Introduction

This report is the first in a series of publications that analyse the use of health services by ex-serving Australian Defence Force (ADF) members up to 30 June 2020. The publications will provide a picture of health service use and the factors associated with variations in health service use (see health services overview landing page).

The purpose of this report is to highlight the different health service use for ex-serving members who died by suicide in the last year of life when compared to other ex-serving members. The hope is that this will illustrate where there are potential opportunities for intervention prior to death by suicide and will improve understanding of the types of health service use that could be used to identify risk of suicide and be an avenue for suicide prevention.

This report builds on previous analysis released by AIHW in 2021 (see Box 1) and 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 dispensing of medications and primary health care services. More information is included in the veteran subtopic data sources.

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.

Box 1: Independent Review of Past Defence and Veteran Suicides

In 2021, AIHW released research conducted as part of the Final report to the Independent Review of Past Defence and Veteran Suicides. The Final Report to the Independent Review included analysis of hospital services, Medicare, medicine use, DVA-funded and some Defence-funded services over 2001 to 2018.

The Final Report found that:

  • 88% of ex-serving males and 96% of ex-serving females who died by suicide used at least one Medicare-subsidised or DVA‑funded health service in the year before death.
  • over half of ex-serving males (53%) and females (60%) who died by suicide between 2014 and 2018 used a mental health-related service in the year before death.

About this report

AIHW analysis found that of all Australians aged 15 to 64 years who died by suicide between 2010 and 2017, almost 9 in 10 people had used a health service in their last year of life (AIHW 2022). These contact points may provide a potential opportunity for suicide prevention activities. This report seeks to identify these opportunities and relevant timing for intervention by analysing the number and types of health services ex-serving ADF members used in the year before death by suicide. Box 2 provides more context on how to interpret the results in this report.

While this report aims to identify potential opportunities for intervention, this analysis is more focussed on identifying which parts of the health system that people interacted with rather than what type of treatment was provided (although mental health and non-mental health service categories are provided throughout). There are challenges in treating and identifying mental health, 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 2: Interpreting health service use and suicide risk

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 treat the injury or disease presented 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 suicide events and must be considered when interpreting the results of suicide risk for people using health services.

This report examines patterns of health service use in the year before death by suicide. It is important to recognise that the use of a health service does not necessarily indicate that suicide risk was present, identified or treated within that interaction. Suicide risk can vary over time and may not have been present at the moment care was accessed. Many people who die by suicide may have sought care for unrelated physical or mental health concerns, and their risk may not have been visible to or recognised by providers at the time. Therefore, suicide risk cannot be directly attributed to inadequate care, nor can service use alone be interpreted as a missed opportunity. Rather, 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, studying patterns of health service use before death by suicide provided valuable insights. This report identifies potential opportunities for earlier intervention, supports improvements in policy and practice, and enhances understanding of how the health system interacts with individuals who may be at elevated risk. Recognising these patterns can inform targeted strategies to strengthen support within healthcare settings and improve suicide prevention efforts.

This report compares the use of health services of ex-serving ADF members in the last year of life (12 months before death) among those who died by suicide (case group) with a control group of ex-serving members who were alive at the time their matched case died. This date is referred to as the index date and is used to ensure consistency in the observation period.

For the purposes of this research, AIHW focused on ex-serving members who died by suicide between July 2011 and June 2020, allowing for a full 12 months of health service data to be captured prior to death (for cases) or the matched index date (for controls). The study was limited to deaths in all jurisdictions excluding Western Australia and Northern Territory as limited data were available for these jurisdictions. A total of 522 ex-serving members in the case group were matched to 2,497 ex-serving members in the control group by age, sex and location of residence at time of death (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 case and control group are included in Supplementary table 1.1. Due to the matching design, there were no differences between cases and controls in sex, age groups, socioeconomic status or remoteness distribution (based on location of residence). However, when comparing the ex-serving members in the case group with those in the control group, a higher proportion of the cases:

  • had separated from the ADF for involuntary medical reasons (11.3% compared with 6.6%)
  • had been separated from the ADF for 1-5 years (15.1% compared with 11.5%)
  • were DVA clients (31.4% compared with 25.0%)
  • 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 (60.3% compared with 34.7%) and MACSS (22.0% compared with 4.7%)
  • had low continuity of General Practitioner (GP) care (not seeing the same GP each time: 40.4% compared with 33.0%) and low regularity of GP care (not having regular GP appointments: 38.1% compared with 31.9%).

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 for ex-serving ADF members who died by suicide accounted 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 based on existing literature (Mitchell and Cameron 2017) as key determinants of health service use and death by suicide.

Box 3 highlights key limitations of the research. More detail is included in the Technical notes.

Box 3: Key data and methodology limitations

There are various limitations to this research which are detailed in Technical notes section of this report. Some of the key limitations are:

  • 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.
  • Findings within this analysis should be interpreted with caution because it cannot be determined whether an individual’s use of a health service is related to suicide.
  • Emergency department care and public 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.
  • Comparisons of health service use by ex-serving ADF members who died by suicide using odds ratios accounted for demographics and adjusted for comorbidities. Other relevant factors (such as ADF service and ADF service length) were examined in subgroup analyses, but not included in adjusted models, so some residual impacts may remain.
  • Case-control studies, such as this research are an observational study design that can identify associations between health service use and death by suicide but cannot establish causality.

 

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