Medication dispensing

Key points:

  • The majority of ADF members (81%) who died by suicide between 2013 and 2018 were dispensed at least one Pharmaceutical Benefits Scheme (PBS), Repatriation Pharmaceutical Benefits Scheme (RPBS) or Pharmaceutical Integrated Logistics System (PILS) medication in the year before death.
  • Between 2012 and 2018, a higher proportion (35%) of all ex-serving members were dispensed at least one mental health-related medication compared to Australians (18%).
  • 60% of ex-serving males who died by suicide between 2013 and 2018 were dispensed mental health-related medications in the year before death compared with 54% of Australian males.
  • Ex-serving ADF members who died by suicide between 2013 and 2018 and separated involuntarily for medical reasons were more likely to have been dispensed a mental health-related medication in the year before death (77%), compared to those who separated involuntarily for other reasons (47%) Meanwhile in 2018, a higher proportion of all ex-serving members who had separated due to medical reasons (44%) were dispensed a mental health medication, compared to those who separated voluntarily (18%).
  • A higher proportion of ADF members who separated involuntary due to medical reasons between 2013 and 2018 were dispensed benzodiazepines (21%) and serotonin-norepinephrine reuptake inhibitors (13%) in the year before separation, compared to those who separated voluntarily (1% and 3%), or involuntarily due to other reasons (0.2 and 0.4%).

This chapter examines medications dispensed to ADF members who died by suicide compared to the Australian population who died by suicide. ADF members can access pharmaceuticals through the Pharmaceutical Benefits Scheme (PBS), the Repatriation Pharmaceutical Benefits Scheme (RPBS), and ADF-specific schemes such as the Pharmaceutical Integrated Logistics System (PILS). In this chapter, the time periods reported for medication dispensing under PBS, RPBS and PILS differs due to data availability. To address the data constraints, comparable time periods for the analysis are used to report on medications dispensing. 

The PBS is available for current Medicare card holders (including serving, reserve and ex-serving members), and subsidises prescription medications listed under the scheme, subject to patient entitlement status. The RPBS is available for Department of Veterans’ Affairs Health Card holders (not all ADF members), and subsidises medications listed under the PBS, as well as additional medications and items for eligible ADF members, war widows and widowers, and their dependents.

Serving ADF members may also access medications via ADF-specific schemes such as through Defence pharmacies on barracks and dispensing in the field. Dispensing data from Defence pharmacies are collected and managed by the Pharmaceutical Integrated Logistics System (PILS).

Under the PBS and the RPBS, the Australian Government sets a maximum ‘co-payment’ amount that people pay towards the cost of their medicines. Prescriptions priced above the maximum co-payment for a patient are referred to as ‘subsidised’ (or ‘above co-payment’) prescriptions, and attract a subsidy from the Australian Government. Those priced below are referred to as ‘under co-payment’ prescriptions, and do not receive a subsidy.

Prior to 1 April 2012, the PBS/RPBS claims data did not collect data on under co-payment medications (See Appendix A5 – Pharmaceutical Benefits Scheme/Repatriation Pharmaceutical Benefits Scheme for further information). As such, this chapter focuses on medications dispensed from 1 April 2012 to 31 December 2018, and deaths from 1 April 2013 or 1 April 2014 to 31 December 2018 (when looking at medications dispensed 1 year or 2 years prior to death).

What is and isn’t included in the PBS/RPBS data?

The PBS/RPBS includes data on medications that are dispensed. It does not include information about medications that were prescribed (but not dispensed), or if the patient used the medication. PBS medications are specified by an item code that may include information about the therapeutic indication for which the medication was prescribed.

The PBS/RPBS data does not include medicines supplied to public hospital in-patients, over the counter medicines or private prescriptions. Unlisted medications may be prescribed to eligible RPBS members with DVA authorisation, however the data dare not coded consistently for analytic purposes.

What is and isn’t included in the PILS data?

PILS records data on medications and products that are dispensed. Unlike the PBS, PILS does not include information about the therapeutic indication for which medications have been dispensed. Many nervous system medications have more than one therapeutic indication.

PILS only collected dispensing data from on-barracks pharmacies until 2017, after which “in the field” dispensing is also included. Data for whether dispensing occurred on barracks or in the field is not supplied.

PILS dispensing is not limited to PBS listed medications and includes unlisted nervous system medications, and a range of pharmaceutical and non-pharmaceutical products that would normally be purchased over the counter without a prescription (see Appendix A5 for examples). PILS also includes some historically dispensed products where the data are not coded consistently enough for analytic purposes.

Medication dispensing under PBS, RPBS and PILS

Between 2013 and 2018, 81% of ex-serving ADF members who died by suicide were dispensed at least one product through PBS, RPBS or PILS in the year before death. Over two thirds (68%) were dispensed medications through PBS/RPBS, while 1 in 5 (20%) had any product dispensed through PILS.

The number of serving ADF members dispensed any PILS medication has steadily increased to just over 50,000 patients in 2018. In 2018, nearly all PILS users were dispensed a non‑nervous system-related product (99%), while 9% were dispensed a medication with a mental-health related indication (i.e. antidepressants, antipsychotics, anxiolytics, or hypnotics and sedatives).

How are medicines grouped?

This report uses the Anatomical Therapeutical Chemical (ATC) classification system, which groups medicines into five hierarchical levels according to the body system or organ on which they act. A single medication may have multiple classifications where it is used for multiple indications. For PBS/RPBS dispensing, PBS item codes are linked to a single classification.

Mental health‑related medications include five ATC level 3 groups: antipsychotics (code N05A), anxiolytics (code N05B), hypnotics and sedatives (code N05C), and antidepressants (code N06A) — prescribed by approved PBS prescribers. Psychostimulants, agents used for ADHD and nootropics (code N06B) are typically also included as mental health-related medications, but have been excluded due to small numbers. Some medicines classed as antiepileptics are also used for mental health conditions, but these too have been excluded as it is not possible to determine the reason for use from the available data.

Mental health-related medications

The proportion of all ex-serving ADF members who were dispensed PBS/RPBS mental health-related medications per year increased from 16% in 2012 to 21% in 2018 (Figure 28). Overall, 35% of the ex-serving population had at least one mental health-related medication dispensed over the 7-year period (while they were ex-serving), compared to 18% of Australians in the same period. Dispensing of mental health‑related medications should be interpreted with some caution, as some medications have more than one therapeutic indication, and may be prescribed to treat non-mental health, or off-label conditions, such as some antidepressants which are used off-label for neuropathic pain.

Figure 28: Percentage of ex-serving members(a) dispensed PBS/RPBS mental health-related medications, by type of medication and year, 2012 to 2018

Note: (a) Medications dispensed to ex-serving members before they were terminated were excluded from the analysis (i.e. while they were serving or before they were hired). The denominator is the number of individuals who were ex-serving for at least one day in the reporting period.

Source: AIHW analysis of PMKeyS-NDI-PBS, 2012-2018.