and 2020, inclusive, are captured in Table 3, as are the corresponding 5-year crude rates. These 5-year crude CAF Regular Force male suicide rates did not appear to vary significantly over 1995 and 2020, but did range from a low of 18.5 per 100,000 population (95% CI: 13.8, 24.4) for the 2005 – 2009 period to a high of 24.5 per 100,000 (95% CI: 19.2, 31.2) in the more recent 2015 – 2019 period. The single year crude rate for 2020 was 21.0 per 100,000 population (95% CI: 10.8, 36.7). The confidence intervals for all 5-year time periods do have substantial overlap and this suggests that the time period differences were not statistically significant.
Regular Force female rates were not calculated because female suicides were uncommon. There were no suicides in females from 1995 to 2002, two in 2003, no suicides in females in 2004 and 2005, one per year from 2006 to 2008, two in 2009, none in 2010, one in 2011, three in 2012, one per year from 2013 to 2016, none in 2017 or 2018 and two in each of 2019 and 2020.
An SMR comparison of suicide rates among Regular Force males to their civilian counterparts is presented in Table 4. The data for the 2005 – 2009 period indicated that the CAF Regular Force male population had a 14% lower suicide rate than the CGP after adjusting for the age differences between the populations. This SMR was not statistically significant as the confidence interval included 100%. While the SMR for 2010 – 2014 was above 100%, its confidence interval also included 100% and although this suggests that the result was statistically non-significant, some caution in interpretation is advised as it was very close to being statistically significant. The 2015 – 2019 SMR was also statistically non-significant.
A further analysis comparing SMRs for members with a history of deployment to SMRs for those without a history of deployment is presented in Table 5. During the 2015 – 2019 period, the higher SMR switched, relative to the prior five year period, from those with a history of deployment to those without one. However, none of the SMRs presented in this table (for any time period) were indicated to be statistically significantFootnote 7
| Year | Number of CAF Regular Force Male Person-YearsFootnote 8 | Number of CAF Regular Force Male Suicidesa | CAF Regular Force Male Suicide Rate per 105 (95% CI) |
|---|---|---|---|
| 1995 | 62,255 | 12 | |
| 1996 | 57,323 | 8 | |
| 1997 | 54,982 | 13 | |
| 1998 | 54,284 | 13 | |
| 1999 | 52,689 | 10 | |
| 1995-1999 | 281,533 | 56 | 19.9 (15.1, 26.0) |
| 2000 | 51,537 | 12 | |
| 2001 | 51,029 | 10 | |
| 2002 | 52,458 | 9 | |
| 2003 | 54,151 | 9 | |
| 2004 | 52,265 | 10 | |
| 2000-2004 | 261,440 | 50 | 19.1 (14.2, 25.2) |
| 2005 | 53,666 | 10 | |
| 2006 | 54,332 | 7 | |
| 2007 | 55,188 | 9 | |
| 2008 | 55,774 | 13 | |
| 2009 | 56,909 | 12 | |
| 2005-2009 | 275,869 | 51 | 18.5 (13.8, 24.4) |
| 2010 | 56,147 | 12 | |
| 2011 | 56,135 | 21 | |
| 2012 | 56,028 | 10 | |
| 2013 | 56,069 | 9 | |
| 2014 | 55,672 | 16 | |
| 2010-2014 | 280,051 | 68 | 24.3 (19.0, 31.0) |
| 2015 | 55,520 | 14 | |
| 2016 | 56,101 | 14 | |
| 2017 | 56,366 | 13 | |
| 2018 | 56,837 | 13 | |
| 2019 | 57,025 | 15 | |
| 2015-2019 | 281,849 | 69 | 24.5 (19.2, 31.2) |
| 2020 | 57,189 | 12 | 21.0 (10.8, 36.7) |
a The number of confirmed suicides for CAF Regular Force males for 2009 increased by one since the “Suicide in the Canadian Forces 1995 to 2012” report.
b Some estimates may have changed slightly compared to previous reports due to updates in the CAF Regular Force male population numbers.
a Some estimates may have changed slightly compared to previous reports due to updates in either the CAF Regular Force male population numbers or Statistics Canada’s reported vital statistics and Canadian male population estimates.
† Statistically significant.
a Some estimates may have changed slightly compared to previous reports due to updates in either the CAF Regular Force male population numbers or Statistics Canada’s reported vital statistics and Canadian male population estimates.
† Statistically significant.
When looking at longer time periods, the Regular Force males with a history of deployment, and those without this history, both did not appear to have a suicide rate that was different from what would be expected in the Canadian male population after adjusting for age distribution differences. The 10-year rate for the 1995 – 2004 period illustrated a slightly lower SMR for those with a history of deployment (SMR: 75% [95% CI: 54, 100]) than for those without this history (SMR: 77% [95% CI: 60, 100]); however, both of these estimates closely approached, but did not reach, statistical significance. Similarly, the 10-year SMRs for the 2005 – 2014 period for those with a history of deployment (SMR: 110% [95% CI: 87, 140]) and those without this history (SMR: 92% [95% CI: 68, 122]) were both not statistically significant, indicating no difference relative to what was expected based on the age-specific rates in the CGP.
An analysis comparing the same groups but using a statistically different method (direct standardization) is presented in Table 6 and it also failed to identify a statistically significant relationship between those with a history of deployment versus those without such a history. However, the observations for the single 2020 year suggested a possibly elevated risk of suicide among Regular Force males who had past deployments when compared to those without this history. Although not statistically significant, this apparent change was attributed to a decrease in the suicide rate among those without a history of deployment, a change that caused the rate among those with a deployment history to appear elevated in comparison. It is important to note that this observation was for a single year and age-adjusted comparisons to the Canadian population were not yet possible. A comparison of the 10-year directly standardized rates by deployment history for the 1995 – 2004 and 2005 – 2014 periods both appeared to be statistically non-significant, with age-standardized suicide rate ratios of 1.02 (95% CI: 0.68, 1.52) and 1.45 (95% CI: 0.97, 2.16), respectively. However, the rate ratio for the 2005 – 2014 period, which indicated a higher rate among those with a history of deployment, was close to being statistically significant.
a Some estimates may have changed slightly compared to previous reports due to updates in CAF Regular Force male population numbers.
* Based on a single year of observation.
3.3 Epidemiology of Suicide in Regular Force Males, by Environmental Command, 2002 – 2020, Inclusive
Over the past 19 years, there were 128 deaths by suicide among the Regular Force males within the Army command and 100 within the other commands combined (Navy, Air Force and Other). The crude Army suicide rate was 32.63 per 100,000 population (95% CI: 27.32, 38.96) compared to 15.08 per 100,000 population (95% CI: 12.34, 18.40) for the non-Army rate. The confidence intervals for these two command rates (i.e., Army and non-Army) did not overlap, indicating that there was a statistically significant difference between the two groups. The age-adjusted, directly standardized, rates (Army: 32.10/ 100,000 [95% CI: 26.39, 37.82]; Non-Army: 15.37/ 100,000 [95% CI: 12.34, 18.40]) were very similar to the crude rates. Furthermore, the age-standardized suicide rate ratio was significant (2.09 [95% CI: 1.60, 2.72]), indicating that the age-standardized suicide rate among Regular force males in the Army was a little over twice as high as it was in the non-Army commands.
SMRs (i.e., comparisons with the CGP) were calculated for each command grouping and time period (i.e., 2002 – 2006, 2007 – 2011, 2012 – 2016, 2017 – 2019 only) (Table 7). The SMRs for the Army command in the 2007 – 2011 and 2012 – 2016 periods were both statistically significant and above 100%, while the SMRs for the Navy/Other command group were statistically significant and below 100% during the 2002 –2006 and 2012 – 2016 periods. In the more recent period of 2017 – 2019, the SMR for the Air Force command group was statistically significant and above 100% but this SMR was based on only three years of observations. This is something that will be tracked closely over the coming years as it may suggest a new high risk group that would benefit from additional suicide prevention activities. All other SMRs were not statistically significant with the exception of the SMR for all commands combined from the 2002 – 2006 period which was below 100% and statistically significant.
a Some estimates may have changed slightly compared to previous reports due to updates in either the CAF Regular Force male population numbers or Statistics Canada’s reported vital statistics and Canadian male population estimates.
† Statistically significant.
* Based on three years of observations.
The suicide rate in Army combat arms occupations in the Regular Force male population was also calculated. Between 2002 and 2020, there were a total of 86 suicides among Regular Force males who had an Army combat arms MOSID. There were no suicides during this time frame in females with an Army combat arms MOSID.
The suicide rate in the Regular Force male population who were in an Army combat arms occupation appeared to be higher than the overall suicide rate among Regular Force males who were in other occupational groups. The crude suicide rates for the 2002 – 2020 period were 31.62 per 100,000 population (95% CI: 25.44, 39.34) in the Army combat arms occupation versus 18.13 per 100,000 population (95% CI: 15.32, 21.44) for those in other occupations. As the confidence intervals between the two rates did not overlap, the difference appears to be statistically significant, indicating an increased risk of suicide in Regular Force males in the Army combat arms relative to those in other occupations.
Figure 1 presents the three-year suicide rate moving average trend (i.e., suicide rates computed for consecutive three year periods that are incremented one year at a time) for all commands combined (represented by the triangular markers), Army command only (represented by the diamond markers) and for the Non-Army commands (represented by the square markers); the three-year moving average rates are reported against the middle year (e.g., the rates for 2018, 2019, and 2020 are incorporated into the moving average reported against 2019) . This figure illustrates that the suicide rate among the Army command had been slightly higher than the rate among all other commands combined for the period up until 2008; however, in a period that began in 2009, the suicide rate exhibited a pronounced increase among the Army command compared with the other commands. This rise in the Army suicide rate appeared to have stopped post-2012, but the average remained well above pre-2010 levels. Between 2010 and 2013, the non-Army suicide rate moving average appeared to be decreasing, but subsequently returned to pre-2011 levels. Since 2012, it would appear that the differential between the crude Army and Non-Army suicide rates had been declining and has become more comparable in recent years. Although the exact attribution for this decline is unknown, the CAF has a comprehensive suicide prevention strategy, programs that aim to reduce the stigma of seeking mental health care and increase both mental health education and resilience, and improved chain of command awareness of suicide risk and mental health. These initiatives may have contributed to this declining trend.
Figure 1: Text
| Year (midpoint of three year moving average) | All | Army | Non-Army |
|---|---|---|---|
| 2002 | 16.82 | 24.11 | 12.92 |
| 2003 | 17.42 | 24.81 | 13.42 |
| 2004 | 17.98 | 22.84 | 15.33 |
| 2005 | 16.73 | 22.88 | 13.38 |
| 2006 | 15.99 | 20.97 | 13.29 |
| 2007 | 17.59 | 24.06 | 14.06 |
| 2008 | 20.26 | 27.95 | 15.89 |
| 2009 | 21.89 | 31.21 | 16.20 |
| 2010 | 26.57 | 42.03 | 16.54 |
| 2011 | 25.55 | 44.62 | 12.86 |
| 2012 | 23.78 | 48.53 | 7.82 |
| 2013 | 20.86 | 40.27 | 8.72 |
| 2014 | 23.32 | 42.72 | 11.53 |
| 2015 | 26.30 | 39.70 | 18.21 |
| 2016 | 24.41 | 39.47 | 15.29 |
| 2017 | 23.63 | 34.32 | 17.11 |
| 2018 | 24.09 | 29.50 | 20.79 |
| 2019 | 23.38 | 24.89 | 22.48 |
4. Data Limitations
- The numbers on which these analyses are based are small and vary from year-to-year; consequently, these findings must be interpreted with caution.
- Female suicide numbers are very small (range between zero and two events per year), which precludes the ability to conduct trend analyses.
- Since an individual’s last known unit/base was used to categorize environmental command, this did not take into account that the individual may have just recently been posted to that environmental command and therefore, not have functioned under that environmental command for an appreciable amount of time.
- The denominator data for this study (number of CAF Regular Force males in each environmental command) were taken from the DHRIM system which occasionally receives data updates. Consequently, denominator data may vary, depending on when the report was run by DHRIM.
- The lack of DHRIM data prior to 2002 makes it impossible to ascertain whether the pre-Afghanistan suicide experience for Army command relative to non-Army command was any different to what is described here.
- Finally, the wide confidence intervals for many of the rates reported here indicate that in some cases, the analyses may not have a high enough power to detect differences that are actually present.
5. Conclusions
The following conclusions of the 2021 analysis of CAF Regular Force male deaths due to suicide are consistent with those of past years and should be considered with the limitations discussed above in mind:
- from 1995 to 2020, there has been no statistically significant change in the overall suicide rate of CAF Regular Force males. Additionally, despite the added stressors associated with the COVID-19 pandemic, the suicide rate and its related characteristics in 2020 were comparable to observations from previous years;
- the rate of suicide among CAF Regular Force males, when standardized for age and sex, was not significantly different from that of the CGP;
- assessment of the 2020 MPTSRs continues to support a multifactorial causal pathway for suicide rather than a direct link with a single risk factor. There was a high prevalence of mental health factors (90.9% having one active disorder and 63.6% having at least two), failing spousal/intimate (63.6%) relationships, excessive debt (54.5%), civil legal problems (27.3%) and job, supervisor or work performance problems (18.2%); and
- analyses suggest that there was a significantly higher crude rate of suicide in Regular Force males in the Army command relative to other CAF commands but the difference has decreased some in recent years. This may be driven in part by the significant difference in the crude Regular Force male suicide rate among the Army combat arms trades relative to those in other trades.
References
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[2] Simkus, K., Hall, A., Heber, A. and VanTil, L. (2019). 2019 Veteran Suicide Mortality Study: Follow-up period from 1976 to 2014. Retrieved from https://www.veterans.gc.ca/eng/about-vac/research/research-directorate/publications/reports/veteran-suicide-mortality-study-2019
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[5] Defence Analytical Services and Advice, Suicide and Open Verdict Deaths in the UK Regular Armed Forces 1984-2012, DASA (MoD): Bristol, UK, Retrieved 27-Feb-2014: http://www.dada.mod.uk/publications/health/deaths/suicide-and-open-verdict/2012/2012.pdf
[6] A Dictionary of Epidemiology, M. Porta, S. Greenland, J.M. Last, eds., Fifth Edition, New York (USA): Oxford UP, 2008.
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