Introduction

This research is the second in a series of publications that analyse the use of health services by ex-serving Australian Defence Force (ADF) members over the 10 years to 30 June 2020. The series of publications will provide a comprehensive picture of mental and physical health service use and the factors associated with variations in health service use.

The purpose of this report is to describe the different health service use patterns for ex-serving ADF members with a hospital admission for intentional self-harm in the year before and after the admission. Understanding the patterns of health service use during this time can help identify those at risk and improve support following the self-harm event.

Examining health service use the year before self-harm can be used to identify potential predictors of self-harm and opportunities for intervention/prevention. Describing health service use in the year after provides insights into care transitions and ongoing support.

This report builds on the Final report to the Independent Review of Past Defence and Veteran Suicides released by AIHW in 2021 and AIHW research released in 2024 on the Characteristics of ex-serving Australian Defence Force members hospitalised for suicidality and intentional self-harm. The 2024 report examined the characteristics of hospitalised ex-serving members to better understand their hospital care needs. The analysis included use of hospitals for any conditions but there was a focus on use for conditions associated with suicidal behaviour.

The 2024 report was the first using the AIHW developed Veteran Health Dataset (VHD). Based on the VHD, the scope of this research was ex-serving ADF members with 1 day or more of service since 1 January 1985 as identified from Department of Defence personnel data. This report also draws on the VHD to analyse health service use patterns over time, including not just hospitals but also use of medications and primary health care services. More information is included at Health services use by ex-serving Australian Defence Force members.

The publication of this report follows the release of the Final Report of the Royal Commission into Defence and Veteran Suicide and Government response to the Final Report. Importantly it further builds the evidence base on the physical and mental health of ex-serving ADF members, including those who died by suicide.

This report provides further insight on matters outlined by the Royal Commission into Defence and Veteran Suicide which delivered its Final Report on 9 September 2024. The Commission had also funded analysis by the Queensland Centre for Mental Health Research which found that there were higher rates of health services use among veterans in Queensland who experienced suicidality resulting in a police or paramedic contact in comparison to veterans (current and ex-serving ADF members) who did not (Meurk et al 2024).

About this report

Intentional self-harm is a strong risk factor for death by suicide, with research showing elevated suicide rates among those with a history of self-harm (AIHW 2025b; Clapperton et al 2024; Carroll et al 2014; Favril et al 2022). Although most people who self-harm do not go on die by suicide, the period following a self-harm event is regarded as a critical window for intervention and support (Mitchell and Cameron 2018). This report examined health service use in the 12 months before and after an index self-harm event (defined as the first recorded hospital admission for intentional self-harm between July 2011 and June 2019). Box 1 provides more context on how to interpret the results in this report.

While this report aims to identify opportunities for intervention by describing types of health services that people interacted with rather than what type of treatment was provided (although mental health and non-mental health categories are provided throughout). It is important to note that not all health service contacts necessarily were related to suicidality or self-harm or mental health, and opportunities for intervention may not always have been present or apparent at the time. There are also challenges in treating and/or identifying mental health, self-harm, suicidality and psychosocial distress; particularly when these concerns are not the primary reason for a health service interaction (Cepiou et al. 2008; Mitchell et al. 2009; WHO 2021).

Box 1: Interpreting health service use and intentional self-harm

Every day, millions of Australians come into contact with the health system. A key role of the health system is to respond to the needs of individuals by providing safe, effective, accessible and appropriate treatment and other services (AIHW 2024). Australia’s health system is complex with multiple different service types. The primary aim of these health services is to support the prevention, treatment, and management of injury, illness and other health conditions, including mental health using the types of procedures and care that can be provided within that setting.

However, addressing mental health concerns, suicidality and psychological distress within these settings can be challenging, particularly when there is a co-occurring physical health issue (Cepiou et al. 2008; Mitchell et al. 2009; WHO 2021). Each setting differs in clinical expertise, service availability, and intervention scope. These differences influence patterns of health service use before self-harm events and must be considered when interpreting the results for those using health services.

This report examines patterns of health service use in the year before and after a hospital admission for intentional self-harm. It is important to recognise that the presence of a health service contact before or after a self-harm hospital admission does not necessarily indicate that the health service use prior to was related to self-harm intention or use of health services after were related to the self-harm behaviour. Many people who self-harm may have sought care for unrelated physical or mental health concerns, and their self-harm risk may not have been present, recognised or disclosed at the time. Therefore, self-harm cannot be directly attributed to the impact of a health service intervention alone. Rather, health service use reflects a complex interaction between the individual’s underlying health conditions, the type of care received and broader social and psychological factors.

Despite these challenges, describing patterns of health service use before and after self-harm provides valuable insights. It helps identify potential opportunities for earlier intervention, informs policy and practice improvements, enhances understanding of the role different parts of the health system play in engaging with individuals at risk and opportunities to understanding changing service needs and improve aftercare. Recognising these patterns allows for targeted strategies to strengthen support within healthcare settings to improve the health and welfare of ex-serving ADF members.

In this report AIHW compares health service use by ex-serving members admitted to hospital for intentional self-harm (the self-harm cohort) with other ex-serving members admitted for non-injury related reasons (the comparison cohort).

The self-harm cohort was defined based on public hospital admitted care, consistent with routine reporting on intentional self-harm nationally (AIHW 2025). Self-harm hospitalisations were identified using International Classification of Diseases (ICD) 10-AM with a principal diagnosis of injury (S00-T75, T79) and with a first external cause of intentional self-harm (X60-X84, Y87.0) (AIHW 2025). For more information see Technical notes. There is limited information on self-harm that does not result in medical treatment or is treated in other health settings (AIHW 2025).

The comparison cohort was derived from the same data source and included ex-serving members who had been admitted to hospital during the study period for reasons other than injury (not included in ICD 10-AM: S00-T75, T79), such as digestive diseases, mental health, and musculoskeletal conditions.

Both cohorts were derived from the admitted patient dataset to enable a comparison of the self-harm cohort with other ex-serving members who have received admitted care. However, differences in admission type, severity, and care pathways may still influence observed health service use patterns and should be considered in interpreting the results.

AIHW acknowledges that both cohorts are defined based on the hospital admission dataset and may be different to ex-serving members who were not admitted to hospital. While previous analysis by AIHW found that the demographic and service-related characteristics of ex-serving members who were admitted to public hospital for any reason were similar to the characteristics of all ex-serving members (including those were not admitted to hospital), some unmeasured differences in health needs, help-seeking behaviour or health system engagement may remain and should be considered when interpreting the findings (AIHW 2024).

This report includes ex-serving members who were hospitalised for self-harm between July 2011 and June 2019 to be able to study the year before and year after the self-harm event. The study was also limited to ex-serving members in all jurisdictions excluding Western Australia and Northern Territory due to limitations in data availability.

There were 1,634 ex-serving members with a self-harm event who were treated in admitted hospital care that were matched to 6,957 ex-serving members in the comparison cohort by age, sex and location (defined by Statistical Area Level 2 or SA2). See Technical notes for more information on the matching process.

The characteristics of ex-serving members in the self-harm cohort and ex-serving members in the comparison group are included in Supplementary table 1.1 (see data). Reflecting the matching study design, there were no differences between the cohorts by socioeconomic status, remoteness and health services accessibility (measured by shortest travel time to select health services). However, when comparing the studied ex-serving members who were admitted for self-harm with other ex-serving members admitted for non-injury reasons, a higher proportion of the self-harm cohort, compared to the comparison cohort:

  • were female (23% compared with 19%)
  • were younger than 35 years (22% compared with 18%)
  • separated involuntarily (32% compared with 24%)
  • served for less than 5 years (59% compared with 53%)
  • separated less than 5 years ago (19% compared with 13%)
  • were DVA clients (36% compared with 29%)
  • had two or more comorbidities based on the prescription-based comorbidity index (RxRisk) and a hospital diagnosis-based comorbidity index (Multipurpose Australian Comorbidity Scoring System or MACSS): RxRisk (82% compared with 48%) and MACSS (33% compared with 10%)
  • had low continuity of General Practitioner (GP) care (not seeing the same GP each time: 41% compared with 32%) and low regularity of GP care (not having regular GP appointments: 48% compared with 37%).

Health services examined in this report include hospital services including emergency department (ED) presentations and admitted care (excluding private hospitals), Medicare-subsidised services (Medicare Benefit Schedule or MBS), dispensing of prescriptions (Pharmaceutical Benefits Scheme/Repatriation Pharmaceutical Benefits Scheme or PBS/RPBS) and DVA-funded primary care services (MBS equivalent).

Within each service type, care was further classified as mental health or non-mental health, allowing analysis of service patterns. Mental health services accessed by ex-serving ADF members were identified based on mental health prescriptions dispensed under the PBS and RPBS, Medicare-subsidised mental health services, mental health ED presentations, and mental health hospitalisations.

Comparisons of health service use by ex-serving members who were hospitalised for intentional self-harm were controlled for the effects of age, sex, socioeconomic status and remoteness categories (using SA2), through matching and for comorbidities through regression-based statistical adjustment. These factors were selected as key determinants of health service utilisation and intentional self-harm based on existing literature (Mitchell and Cameron 2017).

Box 2 highlights key limitations of the research. More detail is included in the Technical notes.

Box 2: Key data and methodology limitations

There are various limitations to the research that is presented here which are outlined in Technical notes. Some key limitations are:

  • Self-harm index events were only identified from the admitted hospital data, which would exclude less severe cases that presented in the ED that do not lead to a hospital admission. Therefore, findings reflect health service use patterns around hospital-admitted self-harm only and may not generalise to individuals with less severe or untreated self-harm episode. Further, hospitalisations data for patients with intentional self-harm injuries includes those with and without suicidal intent.
  • Health services funded out-of-pocket, by Defence, by Open Arms (such as mental health and counselling services), private health insurance, and workers compensation arrangements were not analysed. Consequently, any data from these services are not included in this analysis which means that use of health services are an underestimate.
  • Results within this analysis are descriptive and do not reflect causal associations and should be interpreted with caution because it cannot be determined whether an individual’s use of a health service is related to self-harm.
  • ED care and hospital admitted patient care were analysed separately. Therefore, people who presented to ED and then were transferred to admitted care will have been counted as using both services. This should be considered when interpreting the results.
  • Matched cohort studies, including this research are an observational study design, and can identify associations between health service use and intentional self-harm but cannot establish causality.

See the Technical notes section for more information on limitations.

 

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