Suicide by veterans
The first term of reference of the committee's inquiry is 'the reasons
why Australian veterans are committing suicide at such high rates'. This
chapter will consider issues relating to this term of reference. This includes the
incidence of suicide by ADF members and veterans, including recent results by
the Australian Institute of Health and Welfare (AIHW). On-going and future
research into the welfare of veterans including mental health issues and suicidality
will be examined. It will consider the range of identified contributing factors
to suicide by veterans and the approach of DVA to suicide prevention. Finally, this
chapter will examine issues relevant to veterans accessing appropriate mental
The incidence of suicide
Suicide in Australia
Suicide is a leading cause of death in Australia. A suicide occurs when
a person dies as a result of a deliberate act intended to cause the end of his
or her life. In 2015, 3,027 people died from intentional self-harm. This
is up from 2,864 in 2014. The age-standardised death by suicide rate was 12.6
per 100,000 persons and it is the 13th leading cause of death. In 2015, suicide
was the leading cause of death among all people 15-44 years of age and the
second leading cause of death among those 45-54 years of age.
Around three quarters of deaths by suicide are male. Attempted suicide
is also an important health issue with estimates that as many as 30 people
attempt to end their lives for every death by suicide, the majority being
women. For Aboriginal and Torres Strait Islander peoples the suicide rate is
more than double the national rate.
Suicidality in ADF population
The 2010 ADF Mental Health Prevalence and Wellbeing Study (MHPW study)
found that the rate of suicidality (thinking of suicide and making a suicide
plan) in the ADF was more than double that in the general community; however
the number of suicide attempts was not significantly greater than in the
general community and the number of reported deaths by suicide in the ADF were
lower than in the general population when matched for age and sex.
The MHPW study found that, although ADF members are more symptomatic and
more likely to express suicidal ideation than people in the general community,
they are only equally likely to attempt suicide and less likely to complete the
act. This suggested that 'the comprehensive initiatives on literacy and suicide
prevention currently being implemented in Defence may, in fact, be having a
Defence advised the committee that between 1 January 2000 and
29 September 2016, 118 full-time serving ADF members were suspected
or confirmed to have died by suicide. Of these 37 were with the Royal
Australian Navy, 60 with Australian Army and 21 with the Royal Australian Air
Force (as at 20 September 2016). Eight were female.
Defence commented that for serving ADF members, based on the available
data, there does not appear to be any discernible trend in the number of deaths
by suicide nor is there any clear association with operational deployment. Of
the 118 ADF members confirmed or suspected to have died by suicide 64 had never
deployed. Of the 54 who had deployed, 22 had one or more deployments to the
Middle East Area of Operations.
Suicidality in ex-service
DVA reported that '[a]s at 31 March 2016, DVA has determined claims in
relation to 83 deaths by suicide in the ten years to 31 December 2015'. Of
these 56 were accepted by DVA as service related.
DVA also outlined the practical difficulties in assessing deaths by suicide in
the veteran community. While DVA indicated that it was working with other
agencies to improve understanding of the prevalence of suicide among ex-serving
personnel, it has previously acknowledged that it 'is unlikely to ever obtain
complete information in relation to the prevalence of suicide amongst all those
who have served with the [ADF]'.
DVA generally only becomes aware of a former member's death by suicide
if a dependant submits a claim for compensation or income support. During the
inquiry, the Returned & Services League (RSL) noted that this meant that if
'veterans do not have dependents and a claim is not lodged then the cause of
death will not be recorded by DVA'. Furthermore:
Death can be 'automatically' accepted in a range of
situations...In situations where there is an 'automatic' acceptance of death and
the subsequent granting of benefits to the dependents, or where the veteran had
no dependants, there will be no recording of the cause of death centrally
through DVA, regardless of whether a coroner may have determined that the
cause of death was suicide.
Australian Institute of Health and
In 2016, the AIHW was commissioned by DVA to calculate accurate numbers
and rates of suicide deaths among serving personnel, reservists and ex-serving
ADF personnel. Key information was derived from the Defence PMKeyS database,
the National Death Index (NDI), the Defence Suicide Database and the National
Mortality Database. The AIHW report noted:
Cause of death (suicide) data were obtained only from
certified sources; that is, official fact of death and cause of death
determination (including suicide death) from the Registrars of Births, Deaths
and Marriages in each state and territory and the National Coronial Information
System...Reporting only certified deaths ensures that the results presented here
are defensible, comparable over time and can be reproduced. Differences between
the results of this study and other publicly reported estimates may be due to
differences in scope and/or the source of cause of death information.
Before the AIHW results were released, DVA cautioned that there would be
data limitations. It noted that the specific time-range of the cohort
considered 'means it's not possible to extrapolate the findings to the broader
ex-serving community' and it would not be possible to 'simply compare counts of
death due to suicide between the different services types and the Australian
On 30 November 2016, the AIHW released its initial study. The AIHW found
that between 2001 and 2014, there were 292 certified suicide deaths among
people with at least one day of ADF service since 2001. Of these:
84 occurred in the serving full-time population;
66 occurred in the reserve population;
142 occurred in the ex-serving population; and
272 were men and 20 were women.
In particular, the AIHW study found that after adjusting for age, when
compared with all Australian men, that men serving full-time and in the reserve
had a lower suicide rate (53 per cent and 46 per cent). However, the suicide
rate for ex-serving men was 13 per cent higher. It noted:
In 2002-2014, younger ex-serving men were at higher risk of
suicide death compared with all Australian men of the same age. Among
ex-serving men, those aged 18-24 accounted for 1 in 6 suicide deaths (23
deaths, 17%) and had a suicide rate almost 2 times as high as Australian men of
the same age. This difference was statistically significant.
In its summary report, released in June 2017, the AIHW found that between
2001 and 2015, there were 325 certified suicide deaths among people with at
least one day of ADF service since 2001. Of these deaths:
51 per cent (166) were of people no longer serving at the time of
21 per cent (69) were of people serving in the active and
inactive reserves at the time of their death;
28 per cent (90) were of people serving full time at the time of
their death; and
93 per cent (303) were men and 7 per cent (22) were women.
The AIHW stated:
The suicide rates of ex-serving men were more than twice as
high as for those serving full time or in the reserve (26 suicide deaths per
100,000 people, compared with 11 and 12 per 100,000, respectively). They were also
slightly higher than for their counterparts in the general population after
adjusting for age (14% higher, however this difference was not statistically
Ex-serving men aged 18-24 were at particular risk—2 times
more likely to die from suicide than Australian men of the same age.
Ex-serving men aged 25-29 accounted for slightly more deaths
than other age groups and were 1.4 times more likely to die from suicide than
Australian men of the same age. This difference was not statistically significant.
Men serving full time or in the reserve had significantly
lower suicide rates than for men in the general population (53% and 49% lower,
respectively), after adjusting for age.
The AIHW summary report identified several risk groups among ex-serving
men. These included:
suicide rates for ex-serving men aged 18–49 were between 3 and 4
times as high as for men aged 50–84;
those who were discharged involuntarily (suicide rates were 2.4
times as high as for those discharged for voluntary reasons), particularly if
the discharge was for medical reasons (3.6 times as high as for those
discharged for voluntary reasons);
those who left the ADF after less than 1 year of service (2.4
times as high as for those who had served for 10 years or more); and
all ranks other than commissioned officers (2.8 times as high as
for commissioned officers).
The AIHW observed that that despite methodological differences, the
findings of the study in relation to the influence of age, rank, length of
service and time since discharge on rates of suicide were 'consistent with
findings from studies of ex-serving defence personnel across the United
Kingdom, Canada and the United States'. While it was not possible to analyse
the effect of operational service, the AIHW noted that 'as the study progresses
and data for more years is added, it may be possible to explore suicide rates'
for veterans with these service characteristics in more detail.
Research and data collection
The AIHW study is a component of a range of research funded by both
Defence and DVA into the health and well-being of serving members and veterans,
particularly in relation to mental health. For example, Defence and DVA have
created a database, the Military and Veteran Research Study Roll (held by AIHW)
of contact details of members who transitioned out of the ADF between 2010 and
2014 to facilitate future research.
A current large scale research project is the Transition and Wellbeing
Research Programme (TWRP). This will examine the impact of contemporary
military service on the mental, physical and social health of serving and
ex-serving personnel and their families, and builds on previous Defence
research such as the Military Health Outcomes Program (MilHOP). The TWRP will
consist of three major studies:
Mental Health and Wellbeing Transition Study;
Impact of Combat Study; and
Family Wellbeing Study.
DVA outlined that its strategy for research into mental health was
guided by the DVA Corporate Plan 2016-2020 and by the Veteran Mental Health
Strategy (A Ten Year Framework) 2013-2023:
The Corporate Plan sets out DVA's commitment to better
understanding the health needs of veterans through a continued focus on
research over the next four years and beyond, especially in relation to
rehabilitation and mental health, with a strong emphasis on early intervention
to improve clients' prospects of recovery.
This priority is also reflected in the Veteran Mental
Health Strategy (A Ten Year Framework) 2013-2023. Under this Strategy,
Strategic Objective 6 is "Build the Evidence Base". As a significant
purchaser of mental health services, DVA needs a strong evidence base for best
practice veteran mental health services, treatments and interventions.
However, despite these research programs many submitters and witnesses
highlighted the problems with current research into veteran suicide and that
lack of accurate data collection which could be used to improve the welfare of
veterans. For example, the RSL pointed out it was 'currently impossible to tell
how many veterans live in Australia today':
While our best guess that the numbers are between 310,000
(the number of Australian Defence Medals issued by 2010) and 500,000, there is
no dataset that can provide a definite number. Similarly, there is currently no
dataset that will provide information on the number of veterans receiving
The RSL argued that a 'way of identifying and recording causes of death
for all serving members and veterans needs to be established'. It made a number
of recommendations for gathering information on veterans through the census,
coronial reports, police reports and audits specific cases.
Suicide is recognised to be an inherently difficult social phenomenon to
study due to community stigma, underreporting, and in some circumstances,
uncertainty relating to cause of death. In particular, information concerning
military and ex-military personnel may have a 'healthy worker' bias, due to
recruitment standards and training in the ADF, which meant that the suicide
rate amongst serving and ex-serving members cannot be directly compared to the
general population. For example, the Vietnam Veterans' Federation of Australia
ADF members are screened psychologically and medically as
part of a rigorous selection procedure. They are then systematically trained to
cope with the high levels of physical and emotional demand necessary for sustained
performance in operational roles. It is therefore reasonable to hypothesise
that the incidence of suicide within currently serving and ex-serving veterans
should be less than for the general population, and this hypothesis is
supported by research. If it is the same, or higher, then 'something' has
intervened, and there is again, research evidence to support that it is higher
than would be expected. 
In July 2016, the Australian Institute for Suicide Research and
Prevention (AISRP) published a literature review regarding suicide amongst
veterans in Australia and internationally, and how this compares to the general
population. One of its findings was that there is 'very limited research
information focusing specifically on suicide mortality, non fatal suicidal
behaviour or suicidal ideation among individuals who have left the Australian
It described the lack of information about suicide mortality among ex-serving
Australian personnel as a 'serious shortcoming in current knowledge'.
Similar concerns were expressed by submitters. For example, Suicide
Prevention Australia also considered '[t]he lack of research comprehensively
and specifically addressing suicidal behaviour among Australian veterans is
itself an issue: investment in research is urgently required to uncover the
reasons Australian veterans and ex-service personnel are dying by suicide and
how suicidal behaviour among this population can be prevented'.
The South Australian Government also observed that '[w]ithout accurate data it
is difficult to fully understand the magnitude of the issue although it is
considered that a zero tolerance of suicide amongst the veteran community is a
suitable aspirational target and statistical evidence of one suicide is
sufficient to warrant serious consideration'.
There is no national suicide register in Australia, although some states
have established registers for their jurisdictions. Dr Kairi Kolves from the
AISRP, which administers the Queensland Suicide Register, underscored the
difficulties in identifying veterans who have taken their own lives:
Identifying ex-serving members is pretty challenging, because
when police arrive at the scene, there is often no information as to whether
the person has been an ex-serving member, unless it is indicated by family
members who knew about it. If the informant happens to be somebody else, it is
likely that they will miss it. A similar thing happens with the National
Coronial Information System.
The lack of an official register of serving and ex-serving members who
commit suicide was highlighted during the inquiry. Growing awareness regarding
suicide by ex-service men and women has led to members of the community such as
the Australian Veterans Suicide Register to unofficially highlight
incidence of suicide.
Some raised concerns with the committee that the lack robust official
statistics would allow 'others to sensationalise suicide on social media' and
may contribute to increase suicidal ideation.
Some submitters supported the introduction of a publicly maintained
register of suicide amongst ex-military personnel.
Slater and Gordon Lawyers argued that the data from the AIHW study 'needs to be
gathered on a regular basis and made publicly available in a de-identifiable
format'. It considered that this was 'only way that the extent of the issue can
be properly quantified and understood, and then steps toward a meaningful
solution strategy taken'.
Mr Arthur Ventham proposed that a '[m]ilitary suicide register should be
funded to collect the true number of service and ex-service suicides' with
cross-matched data from state coroners' offices, the ADF and police.
The Catholic Women's League of Australia also urged the Australian Government
to establish a 'government funded and managed data base/register on suicide':
Data collection is paramount to gaining a better understanding
of how widespread suicide is in the armed forces, and being able to take steps to
support those who need support and prevent it from happening. Without an
accurate snap shot of the magnitude of the problem efforts to rectify the
situation can only be half-hearted at best. Furthermore, a lack of data results
in a lack of research and national plan formulation on the issue, only serving
to exacerbate the stigma and shame that is so prevalent around this issue.
However, this is an initiative that needs to be supported, funded and managed
by the Australian government, to ensure consistency and accuracy of data.
Relevant areas for further research were also highlighted. For example,
Dr Andrew Khoo, a consultant psychiatrist, recommended work into 'concepts
which are recently coming under the heading of "Moral injury" and
their possible contribution to suicidal behaviour'. Moral injuries could
include 'guilt over what was or wasn't done and coming to terms with perceived
betrayals and losses'. He noted that 'young men and women have difficulty
resolving the deprivation, disease and death they have encountered, and the
horror of what one human can do to another'.
The NMHC report considered that '[c]ontinued research is required to
develop a comprehensive understanding of suicide and self-harm within current
and former members of the ADF, and their families. It supported the development
of a long-term research program focussed on mental health and wellbeing, and
the prevention of suicide and self-harm in conjunction with expert bodies and
taking in account current research such as the TWRP and the AIHW. In
particular, the NMHC recommended:
The Department of Defence should periodically commission
(e.g. every 2-5 years) repetition of the data-linking study undertaken by the
AIHW that examined the risk of suicide in current and former serving members.
It is only in this way that a more accurate picture of the true risk of suicide
can be built up over the next generation of military service.
In its response to the NMHC report, the Australian Government stated
that it intended 'that AIHW provide regular updates on the suicide data linkage
study to improve the understanding of the true risk of suicide'. It noted that DVA
and Defence were 'currently in discussion with AIHW for the continuation and
regular updating of this study'.
Identified contributing factors
A broad range of interrelated factors were identified as contributing to
the incidence of suicide by veterans. These included both factors which affect
the general population and factors which were linked to the experiences of
those persons who have served in the ADF. In the general community, DVA noted
that 'factors can include pain, despair, guilt, shame, recklessness or an
expression of a person's right to choose the manner of their death'.
Phoenix Australia listed a number of identified risk factors associated with
historical factors, such as any history of suicide attempts, past
abuse, family history of suicide, and family history of mental health problems;
mental health factors, such as current mental health problems and
recent discharge from an inpatient mental health unit;
demographic factors, such as male gender and divorced or widowed
marital status, with peaks between the ages of 40-54 and over 80;
social factors, such as social isolation, loss of relationship,
financial difficulty, and critically, having access to means for suicide; and
medical factors, such as chronic pain and physical health
The recent AISRP report on 'Suicidal behaviour and ideation among
military personnel: Australian and international trends' noted that a 'qualitative
analysis of the case studies concluded that the reasons for suicide among
veterans are multidimensional and include a range of veteran-specific risk
factors such as difficulty returning to civilian life (relationship problems,
mental illness, alcohol and drug misuse, employment problems, bereavement, and
loss of the routine and structure that characterise a military lifestyle) and
veterans' reluctance to seek help for their problems'.
Submitters to the inquiry highlighted a range of issues which contribute
to veteran suicide, self-harm and ideation. These included:
mental health issues, including depression and post-traumatic
stress disorder (PTSD);
homelessness, poverty and lack of income;
unemployment and low job security;
stress on personal relationships and family violence;
social isolation and lack of connectedness;
experiences of sexual assault, bullying and harassment in the ADF;
perceived maladministration within the military justice system;
the side effects of mefloquine (anti-malarial drugs); and
substance and alcohol abuse.
Suicide Prevention Australia recommended consideration of Thomas Joiner's
interpersonal-psychological theory of suicidal behaviour which posits three key
factors in determining the risk of an individual engaging in a lethal suicide
attempt. These factors were 'perceived burdensomeness', 'thwarted belongingness',
and 'acquired capability for suicide'. It detailed how these factors were
relevant to the experiences of veterans.
Similarly, Dr Frank Donovan, a former mental health social worker, noted:
Suicide has commonly been associated with experiences like
alienation from family, community, previous friendship networks, employment and
even intimate partners – leaving the potential suicide with no support, sense
of self-worth, future or a 'life worth living'. Bereft of their former military
milieu which provided for all of these important features of life, suicide is
perhaps seen as the 'best way out' of the veterans new sense of
Dr Andrew Khoo outlined the risk factors for suicide identified by the US
based Center for Disease Control and Prevention which included a 'history of
mental disorders' and 'physical illness'. He noted:
Exposure to trauma (either during deployment, training
exercises or workplace accidents/incidents) during military service is
associated with increased risk of psychological injury. Depending on which research
you peruse 12 month prevalence rates for mental disorders vary between 20-30%
for returned service people, with lifetime prevalence rates of greater than
50%. These rates are significantly higher than matched civilian cohorts.
Suicide research informs us that up to 90% of completed suicides have
diagnosable mental illness.
Comorbidity rates of Alcohol and Drug Use Disorders in
populations with combat related PTSD are as high as 60-80%. Recent US VA
statistics show that 1 in 10 returning personnel have an active drug or alcohol
problem. Whilst the general trend is for serving personnel to have decreased
rates of Substance Use Disorders (SUDs) compared with the civilian population
(ADF prevalence study, US DoD statistics), rates of SUDs accompanying PTSD and
other mental health disorders following service are significant. Of concern is
the effect of both Australian and military culture which has historically
advocated alcohol use as a coping mechanism for stress. Particularly as alcohol
and/or drug intoxication reduces judgment making suicide attempt and success
There are a number of chronic physical conditions which
typify the medical presentation of serving and ex serving military personnel.
These include hearing loss, tinnitus, degenerative osteoarthritic conditions of
weight bearing joints (ie the neck, shoulders, lower back, hips, knees and
ankles), gastro-oesophageal reflux disease, irritable bowel syndrome and sexual
dysfunction. These chronic conditions covey significant pain, disability and
impairment and hence may contribute to numerous functional losses and a sense
of loss of worth, hope or esteem.
The unique nature of military training and the impacts of the stress
caused by training to veterans was also highlighted. For example, the Defence
Force Welfare Association (Queenland) observed that '[f]rom the outset, ADF
members are deliberately exposed to violence and are trained to react and
continue working in stressful and often dangerous situations'. It noted that
there have been many major and minor accidents where ADF members have been injured
and/or killed on duty whilst training for war. It stated that 'training
environment stressors can have a deleterious effect on the mental health of
individuals whether or not they make it through the training program' and
suggested that 'this may be a contributing factor in some suicidal events'.
Recent deployment structures were identified as putting additional
stress on some military personnel, with multiple deployments perceived as
increasing the risks of the development mental health problems.
Limited recovery-time between deployments also was seen as putting additional
stress on veterans and their families.
For example, Mr Max Ball drew the committee's attention to a U.K. Ministry of
Defence recommendation that military personnel be deployed for six months at a
time and for less than twelve months in any three-year period.
While a wide range of factors were identified there were two particular
factors which were a focus in the evidence for the inquiry: PTSD and the
compensation claims process.
Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is a set of reactions that can
develop in persons who have been through a traumatic event which threatened
their life or safety, or those around them. Royal Australian and New Zealand
College of Psychiatrists (RANZCP) highlighted the 'well-researched correlation
between suicidality and PTSD:
Exposure to traumatic events significantly increases the risk
of suicidal ideation and behaviour. The relationship between trauma and suicidality
has been found to exist independent of psychiatric disorders although
comorbidities with mood and substance abuse disorders may still be factors.
Numerous studies have demonstrated a positive relationship between cumulative
trauma and suicidality.
In particular, it emphasised the need for customised treatments for
military-related PTSD. The best-practice treatment for patients with PTSD in
the general population, may not constitute an apt approach to the treatment of military-related
PTSD. It noted:
There are a number of particular treatments which may present
significant benefits for veterans and ex-service personnel but which may be
inaccessible or even disallowed. Private hospital day programs and community
services are good examples of treatment settings to which veterans require
increased access. Family-centred approaches to treatment may also be useful
considering the potential effects of mental ill health on the 'families of
veterans and ex-service personnel suffering from PTSD.
The treatability of PTSD was also emphasised by health professionals and
experts. For example, Dr Robert Tym highlighted evidence of the effectiveness
of Eye Movement Desensitisation and Reprocessing in treating and managing types
of PTSD. Dr Kerr from AISRP noted that, with treatment, military personnel
can return to being 'deployable again':
There is this culture that people still think that PTSD or
other mental health disorders cannot be gotten rid of. And they can be. We have
excellent treatments for some of these disorders, and they go into remission
meaning that they no longer have these disorders. And, for those people, there
is no reason why they should not still be in the uniform.
The compensation claims process
Many submitters identified delays, negative determinations or perceived
maladministration in DVA the compensation claim processes as creating critical
stress for veterans and as a contributing factor to suicide. For example,
Suicide Prevention Australia commented that it had 'received feedback from
multiple sources that the processes involved in engaging with DVA are perceived
to exacerbate veterans' stress and we posit that this may add to the perception
of perceived burdensomeness and thwarted belongingness, and therefore suicide risk'.
Similarly, the AISRP submission listed a number of risk factors for suicide by
Unfortunately the DVA compensation system is complex and
slow, and provides disincentives to work depending on the compensation Act the
person falls under. Additionally, veterans report that they feel a sense of
uncertainty regarding their future and feel they cannot progress their lives
until their compensation issues are finalised. They explain feeling paralysed, 'in
These concerns regarding the impact of the claims process were also
evident in submissions from veterans, their families, advocates and others. For
example, John and Karen Bird told the committee about their son Jesse who had
been diagnosed with PTSD and other mental health conditions:
He has been endeavouring to seek assistance from DVA for the
last eighteen months without success - it seems to him and us that the level of
bureaucracy is intentionally obstructionist and unedifying. The jungle of
paperwork, the lack of follow-up and the non-existent support has contributed
to his deteriorating mental health. He is involved with VVCS and is currently
involved in a 12 Week PTSD Specific Counselling program which finishes in early
December. Jesse has not received any money what-so-ever from DVA or Centrelink
to help him survive and without our financial and emotional help he would be on
the street or worse.
Subsequently, Jesse took his own life. His former partner, Ms Connie
Boglis, outlined the problems Jesse had after his service:
Jesse did not have a 'Part time' 6-10 scale PTSD, Jesse had
PTSD Everyday! Jesse was trained to run into the face of fear, you taught him
that. You broke him down before he even left for war and if that wasn’t enough,
he was deployed to Afghanistan for 9 months when it was only meant to be 6. The
day Jesse landed on Australian soil he should have been handed a white card,
given a pension and options for supports thereafter if he choose. Instead Jesse
was expected to pour out his wounds from the battlefield to a complete stranger
and talk emotions, something you taught him to hide so well. Well he did it,
Then you made him wait, in hope that his voice would be heard, So we continued
to wait, I couldn't wait any longer, So Jesse tried to wait a little more and fight
on his own but you never came.
Mr Peter Thornton, another veteran, described the DVA disability claims
process as 'challenging' and weighing 'heavily upon one's mental health and
well-being, generally at a time when one is at an extremely low ebb'. While he
accepted the need for a 'rigorous process that thwarts fraud', he perceived the
process itself 'could be a contributing factor to suicidal ideation and/or
actual suicide itself, by Veterans who are under immense pressure'.
Another veteran, Mr Shaun Young, highlighted the difficulties for those with
mental health issues in interacting with DVA:
When you suffer day to day with major depression, life is
already hard to get through. You literally have to take it one day at a time.
Then you have to call DVA on one of those days and suddenly you're thinking to
yourself 'what's the point of this bulls**t?' You're in a constant battle with
yourself and then DVA make it so you have to battle them.
In this context, Dr Nick Ford, a psychiatrist who works with veterans, drew
the committee's attention to a 2014 study which examined the aspects of claims
processes that claimants to transport accident and workers' compensation
schemes find stressful and whether such stressful experiences were associated
with poorer long-term recovery.
This study concluded that:
Many claimants experience high levels of stress from engaging
with injury compensation schemes, and this experience is positively correlated
with poor long-term recovery. Intervening early to boost resilience among those
at risk of stressful claims experiences and redesigning compensation processes
to reduce their stressfulness may improve recovery and save money.
RANZCP noted that there was 'an increasing body of evidence indicating
that delays in claim settlement, inappropriate decisions and unnecessary
obfuscation in administrative processes can serve to significantly worsen the distress
and severity of a veteran's condition'. It believed that 'the compensation
system would benefit from a reconceptualisation of compensation as part and
parcel of the health-care system to ensure that the processing of justified
compensation claims do not adversely affect health outcomes'.
Others cautioned against focusing on one factor when the issues relating
to veteran suicide were clearly complex. For example, the Alliance of Defence Service
Organisations (ADSO) considered that 'DVA's responsibility for contributing to
veteran suicidality must, however, be tempered by a reality that seems to
suggest that only 20% of people transitioning out of the ADF become automatic
DVA clients, and around another 15% eventually become DVA clients after
transition has occurred'. Nonetheless, ADSO recommended:
The perception that the rehabilitation and compensation
decision process is unreasonable, oppressive, and runs counter to timely and
equitable support, and therefore contributes to veteran suicide, should be
investigated. Whether the bureaucratic focus on due process is an exacerbating
factor and is contributing to veteran suicide should be investigated.
The government response to the committee's report into the mental health
of the ADF members and veterans in September 2016 described suicide prevention
'for serving and former serving ADF members at risk and support to the families
who have been affected by the tragedy of suicide' as a 'high priority':
The Government's current suicide prevention strategy includes
training to assist at-risk individuals, programs to build resilience, self-help
and educational materials, a 24-hour support line, and access to clinical
services. The Government is continuing to invest in initiatives to prevent
suicide among current and former serving personnel and support those affected
by it. As part of the 2016-17 Budget, funding of $1 million has been provided
to continue the suicide awareness and prevention workshops and to pilot an
alternative approach to suicide prevention in the veteran community. This is in
addition to the $187 million a year that the Government already spends in relation
to veteran mental health. 
DVA outlined that the 'Veteran Mental Health Strategy 2013-2023
provides a ten year strategic framework to support the mental health and
wellbeing of the ex-service community'. Funding for mental health treatment is
demand driven, and is not capped and DVA spends around '$187 million a year on
supporting the mental health needs of its clients'.
The NMHC report contained a useful summary of services available to
veterans through DVA. These included:
post-discharge GP health assessments;
mental health treatments through:
- GP, psychologist, psychiatrist, and social work services
in-patient and out-patient hospital treatment
services through Veterans and Veterans Families Counselling Service
(VVCS), including a 24-hour crisis line, counselling, group treatment programs';
DVA's Operation Life suicide prevention program, which includes
face-to-face workshops, a website and an app;
online resources, including DVA's At Ease online mental health
portal, PTSD Coach Australia app, High Res website and app (stress and
resilience program), and The Right Mix website and On Track with the Right Mix
app (alcohol management program); and
a range of health and wellbeing programs such as Stepping Out
(transition program), Day Club, Men's Health Peer education, and Veterans
The NMHC report noted that mental health treatments for former serving
members can be delivered by practitioners who are registered to provide
services under the Medicare Benefits Schedule (MBS). These services are paid
for by DVA through arrangements that guarantee no out-of-pocket costs for
eligible services that are accessed by holders of Gold and White cards. Other
mental health treatment services are paid for by DVA via contracted arrangements
with providers, such as private hospitals.
It also noted that former members of the ADF 'have access to services in
the general community, including state/territory public health systems, broader
public health initiatives and services provided by non-government organisations
including ex-service organisations (ESOs), and post-traumatic stress disorder
(PTSD) treatments services in the community'.
In November 2015, as part of its response to the NMHC report of mental health
programs, the Australian Government announced a renewed approach to suicide
prevention through the establishment of a new National Suicide Prevention
Strategy. In particular, the strategy was being led by Primary Health Networks
(PHNs) in partnership with local hospital networks, states and territories, and
other local organisations with funding available through a flexible funding
pool. On 28 May 2017, the Hon Greg Hunt MP, Minister for Health,
announced a '$47 million boost to front-line services for suicide prevention
and directly address a growing community need'.
Table – DVA overview of mental health expenditure in
Veterans and Veterans Families
In particular, DVA highlighted the work of the Veterans and Veterans
Families Counselling Service (VVCS) as a frontline mental health service for
the veteran community. VVCS provides a range of services including clinical
support and counselling options to veterans and their families who are
experiencing service-related mental health and wellbeing conditions. DVA noted:
In 2014-15, through its nation-wide network that includes 14
centres, a range of satellite centres, and more than one thousand contracted
outreach clinicians, VVCS delivered 92,861 counselling sessions to 14,627
clients. An additional 5,350 clients had their concerns resolved at intake,
1,610 clients participated in group programs and 6,571 people received after
In its mental health report in 2016, the committee recommended that eligibility
requirements for VVCS be consolidated and broadened to include all current and
former members of the ADF and their immediate families (partners, children, and
carers). The Australian Government partly agreed to expand eligibility to VVCS
to include all current and former permanent members of the ADF through White
Card arrangements and to include certain family groups.
The 2017-18 budget included expansion of eligibility access to VVCS:
Any partner, dependant or immediate family member will have
access to the services and support provided by VVCS, including counselling and
group programs. Former partners of ADF personnel will also be able to access
VVCS up to five years after a couple separates or while co-parenting a child
under the age of 18.
DVA's Operation Life initiative aims to prevent suicide and
promote mental health and resilience across the veteran community. It is
intended to provide veterans and their families with the tools to recognise and
act on suicidal tendencies in the early stages. It includes website resources,
a companion app and workshops run by the VVCS to 'increase the ex-service
community's awareness of, and ability to respond to, suicidal behaviour in
individuals'. The VVCS workshops included;
safeTALK (suicide alertness for everyone) – a half-day
ASIST (Applied Suicide Intervention Skills Training) – 2-day
skills training; and
ASIST Tune-up (Applied Suicide Intervention Skills Training
Tune-Up) – a half-day refresher workshop.
DVA noted the 2016-17 Budget included $1 million over four years for the
Veteran Suicide Awareness and Prevention Programs for the continuation of
Non-liability health care – mental
The Budget 2017-18 included funding of $33.5 million over four years to
provide treatment for all mental health conditions under non-liability health
care arrangements. This built on the previous initiative which allowed all
current and former members of the ADF who had served one day in the full-time
ADF to be able to access treatment for the specific common mental health
conditions such as PTSD. The new initiative was expected to benefit around 2,000
current and former ADF members and would include coverage for adjustment
disorders, acute stress disorder, phobias, panic disorder, agoraphobia, and
bipolar and related disorders.
Treatment under the non-liability health care arrangements is
delivered through the provision of a DVA White Card. Services available under
these arrangements may include general practitioner, psychiatrist, psychologist,
medication, public or private hospital, and counselling.
DVA officials also noted that the expansion of non-liability health care
had been well received. Mr Luke Brown, Assistant Secretary, Policy Support
Branch from DVA told the committee that in the 2016 calendar year for
non-liability health care for mental health conditions, DVA had 8,049
successful claims, which was a 55 per cent increase on last calendar year.
The estimated cost of mental health treatment used in the costing of the 2017-18
Budget measure to expand treatment to all mental health conditions under
non-liability health care arrangements was $4,500 per patient per annum.
A number of pilot studies and programs related to suicide prevention
have recently been announced. On 11 August 2016, the Australian Government
announced a suicide prevention trial site would be established in North
Queensland. Minister Tehan outlined:
This will occur through the North Queensland Primary Health
Network. As part of its work, the trial will focus on veterans' mental health. This
will be one of 12 innovative, front-line trials in our fight against suicide
which will improve understanding of the challenges and work to develop
best-practice services which we can be applied nationwide.
The 2017-18 Budget included funding of $9.8 million over three years to pilot
two new approaches to supporting vulnerable veterans experiencing mental health
concerns. DVA stated:
The two suicide prevention pilots announced in this year's
Budget are specific mental health treatment interventions, which will support
vulnerable veterans with complex acute or chronic mental health conditions. The
first pilot, the Mental Health Clinical Management Pilot, will be delivered to
an at-risk population with complex mental health needs on discharge from a
mental health hospital. These participants will be at risk of self-harm,
re-admission and/or homelessness. The second pilot, the Coordinated Veterans'
Care (CVC) Mental Health Pilot, will be targeted at patients with chronic
mental and physical health comorbidities, who require clinical management through
general practice and, where necessary, other mental health professionals.
Over the two years of the pilot programs, up to 100 veterans will
participate in the Mental Health Clinical Management Pilot, and up to 250
veterans will participate in the expansion of the Coordinated Veterans' Care
In relation to the CVC pilot, DVA provided information from an evaluation which
indicated that 'although expected savings are yet to be achieved, there is
evidence to suggest that these could arise with longer term program enrolments'
and there were 'positive qualitative benefits' based on feedback by veterans
and General Practitioners.
Mental health assistance
Access to mental health services by veterans was perceived as a critical
component in suicide prevention. Many submitters noted the relationship between
incidence of mental illness and rates of suicide. In particular, they
identified veterans with mental illness as being an 'at risk cohort'.
The AISRP noted:
The Mental Health Prevalence and Wellbeing Study (MHPW) found
that more than half of the ADF population sampled had experienced mental
illness in their lifetime, significantly higher compared to the general
population, despite the "healthy worker effect" (those selected into
the military are screened for mental illness prior to entry, creating a more
healthy population). In March 2015, DVA reported it was supporting 147,318
veterans, with 49,668 of these having accepted mental disorders.
Phoenix Australia also observed that the 2010 MHPW study indicated that
90 per cent of those reporting suicidal ideation had a mental health condition.
Accordingly, it considered it was important 'to address the quality of mental
health treatment available to veterans, and improve the service system that
delivers treatment, in order to address this risk factor and reduce the rate of
Lack of expertise in treating veterans
It was highlighted that the ADF only employed one full-time psychiatrist
at the ADF Centre for Mental Health.
Dr Jonathan Lane, a consultant psychiatrist, considered:
This has the unfortunate consequence that there is not a body
of clinicians who actually have a significant amount of experience working with
the military, full stop, let alone working with veterans. There are no formal
training pathways for military psychiatry or for dealing with veterans, so it
is a very under-utilised and under-resourced area in the clinical expertise
that clinicians have when they are dealing with veterans.
I think this leads to the estrangement of veterans when they
actually have left the military and when they are trying to access services in
the civilian community.
Dr Lane also noted that there was 'no training for psychiatrists during
medical school or during your training period as a psychiatrist in military
psychiatry or in veterans culture and community'.
Similarly, Dr Khoo observed that 'there are a lot of my colleagues who provide
reports who would not have a clue about military medicine, military culture or
what happens to a soldier after they are deployed and after they are discharged'.
This point was also echoed by veterans and ESOs. For example, the William
Kibby VC Veterans' Shed noted a previous proposal that 'both men and women
exiting the ADF be offered placements at various universities around Australia,
to study medicine, the view to branching to either studying Psychiatry or Psychology'.
This idea was brought up because of the extreme shortage of
both Psychiatrists and Psychologists with an ADF background.
All too often we at the Veterans' Shed have heard the
comments of "how would they know, they weren't there", which translated
means how can someone without an operational experience treat someone who has
seen operational service?
Defence specific training for clinicians was available through online
courses offered by DVA and training programs offered by the Phoenix Australia.
DVA noted there were six e-learning programs for mental health practitioners that
were available through the At Ease portal. These were:
Understanding the Military Experience;
Working with Veterans with Mental Health Problems (GP specific);
PTSD - Psychological Interventions Program; and
the VVCS Practitioners Guide.
In addition to these resources, DVA outlined that it 'provides a
research dissemination website, known as Evidence Compass, an on line version
of an assessment tool, ADF Post-discharge GP Health Assessment,...Mental
Health Advice Book and Beyond The Call: stories from veterans and their
The Australian Psychological Society thought that the 'current DVA suite
of eLearning online training such as 'understanding the military experience'
modules are important in building a cohort of providers informed in the
military experience'. However it noted:
[T]here is no requirement for DVA providers to undertake this
training and there are currently no incentives for health practitioners to
complete the training. Additionally, there is no mechanism for referrers or
consumers to identify service providers who have undertaken the DVA training.
This gap could be remediated by (a) introducing enhanced
comprehensive training for service providers delivering mental health services
to this cohort; this could comprise a series of linked modules that include an
assessment component and evidence of completion and would provide an indication
of basic competencies (Practice Certificate), (b) implementing a system for
identifying who has undertaken the training, and (c) introducing incentives for
undertaking the training and demonstrating outcomes in clinical practice.
Similarly, Mates4Mates argued that '[c]linicians who treat veterans need
to also have astrong understanding of the military context from which the
veteran has originated'. It suggested:
To instill confidence in veterans it would be useful if there
was a way for them to know which provider has completed the DVA training
modules. This will provide veterans with a level of confidence that these service
providers have an understanding of their unique situation – this will help with
the development of a strong therapeutic relationship and means the veteran will
hopefully be in a better position to continue to seek support.
The AISRP commented that '[w]orking with current and ex-serving members
requires a unique and specialised skill set incorporating intimate knowledge of
their work experiences, demands, organisational culture, and traumas'. Many mental
health clinicians feel under-skilled or unprepared for working with veterans,
and therefore choose not to see this client group. It observed:
DVA provides online training to up-skill practitioners,
however there are no incentives for clinicians to undertake this training, and eLearning
only suits those comfortable with that learning style. DVA could introduce
face-to-face training for clinicians to increase confidence and skills and
provide remuneration for this, which would increase the number of experienced
and high quality professionals working with veterans.
The NMHC report recommended further enhancement of specialist mental
health expertise within the ADF. This could include 'a greater number of
military psychiatrists, engagement of mental health nurse practitioners, and
more allied health practitioners with clinical mental health expertise'. The
NMHC suggested the cost of this enhancement could be off-set by reducing
outsourced mental health specialist services.
In relation to this issue, Defence emphasised that the Defence White Paper
included engagement of additional permanent ADF specialist mental health
This initiative will expand the Medical Specialist Program to
include the specialty of psychiatry through an additional seven specialist
psychiatrist or trainee registrar positions. This will form the core of ongoing
reform of delivery of specialist mental health services to deployable, deployed
and returned ADF personnel.
The NMHC also proposed that consideration be given to 'funding and
developing further specialist mental health centres of excellence within all
major defence service regions, providing local capability and knowledge as well
as the opportunity to form partnerships and build the evidence base through
high quality research and service evaluation'. It stated:
Such centres would see consultant psychiatrists working
within specialist multi-disciplinary teams which include mental health nurses,
allied health practitioners and peer workers, and could potentially offer
services to current and former serving personnel, and their families.
The Australian Government response noted that 'Defence has a number of
current actions in place to expand specialist mental health expertise within Defence
Health Services supported by an expansion of the role of the ADF Centre for
Mental Health'. It stated:
Defence has a proposal to expand the existing ADF Centre for
Mental Health as the centre of excellence within Defence, to create a bespoke
model for supporting access to clinical expertise across Defence regional
health services and develop partnerships with other external national centres
As part of the 2016 Election commitments, the Government
committed to providing $6 million over four years from 2016-17 to develop the
Centenary of Anzac Centre in partnership with Phoenix Australia. The Centre
will perform two primary functions, of providing practitioner support and
During the inquiry into the mental health of ADF serving personnel, the
committee raised concerns regarding the evidence that psychologists are
unwilling or unable to treat veterans due to DVA providing inadequate funding
for psychological services. The committee noted that there is a significant gap
between the DVA schedule of fees and the Australian Psychological Society's
schedule of recommended fees. The committee raised concerns that inadequate
funding of psychological services would limit the already scarce mental health
services available to veterans (especially those living in regional or remote
The committee recommended that the DVA Psychologists Schedule of Fees be
revised to better reflect the Australian Psychological Societies' National
Schedule of Recommended Fees, and that any restrictions regarding the number of
hours or frequency of psychologist sessions are based on achieving the best
outcome and guaranteeing the safety of the veteran.
These concerns during the gaps in fees paid by DVA and access to
specialist care were repeated during the current inquiry. The Australian
Psychological Society commented:
At the present time, there is a freeze on the DVA Psychology
Schedule of Fees. This freeze dates back to 2014 and acts as a disincentive for
the uptake of skilled clinicians. Unlike other existing mental health services
for civilians (e.g. Better Access to Psychiatrists, Psychologists and General
Practitioners through the MBS initiative), there is no capacity to charge a
co-payment for DVA services. This inability to strike a fee that reflects the
practitioner's expertise and the typically complex needs of ex-serving
personnel and veterans is an operational disincentive to the uptake of such
work by practitioners who would otherwise be willing and suited to it.
The AISRP also commented on this 'large discrepancy' between the fee
charged to private civilian clients and 'that which DVA pays; which was
creating a disincentive for experienced and skilled clinicians to see veterans:
If DVA would match the fee schedule provided by Medibank
Health Solutions or that recommended by the APS, this would increase the number
of psychologists willing to see veterans and would increase the delivery of gold-standard
interventions which have high success rates in treating mental disorders. Many
veterans report receiving pharmacological treatment, but are not receiving
psychological treatment which is the gold-standard because it is highly
effective in creating many disorders commonly experienced by veterans (eg.
PTSD, depression, anxiety, substance use disorders).
When questioned on this issue, Ms Sue Campion, First Assistant
Secretary, Health and Community Services with DVA stated:
The difference is that generally our health services are
based on the MBS and PBS and other things, and then we add to them. So in the
case of the MBS and fees, we pay the MBS fee plus an additional percentage to
reflect the fact that our fees represent the full payment for service, so there
is no patient contribution. Defence's model is that they have purchased the
provision of health services through, in this current instance, Medibank, but
they are not referencing necessarily to the MBS rates. They have negotiated a
separate contract for the provision of their services, whereas we rely on the
general universal access health system and then add to it.
DVA acknowledged evidence provided to the committee about psychiatrists
and psychologists not accepting DVA fee arrangements or withdrawing from these
arrangements. However, it considered it was not possible 'to discern trends
from the data about the extent of provider participation in DVA arrangements'.
In the event that a practitioner may not accept DVA fees or
there are no providers, DVA provides assistance in identifying another suitable
practitioner, providing transport assistance, or considering a provider’s
request to fund services above DVA fees. An 'above fee' request is determined
on the basis of clinical need, and includes consideration of the patient’s
ability to reasonably access another suitable practitioner. 
DVA argued it was not possible to directly compare Defence fees with
those of DVA. It noted that on base health services provided to currently
serving members 'are delivered by a mixed workforce of ADF, APS and
contractors, inclusive of mental health professionals'. The on-base contractor
health workforce is provided under the contract with Medibank Health Solutions.
In contrast, DVA arrangements for medical services, including psychiatry are
aligned to Medicare although it highlighted that DVA fees are set at a higher
rate than comparable Medicare fees.
DVA psychiatry consultations are paid at 135 percent of the
equivalent Medicare fee, with a psychiatrist consultation of between 45 minutes
and 75 minutes currently $247.95 under DVA and rebated under Medicare at
$156.15 (which is 85 per cent of the Medicare fee).
In 2010 when DVA introduced individual fee schedules for each
allied mental health profession, the fees reflected the MBS-equivalent time
based items and were paid at 100% of the MBS rate, as part of a package
negotiated with the relevant provider associations at the time.
Under current DVA arrangements for clinical psychology, a consultation
lasting 50 minutes or more attracts a fee of $148.95 where the equivalent is
rebated under Medicare for $124.50 (which is 85 percent of the Medicare fee of
$146.45). The indexation of the DVA fees has been paused since November 2014,
with the pause to continue until 30 June 2018.
Model of care
The most effective model for mental health services to support veterans
and the need for veteran-specific services was also discussed during the
inquiry. The relevance of this issue was illustrated by the planned closure of
the Repatriation General Hospital in Adelaide at the end of 2017 and the
movement of services to the Jamie Larcombe Centre at Glenside Health Service
Campus. The South Australian Government outlined that this new $15 million
facility was intended to be a '[post-traumatic stress] Centre of Excellence in
recognition of the potential impact of military service on the mental health of
service and ex-service personnel':
The new facility will be purpose built and will incorporate
an acute 24 bed inpatient unit, outpatient services, teaching and research
spaces...It is envisaged that the Precinct will provide comprehensive, trusted
and person centred, family orientated veteran mental health services.
In the context of the new Veterans Mental Health Precinct, it
has been timely to review the Model of Care for specialist mental health
services for veterans. Clinicians, managers, consumers, carers and emergency
service personnel are engaging in the process and contributing to the Model of
Care that will incorporate innovation, is shaped by evidence based practice,
and defined by standards of care to address the mental health care needs of
veterans and emergency service personnel. Research is seen as a critical
element to ensure the Model of Care is flexible and able to identify the most
appropriate treatment options.
There were perceived advantages in services for veterans being
co-located and veterans being able to receive treatment together. For example,
Mr Guy Bowering told the committee about his experiences in Ward 17 at the Repatriation
The crash and burn of my PTSD experience within the
Repatriation General Hospital also allowed my other comorbidities to be taken
care of all in one place. No-one I met within Ward 17 had just PTSD; they had
things like sleep problems, gastrointestinal problems, diabetes, chronic pain
et cetera. All these were taken care of on one site...Military and veteran mental
health is not a cookie-cutter version of a normal mental health facility. It
acknowledges the peculiar service and stresses that we put on our military
members, and the treatment is tailored with that in mind. Ward 17 cannot exist
as a standalone facility. It requires the support of facilities that only a
hospital campus like the Repatriation General Hospital can supply. With the
move, current ADF members and veterans will receive a degraded service.
RANZCP noted that as specialist services, veteran hospitals provide a
number of advantages. These included:
specialist staff across a range of health domains, including
psychiatry, representing consolidated clinical knowledge passed down through
generations of specialist training and 'on-the-job' experience;
evolving models of care attendant to changing needs based on
clinical observation and assessment, consolidation of knowledge and innovation
assured service provision with continuity of care; and
improved advocacy and understanding of system deficiencies
facilitated by structured communication lines between veterans and community
members, health professionals and departmental management.
The RANZCP commented that without the concentration of expertise engendered
by a system of veteran-specific hospitals, health care is provided to veterans
according to the purchaser-provider model, requiring them to source their own
service. It noted this could lead to fragmented services offering models of
care at varying levels of quality with no guaranteed continuity of care. It was
aware of veterans which had found sourcing of appropriate care difficult.
The RSL observed that the purchaser provider model is 'very much focused
on the provision of funding for consultations and episodes of care'.
It takes little overarching analysis of the different
requirements of patients with different levels of acuity. There needs to be a
system that has secondary and tertiary referral services for those who are not
responding to the primary evidence-based treatments. The access to the higher acuity
levels of care for veterans needs to be audited.
As veterans hospitals substantially no longer exist, the
priority care for veterans is more difficult to deliver. Much of the care,
particularly when the very unwell, is now provided within the state systems. We
know that these are underfunded and often individuals who represent a
significant suicide risk are turned away. They have little expertise in
trauma-related psychopathology and are not likely to deal well with the types
of needs a veteran is likely to present.
Another key concern was enabling choice by veterans in relation to
mental health services. For example, DefenceCare RSL considered that DVA's
services were 'prescriptive and based on clinical-only treatment' leaving
veterans with 'little say in the allocation of funding to clinical or
non-clinical treatments or aids that they believe are important to their
particular circumstances'. It recommended investigation and a trial of a model
of consumer directed care (CDC) for veterans:
CDC empowers the consumer to have more control over their
life and be in charge of decisions about their lifestyle and support. It
focuses on the person's life goals and strengths, placing their needs at the
centre of the services and support. The person makes choices and/or manages the
services they access, to the extent they can and wish to do so, including who
will deliver services and when.
The Australian Psychological Society commended DVA's work over the last
decade to review and improve 'the range of funded inpatient, outpatient,
teleconferencing and online services for veterans'. However, it noted that
there was evidence that 'current service models do not effectively reach a
large number of veterans' and this particularly disadvantaged veterans in rural
and remote areas and veterans with physical disabilities. It suggested a 'hub
and spoke model of service delivery could improve access for many of these
veterans'. It stated:
The NMHC report advised Defence and DVA to 'continue to build on the
stepped mental health care model in place and ensure that a range of early
intervention options are available that can maximise early help-seeking and
minimise the impact that mental illness may have (e.g. on career progression or
deployment or post-military employment)'.
The Government's response to the NMHC report noted that the Department of
Health through primary health networks and national programs was increasing the
availability of low intensity services including digital services which would be
able to support both current and former members of the ADF. In particular, these
digital services, including the $30M investment in the Synergy IT, would
respond to 'the help-seeking behaviours of at-risk young men'.
Conclusion and recommendations
Suicide by veterans is particularly disturbing due to a recognised collective
responsibility for the welfare of those who have rendered service on behalf of the
community. Further, ADF members are a healthy and resilient group, who benefit
from high-quality support while in uniform. In this context, there are
understandable concerns that the suicide rate for the veteran community is not
significantly lower than the general population.
The reasons why a person may decide to take their own life can be very
complex. In particular, not everyone who has suicidal ideation has a mental
health condition. The evidence received covered a range of factors which might contribute
to veterans and ex-service personnel taking their own lives. Research in this
area is still continuing and at this stage it is difficult to discern any clear
trend or common factor. To the committee, this indicates that the current
preventative, early intervention model targeted to those at risk, together with
a holistic response to improve the overall welfare of veterans is the most appropriate
approach to reduce the rate of suicide amongst veterans.
The NMHC report recommended addressing the needs of younger veterans
following the release of the first AIHW results which identified this cohort as
a vulnerable group. The NMHC urged 'as a matter of priority' that the Minister
of Veterans' Affairs liaise with the Minister for Health 'to oversee the
development of strategies, utilising a co-design process, to engage and support
former members of the ADF aged 18-29 years, who have left the service in the last
5 years and who could be at risk of suicide or self-harm'.
The Government response outlined several initiatives directed to this age
group. These included:
The Government recently allocated $30 million to develop
digital mental health initiatives as part of Project Synergy, including an
internet-based platform for mental health tools primarily targeted at young
people. As part of this investment, a trial with VVCS clients will be conducted...
The Australian Government funds the headspace network, which
provides free or low cost access to youth specific mental health services for
young people aged 12-25 years. headspace services are also available to young
veterans, defence personnel and their families across Australia. headspace
takes a holistic approach to mental health by also providing support for
related physical health, drug and alcohol problems, and social and vocational
support. Where headspace is not the best service for a young person, headspace
will use established clinical pathways to connect young people to appropriate
Government is partnering with Lifeline Australia to support
the $2.5 million trial of a new crisis text service, Text4Good, for all
Australians in need.
In the view of the committee, there is more that can be done to respond
to these new research findings. The recent AIHW research findings concerning at
risk groups based on their age, discharge and service characteristics should be
used to develop new targeted suicide prevention and veteran support programs. Additional
targeted programs to these at-risk veterans could yield long-term improvements
in the health and welfare outcomes as well as contributing to reducing the
incidence of suicide and self-harm.
In particular, DVA has already outlined to the committee the positive
results achieved by the DVA Reconnects project which aims to reconnect
with clients through proactive contact attempts and the provision of a complex and
multiple needs assessment.
DVA (with the assistance of with Defence) should be matching the information
they have about recent veterans with these identified 'at-risk'
characteristics. Where DVA identifies veterans who have these at-risk
characteristics, DVA should be proactively seeking to contact these veterans to
ensure that they are aware of the supports available to them.
The committee recommends, that in the context of recent Australian
Institute of Health and Welfare findings concerning veterans at risk of
suicide, the Australian Government:
develop and implement specific suicide prevention programs
targeted at those veterans identified in at-risk groups; and
expand the DVA Reconnects Project to proactively contact veterans
in these identified in at-risk groups.
A large number of submissions from veterans focussed on the issues confronting
them due to the complex legislative framework of veterans' entitlements and its
administration by DVA. Problems with the compensation claims process were often
perceived as key stressors and contributing factors to suicide by some veterans.
Further consideration of improvements in these areas will be addressed in the
next chapters. However, in the view of the committee, there is a lack of
research in this specific area. In particular, the impact of DVA claim
assessment processes as a stressor on veterans and their families.
On the evidence received, the committee considers this topic merits an
independent investigation. The results of this study should be used to improve
and restructure DVA assessment processes to reduce the stress for veterans and
improve overall outcomes.
The committee recommends that the Australian Government commission an
independent study into the mental health impacts of compensation claim
assessment processes on veterans engaging with the Department of Veterans'
Affairs and the Commonwealth Superannuation Corporation. The results of this
research should be utilised to improve compensation claim processes.
The committee welcomes the valuable investment of DVA and Defence in the
Transition and Wellbeing Research Programme and other research initiatives. The
AISRP report has highlighted that research into veteran suicide carried out in
other countries cannot necessarily be applied to Australia. Further, ongoing
research will be needed. The committee notes that DVA and Defence are currently
in discussions with AIHW to continue and regularly update its work on the
incidence of veteran suicide. Building on this recent valuable study, there
needs to be consideration regarding the establishment of a permanent National
Veteran Suicide Register based on the model of the Queensland Suicide Register
The QSR works with police and the coronial system to gather more detailed
data on deaths by suicide that occur in that jurisdiction. While the broad
direction of the suicide rate amongst veterans will be useful in determining
the extent of the issue and to track change, there is a range of other
significant information that could be collected to inform policy approaches in
the future. The creation of an official publicly funded register may also serve
to allay concerns raised that unofficial registers could sensationalise the
topic of veteran suicide and have other negative consequences.
The committee recommends that the Australian Government establish a
National Veteran Suicide Register to be maintained by the Australian Institute
of Health and Welfare.
The committee was concerned by evidence regarding a lack of psychiatric
expertise within Defence. However, Defence has indicated it is improving mental
health care and support for ADF members, including through the 'engagement of
an additional six specialist psychiatric trainees and specialists as well as
one administrative coordinator'.
The lack of experience in treating veteran-specific issues within the
Australian professional mental health community was also troubling. The
Australian Psychological Society made a number of proposals to enhance the
online training to practitioners provided of DVA. In the view of the committee,
these proposals deserve departmental consideration.
The committee recommends that the Australian Government review the enhancement
of veteran-specific online training programs intended for mental health
professionals. In particular:
requirements for providers to undertake training;
the introduction of incentives for undertaking online training
and demonstrating outcomes in clinical practice.
The committee was concerned that discrepancies between the fees paid by
Defence and DVA continue to be identified as a barrier to veterans accessing
professional mental health services. In order to ensure seamless care is
provided to both serving ADF members and veterans, the committee considers that
these arrangements for the provision of mental health care should be aligned.
In particular, there should be no difference in the fee paid to a mental health
professional by Defence or DVA regardless of whether the patient is a serving
ADF member or a veteran.
The committee recommends that Defence and the Department of Veterans'
Affairs align arrangements for the provision of professional mental health
During the inquiry, committee members expressed concern with the
progress of the suicide prevention trial for Townsville. In May 2017, it was
announced that a Veteran Suicide Prevention Project Manager had been appointed.
While the committee understands this project is being led the North Queensland
Primary Health Network, the committee urges the Australian Government to work
to expedite implementation and assessment of this trial which has the potential
to be an important model for support services in other parts of Australia.
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