Introduction. The mental health of Canadian Armed Forces (CAF) populations emerged as an important concern in the wake of difficult CAF deployments in the 1990s. This article is the first comprehensive summary of findings from subsequent surveys of mental health and well-being in CAF Veterans, undertaken to inform mental health service renewals by CAF Health Services and Veterans Affairs Canada (VAC). Methods. Epidemiological findings in journal publications and government reports were summarized from four cross-sectional national surveys: a survey of Veterans participating in VAC programs in 1999 and three surveys of health and well-being representative of whole populations of Veterans in 2003, 2010, and 2013. Results. Although most Veterans had good mental health, many had mental health problems that affected functioning, well-being, and service utilization. Recent Veterans had a higher prevalence of mental health problems than the general Canadian population, earlier-era Veterans, and possibly the serving population. There were associations between mental health conditions and difficult adjustment to civilian life, physical health, and multiple socio-demographic factors. Mental health problems were key drivers of disability. Comparisons with other studies were complicated by methodological, era, and cultural differences. Discussion. The survey findings support ongoing multifactorial approaches to optimizing mental health and well-being in CAF Veterans, including strong military-to-civilian transition support and access to effective mental and physical health services. Studies underway of transitioning members and families in the peri-release period of the military-to-civilian transition and longitudinal studies of mental health in Veterans will address important knowledge gaps.

Chronic diseases have a major impact on populations and healthcare systems worldwide. Administrative health data are an ideal resource for chronic disease surveillance because they are population-based and routinely collected. For multi-jurisdictional surveillance, a distributed model is advantageous because it does not require individual-level data to be shared across jurisdictional boundaries. Our objective is to describe the process, structure, benefits, and challenges of a distributed model for chronic disease surveillance across all Canadian provinces and territories (P/Ts) using linked administrative data. The Public Health Agency of Canada (PHAC) established the Canadian Chronic Disease Surveillance System (CCDSS) in 2009 to facilitate standardized, national estimates of chronic disease prevalence, incidence, and outcomes. The CCDSS primarily relies on linked health insurance registration files, physician billing claims, and hospital discharge abstracts. Standardized case definitions and common analytic protocols are applied to the data for each P/T; aggregate data are shared with PHAC and summarized for reports and open access data initiatives. Advantages of this distributed model include: it uses the rich data resources available in all P/Ts; it supports chronic disease surveillance capacity building in all P/Ts; and changes in surveillance methodology can be easily developed by PHAC and implemented by the P/Ts. However, there are challenges: heterogeneity in administrative databases across jurisdictions and changes in data quality over time threaten the production of standardized disease estimates; a limited set of databases are common to all P/Ts, which hinders potential CCDSS expansion; and there is a need to balance comprehensive reporting with P/T disclosure requirements to protect privacy. The CCDSS distributed model for chronic disease surveillance has been successfully implemented and sustained by PHAC and its P/T partners. Many lessons have been learned about national surveillance involving jurisdictions that are heterogeneous with respect to healthcare databases, expertise and analytical capacity, population characteristics, and priorities.

M ilitary personnel transitioning from military service to civilian life undergo a complex, multifaceted process with variable institutional, health, psychological, work, family, and community dimensions. 1-4 For most, transition is relatively smooth; for some, transition is characterized by decreased wellbeing, including compromised physical and mental health, social problems, role disability, disadvantages in determinants of health and decreased quality of life. 5 While there is no clear consensus on how to define successful transition, optimum self-perceived wellbeing is an important public policy objective. 6-8 The terms "wellbeing" and "quality of life" are often used interchangeably, and there is little consensus on definitions. 9 The well-being of serving and former Canadian Forces (CF) personnel is of interest to Veterans Affairs Canada (VAC), the Department of National Defence (DND), the CF, and to Veterans administrations internationally. 10-12 There are no publications quantitatively describing the well-being of Canadian Veterans after transition to civilian life. More is known about Veterans participating in VAC programs, but in 2010 only 10% of the 590,000 living Veterans with service in other than the Second World War and the Korean War were VAC clients. 3,13 The 2010 Survey on Transition to Civilian Life (STCL) provided an opportunity to study health-related quality of life (HRQoL) in former CF Regular Force personnel who released from service during 1998-2007. 5 They enrolled during the 1960s to 2000s and had varied experience in training (19% released as recruits or cadets), domestic disaster response, international peacekeeping and the recent increased operational tempo experienced by the CF since the first Persian Gulf War in 1990-91. 5 The survey was conducted before Canada's Afghanistan combat role ceased in 2011, and at a time when CF, DND and VAC were introducing major initiatives to improve disease prevention, health promotion, health care, and disability management for serving and released personnel. 14,15 The objectives of this study were to describe the HRQoL of recently released CF personnel (Veterans) in relation to socio-demographics, health, disability and determinants of health, to identify possible protective and risk factors for HRQoL, and to compare HRQoL to

uicide is an important public health problem and therefore is of interest to Veterans Affairs Canada (VAC) and similar agencies worldwide that support the well-being of veterans and their families. The protracted conflicts in Afghanistan and Iraq have triggered renewed interest in the life-course health effects of military service, including suicide. 1,2 Historically, suicide rates among serving and released (veteran) military populations have tended to be similar or lower than in civilian populations, consistent with a healthy worker effect. 2-5 Suicide rates have increased in the US and UK in the past decade among serving personnel 2-4,6-9 and in some veteran subpopulations, including young males and those with chronic health problems. 3,6-8,10,11 A mortality study of Canadian Armed Forces personnel who enrolled in 1972-2005 found elevated rates among veterans. 4 Suicide risk in contemporary veterans needs explanation. 2 Mental health problems are strongly associated with suicidality (ideation, attempt and death) and are known military occupational risks. 1,2,11-19 In an expert consensus framework proposed for suicide prevention, stressful life events, psychiatric disorders and dispositional risks, including personality and social factors, were viewed as key pathways toward suicidal behaviour, but physical health was not included. 20 The possibility that physical health also plays a role in explaining suicide risk has not been well explored in veterans. A broad range of chronic physical health conditions also occur in military service. 1 In veterans, as in the general public, physical conditions are about 2-4 times more prevalent than diagnosed mental health conditions, and the prevalence of some physical conditions, particularly musculoskeletal disorders, has been higher in some veteran populations than among comparable civilians. 21,22 Age and sex have been consistently associated with suicidality, and socioeconomic factors, including marital status, education and financial status, have been associated with suicidality as influencing factors. 2,4,5,7,10-13,23-30 Military rank has been found to be associated with Canadian and UK veteran suicide. 4,8 Associations between physical health and suicidality are supported by a developing body of evidence in civilian studies, particularly of chronic pain, 10,23-26,31 but are less well established than for mental disorders owing to inconsistent findings and methodological variability. 25 Physical health has been little studied as a risk factor for veteran suicidal ideation. In US veteran studies,

Disability, measured as activity limitation, was associated with a range of personal and environmental factors and health conditions, indicating multifactorial and multidisciplinary approaches to disability mitigation.

In the United States, extensive research has been conducted investigating chronic pain among Veterans; however, such research has not been conducted among Canadians who served in the military. Accordingly, this study aimed to investigate the prevalence of chronic pain among Canadian Veterans, and to determine correlates of chronic pain in this population. Data for this study were obtained from the Survey on Transition to Civilian Life; 3154 Veterans released from service between January 1, 1998 and December 31, 2007 responded to the survey.

Introduction: The Survey on Transition to Civilian Life (STCL) was created to measure the adjustment outcomes of recently released Canadian Armed Forces (CAF) members. The survey was administered to a sample of CAF regular force members released from 1998 to 2007. The aim of the current study was to examine resources that promote the successful adjustment to civilian life. Specifically, the goal was to conduct a secondary analysis of the STCL that examined the roles of mastery and social environment (that is, community belonging and satisfaction with support) in the transition to civilian life, as well as how these variables correlate with health and life stress. Methods: The sample data were used to conduct Kendall's tau correlations. Prevalence estimates, 95 per cent confidence intervals, and ordinal logistic regressions were conducted using weighted data that accounted for the complex survey design to ensure findings were representative of the sampled veteran population. Results: Ordinal logistic regression results revealed that mastery, satisfaction with types of social support (friends and family), and a sense of community belonging acted as potential protective factors that were associated with easier adjustment to civilian life for Veterans with physical health conditions, mental health conditions, and higher levels of life stress. The first model showed that the odds of an easier adjustment were lower for those who were more stressed (adjusted odds ratio [AOR]=0.13), self-reported a physical health condition (AOR=0.53), and self-reported a mental health condition (AOR=0.23). The second model revealed that the odds of an easier adjustment were lower for those Veterans dissatisfied with their family relationships (AOR=0.42) and their relationships with friends (AOR=0.47) and those with a very weak sense of community belonging (AOR=0.39), and they were higher among those with high levels of mastery (AOR=3.93). Discussion: The results of this study point to the importance of personal characteristics and aspects of the social environment in the adjustment to civilian life among military veterans. As well, ensuring a successful adjustment to civilian life may lead to better outcomes, such as enhanced mastery, following transition.

Introduction: The risks of suicidality (suicidal ideation or behaviour) are higher in Canadian Armed Forces (CAF) Veterans (former members) than in the Canadian general population (CGP). Suicide prevention is everyone’s responsibility, but it can be difficult for many to see how they can help. This article proposes an evidence-based theoretical framework for discussing suicide prevention. The framework informed the 2017 joint CAF – Veterans Affairs Canada (VAC) suicide prevention strategy. Methods: Evidence for the framework was derived from participation in expert panels conducted by the CAF in 2009 and 2016, a review of findings from epidemiological studies of suicidality in CAF Veterans released since 1976, suicide prevention literature reviews conducted at VAC since 2009, and published theories of suicide. Results: Common to all suicide theories is the understanding that suicide causation is multifactorial, complex, and varies individually such that factors interact rather than lie along linear causal chains. Discussion: The proposed framework has three core concepts: a composite well-being framework, the life course view, and opportunities for prevention along the suicide pathway from ideation to behaviour. Evidence indicates that Veterans are influenced onto, along, and off the pathway by variable combinations of mental illness, stressful well-being problems and life events, individual factors including suicidal diathesis vulnerability, barriers to well-being supports, acquired lethal capability, imitation, impulsivity, and access to lethal means. The proposed framework can inform discussions about both whole-community participation in prevention, intervention and postvention activities at the individual and population levels, and the development of hypotheses for the increased risk of suicidality in CAF Veterans.