The mental health of veterans and defence force service members

The RANZCP notes that the following document 'The mental health of veterans and defence force service members' is due for review. The contents of 'The mental health of veterans and defence force service members' were developed using an evidence-informed process and still may be relevant. Any questions regarding this document can be directed to policy@ranzcp.org.

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. It is essential that action is taken to improve mental health outcomes for current service members and veterans.

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 a skilled workforce, including psychiatrists, with 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/whanāu, friends and carers, in supporting current service members and veterans, and support should be made available for family/whanāu, friends and carers.

Definitions

A Roundtable of Australian Veterans’ Ministers recently defined a veteran as ‘a person who is serving or has served in the ADF [Australian Defence Force]’ (Tehan, 2017). This is broader than the previous Australian Department of Veterans’ Affairs (DVA) definition, where a veteran is defined as a person (or a deceased person) who has rendered eligible war service, or was a member of the defence forces who on or after 31 July 1962 was outside Australia, but not on operational service, who was killed or injured by the action of hostile forces (DVA, 2015). 

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 (NZDF, 2018a).
For the purposes of this position statement, the RANZCP adopts the definition of a veteran as a person who is serving or has served in the ADF or NZDF.

Background

In recent years both the ADF and the NZDF have made significant efforts to improve the mental health and wellbeing of current service members and veterans. This reflects not only the growing awareness of mental health issues in current service members and veterans, but also the changing demographics of those joining the defence and veteran community (AIHW, 2018a). In the NZDF, this has involved the development of a holistic model of wellbeing, which integrates physical health as well as aspects of mind, spirit and family/whānau (NZDF, 2018a). 

Despite these efforts, current service members still face significant, and often unique, risk factors for mental illness services, including stigma, exposure to trauma and other military-related stressors, such as prolonged deployments and also barriers to accessing services (Van Hooff et al., 2018b). These barriers do not end when they leave the service. During their transition into civilian life, veterans are confronted by complex systems, both legislatively and administratively, of compensation, rehabilitation and general support (Paterson, 2018; Productivity Commission, 2018). Transitioning from the military environment is challenging for some, as many veterans may face social and occupational stressors when integrating in to the civilian workforce and society. Issues accessing services are exacerbated by the separate and often fragmented systems governing the health and welfare of current members and veterans. It is clear that whole-of-system reform is required to ensure support, compensation and services throughout the life of a service member and also to ensure these services are person-centred, seamless and proactive.

One of the key challenges faced by governments is the provision of effective, accessible and appropriate support over the lifetime of current service members and veterans in what is a compensation based system. Contemporary veterans have very distinct needs, including vocational and training support, from those of earlier veterans. It is important to note also that with increasing age comes a variety of other risk factors and service needs not distinct to veterans, including the increased probability of non-service related physical injuries, greater need for aged care services and other medical comorbidities. 

Currently mental health care for veterans relies heavily on civilian health services provided by generic private and public health systems. While this may be suitable for some, the lack of specialised services and knowledge means that veterans can struggle to obtain the care they need, leading to sub-optimal outcomes. This issue is compounded by a lack of exposure of health professionals in training to the unique needs and experiences of current service members and veterans, in particular the complex symptoms which may result from cumulative trauma exposure. The RANZCP has recognised the need to augment training in this area.

Evidence

As a consequence of selection processes and access to ancillary health services, current service members are normally expected to be significantly healthier than the general population. However, an estimated 46% of former ADF members, transitioned within the past five years, met diagnostic criteria for a mental illness in the preceding 12-months (Van Hooff et al., 2018a). This is more than double the 12-month prevalence of mental illness found in the Australian population (ABS, 2008). The most common type of disorder in the recently transitioned ADF cohort was anxiety disorder (37%), followed by affective disorders (23.1%) and alcohol use disorders (12.9%).

Less is known about the mental health of current service members and veterans of the NZDF. NZDF records show that between 5% and 10% of current service members will seek support related to mental health through primary health care services in the NZDF each year (NZDF, 2018b). A recent review of Veteran Affairs noted that 1 in 6 NZDF veterans have a long-term mental health and addiction issues (Paterson, 2018). This report notes that alongside psychological stress and harm, veterans can experience a moral injury. Moral injury refers to a moral injury to an individual’s conscience e.g. participating in an act that transgresses the individual’s beliefs about what is wrong or right.

Current service members and veterans can present with complex symptoms and mental illness characterised by the extended, repetitive and intensive nature of cumulative trauma (Price et al., 2013), a combination of mortal threats, traumatic losses and morally compromising experiences (Steenkamp et al., 2015; Steenkamp et al., 2011; Price et al., 2013; Stein et al.; 2012). While experiences such as witnessing atrocities or accidentally injuring or killing another person can pose the most significant risk (ADF, 2010), it is important to acknowledge the wide range of causes of mental health issues affecting current and former service members including bullying, harassment and sexual trauma (Surìs et al., 2007; Zinzow et al., 2007). 

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 (Eekhout et al., 2015). As such, the traumatic experiences of military service present a risk factor to individuals not merely during the time of their service but potentially for the rest of their lives. This is of great relevance in planning transitions to retirement and access to treatment after leaving the service.

A key area of concern is the suicide rate in veterans. While the age-adjusted suicide rate was lower for serving and reserve men than for all Australian men, those who had left the service aged under 30 had a suicide rate 2.2 times that of Australian men the same age (AIHW, 2018b). From 2001 to 2016, there were 373 suicides in serving, ex-serving and reserve ADF personnel (AIHW, 2018b). The suicide rate for veterans is a critical issue, which must be managed through evidence-based support specifically tailored for veterans.

Appropriate treatment for current and former defence force members may need to address a range of issues not usually considered in mental health treatments including alienation from civilian life, difficulties in restoring interpersonal connections, challenges in social and/or occupational functioning and complex feelings of guilt, grief, blame, mistrust, control, withdrawal and/or rage (Yehude and Hoge, 2016). Difficulties in transitioning to civilian life may relate to social, occupational and/or psychiatric functioning and may be experienced as feelings of not belonging, a factor in the suicidal process (Sher and Braquehais, 2013). Additionally, trends in alcohol and drug use by current and former defence force members may differ from the general population, which should be addressed within health services accessed by this population (AIHW, 2018a; Davy et al., 2012).

Appropriate cultural services also need to be developed. In New Zealand, 15% of the total NZ Defence Force are Māori (in the army 22% of the service personnel identified as Māori) therefore particular approaches are required to address their needs that include a Te Ao Māori perspective (TEARA, 2012). The Paterson Review noted that veterans received little assistance from Veteran Affairs that was specifically tailored for Māori and that there was not a good understanding of Māori tikanga (Paterson, 2018). The RANZCP suggests there should be greater liaison between Te Puni Korkiri and Veteran Affairs to ensure a greater emphasis on delivering services and support from a Te Ao Māori perspective. 

Recommendations

The RANZCP recommends that the Australian Government:

• Provide targeted and seamless support for current service members and veterans through one consolidated government body which has appropriate levels of resourcing and staffing
• Embed medical specialist expertise within government bodies that work with current service members and veterans, with specific representation from psychiatry
• Re-develop and implement the Veteran Mental Health Strategy to improve veteran mental health care by setting out clear priorities, actions, performance reporting and evaluation of government bodies
• Improve the organisation and coordination of health services across all levels and types of care through the:
  • development and integration of proactive, outreach-focused and responsive health and non-health service capability
  • increase involvement of, and support for, families and community in therapeutic and administrative processes
  • evaluation of remuneration for psychiatric consultations to ensure parity with other workers compensation schemes
• Require that training for those working with current service members and veterans includes competencies relating to trauma informed care and vulnerable populations and implement training in these competencies
• Establish long-term research programs to guide evidence-based service delivery, with an emphasis on the collection and use of statistics for veterans, female service members and any other identified knowledge gaps in Australia.

The RANZCP recommends that the New Zealand Government:

• Implement the findings of the Independent Review of Veteran’s Support Act which calls for greater funding and resources for Veteran’s Affairs to provide “wrap around” mental health care and support for veterans
• Ensure that relevant government agencies – Te Puni Kōkiri, the Ministry of Health, the Ministry of Social Development, and the Accident Compensation Corporation (ACC) – work in unison to provide clinical support and guidance to Veteran’s Affairs
• Investigate and progress new policies focusing on developing a wellbeing and health assessment process for veterans when they leave the NZDF
• Educate individuals across the health and disability sector in New Zealand regarding the specific support, care, treatment and rehabilitation needs of veterans 
• Work with the relevant Government agencies, as well as clinicians, to support greater data collection relating to the mental injuries arising from deployment. 
• Establish long-term research programs to guide evidence-based service delivery, with an emphasis on the collection and use of statistics for veterans, female service members and any other identified knowledge gaps in New Zealand.

Responsible committee: Faculty of Child and Adolescent Psychiatry 

References

Australian Bureau of Statistics (ABS) (2008) National Survey of Mental Health and Wellbeing 2007: summary of results. ABS cat. no. 4326.0. Canberra: ABS.

Australian Defence Force (2010) Mental Health of the Australian Defence Force – 2010 ADF Mental Health Prevalence and Wellbeing Study Report. Canberra, Australia: Australian Defence Force. Available at: www.defence.gov.au/Health/DMH/MentalHealthReformProgram.asp#MHRP (accessed 17 May 2018).

Australian Institute of Health and Welfare (AIHW) (2018a) A profile of Australia’s veterans 2018. Canberra, Australia: Australian Institute of Health and Welfare. Available at: https://www.aihw.gov.au/getmedia/1b8bd886-7b49-4b9b-9163-152021a014df/aihw-phe-235.pdf.aspx?inline=true (accessed 18 December 2018).

Australian Institute of Health and Welfare (AIHW) (2018b) National suicide monitoring of serving and ex-service Australian Defence Force personnel: 2018 update. Canberra, Australia: Australian Institute of Health and Welfare. Available at: https://www.aihw.gov.au/getmedia/99c20935-ac59-4a78-88d7-e37b6cd3b969/aihw-phe-222.pdf.aspx?inline=true (accessed 15 October 2018). 

Davy C, Dobson A, Lawrence-Wood E, Lorimer M, Moores K, Lawrence A, Horsley K, Crockett A, McFarlane A (2012) Middle East Area of Operations (MEAO) Health Study: prospective study report. Adelaide, Australia: The University of Adelaide. Available at: http://www.defence.gov.au/Health/Home/Docs/130318-MEAOProspectiveStudyExecutiveSummary.pdf (accessed 25 June 2019).

Department of Veterans’ Affairs (DVA) (2015) Definition of a Veteran. Available at: http://clik.dva.gov.au/compensation-and-support-policy-library/part-1-service-requirements/11-veterans/111-who-veteran/definition-veteran (accessed 12 November 2018).

Eekhout I, Reijnen A, Vermetten E, Geuze E (2015) Post-traumatic stress symptoms 5 years after military deployment to Afghanistan: an observational cohort study. Lancet Psychiatry 163(4): 659-666.

New Zealand Defence Force (NZDF) (2018a) The Veteran Rehabilitation Strategy. Wellington, New Zealand: Veterans’ Affairs, New Zealand Defence Force.

New Zealand Defence Force (NZDF) (2018b) Defence Force Gifts Mental Health Resources to Public Sector’s Frontline. Available at: https://medium.com/@nzdefenceforce/defence-force-gifts-mental-health-resources-to-public-sectors-frontline-f23d08a272c (accessed 21 January 2021). 

New Zealand Government (2019) Boost for services to veterans and their families. Available at: https://www.beehive.govt.nz/release/boost-services-veterans-and-their-families 

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

Price M, Gros DF, Strachan M, Ruggiero KJ, Acierno R (2013) 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 20(4): 277–285.

Productivity Commission (2018) A better way to support veterans, Draft Report. Canberra, Australia: Commonwealth of Australia. 

Sher L and Braquehais M (2013) Suicidal behaviour in military veterans and health care professionals. Australian and New Zealand Journal of Psychiatry 48(6): 589.

Steenkamp MM, Litz BT, Gray MJ, Lebowitz L, Nashe W, Conoscentif L, Amidong A, Langh A (2011) A brief exposure-based intervention for service members with PTSD. Cognitive Behavioral Practice 18(1): 98–107.

Steenkamp MM, Litz BT, Hoge CW, Marmar CR (2015) Psychotherapy for military-related PTSD: a review of randomized clinical trials. JAMA Psychiatry 314(5): 489–500.

Stein NR, Mills MA, Arditte K, Mendoza C, Borah AM, Resick PA, Litz BT, STRONG STAR Consortium (2012) A scheme for categorizing traumatic military events. Behavior Modification 36(6): 787–807.

Surìs A, Lind L, Kashner T, Borman P (2007) Mental health, quality of life, and health functioning in women veterans: differential outcomes associated with military and civilian sexual assault. Journal of Interpersonal Violence 22(2): 179–197.

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

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

Van Hooff M, Forbes D, Lawrence-Wood E, Hodson S, Sadler N, Benassi H, Hansen C, Grace B, Avery J, Searle A, Iannos M, Abraham M, Baur J, Varker T, O’Donnell M, Phelps A, Frederickson J, Sharp M, McFarlane A (2018b) Mental Health Prevalence and Pathways to Care Summary Report, Mental Health and Wellbeing Transition Study. Canberra, Australia: Department of Veterans’ Affairs.

Van Hooff M, Lawrence-Wood E, Hodson S, Sadler N, Benassi H, Hansen C, Grace B, Avery J, Searle A, Iannos M, Abraham M, Baur J, McFarlane A (2018a) Mental Health Prevalence, Mental Health and Wellbeing Transition Study. Canberra, Australia: Department of Veterans’ Affairs. 

Yehuda R, Hoge CW (2016) The Meaning of Evidence-Based Treatments for Veterans With Posttraumatic Stress Disorder. JAMA Psychiatry 73(5): 433–43.

Zinzow H, Grubaugh A, Monnier J, Suffoletta-Maierle S, Frueh B (2007) Trauma among female veterans: a critical review. Trauma, Violence, & Abuse 8(4): 384–400.

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.