Table Of ContentINDEPENDENT STUDY INTO SUICIDE IN THE
EX-SERVICE COMMUNITY
initiated by the Minister for Veterans’ Affairs,
the Hon Alan Griffin MP
Prof David Dunt
January 2009
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DHES DUNT HEALTH EVALUATION SERVICES
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Clifton Hill 3068 VIC
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Acknowledgments
I wish to thank Ms Naomi Berman particularly who participated fully in all parts of the study
and had carriage of the public submissions process. She also was responsible for the write-up
of:
Appendix 1 Emergent themes from public submissions to the Independent study into
suicide in the ex-service community; and
Appendix 5 Rapid literature review of barriers to mental health care in the ex-service
community including stigma;
Dr Colleen Doyle wrote Section 3 Summary of current research and literature review on
suicide in veterans with extra input from Dr Jo Robinson.
Dr Susan Day was responsible for the write-up of:
Appendix 7 Rapid literature review of interventions to reduce alcohol misuse; and
Appendix 8 Rapid literature review of combat exposure and PTSD.
Mr Peter Feldman was responsible for the write-up of:
Section 4 Rapid literature review of PTSD and best-practice treatment; and
Appendix 3 Rapid literature review of Adjustment disorders and best-practice treatment.
Appendix 8 Rapid literature review of suicide prevention programs;
Mrs Joy Yeadon was always unfailingly helpful in making arrangements often at short
notice!
I would also like to thank particularly Mr Wayne Penniall and Ms Christine Reed from the
Department of Veterans Affairs (DVA) who were responsible for organising much of this
review. They were always knowledgeable, helpful and enthusiastic in getting things right.
I would like to thank Prof Mark Creamer, A/Profs Virginia Lewis, David Forbes and John
Pead of the Australian Centre for Posttraumatic Stress who provided very considerable
support and advice and gave very generously of their time.
I would like to thank members of the National Veterans Mental Health and Wellbeing Forum
and the Prime Ministerial Advisory Council on Ex-Service Matters.
I would also like to thank Prof Sandy McFarlane from the Australian Centre for Military and
Veterans Health.
Finally I would like to thank members of the Governance Board for the Study which was
chaired by Mr Ed Killesteyn Former Deputy President of the Repatriation Commission
(Chair) and more recently Mr Gary Collins, DVA. The other members were Mr Barry Telford
and Mr Wayne Penniall (in addition to his role above), all of DVA, Major General Bill Crews
AO (Retd), National President Returned & Services League of Australia and Mr Blue Ryan
OAM, National President Australian Federation of Totally and Permanently Incapacitated
Ex-Servicemen and Women. I would like to thank from the ADF and Department of Defence
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(DoD), MAJGEN Paul Alexander, BRIG Tony Gill Mr Martin Bowles, Head Defence
Support Group (DoD) and LTGEN David Hurley VCDF all gave wise counsel. LTGEN
Hurley took time out from his many demanding duties to give wise counsel as a member of
the Governance Board.
A list of the Ministers, senior and other staff in the Department of Veterans Affairs, the
Department of Defence and the ADF and Ex-Service Organisations follows. They all gave
very generously of their time and interest. A list of individuals and group making public
submissions is not included as the call for public submissions was marked in confidence.
Ministers
The Hon Alan Griffin (Minister for Veterans Affairs);
The Hon Warren Snowdon (Minister for Minister for Defence Science and Personnel);.
Department of Veterans’ Affairs
Senior Executives
Ian Campbell PSM, Secretary
Ed Killesteyn PSM, Former Deputy President
Barry Telford, General Manager Policy & Development
Wayne Penniall, National Manager Community & Aged Care
Sean Farrelly, National Manager, Compensation & Income Support
Roger Winzenberg, National Manager, Rehabilitation, Research & Development
Sandy Bell, National Manager, Military Compensation
John Geary, National Manager Veterans’ Compensation
David Morton, National Manager VVCS- Veterans & Veterans Families Counselling Service
Neil Bayles, National Manager Investigations Practices
Other DVA Staff
Richard Barrington-Knight, Director Statistical Services & Analysis
Eileen Wilson, Director Strategic Research & Development
Joanne Krueger, A/g Director Mental Health Policy
Maralyn Newman, Director Primary Claims Veterans Compensation
Margaret Jenyns, Director Military Rehabilitation & Compensation Claims
Kevin Herman, Director Reviews Veterans Compensation
Jeff Fairweather, Assistant Director Defence Links
James Rope, Assistant Director Statistical Services & Analysis
Glen Yeomans, Assistant Director Statistical Services & Analysis
Julie Bennett, Assistant Director Client Liaison Unit
Department of Defence and ADF
AIR CHIEF MSHL Angus Houston (Chief of the Defence Force);
LTGEN David Hurley (Vice Chief of the Defence Force);
Mr Martin Bowles (Deputy Secretary, Defence Support Group);
MAJ GEN Alexander (Commander Joint Health Command).
CDRE Robyn Walker (Director General Garrison Health Support); and
AIRMSHL Mark Binskin (Chief of Air Force);
VADM Russell Crane (Chief of Navy);
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LTGEN Kenneth Gillespie (Chief of Army);
AVM Tony Austin (former Head Defence Health Service);
BRIG Anthony Gill, Director General Health Policy.
Ms Nicole Quinn (National Coordinator, Defence Families Australia);
Ms Rowena English (Deputy Director Development, Directorate of Rehabilitation Services).
Mr Bill Traynor, Transition Management, Personnel Services Division).
Mr John Duffy (Defence Community Organisation (Strategy Review);
Nicky Curtin Transition Management, Personnel Services Division
Ex-Service Organisation Representatives
Major General Bill Crews AO (Retd), National President Returned & Services League of
Australia Inc
Mr Blue Ryan OAM, National President Australian Federation of Totally and Permanently
Incapacitated Ex-Servicemen and Women
Mr Paul Copeland AO, National President Australian Peacekeeper & Peacemaker Veterans’
Association
Mr Tim McCombe OAM, National President Vietnam Veterans Federation of Australia
Mr Ron Coxon OAM, National President Vietnam Veterans’ Association of Australia
Ms Gail MacDonell, Health & Education Coordinator, Partners of Veterans Association of
Australia Inc
Mr Brian McKenzie OAM, Vice President Vietnam Veterans’ Association of Australia
(Greater Hobart Branch)
Mr Derek Phillips JP, National Coordinator, ProgramASIST State Coordinating Committee
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Glossary
AAT Administrative Appeals Tribunal
ACPMH Australian Centre for Posttraumatic Mental Health
ADAPCP Alcohol and Drug Abuse Prevention and Control Program
ADF Australian Defence Force
ADFRP Australian Defence Force Rehabilitation Program
AIHW Australian Institute of Health and Welfare
AOD Alcohol and Other Drugs
APVA Australian Peacekeper and Peacemakers Veteran’s
Association
APS Australian Psychological Society
AREP Alcohol and Rehabilitation and Education Program
ASIST Applied Suicide Intervention Skills Training
ATODS Alcohol, Tobacco and Other Drugs Services
AUDIT Alcohol Use Disorder Identification Test
AWOL Absent Without Leave
BAI Brief Alcohol Intervention
BEST Building Excellence in Support & Training
BPA Bureau of Pensions Advocates
CALD Culturaly and Linguisticaly Diverse
CDF Chief of the Defence Force
CIDI Composite international Diagnostic Instrument
CLU Client Liaison Unit
CMVH Centre for Military and Veterans Health
COAG Council of Australian Governments
CTAS Carer Transition Asistance Scheme
DCO Defence Community Organisation
DESO Directory of Ex-Service Organisations
DFRDB Defence Force Retirement & Death Benefits Fund
DHSP Deployment Health Surveillance Program
th
DIS-IV Diagnostic Interview Schedule – 4 Edition (Version IV)
DoD Department of Defence
DSG Defence Suport Group
DSM-IV Diagnostic and Statistical Manual of Mental Disorders,
th
4 edition (Version IV)
DSO Department Service Oficers
DVA Department of Veterans' Afairs
EDA Extreme Disablement Adjustment
EMDR Eye Movement Desensitisation and Reprocessing
ESO Ex-Service Organisations
FaCHSIA Families, Housing, Community Services and Indigenous
Afairs (Department)
GARP (V) Guide to the Assessment of Rates of Veterans' Pensions
GIP Guaranted Income Payment
GPs General Practitioners
HMAS Her Majesty’s Australian Ship
HMCMP High Needs Case Management Pilot
IPS Integrated People Suport Strategy
IWB Interdepartmental Working Group
LMOs Local Medical Oficers
MEC Medical Employment Clasification
MECRB Medical Employment Classification Review Board
MRCA Military Rehabilitation and Compensation Act 2004
MRCC Military Rehabilitation and Compensation Commission
MRCG Military Rehabilitation and Compensation Group
MSBS Military Superannuation and Benefits Scheme
NSV National Survey of Veterans
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NVVRS National Vietnam Veterans Readjustment Study
OSIs Operational Stres Injuries
PCL Postraumatic Stres Disorder Checklist
PCL-C Posttraumatic Stress Disorder Checklist – Civilian
PCL-M Posttraumatic Stress Disorder Checklist - Military
PCL-S Postraumatic Stres Disorder Checklist – Non-military
PC-PTSD Primary Care – Posttraumatic Stress Disorder
PDHA Post-Deployment Health Asesment
PS Personel Suport Services
PTSD Postraumatic Stres Disorder
RAAF Royal Australian Air Force
RCCS Repatriation Comprehensive Care Scheme
RMA Repatriation Medical Authority
RPBS Repatriation Pharmaceutical Benefits Scheme
RPPS Repatriation Private Patient Scheme
RSL Returned and Services League of Australia
SCM Symptom Cluster Method
SoPs Statements of Principles (more than one)
SOS Signs of Suicide
SPTSS Screen for Posttraumatic Stress Syndrome
SPVA Service Personel and Veterans Agency
SRCA Safety Rehabilitation and Compensation Act 1988
SRMR Standardised Relative Mortality Ratio
SRI Selective Serotonin Reuptake Inhibitor
TAFE Technical and Further Education
TFCBT Trauma Focussed Cognitive Behavioural Therapy
TIP Training and Information Program
TMS Transition Management Service
TPI Totaly Permanently Incapacitated
TRIM The Records Information Management - software
UK United Kingdom
US United States
VA Veterans Afairs (USA)
VAC Veterans Afairs Canada
VEA Veterans' Entitlements Act 1986
VRAB Veterans Review and Appeals Board
VRB Veterans' Review Board
VVAA Vietnam Veterans Asociation of Australia
VVCS Veterans and Veterans Families Counselling Service
VVFA Vietnam Veterans Federation of Australia
VVRS Veterans' Vocation Rehabilitation Scheme
WWI World War Two
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Table of contents
Acknowledgments 3
Glossary 6
Table of contents 8
Executive Summary and Recommendations 10
Section 1 Introduction 20
1.1 Terms of Reference 20
1.2 Methodological approach 22
Part A Suicide and suicide programs in veterans 24
Section 2 Overview of suicide and suicide prevention 25
2.1 Introduction 25
2.2 Conclusions of the literature review on suicide in veterans 25
2.3 Evidence-based suicide prevention programs 26
2.4 Operation Life 26
2.5 Assessment and recommendation 28
Section 3 Review of the research literature on suicide and its risk factors in veterans 30
3.1 Summary 30
3.2 Background 30
3.3 Method 31
3.4 Results 32
3.5 Discussion 43
3.6 Conclusions and recommendations 44
Appendix 3.1 International studies of suicide in veterans 46
Appendix 3.2 Selected studies of suicide in Australian veterans 49
References 51
Section 4 Rapid literature review of suicide prevention programs 54
4.1 Military studies 54
4.2 Civilian studies 55
4.3 Summary comments 58
Part B - Services for Australian Veterans with mental health problems 61
Section 5 Transition from the ADF 62
5.1 Introduction 62
5.2 Transition Support Services and ADF Transition Centres 62
5.3 Transition Management Service 63
5.4 The Integrated People Support Strategy 64
5.5 Stepping Out Program 66
5.6 The Lifecycle Transition Mental Health & Family Collaborative 66
5.7 Defence Links - The Interdepartmental Working Group (IWG) 67
5.8 Role of the ESOs in the transition process 67
5.9 Programs and schemes impacting at both ends of the transition process 68
5.10 Transition culture and context 69
5.11 The Keeping In touch program 70
5.12 Assessment 70
5.13 Conclusions and recommendations 71
Section 6 Veteran compensation schemes and mental health 73
6.1 The Veterans’ Entitlement Act 73
6.2 The Safety Rehabilitation and Compensation Act 75
6.3 The Military Rehabilitation and Compensation Act 75
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6.4 The DVA decision making process 77
6.5 The appeal process 78
6.6 The Client Liaison Unit 80
6.7 The High Needs Case Management Pilot 80
6.8 The post-HNCMP work of the national MRCG group 81
6.9 DVA operations 82
6.10 Study into barriers to veterans’ social and occupational rehabilitation 82
6.11 Experience from other countries 83
6.12 Assessment 84
6.12.1 Veterans and their dealings with DVA 84
6.12.2 Complex schemes and complex cases 85
6.12.3 Appeals, delays and distress 87
6.12.4 Claims involving chronic mental conditions 87
6.13 Recommendations 88
Section 7 PTSD and compensation 90
7.1 Introduction 90
7.2 Does compensation hinder recovery from PTSD? 90
7.3 The SoPs, evidence-based methods and rigorous assessment procedures 92
7.4 Tip offs and false stressor cases 94
7.5 Likely future trends in PTSD claims 95
7.6 Conclusion and recommendations 98
Endnote 9
Section 8 Mental health, compensation & the Ex-Service Organisations 101
8.1 Introduction 101
8.2 TIP and BEST programs 102
8.3 Support for veterans making compensation in other countries 102
8.4 Assessment 104
8.4.1 Need for a new system 105
8.5 Recommendations 106
Section 9 Mental health programs and services for veterans 107
9.1 Repatriation and other health services and programs 107
9.2 Specialised mental health programs and services for veterans 108
9.2.1 Mental health promotion and literacy programs 108
9.2.2 Education of health professionals 109
9.2.3 Counselling services 111
9.2.4 Lifecycle project targeting ‘hard to engage’ ex-service members 112
9.2.5 Specialised PTSD clinics 113
9.3 DVA mental health policy 113
9.4 DVA-supported research 114
9.5 Assessment 118
9.6 Recommendations 125
Appendix 1 Emergent themes from public submissions 127
Appendix 2 Rapid literature review of PTSD and best-practice treatment 135
Appendix 3 Rapid literature review of Adjustment disorders and its treatment 138
Appendix 4 Rapid literature review of PTSD and deployment 140
Appendix 5 Barriers to mental health care in the veteran community 157
Appendix 6 Rapid literature review of mental health promotion programs 162
Appendix 7 Rapid literature review of interventions to reduce alcohol misuse 165
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Executive Summary and Recommendations
EXECUTIVE SUMMARY
PART A Suicide and suicide programs in veterans
Section 2 Overview of suicide and suicide prevention
While there is evidence that military and similar institutionally-based ‘gatekeeper programs’
are effective (and may involve courses like ASIST in part), this is less true for community-
based programs. While ASIST courses around the world have been evaluated many times, the
evaluations are restricted to the levels of satisfaction and perceived utility by attendees and
not their impact in reducing suicide or suicide attempts.
Systemic reviews of the research literature point to the value of other interventions such as
clinician education including detection and treatment of depression and restricting access to
lethal means.
Programs need to alert GPs and mental health professionals to the increased suicide risk
among veterans, as well as their access to firearms. This is true particularly for rural
clinicians as veterans living in rural areas are more vulnerable because of both their lack of
access to mental health services and higher suicide rates in the general population. Can Do
addresses some of these issues but could perhaps be developed further.
Strong evidence does not exist for veterans suicide prevention program aimed at risk factors
known to be important in veterans, such as screening for at risk veterans who are depressed,
living alone or following the break-up of a close relationship.
Section 3 Review of the research literature on suicide and its risk factors in veterans
Suicide is recognised as a public health problem that can affect all sectors of society. Whilst
suicide rates are lower in serving military groups than in the general population due to
‘healthy worker’ selection effects, this effect fades over time, so that some years after service,
veterans of military service can have health problems that are worse than the general
population.
The aim of this review is to examine suicide rates among the ex-service community both in
Australia and overseas and to examine whether or not there are risk factors for suicide that
are specific to suicide in this population upon which preventative strategies can be based. A
literature search using key words related to veterans and suicide was conducted.
While Australian veterans have not been studied as extensively as overseas veterans the
studies that have been undertaken have shown some evidence to indicate elevated suicide
rates among Australian veterans compared to the general population. The evidence is
however by no means conclusive. Whilst US based studies mostly indicate elevated suicide
rates among veterans, the data from other countries is also not conclusive.
Risk factors for suicide among veterans can be classified into the following categories: socio-
demographic factors; psychiatric and psychological factors; access to and availability of
means of suicide and exposure to combat.
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