The Final Report of the Royal Commission into Defence and Veteran Suicide was handed down on 9 September 2024. Since it was established in 2021, the Royal Commission held 12 public hearings, received oral evidence from over 340 witnesses, held 897 private sessions and received over 5,865 submissions.1 This has culminated in an extensive Final Report which comprises of 7 volumes and 122 recommendations. For the purposes of this article, we focus on Volume 4 of the Final Report.
Volume 4 of the Final Report addresses health care for both serving and ex-serving members of the Australian Defence Force (ADF) and is of particular relevance for health professionals. Volume 4 particularly focuses on mental health issues and highlights the increased likelihood of those who have served in the ADF having a mental health condition. Of note, the Final Report quotes data from the 2020-2021 National Health Surgery which notes that:
- 27% of those who have served have suffered a mental or behavioural condition compared to 17% of men who had never served;
- 21% of those who have served reported suffered an anxiety related disorder compared with 11% of men who had never served and
- 12% of those who have served have suffered reported having depression or feeling depressed compared with 9.4% in those who have never served.2
The Final Report is extensive, with Volume 4 alone consisting of 420 pages and 9 chapters which are briefly outlined below.
Chapter 15 of the Final Report provides an overview of the ADF’s current initiatives related to the physical and mental health of serving members. The Chapter also highlights the tensions between recruitment and retention issues and decisions which would promote and protect the health of individual members. The Chapter also sets out some of the challenges at the individual level regarding the “real fears of medical downgrade, stigma around perceived weakness, a culture of stoicism and self-reliance, and other barriers to help seeking reduce opportunities for early intervention”.3 The complexity of these issues are important to keep in mind for any clinicians treating current serving members of the military. The recommendations in this Chapter are focused on removing barriers to help including reducing stigma, improving injury surveillance and prevention strategies and improving screening processes.
Chapter 16 is focused on the current structure of the healthcare and rehabilitation services delivered by the ADF noting “accessible, quality and timely health care is critical to suicide prevention”.4 Recommendations are made in relation to the rehabilitation services including “recovering at work” where safe to do so, “unit-based” health and welfare support, strengthening the existing clinical governance framework and clarification of privacy, information and consent policies to ensure this doesn’t inadvertently prevent appropriate sharing of information.5
Chapter 17 also outlines the Suicide Prevention Programs that the ADF already has in place, noting that despite these initiatives the rates of suicide and suicidality in both serving and ex-serving members has not declined.6 The Chapter highlights the importance of “high-quality aftercare” in reducing the risk of suicide and emphasises the importance of recovery and reintegration into work.7 Recommendations are made in relation to enhancing the ADF’s suicide prevention training and clinical protocols for members experiencing a mental health or suicidal crisis.
Chapter 18 outlines important issues for clinicians in relation to treating ex-serving members when accessing and receiving health care after transitioning out of military services. The Final Report highlights the importance of veterans being able to access “adequate, timely and accessible” health care which is provided by practitioners who understand the veteran experience and military culture.8 The Final Report made a number of observations regarding the current state of the veteran health system including a lack of awareness of the health system’s complexity, poor health literacy among veterans, poor continuity of care following separation, supply issues affecting access to care, shortcomings in providing health care informed by an understanding of veterans needs and issues with data sharing.9 To make it more attractive for clinicians to provide services to veterans, Recommendation 71 proposes amending the DVA fee schedule to align with the National Disability Insurance Scheme (at a minimum).10 Proposed recommendations also include developing “networks” of care to improve access to, and communication between, specialist healthcare services for veterans and other healthcare services and also to improve military cultural competency in health professions working with veterans.11
Chapter 19 addresses OpenArms, which is a government funded nationally accredited mental health organisation run by the Department of Veteran Affairs (DVA). Substantial reviews and changes to this organisation had already been made prior to the Royal Commission including into the suicides of several clients involved in this program. The Final Report recommends a further wide-ranging review of this service begin in 2027.12
Chapter 20 focuses on postvention which is the support offered to the people affected by a suicide death, noting that on average 135 people are impacted by a single suicide including family members, colleagues, friends, support people and first responders.13 The Final Report recommendations a postvention framework be developed by the ADF, but also serves as a reminder of the significant impact that suicide can have on others, which is not just limited to immediate family.
In Chapter 21, the Final Report discusses the issues around moral injury which is a term developed by a clinical psychiatrist, Dr Jonathan Shay ‘when there has been (a) a betrayal of ‘what’s right’; (b) either by a person in legitimate authority … or by one’s self …; (c) in a high stakes situation”.14 Interestingly, moral injury is not something which appears in the DSM-V. The Final Report distinguishes moral injury from Post Traumatic Stress Disorder (PTSD) noting that whilst a person may experience both, they are different, with PTSD causing fear-based emotions and moral injury triggering emotions of shame and guilt.15 The report highlights that identifying moral injury early creates the best opportunity for successful treatment.16The Final Report highlights that understanding around this type of psychological injury is still developing and recommends that Defence and DVA work collaboratively to develop an agreed approach to minimise the negative impact of moral injury including the risks of suicide.17
Finally, Chapter 22 of Part 5 of the Final Report covers mefloquine and tafenoquine, both of which are medications which have been used by defence force personnel to prevent and treat malaria. These medications have known side effects which include psychiatric symptoms. The Final Report outlines the history regarding the previous clinical trials of these medications and the Defence and DVA’s response to members concerns about their use.18
Overall, Volume 4 of the Final Report highlights the significant and unique challenges which can arise when treating both current and former members of the ADF and the impact treatment can have on the risk of suicide. The Final Report recognises that the task of providing health care to served and ex-serving members is significant, and their health profile differs from the general Australian population.19
It is clear that health professionals play a key role in supporting ex-serving members transitioning from military to civilian life, and the need for experience and expertise in trauma informed care is significant. Ex-serving members are faced with accessing the Australian civilian healthcare system which can be complex.20 This can present a significant challenge for ex-service members, particularly those who may have poor health literacy. The role of primary care, including that provided by general practitioners, who are often the first point of contact an ex-service member may have in the health system, cannot be underestimated.21
Deputy Prime Minister and Minister for Defence, The Hon. Richard Marles, has said that the government will now take time to carefully consider the recommendations of the final report.
This article was written by Brit Mainhoff, Partner, Victoria Upton, Senior Associate, and Liarne McCarthy, Senior Associate.
1 Commonwealth, Royal Commission into Defence and Veteran Suicide, Final Report, vol 1, 6-7.
2 Commonwealth, Royal Commission into Defence and Veteran Suicide, Final Report, vol 4, 8.
3 Ibid 47.
4 Ibid 115.
5 Ibid 116.
6 Ibid 175.
7 Ibid 175.
8 Ibid 219.
9 Ibid 219.
10 Ibid 245.
11 Ibid 219, 254, 255.
12 Ibid 273.
13 Ibid 307.
14 Ibid 357.
15 Ibid 357.
16 Ibid 365.
17 Ibid 383.
18 Ibid 391.
19 Ibid 6.
20 Ibid 230.
21 Ibid 226.
