Conclusion of the Report of the CF Expert Panel on Suicide Prevention

The CF is interested in suicide prevention because suicide is an important public health threat that is a leading cause of premature mortality in men of military age. The above discussion of targets for suicide prevention in the CF demonstrates that military organizations have a number of conventional opportunities for suicide prevention that go far beyond the tools that a typical civilian employer has at its disposal: For example, military organizations can mandate mass education and screening. They control most of the health system that should be providing appropriate care in the form of medications, psychotherapy, and follow-up of high-risk patients. While the CF cannot directly control media reporting of suicides, it can attempt to engage with the media to minimize the risk of imitative suicidal behaviour. Opportunities for means reduction are limited by the extent to which suicidal individuals access their lethal means outside of the CF, but additional efforts in terms of controlling access to service firearms and changes in drug packaging might offer incremental benefits.

Military organizations also have points of influence that go beyond this conventional list of potential targets for suicide prevention. They can mitigate work stress through effective leadership and through policies that are intended to decrease work stress (e.g., PERSTEMPO policies). They can exploit primary risk factor modification through resilience training, at least in theory. Military organizations can take steps to overcome a broad range of barriers to mental health care. Finally, they can take systematic steps to improve the quality of mental health care delivered within their walls. Because the CF does not provide inpatient care, it does not have control over one of the key pieces of the suicide prevention puzzle. The best it can to in this area is to coordinate aftercare as effectively as possible.

The CF is already engaged in at least some activities in each of the conventional and more military-specific areas. Efforts to overcome barriers to mental health care have been particularly strong in the CF, and data is starting to show that these efforts are bearing fruit. The CF’s effort to develop and deliver a coordinated mental health education program across the career cycle is still in its early phases, but it shows great promise. Viewed broadly, the CF thus has a strong and comprehensive suicide prevention program. Its program compares favourably with those of its closest allies, including the US Air Force’s benchmark program.

The area in which the most potential gains can be made in the CF is in the realm of systematic efforts to improve the quality of mental health care. It has built a strong system that should be delivering quality care, and it has Quality Improvement Coordinators at its major clinics, who will be able to drive continuous improvement locally. However, the CF has little capacity to measure and document the quality of care it is delivering and the favourability of the outcomes it is seeing. Having well-trained, motivated, and well-equipped mental health providers is not in and of itself a reliable recipe for the consistent delivery of excellent care.

The foregoing discussion should also demonstrate that responsibility for suicide prevention must be shared among leaders, members, clinicians and other providers of in-service support. Clinicians have a responsibility to provide optimal, evidence-based care (to include systematic efforts to follow-upon high-risk patients). They are also responsible for identifying and addressing weaknesses in their knowledge or skills in the management of potentially suicidal patients. They need to be responsible for doing outreach and making other systematic attempts to overcome the broad range of barriers to mental health care. Finally, they must take the lead in pursuing systematic efforts at quality improvement in their clinics.

The primary responsibility of leaders is to provide excellence in leadership. Relatively little of the positive impact of good leadership on suicide rates is likely to be due to suicide-specific knowledge or skills. However, because leaders act as gatekeepers, they do need strong skills to be able to facilitate effective care for those in need of it, whether they are suicidal or not. Senior leaders need to enact and enforce policies that promote mental health and wellbeing (e.g., those targeting harassment, workplace conflict, and family integrity). Both clinical and non-clinical leaders need to assure that clinicians have the resources, tools, and supports in order to excel in mental health care.

Members have a responsibility to recognize when they need help, to seek help and to comply with recommended treatment. They also have a responsibility to watch out for and support peers and colleagues who may be contemplating suicide, and to take effective steps when others voice suicidal thoughts or intent. The psycho-education that CF members receive throughout their career will facilitate these roles.

Many suicide prevention programs (including the CF’s 1996 policy) have mass education as their “centre of gravity.” The Panel proposes instead that the centre of gravity for the CF’s program should be the delivery of effective mental health care to those who need it. This is because effective mental health care is what “fixes” suicidal ideation and behaviour. Leaders and the rank-and-file can play a facilitative role, but for suicide prevention at least, the ultimate focus of their actions needs to be getting those with mental health problems and/or suicidal ideation into effective care.

In closing, it is important to have reasonable expectations about how effective the CF’s suicide prevention program can be: The benchmark USAF program appears to have decreased completed suicides by at most 30%. Given that the CF has already implemented most of the elements of the USAF program, the results it will see will likely be less than that. This would translate into the prevention of at best a few suicide deaths a year, a change that would be difficult to detect over the coming years. Nevertheless, even this relatively small preventive effect will be priceless for the individuals and families touched by suicide.

Many factors contribute to the limited preventability of suicide, including intrinsic technological limitations in mental health care, the complexities of providing mental health care, the broad range of contributors to suicidal behaviour, and important scientific uncertainties as to how best to treat mental disorders and prevent suicides. While mental health treatments are better than ever, mental illnesses are powerful disorders: Even the best equipped clinicians cannot pry every patient from their grasp. It is for these and other reasons that only 20 to 25% of suicides in those in mental health care are judged to be preventable.

The Panel included a number of recommendations that are of uncertain (though plausible) benefit with respect to suicide prevention. In most cases, though, the recommended interventions have other tangible benefits that should sustain them. For example, better leadership may have suicide preventive effects, but it certainly offers many other benefits to the organization. In fact, it is these ancillary effects of the CF’s suicide prevention strategy that will likely overshadow its impact on suicide per se.