2020 Report on Suicide Mortality in the Canadian Armed Forces (1995 to 2019)

List of Figures

List of Tables

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 2019.

Methods: This report describes crude suicide rates from 1995 to 2019, 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 2019.

Results: Between 1995 and 2019, there were no statistically significant increases in the overall suicide rates. 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 most recent findings (2015 – 2019) 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: 1.13 [95% CI: 0.59, 2.16]). 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: 1.46 [95% CI: 0.98, 2.18]).

These rate ratios also highlighted that, since 2006 and up to and including 2019, 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: 2.13 [95% CI: 1.62, 2.79]). 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 (31.51/100,000 [95% CI: 25.18, 39.36]) compared to Regular Force males in other occupations (18.20/100,000 [95% CI: 15.31, 21.62]).

Results from the 2019 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.

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. However, small numbers do limit the ability, or power, of statistical assessments to detect statistical significance. The increased risk in Regular Force males under Army command compared to those under non-Army commands 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 epidemiology of Regular Force males that died by suicide between 1995 and 2019, with additional information on the risk factors associated with Regular Force males that died by suicide in 2019.

Methods

Data described in Section 3.1 [Results from the Medical Professional Technical Suicide Review (MPTSR) Reports, Regular Force Males, 2019 Results Only] are drawn from the 2019 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 by the Deputy Surgeon General 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 General Duty Medical Officer.

Epidemiological data described in Section 3.2 (Epidemiology of Suicide in Regular Force Males, 1995 – 2019, inclusive) and 3.3 (Epidemiology of Suicide in Regular Force Males, by environmental command, 2002 – 2019, 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 makeup as the Canadian general population) and directly standardized rates were calculated. SMRs were calculated until 2018 in this report because Statistics Canada has released data for the Canadian general population only up to that year.

Results

Mental Health Diagnosis of Those Who Died by Suicide in 2019

The mental disorders that were identified among the Regular Force males at the time of their suicide death in 2019 included depressive disorders (28.6%), anxiety disorders (14.3%), post-traumatic stress disorder (21.4%), or other trauma and stress-related disorders (14.3%). A documented substance use disorder was reported in slightly over half (57.1%) of these suicide deaths. It was common (50.0%) 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 2019

At the time of death, all of the Regular Force males that died by suicide in 2019 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); almost all (92.9%) had two or more concomitant stressors prior to their death.

Crude Suicide Rates, 1995 – 2019

In 2015 – 2019, the crude suicide rate for Regular Force males was 24.5 per 100,000 population (95% CI: 19.2, 31.1). This rate was consistent with the 2010-2014 crude rate (24.2/ 100,000 [95% CI: 19.0, 30.9]). Additionally, the suicide rate confidence intervals for all measured periods had some degree of overlap, suggesting a low likelihood of statistically significant differences in the crude rates over time.

Comparison of CAF Regular Force Male Suicide Rates to Canadian Rates Using Standardized Mortality Ratios, 1995 – 2018

The SMR for 2010 – 2014 (126% [95% CI: 99, 159]) and for 2015 – 2018 (119% [95%CI: 90, 156]) 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 (92% [95%CI: 75, 113]) and those without this history (94% [95%CI: 77, 115]) for the 1995 – 2018 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 – 2019 period. This was statistically significant [2.13 (95% CI: 1.62, 2.79)], 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 [173% (95% CI: 123, 237)] and the 2012 – 2016 period (186% [95% CI: 134, 252]), indicating that suicide rates were higher than what would be expected among the male Canadian population with a similar age distribution.

The crude suicide rate among the Regular Force male population who were in an Army combat arms occupation was also calculated and for the 2002 – 2019 period. It was found to be higher than the overall suicide rate among Regular Forces males in other occupations (31.51/ 100,000 [95% CI: 25.18, 39.36]) versus 18.20/ 100,000 [95% CI: 15.31, 21.62]).

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. However, small numbers do limit the ability, or power, of statistical assessments to detect statistical significance. The increased risk in Regular Force males under Army command compared to those under non-Army commands is a finding that 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 2019 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:

  1. 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).
  2. 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.
  3. 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 Deputy Surgeon General 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 Canadian Forces Health Services (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.  The mental health factor categories included:

  1. 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.
  2. 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.
  3. 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.
  4. addictions or substance-use disorders;
  5. traumatic brain injury: considered to be an active issue if it occurred at any time in an individual’s past; and
  6. 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:

  1. failed or failing spousal or intimate partner relationship;
  2. failed or failing other relationship (e.g. family, friends);
  3. completed spousal, family or friend suicide (considered to be an active issue if it had occurred at any time in an individual’s past);
  4. family or friend death (other than suicide);
  5. physical health problem;
  6. chronic illness in spouse or family member;
  7. excessive debt, bankruptcy or financial strain;
  8. job, supervisor or work performance problem; and
  9. civil 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 department IDs and deployment units 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 2018 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 2018 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,  for 2017 and 2018 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:

  1. If command was explicitly stated in the MPTSR or in the Suicide Event Report for an individual (2011 – 2019 cases), that command information was used.
  2. 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.
  3. 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 2019. 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 2018. This method controls for the difference in age distribution 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, 2019 Results Only

3.1.1 Mental Health Factors

MPTSRs were completed on 14 of the 15 2019 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, 13 (92.9%) had at least one of the mental health factors in Table 1 identified as an active issue.  The ‘addictions or a substance use disorder’ mental health factor was most frequent, identified in eight (57.1%) individuals. The trauma and stress-related disorders category was the next most prevalent with a total of five (three (21.4%) individuals having PTSD and two (14.3%) individuals having other disorders in this category).  Depressive disorder was recorded in four (28.6%) individuals, and two (14.3%) individuals had an anxiety disorder. Two individuals had a traumatic brain injury in the past; one individual had the injury within a year prior to death while the other individual had two such injuries but more than a year prior to death.

Documented evidence of prior suicidal ideation and/or prior suicide attempts was noted for four (28.6%) individuals (not shown). Overall, seven (50.0%) 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 14 individuals with a completed MPTSR.

Table 1: Mental Health Factors
Factor 2019 (N (%))a
i) Depressive disorders 4 (28.6%)
ii) Trauma and stress-related disorders 5 (35.7%)
Trauma and stress-related disorders (PTSD) 3 (21.4%)
Trauma and stress-related disorders (Other) 2 (14.3%)
iii) Anxiety disorders 2 (14.3%)
iv) Addictions or a substance-use disorder 8 (57.1%)
v) Traumatic brain injury (ever) 2 (14.3%)
vi) Personality disorders (ever identified) 1 (7.1%)

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 2019 are listed in Table 2.  All individuals had at least one reported stressor and 13 (92.9%) individuals had two or more.  The most prevalent stressor was a failed or failing spousal or intimate partner relationship, identified in 10 (71.4%) individuals.

Table 2: Prevalence of Documented Work and Life Stressors Prior to Suicide
Work and life stressors 2019 (N (%))a
Failed or failing spousal or intimate partner relationship 10 (71.4%)
Failed or failing other relationship (e.g. family, friends) 5 (35.7%)
Completed spousal, family or friend suicide (ever)b 4 (28.6%)
Family or friend death (other than suicide) 2 (14.3%)
Physical health problem 7 (50.0%)
Chronic illness in spouse or family member 2 (14.3%)
Excessive debt, bankruptcy or financial strain 6 (42.9%)
Job, supervisor or work performance problem 7 (50.0%)
Civil legal problems (e.g. child custody dispute, litigation) 2 (14.3%)

a The total does not equal 100% as thirteen individuals had more than one stressor.

b Determined to be an active concern if it occurred during an individual’s life history.

In addition to these stressors, six (42.9%) individuals had a documented history of being a victim of physical, sexual and/or emotional abuse or assault during their lifetime. There were five (35.7%) individuals who had been experiencing some sort of legal, disciplinary or ‘other’ proceedings prior to their death.  There were two (14.3%) individuals who were in the process of being released from the CAF; one was a voluntary release that was initiated by the service member and the other was to be a 5b release that was initiated be the member’s chain of command.

3.2 Epidemiology of Suicide in Regular Force Males, 1995 – 2019, Inclusive

The annual number of male Regular Force suicides between 1995 and 2019, 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 2019, 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, 31.3) in the more recent 2015 – 2019 period. 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 in 2013, one in 2014, one in 2015, one in 2016, none in 2017 or 2018, and two in 2019.

An SMR comparison of suicide rates among Regular Force males to their civilian counterparts is presented in Table 4. The 2005 to 2009 data indicate 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 is not statistically significant as the confidence interval includes 100%. While the SMR for 2010 – 2014 is above 100%,
its confidence interval also includes 100% and although this suggests that the result is statistically non-significant, some caution in interpretation is advised as it was very close to being statistically significant. The 2015-2018 (4-year) SMR was 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. For the four-year period between 2015 and 2018, the higher SMR switched, relative to the prior five year period, from those with a history of deployment to those without one; additionally, the SMR for this 2015 to 2018 period appeared to be statistically significant for those without a history of deployment.  None of the other SMRs presented here (for any time period) were indicated to be statistically significantFootnote 7

Table 3: CAF Regular Force Male Multiyear Suicide Rates (1995-2019)b
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 56,231 12  
2011 56,213 21  
2012 56,117 10  
2013 56,134 9  
2014 55,724 16  
2010-2014 280,419 68 24.2 (19.0, 30.9)
2015 55,575 14  
2016 56,465 14  
2017 56,406 13  
2018 56,699 13  
2019 57,052 15  
2015-2019 282,197 69 24.5 (19.2, 31.1)

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.

Table 4: Comparison of CAF Regular Force Male Suicide Rates to Canadian Male Rates Using Standardized Mortality Ratios (SMRs) (1995-2018)a
Year SMR for Suicide (95% Confidence Intevals)
1995-1999 72% (55, 94)
2000-2004 80% (60, 106)
2005-2009 86% (64, 114)
2010-2014 126% (99, 159)
2015-2018** 119% (90, 156)

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.

** Based on four years of observations only to 2018 because Statistics Canada data for 2019 was not available at time this report was prepared.

† Statistically significant.

Table 5: Standardized Mortality Ratios for Suicide in the CAF Regular Force Male Population by History of Deployment (1995-2018)a
Year SMR (95% CI) for those With a History of Deployment SMR (95% CI) for those Without a History of Deployment
1995-1999 68% (42, 105) 74% (52, 103)
2000-2004 81% (53, 120) 79% (51, 118)
2005-2009 99% (67, 141) 73% (45, 112)
2010-2014 121% (87, 165) 111% (74, 162)
2015-2018** 90% (56, 136) 153% (105, 216)

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.

** Based on four years of observations only to 2018 because Statistics Canada data for 2019 was not available at time this report was prepared.

† Statistically significant.

When looking at longer time periods, the Regular Force males with a history of deployment, and those without this history, 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, there was no statistically significant difference in the 10-year SMRs for the 2005 – 2014 period among those with a history of deployment (SMR: 111% [95% CI: 87%, 140%]) or for those without this history (SMR: 91% [95% CI: 68%, 121%]), indicating no difference relative to what was expected in the age-adjusted 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. 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 1.46 (95% CI: 0.98, 2.18), 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.

Table 6: Comparison of CAF Regular Force Male 5-Year Suicide Rates by Deployment History Using Direct Standardization (1995-2019)a
Year History of Deployment (Rate per 105 No History of Deployment (Rate per 105 Suicide Rate Ratio (95% CI)
1995-1999 19.83 19.90 1.00 (0.57, 1.75)
2000-2004 18.97 17.89 1.06 (0.60, 1.88)
2005-2009 24.85 15.60 1.59 (0.86, 2.97)
2010-2014 25.79 19.07 1.35 (0.80, 2.28)
2015-2019 30.30 26.91 1.13 (0.59, 2.16)

a Some estimates may have changed slightly compared to previous reports due to updates in CAF Regular Force male population numbers.

3.3 Epidemiology of Suicide in Regular Force Males, by Environmental Command, 2002 – 2019, Inclusive

Over the past 18 years, there were 122 deaths by suicide among the Regular Force males within the Army command and 94 within the other commands combined (Navy, Air Force and Other). The crude Army suicide rate was 32.88 per 100,000 population (95% CI: 27.43, 39.39) compared to 14.97 per 100,000 population (95% CI: 12.17, 18.45) 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: 32.35/ 100,000 [95% CI: 26.44, 38.27]; Non-Army: 15.22/ 100,000 [95% CI: 12.12, 18.31]) were very similar to the crude rates. Furthermore, the age-standardized suicide rate ratio was significant (2.13 [95% CI: 1.62, 2.79]), 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 – 2018 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 in the 2002 –2006, 2012 – 2016, and 2017 – 2018 periods were statistically significant and below 100%. All other SMRs were not statistically significant. Furthermore, the SMR for all commands combined was systematically not statistically significant across all four time periods.

Table 7: Standardized Mortality Ratios for Suicide in CAF Regular Force Males by Environmental Command (2002-2018)a
Environmental Command SMR for Suicide (95% Confidence Intervals), 2002-2006 SMR for Suicide (95% Confidence Intervals), 2007-2011 SMR for Suicide (95% Confidence Intervals), 2012-2016 SMR for Suicide (95% Confidence Intervals), 2017-2018*
Army 105% (66, 159) 173% (123, 237) 186% (134, 252) 173% (97, 286)
Air Force 76% (36, 140) 80% (38, 147) 89% (44, 159) 189% (87, 360)
Navy/Other 51% (27, 87) 73% (44, 116) 41% (20, 75) 21% (3, 77)
All Commands 76% (55, 101) 112% (88, 144) 106% (82, 137) 114% (74, 168)

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 two years of observations.

The suicide rate in Army combat arms occupations in the Regular Force male population was also calculated. Between 2002 and 2019, there were a total of 81 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 – 2019 period were 31.51 per 100,000 population (95% CI: 25.18, 39.36) the Army combat arms occupation group versus 18.20 per 100,000 population (95% CI: 15.31, 21.62) 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 2017, 2018, and 2019 are incorporated into the moving average reported against 2018) . This figure illustrates that the suicide rate among the Army command had been slightly higher or equal to 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.

Figure 1: Three Year-Moving Averages by Command, Canadian Armed Forces, 2002 – 2019
Figure 1: Text
Figure 1: Three year-moving averages by Command, Canadian Armed Forces, 2002-2019
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 21.88 31.21 16.19
2010 26.54 42.03 16.52
2011 25.51 44.62 12.83
2012 23.74 48.53 7.80
2013 20.84 40.27 8.70
2014 23.29 42.72 11.15
2015 26.23 39.72 18.13
2016 24.34 39.49 15.22
2017 23.59 34.32 17.07
2018 24.10 29.49 20.81

4. Data Limitations

  1. The numbers on which these analyses are based are small and vary from year-to-year; consequently, these findings must be interpreted with caution.
  2. Female suicide numbers are very small (range between zero and two events per year), which precludes the ability to conduct trend analyses.
  3. 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.
  4. 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.
  5. 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.
  6. Finally, the wide confidence intervals for many of the rates reported here indicate that the analyses may not have the power to detect statistically significant differences.

5. Conclusions

The following conclusions of the 2020 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:

  1. from 1995 to 2019, there has been no statistically significant change in the overall suicide rate of CAF Regular Force males;
  2. the rate of suicide among CAF Regular Force males, when standardized for age and sex, is not significantly different from that of the CGP;
  3. assessment of the 2019 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 (92.9% having one active disorder, and 50% having at least two), failing relationships [including spousal/intimate (71.4%) and other (35.7%)], physical health problems (50.0%), job, supervisor or work performance problems (50.0%) and excessive debt (42.9%); and,
  4. analyses suggest that there is a significantly higher crude rate of suicide in Regular Force males in the Army command relative to other CAF commands. 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

[1] Statistics Canada. Disclosure control strategy for Canadian Vital Statistics Birth and Death Databases. Ministry of Industry: Ottawa, 2016.

[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

[3] Breslow, N.E. and Day, N.E. (1987). Statistical Methods in Cancer Research. Vol. II, The Design and Analysis of Cohort Studies (IARC Scientific Publication No. 82). Lyon, France: International Agency for Research on Cancer.

[4] Rothman, K.J. and Greenland, S. (1998). Modern Epidemiology (2nd ed.). Philadelphia, PA: Lippincott Williams &Wilkins.

[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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