Contact
Log in Log in

The mental health of veterans and defence force service members

Position statement Last updated: Feb 2024 Published in Australia Reference: PS #99

The position statement outlines the necessary action to improve mental health outcomes for current defence force service members and veterans.

Purpose

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) recognises the unique occupational risks associated with military roles and the mental health challenges that may be faced by Australian and New Zealand veterans and current defence force service members.

Key messages

  • Mental health care for current service members and veterans should be evidence-based and focused on long-term wellbeing and recovery.
  • Support services for current service members and veterans should be underpinned by psychiatric expertise and a specialised knowledge of military mental health.
  • Service members and veterans are a diverse group and tailored approaches to meet their unique needs should be integrated into service planning and delivery.
  • Support for current service members and veterans should be seamless, ensuring continuous access to services throughout enlistment, training, deployment, discharge and ongoing civilian life.
  • Mental health service design should incorporate the role of community, including family/whānau, friends and carers, in supporting current service members and veterans, and support should be made available for family/whānau, friends and carers.

Definitions

The Australian Defence Force (ADF) defines a veteran as a person who is serving or has served in the ADF, including permanent, reserve, and former (ex-serving) personnel.[1] The New Zealand Defence Force (NZDF) defines a veteran as those who have had any service in the New Zealand armed forces before 1 April 1974, and those with qualifying operational service after that date. Qualifying operational service covers service at a time of war, or in deployments overseas where a ministerial declaration has confirmed significant risk of harm.[2] The Veterans’ Advisory Board in New Zealand has recommended however that all who have served should be considered veterans, irrespective of where that service took place.[3]

For the purposes of this position statement, the RANZCP adopts the definition of a veteran and service member as a person who has served or is serving in the ADF or NZDF respectively.

Background  

Service members and veterans face significant, and often unique, risk factors for mental illness, including stigma, exposure to trauma and other military-related stressors such as prolonged deployments and barriers to accessing services.[4-5] Current service members and veterans can present with complex ranges of symptoms of mental illness, characterised by the extended, repetitive and intensive nature of cumulative trauma, a combination of mortal threats, traumatic losses, morally compromising experiences, bullying, harassment and sexual trauma.[6-12] 

NZDF research details the higher occurrence of stress disorders, risk of self-harm and exposure to trauma.[13] Between July 2019 and June 2021, approximately 1,439 serving members of the ADF presented to clinics for suicidal ideation with 84 presentations for suicidal behaviours[1].[14] While serving members are less likely to die by suicide than civilians, there appears to be higher levels of suicidal ideation and suicide plans among serving members than civilians.[15]

Many veterans may also face social and occupational stressors when transitioning from the military environment and integrating into the civilian workforce and society. The risks associated with traumatic experiences do not diminish after discharge from service, with strong evidence to support the continuing effect of traumatic stressors on an individual’s mental health.[16] 

Whilst serving members of the ADF are nearly 50% less likely to die by suicide than non-serving Australians, unfortunately the risks increase for ex-Serving members, particularly women.[14] The age-adjusted rates of death by suicide for ex-serving male veterans are 21% higher (odds ratio of 1.21), and unfortunately much higher for women veterans at 127% (age adjusted odds ratio of 2.27) (Ref 14, AIHW, Table S2.1).[14] Medical or involuntarily discharged ex-serving ADF male members have even higher rates of death by suicide, at 66% higher for medical discharge and 36% for any other involuntary discharge, in comparison to the 21% increased rate for those who had a voluntary discharge (AIHW table S5.1).[14] In New Zealand, 1 in 6 NZDF veterans have a long-term mental health condition and substance use disorder.[17]

Improving access to mental health treatment 

Service members and veterans require appropriate diagnosis and treatment for any present mental health condition, yet there remain barriers to accessing this care. Of service members and veterans who died by suicide, 66% were not accessing DVA services.[18] Similarly, NZDF records show that only 5-10% of current service members seek mental health support through primary health care services in the NZDF each year.[13] Veterans and service members currently rely on the civilian health system (private and public), which can lack the relevant specialised services and knowledge and lead to sub-optimal mental health outcomes.

Access to psychiatry plays a critical role in supporting the mental health of veterans. Psychiatrists have comprehensive clinical knowledge of identifying and treating mental health conditions. This is critical to suicide prevention, as the presence of a mental disorder is a high-risk factor for suicidal behaviour.[19-21] Psychiatrists have a key role in supporting the delivery of mental health services for serving members and veterans, as a part of a multidisciplinary approach with clear treatment and referral pathways to other care services along a continuum of care. This collaborative care must include the informal care workforce to utilise the ability of family and community to support service members and veterans. This is a protective factor against suicide.[4] Support should also be made available for family/whānau, friends and carers.

Appropriate cultural services also need to be developed. For instance in New Zealand, 15% of the total NZDF are Māori and require particular approaches to address their needs through a Te Ao Māori perspective.[22] The Paterson Review noted that veterans received little assistance from Veteran Affairs that was specifically tailored for Māori and a poor understanding of Māori tikanga.[17] Greater liaison is required between Te Whatu Ora, Te Aka Whai Ora, Te Puni Kōkiri and Veteran Affairs and the Aotearoa New Zealand Returned and Services Association to deliver services with support from a Te Ao Māori perspective. 

Improving access to evidence informed mental health treatment for conditions and disorders arising in serving members and veterans requires a skilled workforce with specialised knowledge of military mental health.[23] Workforce shortages, and associated issues such as high workloads, burnout and poor retention, inhibit the delivery of this care.[24] Building workforce capacity through further education, training and specialisation is required to improve veteran and service member access to culturally safe (in relation to military culture) care.[25-26]

Access barriers to mental health treatment also include military culture and the associated stigma (both self-stigma and intra-personal stigma) of treatment.[27-28] As military culture prioritises a commitment to ‘service before self’, individuals may avoid help-seeking to avoid stigma, appear ‘strong’ and protect their ongoing employment, deployment, and promotional opportunities.[29-30] Implementing cultural change centred around help-seeking and recovery is key to de-stigmatising mental health services and improving access.[30] 

Integrating systems 

Veterans and service members are confronted by fragmented and complex systems, both legislatively and administratively, of compensation, rehabilitation and general support.[31-33] Through a ‘lifetime wellbeing’ approach, these systems must be grounded within social and economic structures and policies that enhance wellbeing and minimise distress. This approach necessitates tailored support that reflects the distinct needs of veterans and service members across their lifespan, alongside their families, carers, and households. 

As these needs span service types, whole-of-system reform is required to ensure veteran and service member access to services that are person-centred, seamless and proactive throughout enlistment, training, deployment, discharge and ongoing civilian life. Strengthening and consolidating governance mechanisms is required to promote accountability within this comprehensive approach to service delivery, one which bridges gaps between fragmented services, organisations, communities, cultures and environments and combines varying treatments, supports and interventions.[31]

These varying treatments, supports and interventions encompasses range of issues not usually considered in mental health. Difficulties in transitioning to civilian life may relate to social, occupational and/or functioning, with requirements such as housing and/or employment supports.[34] A clear point of management for these services is key to holistically meet the needs of veterans and service members and achieve the best outcomes (mental health and otherwise).

Growing and utilising an evidence base 

Whilst there is growing awareness of mental health issues in service members and veterans, research and evaluation are key in building an evidence base. Long-term research should be prioritised, and appropriately funded. This is essential for improving evidence informed service design and delivery, for the betterment of service member and veteran mental health treatment and outcomes. 

It is pertinent that the approach to research is coordinated, consistent and strategic, developed by experts in the field (including psychiatrists) and in consultation with service members and veterans. Research should build on the existing body of knowledge to further advancements in the field. Strong strategic partnerships between government, research agencies and universities serve to connect the academic workforce with the governance mechanisms responsible for the care of service members and veterans.[35-36] 

Research efforts must coincide with effective processes to consistently evaluate the effectiveness of existing services, initiatives, programs, and trials aimed at improving service member and veteran mental health.[37-38] Assessing the quality of care of psychiatric treatment is key to improving treatments and treatment outcomes. Evaluation can reveal strengths, weaknesses, and unintended consequences of current practices and services, with the findings used to improve future interventions and facilitate better outcomes. Assessing the quality of care of mental health services for military personnel and veterans should include experienced psychiatrists with knowledge of the health systems involved, as is done in other domains of health planning.

Finding the patterns in service members and veterans is also key to preventing future suicides. Research often focuses on single diagnosis studies, whereas psychiatrists see patients who often have dual or multiple diagnoses that are considered to heighten risk of suicidality. One key method is to ensure that psychological autopsies are conducted in the event of suicide, a rigorous method of determining the presence of mood disorder.[39-40] Autopsies must coincide with an evaluation of the service delivery for those who die by suicide.

Recommendations

The RANZCP recommends that both the Australian and New Zealand Governments:

  • Provide targeted and seamless support for current service members, veterans and their families through government bodies working in unison and with appropriate levels of resourcing.
  • Embed medical specialist expertise, including psychiatric, within government bodies that work with current service members, veterans, and their families. 
  • Improve the organisation and coordination of health and non-health services throughout enlistment, training, deployment, discharge and ongoing civilian life, via the development and integration of seamless proactive, outreach-focused and responsive services. 
  • Establish long-term research programs to guide evidence-based service delivery, with an emphasis on the collection and use of statistics for identified knowledge gaps and a continual evaluation of services. 
  • Investigate and progress new policies focusing on developing a lifetime wellbeing and health assessment process for veterans when they leave service. 
  • Incorporate the role of community, including family/whānau, friends and carers, in supporting current service members and veterans, and make support available for family/whānau, friends and carers too. 

Additional Resources 

References

1. Tehan D. Joint communique–Veterans’ Ministers’ meeting. Media release. Canberra, Australia: Minister for Veterans’ Affairs. 2017. 

2. New Zealand Defence Force. The Veteran Rehabilitation Strategy. Wellington, New Zealand: Veterans’ Affairs, New Zealand Defence Force.2018

3. Veterans’ Advisory Board. Interim Report of the Veterans’ Advisory Board What Constitutes a Veteran and How Should Their Service In The Armed Forces Be Recognised?. 2019.

4. Australian Institute of Health and Welfare. A profile of Australia’s veterans 2018. 2018. Available at: https://www.aihw.gov.au/getmedia/1b8bd886-7b49-4b9b-9163-152021a014df/aihw-phe-235.pdf.aspx?inline=true. 

5. Van Hooff M et al. Mental Health Prevalence, Mental Health and Wellbeing Transition Study. Department of Veterans’ Affairs. 2018.

6. Price M et al. Combat experiences, pre-deployment training, and outcome of exposure therapy for post-traumatic stress disorder in Operation Enduring Freedom/Operation Iraqi Freedom veterans. Clinical Psychology & Psychotherapy. 2013;20(4): 277–285.

7. Steenkamp MM et al. A brief exposure-based intervention for service members with PTSD. Cognitive Behavioral Practice 2011;18(1): 98–107.

8. Steenkamp MM et al. Psychotherapy for military-related PTSD: a review of randomized clinical trials. JAMA Psychiatry. 2015;314(5): 489–500.

9. Stein NR et al. A scheme for categorizing traumatic military events. Behavior Modification. 2012;36(6): 787–807.

10. Australian Defence Force. Mental Health of the Australian Defence Force – 2010 ADF Mental Health Prevalence and Wellbeing Study Report. 2010 Canberra. Available at: www.defence.gov.au/Health/DMH/MentalHealthReformProgram.asp#MHRP.

11. Surìs A et al. Mental health, quality of life, and health functioning in women veterans: differential outcomes associated with military and civilian sexual assault. Journal of Interpersonal Violence. 2007;22(2): 179–197.

12. Zinzow H et al. Trauma among female veterans: a critical review. Trauma, Violence, & Abuse. 2007;8(4): 384–400.

13. New Zealand Defence Force Defence Force Gifts Mental Health Resources to Public Sector’s Frontline. 2018. Available at: https://nzdefenceforce.medium.com/defence-force-gifts-mental-health-resources-to-public-sectors-frontline-f23d08a272c.  

14. Royal Commission into Defence and Veteran Suicide Introductory Defence Briefing Australian Government Department of Defence. 2021. Available at https://apo.org.au/sites/default/files/resource-files/2021-09/apo-nid315296.pdf.

15. Sadler N et al. Suicide and suicidality in contemporary serving and ex-serving Australian Defence Force personnel. Australian & New Zealand Journal of Psychiatry. 2021:1-13.

16. Eekhout I et al. Post-traumatic stress symptoms 5 years after military deployment to Afghanistan: an observational cohort study. Lancet Psychiatry. 2015;163(4): 659-666.

17. Paterson, R. Warrant of Fitness – An independent review of the Veterans’ Support Act 2014. 2018. Available at: https://www.veteransaffairs.mil.nz/assets/News-attachments/2018/review-report-warrant-of-fitness.pdf. 

18. Final report to the Independent Review of Past Defence and Veteran Suicides: Australian Institute of Health and Welfare. 2021. Available at: https://www.aihw.gov.au/reports/veterans/independent-review-past-defence-veterans-suicides/contents/measures-of-risk-and-protective-factors/psychosocial-risk-factors.

19. Matthew K et al. Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. The British Journal of Psychiatry. 2008;192:98-105.

20. Matthew K. et al. Cross-National Analysis of the Associations among Mental Disorders and Suicidal Behavior: Findings from the WHO World Mental Health Surveys. PLoS Medicine. 2009;6(8).

21. Brådvik L. Suicide Risk and Mental Disorders. International journal of environmental research and public health. 2018;15(9):2028.

22. TEARA. Defence Force Personnel by Gender and Ethnicity. 2012. Available at: https://teara.govt.nz/en/graph/35716/defence-force-personnel-by-gender-and-ethnicity-2012.

23. Jamalulhak AI et al. Improving services for those who serve: A private practice initiative to improve psychiatric care for first responder and military patients. Australasian Psychiatry. 2021.

24. Royal College of Psychiatrists. Position Statement on supporting the mental health and wellbeing of psychiatrists: 2018. Available at: https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/position-statements/ps03_18.pdf?sfvrsn=79ca7b99_4.

25. Lane J. Culturally Informed Interventions for Military, Veteran and Culturally Informed Interventions for Military, Veteran and Emergency Service Personnel: The Importance of Group Emergency Service Personnel: The Importance of Group Structure, Lived Experience Facilitators, and Recovery-Oriented Structure, Lived Experience Facilitators, and Recovery-Oriented Content Content. Journal of Community Engagement and Scholarship. 2021;13.

26. Lane J, Wallace D. Australian military and veteran’s mental health care part 1: An introduction to cultural essentials for clinicians. Australasian Psychiatry. 2020;28(3):267-9.

27. Van Hooff M et al. Mental Health Prevalence and Pathways to Care Summary Report: Mental Health and Wellbeing Transition Study. Department of Veterans’ Affairs. 2018. Available at: https://www.dva.gov.au/documents-and-publications/transition-and-wellbeing-research-programme-mental-health-prevalence-and.

28. Ganz APDY et al. Military Culture and Its Impact on Mental Health and Stigma. Journal of Community Engagement and Scholarship. 2021;13(4).

29. Fairweather-Schmidt K et al. Suicidality in the Australian Defence Force: Results from the 2010 ADF Mental Health Prevalence and Wellbeing Dataset: Report for Joint Health Command, Department of Defence Canberra. 2012.

30. Preliminary Interim Report: Interim National Commissioner for Defence and Veteran Suicide Prevention. 2021. Available at: https://www.nationalcommissionerdvsp.gov.au/system/files/2021-09/preliminary-interim-report.pdf.

31. Royal Australian and New Zealand College of Psychiatrists. Position Statement 101: Suicide prevention – the role of psychiatry.2020. Available at: https://www.ranzcp.org/news-policy/policy-and-advocacy/position-statements/suicide-prevention-the-role-of-psychiatry.

32. Zalsman G et al. Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry. 2016;3(7):646-59.

33. Productivity Commission. A better way to support veterans, Draft Report. 2018. 

34. Tsai J, Trevisan L, Huang M, Pietrzak RH. Addressing Veteran Homelessness to Prevent Veteran Suicides. Psychiatr Serv. 2018;69(8):935-7.

35. McFarlane AC et al. Mental health in the Australian Defence Force: 2010 ADF Mental Health and Wellbeing Study. 2011.

36. Department of the Senate, Foreign Affairs, Defence and Trade References Committee. The Constant Battle: Suicide by Veterans. 2017. Available at: https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Foreign_Affairs_Defence_and_Trade/VeteranSuicide/Report.

37. Interim National Commissioner for Defence and Veteran Suicide Prevention. Preliminary Interim Report: Recommendations. 2021. 

38. McCarthy JF et al. Evaluation of the Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment Suicide Risk Modeling Clinical Program in the Veterans Health Administration. JAMA Netw Open. 2021;4(10):e2129900.

39. Yoshimasu KK & C. Miyashita, K. The Stress Research Group of the Japanese Society for Hygiene. Suicidal risk factors and completed suicide: meta-analyses based on psychological autopsy studies. Environmental Health and Preventive Medicine. 2008;13:234-56.

40. Nock MK et al. Psychological autopsy study comparing suicide decedents, suicide ideators, and propensity score matched controls: results from the study to assess risk and resilience in service members. Psychol Med. 2017;47(15):2663-74.

Disclaimer: This information is intended to provide general guidance to practitioners and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.