This section presents information on risk factors for permanent, reserve and ex-serving ADF members who died by suicide, including psychosocial, natural disease and mental and behavioural disorder risk factors. Analysis of risk factors among deaths by suicide in the Australian population are presented here as a reference point. However, direct comparisons should be made with caution due to the limitations in the coding of risk factors in ADF and Australian populations. Further information can be found in the Technical notes.
The key findings in this section reveal that psychosocial risk factors were the most common type of risk factor identified among ADF males and females who died by suicide, followed by mental and behavioural disorders and natural disease.
Further, the three most common risk factors for ADF males and females who died by suicide were:
- Mood (affective) disorders (for example, depression) were the most commonly identified risk factor for ADF members who died by suicide.
- Problems in spousal relationship circumstances and suicide ideation, were the second and third most commonly identified risk factors for ADF males who died by suicide.
- Personal history of self-harm and problems in spousal relationship circumstances were the second and third most commonly identified risk factors for ADF females who died by suicide.
It is widely acknowledged that suicide is affected by a complex interaction of factors over the course of an individual’s lifetime. Broadly, these can include biological (such as disease or injury), psychological (such as mental ill-health or substance abuse disorders) and psychosocial factors (such as family and education history) (ABS 2019). ‘While there is uncertainty about the extent of causation between psychosocial factors and suicide, it is generally accepted that having this information allows for further public health responses to suicide prevention’ (ABS 2019).
Psychosocial risk factors are not routinely certified or captured in mortality coding, yet this information is clearly highly informative in suicide prevention efforts. This information not being routinely available is a construct of using the legal death certification for mortality coding, which only lists diagnosable conditions, diseases and external events causing injury. However, coroner referred death investigations (which include suicide) provide a wealth of information which is captured in the National Coronial Information System (NCIS) for deaths registered since July 2000 (January 2001 for Queensland cases). Using the NCIS, the ABS can supplement the standard death certificate information with psychosocial factors to create an enhanced mortality dataset (ABS 2019).
For the current study, the AIHW commissioned the ABS to identify and code information from the NCIS (using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10)) to capture psychosocial risk factors for ADF members who died by suicide between 1 January 2001 and 31 December 2020 and who had at least one day of service from 1 January 19851. As the NCIS only includes a nationally complete set of records from 1 January 2001 onwards, the ABS coding was limited to deaths after 1 January 2001.
Capturing information on risk factors relating to deaths by suicide can highlight areas of a person's life experience that may need additional attention to provide the most effective suicide prevention interventions. However, it is important to note that the presence of one or more of these risk factors in an individual’s life does not necessarily mean they will have suicidal behaviours. The vast majority of people who have these risk factors will not experience suicidal behaviours.
What is a psychosocial risk factor?
The ABS define psychosocial risk factors as ‘social processes and social structures which can have an interaction with individual thought or behaviour and health outcomes’ (ABS 2019). Examples of psychosocial factors include relationship status, employment status, bereavement, contact with the legal system and educational outcomes.
The ABS coded psychosocial risk factors for ADF members and Australians who died by suicide using the International Statistical Classification of Diseases and Related Health Problems (ICD-10) codes Z00-Z99 (see Technical notes for more information)2.
Natural disease, as defined by the ABS, includes ‘all disease and health related conditions with the exclusion of mental and behavioural disorders, injuries, and external causes’ (ABS 2019). These correspond with the ICD 10 codes A00-E90, G00-R99, U071-U072, and U08-U09, with some exclusions (see Technical notes).
Mental and behavioural disorder risk factors are recorded with ICD-10 codes F00-F99 (ABS 2019). A disorder refers specifically to ‘a clinically recognizable set of symptoms or behaviours associated in most cases with distress and with interference with personal functions’ (WHO 1992).
Psychosocial or other risk factors should not be considered in isolation (ABS 2021b). The factors that can lead someone to suicide can be complex and often involve a mixture of causal and circumstantial risk factors. A combination of factors can contribute to increased risk. Further, a presence of protective factors may reduce the risk of suicide (Open Arms 2019).
Box 4: Concepts of mortality and causes of death
Deaths in Australia are recorded under certain processes and conventions, this is particularly relevant in understanding the analysis of deaths by suicide risk factors presented in this section. The following briefly introduces two key concepts:
Concept: type of deaths
All causes of death can be grouped to describe the type of death, whether it be from a disease or condition, or from an injury, or whether the cause is unknown. These are generally described as: natural causes, external causes and unknown causes. In particular, deaths by natural causes include deaths due to diseases (such as diabetes, cancer, heart disease etc.) and mental and behavioural disorders (such as depression, anxiety) (ABS 2018).
Concept: underlying and multiple causes of death
There are multiple causes of death recorded on an individual’s death certificate and rules applied to select an underlying cause of death. The underlying cause of death is defined as ‘the disease or injury that initiated the train of morbid events leading directly to death’. Accidental and violent deaths are classified according to the external cause, that is, to the circumstances of the accident or violence which produced the fatal injury rather than to the nature of the injury sustained.
Multiple causes of death include all causes and conditions reported on the death certificate (that is both underlying and associated causes). As all entries on the death certificate are taken into account, multiple causes of death analysis (such as in this section) are valuable in recognising the impact of factors which are less likely to be an underlying cause, highlighting relationships between concurrent processes, and giving an indication of injuries which occur as a result of specific external events (ABS 2018).
Risk factors and deaths by suicide
Risk factors for Australian males and females who died by suicide are presented with those for ADF members to highlight risk factors that may be specific to ADF members. However, direct comparisons of prevalence should be made with caution due to the limitations in the coding of risk factors in ADF and Australian populations. Further information can be found in the Technical notes. Risk factors are presented for Australian males and females who died by suicide where the death was registered in 2018 (sourced from the National Mortality Database (NMD)), as data from more recent years have a greater proportion of coronial cases remaining open and not yet able to be fully coded for risk factors (see Technical notes). For the data presented, the age range of the Australian population was restricted to the minimum and maximum ages of the ADF population (for permanent, reserve, or ex-serving males and females respectively, age at death ranges from 17 to 78, and 22 to 70).
Risk factors captured in the coding depend on available information. How comprehensively the risk factors experienced by an individual are captured in the coding may vary for different individuals, jurisdictions and cohorts3. While coding risk factors, ABS allocated ADF members a specific code which is not used in the Australian population cause of death coding to capture ‘Defence force related deployment’ (see Technical notes for further information).
Risk factors may have been present at any point of the life of an ADF member, including before, during or after ADF service. Risk factors identified for ADF members who died by suicide may or may not be directly related to ADF service.
Figure 20 presents the proportion of male and female ADF members who died by suicide (between 1 January 2001 and 31 December 2020) and Australian males and females who died by suicide (registered in 2018) who had at least one risk factor. It should be noted that the female ADF cohort is smaller than that for males and in general, suicide rates for ADF females are lower. Due to the small numbers of suicides for ADF females, female ADF comparisons should be interpreted with caution.
The median age at death for ADF members who died by suicide between 1 January 2001 and 31 December 2020, included in this analysis, was 40 for ADF males and 41 for ADF females. When restricting the age at death range to the relevant ADF populations, the median age for those who died by suicide in the Australian population (registered in 2018) was 43 for males and 45 for females.
Psychosocial risk factors were the most common type of risk factor identified among ADF males and females who died by suicide, followed by mental and behavioural disorders and natural disease.
- 80% of male ADF members who died by suicide had at least one reported psychosocial risk factor. Of Australian males who died by suicide, 74% had at least one psychosocial risk factor.
- 53% of male ADF members who died by suicide had at least one reported natural disease. Of Australian males who died by suicide, 56% had at least one reported natural disease.
- Over 8 in 10 (84%) female ADF members who died by suicide had at least one psychosocial risk factor. Of Australian females who died by suicide, 7 in 10 (71%) had at least one psychosocial risk factor.
- 64% of female ADF members who died by suicide had at least one natural disease. Of Australian females who died by suicide, 58% had at least one natural disease.
Figure 20: Proportion of ADF males and females who died by suicide, 2001–2020, and Australian males and females who died by suicide, 2018, with at least one risk factor