Nine steps that will halt suicide in Australian Defence Force (ADF) members and ex-ADF members
Prof Philip Morris MB BS, BSc med, PhD, FRANZCP, FAChAM (RACP)
Executive Director, Australian and New Zealand Mental Health Association
Foundation Director of the National Central for War-related Post Traumatic Stress Disorder (now Phoenix Australia – Centre for Posttraumatic Mental Health)
Psychiatric Advisor Department of Veterans’ Affairs 2001-2015
- Publish annual suicide and attempted suicide statistics for Australian Defence Force members and suicide statistics for ex-ADF members
Before changes can be made to influence the rate of suicide in serving members of the ADF or ex-serving members of the ADF it is essential to know what the extent of the problem is. Who would consider making interventions to reduce the Australian road toll without knowing what the road toll is and how it is changing? The same applies to suicide in current and ex-ADF personnel. Annual statistics of suicide for ex-ADF personnel and both suicide and attempted suicide (as attempted suicide is a powerful predictor of completed suicide) for current ADF personnel must be made public. The data should be stratified by state and territory, age band, gender, service type (Army, Navy Air force), and deployment history. These data should be readily available for current ADF personnel. The information will be harder to obtain for ex-ADF personnel but all coroners and other officials dealing with suicide should be asked to note if the individual has a service history. Trends in the raw numbers and standardised rates of suicide and attempted suicide in ADF and ex-ADF personnel should be made available over 5 and 10-year periods. This information can then be used to assess the impact of interventions to reduce suicide in these populations. I am aware that the Australian Institute of Health and Welfare has produced a report on completed suicides over the past decade in the ADF and among veterans. This is a good start but ongoing surveillance of suicide statistics will need to continue.
- Provide a medical treatment Gold Card equivalent to all ex-ADF members as they leave military service
The equivalent of Gold Card access to medical (and psychiatric) treatment should be a mandated benefit (entitlement) of ADF service following discharge. Psychiatric illness still carries significant stigma that prevents individuals accessing treatment. Many ADF personnel are not recognised at discharge as having a mental illness, which often becomes overt later, and frequently service-related mental disorders take years to develop. While treatment for certain psychiatric and substance use disorders is supported by the Department of Veterans’ Affairs (DVA) (non-liability health services) and is accessed by ex-ADF personnel (over 10,000 occasions of service in a recent year illustrating the depth of demand) the affected individual has to be considered as a ‘case’ before funding flows. This is a disincentive to early treatment. Providing all ex-ADF personnel a Gold Card treatment equivalent will eliminate this barrier to treatment – physical health problems and mental health problems will be regarded equally. The reallocation of Medicare funds that would otherwise be used to subsidise the physical and mental health care of ex-ADF members to a seamless specialised system of health care for ADF and ex-ADF personnel would also encourage the aggregation of ADF and DVA medical services to allow the development of a critical mass of health providers in different regions coordinated to establish programs of care. The earlier treatment and more effective social and vocational rehabilitation of mental health disorders are likely to be a net financial benefit to the overall DVA budget.
- Fast-track pension and compensation entitlements with a minimal adversarial approach
The perception of some ex-ADF personnel is that the DVA ‘fights’ eligibility for pensions and juxtaposes readiness for work as evidence for pension review. While this perception is frequently inaccurate, the impression of an adversarial approach does little to improve functioning, and does not address or support the social, family and personal factors that augur well for recovery. A minimum fuss, fast-track approach for valid and reliable assessment for eligibility for pension and other benefits needs to be developed. Individuals with special needs generated by the claims process such as those with psychiatric disorder and personality difficulties should be offered additional support during and after the determination of their claims. Claims staff needs to become more attuned to the effects of the decision-making process on these vulnerable potential beneficiaries.
- Establish networks of clinical excellence among health care providers funded by ADF and Department of Veterans’ Affairs in high density ADF and ex-ADF member locations
Before the mid 1990’s the DVA had a network of Repatriation Hospitals and outpatient clinics dedicated to the physical health and mental health care of ex-ADF personnel. In the mid 1990’s these facilities were transferred to state and private health services. With some notable exceptions the level of mental health services dedicated to ex-ADF personnel has declined over the past two decades. To redress this change and to improve the availability, access, and quality of mental health services we need to establish networks of clinical excellence specialising in the mental health care of ADF and ex-ADF personnel. Initially these networks should be established in areas of high ADF and ex-ADF personnel density such as Townsville, Darwin and the state capital cities. Given the small proportion of defence-related population in Australia (compared with the USA for example) it would be advisable to join clinicians caring for the mental health needs of ADF personnel with those caring for ex-ADF personnel. This would mean bringing together general practitioners, psychiatrists, psychologists, allied health professionals and social and vocational rehabilitation specialists involved in the treatment of Army, Navy and Air force personnel with similar professionals treating ex-ADF personnel in the community in the same geographic region. Networks developed in this way would have sufficient numbers of clinicians to be viable arrangements for collaboration, training, sharing knowledge and skills, and acting as referral networks for the special needs of ADF and ex-ADF patients. Phoenix Australia (Centre for Posttraumatic Mental Health) and the Centre for Traumatic Stress Studies University of Adelaide may have a role in establishing and supporting these networks of clinical excellence. Providing a seamless health care system as outlined above will facilitate this process of mental health care service enhancement.
- Make transparent the career implications for ADF members acknowledging mental health problems
The onset of a mental health disorder in a serving ADF member has serious consequences for the career prospects for this person. Despite progressively more informed attitudes in the ADF to mental illness, stigma persists and there are real practical limitations for career progression for ADF personnel suffering from mental illness – particularly for future deployments. This should be acknowledged openly and alternate career paths developed to allow ADF members to continue serving and advancing in their careers where ever possible. This approach should reduce the proportion of ADF personnel who delay acknowledgement and treatment of a mental illness, but there will continue to be members who deny or conceal their problems – and this situation should be openly recognised. ADF personnel who ‘suffer in silence’ like this are likely to be missed as needing support when they are discharged and will be unknown to the DVA until their mental health problems bring them to attention later. At that stage treatment and rehabilitation may be much less effective. The ADF and DVA should work in unison to transition individuals who would be disadvantaged by continued trauma exposure as part of their military careers.
- Enhance the transition and follow-up process from ADF member to ex-ADF member status
The transition process from serving member of the ADF to ex-ADF status is a vital opportunity to identify and support personnel who have developed mental illness in the ADF or who are at increased risk of doing so following discharge. For those who have developed mental health problems, the prospect of leaving the ADF can have both positive and negative effects. For some leaving the ADF means ‘leaving their problems behind’. Unfortunately for many individuals mental health problems do not go away when they are discharged from the ADF. Leaving service life also means leaving an organised social and work environment. The loss of this support can worsen the mental health problems of ex-ADF personnel. Although some ex-ADF personnel may want nothing to do with the DVA at this time, none-the-less the transition period is an important time for clinical relationships to be established and regular supportive follow-up to start. Most important is the pre-discharge medical and psychological review. A medical practitioner proficient with mental health screening assessment should conduct the review. While questionnaires and checklists can accomplish a lot, they do not replace the value of a personal examination by a physician. This assessment can identify current problems and anticipate future mental health risks and treatment needs and develop a plan of appropriate referral and follow up to address them. A six to 12-monthly physical/mental health follow-up review with a mutually agreed local doctor with expertise in the care of ex-ADF members for the first five years would be helpful, with one to two yearly follow-up after that. Ongoing physical and mental health surveillance is crucial for service improvement. Giving all ex-ADF personnel a Gold Card treatment entitlement equivalent as outlined above would facilitate this level of post-discharge support and allow more detailed monitoring of health status and service usage.
- Refocus vocational rehabilitation to how work (or other productive activity) can help recovery from mental health problems
Many ADF personnel discharged from military service will be in their mid careers. They will have two to three decades of working life ahead of them. Ex-ADF personnel suffering from mental illness and their physicians need to be encouraged to see work (or other productive activity) as part of the recovery process rather than an end in itself. The question should be ‘how can work aid recovery?’ rather than ‘when will the patient be fit to return to work?’ This change in attitude requires a new approach to vocational rehabilitation (individual placement and support, or supported employment methods) and improved flexibility in workplaces to accommodate the special needs and part-time working schedules of recovering patients. DVA compensation and pension arrangements need to take this situation into account. Pension payments should be flexible in order to encourage part-time return to suitable work without the recipient losing the pension or having to re-qualify for it. Making vocational rehabilitation a positive experience rather than a source of adversarial tension should improve the treatment environment for ex-ADF personnel with mental health problems.
- Provide all ex-ADF members and their immediate family specific training in mental health first aid as they leave military service
An important way of empowering ex-ADF personnel and their families to deal with mental illness and suicide risk is to provide them with training in mental health first aid. This will have the additional benefit of further de-stigmatising mental illness. At the point of discharge from the ADF the leaving member and his/her immediate adult family should be provided the ‘Mental Health First Aid Course’ suitably modified to take into account common conditions suffered by ex-ADF personnel as well as how to respond to potential and real suicide risk situations. In a similar way an occupational health intervention of mental health first aid training should be introduced for all individuals in leadership positions in the ADF.
- Overcome isolation of distressed ADF and ex-ADF members
Isolation from others is a powerful risk factor for suicide. Perhaps the most important thing that can be done to prevent suicide is to connect the person at risk with individuals from caring networks of peers, family, and professionals. Personal contact with the person at risk by one or more of the individuals from the caring network reduces isolation and improves self-esteem – both likely to increase the threshold against self-harm. The ADF and DVA should be doing all they can to identify individuals at risk (see above points) and to encourage and support the building and maintaining of carer networks. This will mean a more accepting attitude of veteran-based rehabilitation programs that focus on social inclusion and participation.
Taken together these nine steps will help reduce suicide and self-harm behaviour in ADF and ex-ADF personnel. Monitoring the suicide statistics mentioned in step 1 will provide proof of the effect of these interventions.
Prof Philip Morris.