summary - department of veterans' · web viewthere has been particular interest in the...

Technical report

Suicidal behaviour and ideation among military personnel: Australian and international trends

July 2016

© Commonwealth of Australia 2016

This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth. Requests and inquiries concerning reproduction and rights should be addressed to the publications section of the Department of Veterans’ Affairs or emailed to [email protected].

For citation

Australian Institute for Suicide Research and Prevention (2015). Suicidal behaviour and ideation among military personnel: Australian and international trends. Technical report prepared for the Department of Veterans’ Affairs. Australian Institute for Suicide Research and Prevention.

Please direct any comments or queries relating to this report to [email protected].

Disclaimer

The material presented in this report, the selection of articles and summaries, and the interpretations offered are the responsibility of the Australian Institute for Suicide Research and Prevention and do not necessarily reflect the views of the Australian Government. Other sources of information, such as grey literature, were taken into account for the review. Evidence predating the year 2005 was not considered.

Readers are advised to consider evidence arising since publication of this report. They should examine not only the papers described here but also other sources of information if they are interested in the subject.

Acknowledgments

The Australian Government Department of Veterans’ Affairs funded this project. The department’s Mental Health Adviser edited the document and a departmental officer provided information about current programs. We thank Dr Stephanie Hodson, Mr Luke Brown, Ms Nisha Amin and Ms Sophie Eltringham from the department for their support.

mailto:[email protected]

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Suicidal behaviour and ideation among military personnel

ContentsSummary........................................................................................................................................4

Introduction...................................................................................................................................6

Method..........................................................................................................................................7Defining the populations.................................................................................................................7Defining the outcomes....................................................................................................................7The searches...................................................................................................................................7Paper selection................................................................................................................................8Information management...............................................................................................................9Evaluation of the evidence..............................................................................................................9

Results.........................................................................................................................................11Suicidal behaviour and ideation in the Australian community......................................................11

Prevalence..............................................................................................................................11Risk groups and factors...........................................................................................................13

Suicidal behaviour and ideation among serving military personnel..............................................14Australian literature................................................................................................................15International literature...........................................................................................................16

Suicidal behaviour and ideation among ex-serving personnel......................................................18Australian literature................................................................................................................18International literature...........................................................................................................20

Discussion....................................................................................................................................24Suicide prevention........................................................................................................................26Limitations of the review..............................................................................................................27

Conclusion....................................................................................................................................28

References...................................................................................................................................29

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SummarySuicide is the leading cause of death among Australians aged between 15 and 44 years. There has been particular interest in the incidence of suicidal behaviour among serving and ex-serving Australian Defence Force personnel.

The Australian Institute for Suicide Research and Prevention conducted this literature review at the request of the Commonwealth Department of Veterans’ Affairs. The focus question was ‘What current literature exists about suicidal behaviour and ideation in military personnel, the Australian community and international militaries?’ The aim of this evidence assessment was to provide national and international comparison points for suicidal behaviour and ideation among Australian military personnel, as well as identifying any emerging risk and protective factors.

Fifty-one papers and reports were included in the review. Of these, 19 originated in Australia: 12 dealt with suicide in the general Australian community, four dealt with suicide among ex-serving Australian personnel, and three dealt with suicide among currently serving Australian personnel. Twenty-two papers and reports dealt with suicide among ex-serving international military personnel and 10 covered serving international military personnel. Of these 32 international papers, 24 originated in the United States, four originated in Canada, and one in each of the United Kingdom, Sweden, Denmark and New Zealand.

Since 2004 suicide rates in the Australian community have remained relatively stable, although there has been a small upward trend since 2006 (ABS, 2015). Australian Bureau of Statistics data show that in 2013 the overall suicide rate in Australia was 10.9 deaths per 100,000 (16.3 per 100,000 for males and 5.4 per 100,000 for females). Among the risk factors for suicide mortality in the Australian population are male gender (ABS, 2015), unemployment (Milner et al., 2014), being employed in the agricultural, transport or construction industries (Andersen et al., 2010) and living in a rural area (Sankaranarayanan et al., 2010). Research into non-fatal suicidal behaviour and suicidal ideation in the Australian community has shown that young females account for the highest proportion of suicidal ideation, plans and attempts (Slade et al., 2009). Other risk factors are diagnosed mental illness (Slade et al., 2009), being separated, divorced or never married, financial problems and psychosocial stress (Taylor et al., 2007).

In the case of military personnel, the literature appears to show that currently serving Australian personnel could have been at increased risk of suicidal ideation and plans in the year preceding the survey (McFarlane et al., 2011) but have similar levels of non-fatal suicidal behaviour and possibly lower rates of suicide mortality compared with the general population (Hadfield & Sheffield, 2009; Kõlves et al., 2012). Among the risk factors for currently serving Australian personnel is the presence of a psychiatric disorder, particularly an affective disorder (McFarlane et al., 2011).

International research into the prevalence of suicide in currently serving military personnel shows mixed results when comparisons are made with the general community. Research into risk factors among serving international military personnel showed similarities with those for the general population, with negative life events such as intimate relationship problems, family problems, a recent crisis or job problems (Skopp et al., 2012; Logan et al., 2015) and mental illness (Skopp et al., 2012) playing significant roles. In contrast, the findings in relation to the effect of military deployment and non-deployment on the risk of suicide were mixed. The studies reviewed suggested that active female military personnel might be at increased risk of suicidal ideation (Belik et al., 2010;

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Nock et al., 2014) and attempts (Belik et al., 2010, 2009) compared with active male military personnel. Other risk factors for non-fatal suicidal behaviour are psychiatric illnesses (Belik et al., 2010; Nock et al., 2014) and excessive drug use (Ejdesgaard et al., 2015).

Although there has been no specific research done that would allow a comparison of suicide mortality rates between Australian ex-serving personnel and the general community, research into non-fatal suicidal behaviour and suicidal ideation among Australian Vietnam veterans appears to show that they could be at increased risk and might experience risk factors similar to those experienced in the general community—for example, having a diagnosed mental illness such as posttraumatic stress disorder, depression, alcohol dependence, phobia and agoraphobia (O’Toole et al., 2015).

Research into the risk of suicide mortality among Australian veterans in general suggests that veterans might experience a number of veteran-specific risk factors such as difficulty returning to civilian life (relationship problems, mental illness, alcohol and drug misuse, employment problems, bereavement, and loss of routine and structure) and a reluctance to seek help for their problems (McKay et al., 2010).

There is strong evidence that US veterans and ex-serving personnel are at increased risk of suicide mortality compared with the general US population (Kaplan et al., 2012; Kaplan et al., 2007; Maynard & Boyko, 2008; McCarthy et al., 2009; Kang et al., 2015; Reger et al., 2015; Hoffmire et al., 2015).

The US studies reviewed show that among the risk factors for suicide are being male (Zivin et al., 2007; Kapur et al., 2009; Ilgen et al., 2010; Katz et al., 2012), being Caucasian (Kaplan et al., 2007; Zivin et al., 2007), having a diagnosed psychiatric disorder (Ilgen et al., 2010) or traumatic brain injury (Brenner et al., 2011), living in a rural area (McCarthy et al., 2012) and not making use of Veterans Health Administration services (Katz et al., 2012; Hoffmire et al., 2015). There were mixed findings in relation to which age groups were at greatest risk and whether deployment to conflict had any impact on risk.

In contrast with the research from the United States, researchers from Sweden (Michel et al., 2007) and the United Kingdom (Kapur et al., 2009) did not find increased risk among veterans compared with the respective general populations. The Swedish study found a significantly lower risk of suicide among peacekeepers compared with the general population (Michel et al., 2007). The UK study showed no significant differences in suicide rates among veterans and the general population, the only exception being an increased risk in male veterans aged 24 years or less compared with the same age group in the general population (Kapur et al., 2009).

The literature review was limited by the lack of Australian studies in the field, which made it difficult to draw conclusions about suicide prevalence and risk among Australian veterans compared with the general Australian population. Despite the evidence from international studies, their results have limited generalisability to the Australian context.

The reviewers conclude by emphasising the importance of suicide prevention efforts directed at ex-serving personnel in the light of veteran-specific risk factors for suicide that are highlighted in the research.

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IntroductionIn Australia suicide is the leading cause of death among people aged between 15 and 44 years (ABS, 2016). Serving and former serving men and women of the Australian Defence Force are not an exception.

Military service entails both benefits and risks. In this instance, veterans can experience a number of risk factors for suicidal behaviour, among them a high prevalence of posttraumatic stress disorder, depression (Seal et al., 2009), traumatic brain injury and physical health problems (Hoge et al., 2008). Extensive research into the prevalence of suicide among US veterans compared with the general population has yielded mixed results. Recent papers have suggested, however, that US veterans might be at increased risk of suicide (Hoffmire et al., 2015; Kaplan et al., 2007; Maynard & Boyko, 2008; Kaplan et al., 2012; Kang et al., 2015; Reger et al., 2015; McCarthy et al., 2009). In a previous review of the literature Dunt (2009) found that Australian veterans might also be at increased risk of suicide; there has, however, been only limited research in the Australian context.

The Australian Institute for Suicide Research and Prevention performed the present literature review at the request of the Department of Veterans’ Affairs. The aim of the review was to provide national and international comparison points for suicidal behaviour and ideation among Australian military personnel, as well identifying any emerging risk and protective factors. The review focused on the question ‘What current literature exists about suicidal behaviour and ideation in military personnel, the Australian community and international militaries?’ Suicidal behaviour was defined as both fatal suicidal behaviour (suicide) and non-fatal suicidal behaviour (for example, self-harm and suicide attempts). Research into suicidal ideation (thinking about suicide) was also included.

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MethodThe literature review was limited to the period from January 2005 to June 2015, and article selection was limited to peer-reviewed English-language studies.

Because of the lack of research into suicidal behaviour among Australian veterans (serving and non-serving), grey literature in the form of reports was included. There were, however, numerous high-quality peer-reviewed publications dealing with suicidal behaviour among members of the general Australian community, so grey literature was not included in this case.

Specific criteria were developed for screening studies and reports for inclusion in the review.

Defining the populationsIn Australia the term ‘veteran’ refers to both currently serving and former serving members of the Australian Defence Force. Generally speaking, under past Australian military compensation legislation a ‘veteran’ is someone who has rendered ‘warlike’ or ‘non-warlike’ service (or the equivalent historical terminology) in the ADF. Under the legislative definition, therefore, a veteran could either be currently serving or have left full-time service in the ADF, which includes those who have transferred from full-time service to the reserves.

It is important to note that differing health support systems apply for former serving members of the ADF and currently serving members of the ADF. As a result, for the purposes of this review, the literature pertaining to currently serving or ex-serving military personnel was examined separately, and the review findings will thus have differing implications for policy and programs aimed at suicide prevention in the defined populations.

Individuals (both deployed and non-deployed) who were serving in the ADF at the time of the study were defined as ‘serving military’ for the review. International literature for this population also refers to ‘actively’ serving military personnel. Individuals (both deployed and non-deployed) who had left service at time of the study were defined as ‘ex-serving military’ for the review. Australian and international literature for this population also refers to ‘veterans’ and ‘ex-military’.

Defining the outcomesSuicide is defined as ‘an act with [a] fatal outcome, which the deceased, knowing or expecting a potentially fatal outcome, has initiated and carried out with the purpose of bringing about wanted changes’ (De Leo et al., 2006). In this review suicidal behaviour is defined as both fatal and non-fatal. Non-fatal suicidal behaviour can be defined as ‘a non-habitual act with nonfatal outcome that the individual, expecting to, or taking the risk to die or to inflict bodily harm, initiated and carried out with the purpose of bringing about wanted changes’ (De Leo et al., 2006). Suicidal ideation refers to experiencing thoughts of suicide.

The searchesScopus, the Web of Knowledge, ProQuest and PubMed were searched in order to retrieve relevant peer-reviewed papers published between 2005 and 2015. Filters were used to ensure that only the relevant papers were retrieved. Relevant grey literature was retrieved through Google searches.

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Specific search terms were used to retrieve peer-reviewed articles for each population of interest. The terms were used to search the titles and abstracts of papers. The titles and abstracts retrieved in this way were read by two researchers in order to identify potentially relevant papers, and the full texts of those papers deemed potentially relevant were read before a final decision was made on inclusion or exclusion. Discussions between Australian Institute for Suicide Research and Prevention and Department of Veterans’ Affairs personnel led to the identification of relevant grey literature.

Papers and grey literature were assessed for quality and the risk of bias, the quantity of evidence, and generalisability to the target population. Table 1 shows the key words used in the different searches, the number of papers retrieved through the searches before and after the removal of duplicate papers, and the number of papers and reports included for each section of the review from key word searches and an examination of grey literature.

Table 1 Searches to find papers and reports for inclusion in the review

Key words Databases Years Result of database search Grey literature

veterans AND suicid*

ScopusWeb of KnowledgeProQuestPubMed

2005 – June 2015 Total: 2,463After duplicate removal: 1,226Relevant papers included: 22

Grey literature included? No

veterans AND suicid* AND Australia*


2005 – June 2015 Total: 22After duplicate removal: 19Relevant papers included: 1

Grey literature included? YesNumber of reports included: 3

military AND suicid*


2005 – June 2015 Total: 2,841After duplicate removal: 1,348Relevant papers included: 9


military AND suicid* AND Australia*




Australia* AND suicid* AND population




Total: 42 Total: 9

Note: The asterisk is a commonly symbol used for database searches. It allows the search to retrieve variations on a word stem or root.

Paper selectionThe peer-reviewed studies were evaluated according to the inclusion and exclusion criteria shown in Table 2. All Australian papers on suicide among currently serving and ex-serving military personnel that met the inclusion criteria were included. Because of the restricted scope of the review, however, and the extensive number of papers on suicide in the general Australian community, as well as the extensive number of US papers on suicide among international serving and ex-serving military personnel, the most relevant papers were selected on the basis of the expert opinion of those performing the evidence assessment. This means that all papers included in the review met the strict inclusion criteria, but only high-quality papers with a sound methodology and adequate statistical power were included.

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Table 2 Inclusion and exclusion criteria

Inclusion criteria Exclusion criteria

All peer-reviewed studies Papers published between 1 January 2005 and 1 June

2015 Human adults aged 18 years and over—for all except

the Australian community population English language Populations: individuals who had separated from the

Australian military, individuals who had separated from the international militaries included, currently serving Australian personnel, currently serving international personnel, and the general Australian population

The prevalence of and/or risk factors for suicidal behaviour—suicide, non-fatal suicidal behaviour and suicidal ideation—measured

Non–English language Papers published before 2005 Papers for which a full-text version was not readily

available Stand-alone method papers Studies that did not include any measure of suicidal

behaviour Studies that did not include serving and ex-serving

military or the general Australian population Papers with unclear or questionable methodology Papers with no usable data

Information managementPeer-reviewed papers identified through the key word searches were exported from the electronic databases into EndNote software and then exported from EndNote into Microsoft Excel spreadsheets. Initial eligibility screening of the titles and abstracts of papers was performed by one researcher and then double-checked by a senior researcher. Full-text versions of the papers that satisfied the initial screening criteria were then obtained. After reading the full text the reviewer decided which papers should be included or excluded; this was again checked by a senior researcher before a final decision was made.

Grey literature was retrieved through searches of Google and through discussions with officers of the Department of Veterans’ Affairs and other professionals. Inclusion of grey literature was based on applicability to the topic and the reliability of the source.

Evaluation of the evidenceThe evidence was evaluated using three main criteria:

quality and risk of bias

quantity

generalisability.

‘Quality and risk of bias’ included measures such as randomly selected samples, clear definitions of the study population, and the use of reliable and standard data collection methods. ‘Quantity’ referred to the number of participants in each study and the number of studies included. ‘Generalisability’ referred to how well the evidence in the studies could be generalised to the population of interest; for example, a large national study of ex-serving personnel from the United States would be considered to be generalisable to US ex-serving populations but would have limited generalisability to Australian ex-serving personnel because of differences in characteristics between the respective militaries and countries.

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The research criteria involved questions about prevalence and risk rather than about the effectiveness of an intervention, so no ranking of the evidence was done.

Appendix A provides a summary of each of the papers and reports included in the review and shows their degree of conformity to the three evaluation criteria.

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ResultsFifty-one papers and reports were included in the review. Of these, 19 originated in Australia: 12 dealt with suicide in the general Australian community, four dealt with suicide among ex-serving Australian personnel, and three dealt with suicide among currently serving Australian personnel. Twenty-two papers and reports dealt with suicide among ex-serving international military personnel and 10 covered serving international military personnel. Of these 32 international papers, 24 papers originated in the United States, four originated in Canada, and one in each of the United Kingdom, Sweden, Denmark and New Zealand. Figure 1 shows the year of publication of the studies and reports reviewed.

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 20150

2

4

6

8

10

12

1 1

4

1

6

9

3

10

0

6

10

Year

Num

ber

Figure 1 Studies and reports included in the review: year of publication

Suicidal behaviour and ideation in the Australian communityIn order to provide context for understanding suicidal behaviour and ideation among Australian military personnel, the researchers conducted a rapid review of the literature applying to the Australian community in general. Because of the large quantity of papers on the topic, only papers and reports of high quality were included; the result was that all papers are of high quality, with little risk of bias, and are generalisable to the Australian population, which includes serving and ex-serving veterans.

PrevalenceSuicideSince 2009 the Australian Bureau of Statistics has implemented a data-revision process involving two rounds of revisions 12 and 24 months after the initial processing of coroner-certified deaths (ABS, 2015). This has allowed for improved accuracy when reporting suicide statistics. At the time of

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writing, the 2013 data were yet to undergo the revision process. Preliminary data from an ABS report show, however, that in 2013 there were 2,522 cases of suicide (1,885 males and 637 females); this equates to an overall suicide rate of 10.9 deaths per 100,000 (16.3 per 100,000 for males and 5.4 for females) (ABS, 2015). Suicide was the 14th leading cause of death in Australia and the 10th leading cause of death in males (ABS, 2015). Suicide rates have remained relatively stable in Australia since 2004, although there has been a small upward trend since 2006 (see Figure 2).

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012* 2013**0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

Males - revised data Females - revised data Persons - revised dataMales - preliminary data Females - preliminary data Persons - preliminary data

Year

Rate

per

100

,000

pop

ulati

on

Note: *Data for 2012 had undergone one revision only; **data for 2013 are preliminary.Source: ABS (2015).

Figure 2 Trends in Australian suicide, 2003 to 2013

The most common method of suicide in Australia in 2013 was hanging, strangulation and suffocation (55.2% of deaths), followed by poisoning by drugs (13.8%) and poisoning by other methods (8%). The proportion of suicides in Australia involving any type of firearm was 6.5% (ABS, 2015). Research has shown that the incidence of suicide methods used changed significantly between 1988 and 2007, there being an overall increase in suicide by hanging and a decrease in suicide by firearm, gassing (motor vehicle carbon monoxide), poisoning and drowning in males and firearm, gassing, jumping and drowning in females (Large & Nielssen, 2010).

Non-fatal suicidal behaviour and suicidal ideationInformation on non-fatal suicidal behaviour in the Australian community has been gathered in a number of large community surveys that were summarised in a report published by AISRAP (Kõlves et al., 2013). In 2007 the National Survey of Mental Health and Wellbeing of Australians aged 16 to 85 years and the World Health Organization Multisite Intervention Study on Suicidal Behaviours (referred to as the SUPRE-MISS study) among Brisbane and Gold Coast residents aged over 18 years

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both showed that 0.4% of the community samples had attempted suicide in the preceding 12 months.

A 2009 report by Slade et al., also using data from the 2007 National Survey of Mental Health and Wellbeing, showed that 13.3% of Australian adults reported suicidal ideation during their lifetime, 4.0% reported a suicide plan, and 3.3% reported a suicide attempt in their lifetime. These results were comparable with those from the SUPRE-MISS study, which found that 10.4% of the overall sample had seriously considered suicide during their lifetime, 4.4% had made a suicide plan, and 4.2% had attempted suicide (De Leo et al., 2005). The SUPRE-MISS study showed differences in the method used for suicide attempts between genders, males being more likely to use methods such as hanging (8.9% compared with 3.3% of females), carbon monoxide poisoning (8.2% compared with 1.2%), crashing of a motor vehicle (7.5% compared with 4.1%) and firearms (6.2% compared with 0.4%) (De Leo et al., 2005).

Risk groups and factorsSuicideMales in the Australian community have had a consistently higher rate of suicide than females (ABS, 2015). Particular age groups can be at increased risk of suicide mortality, and this tends to differ according to gender. ABS data show that in 2013 the highest suicide rates overall were in the 85 years and over group (17.7 per 100,000), followed by the 35–44 and 45–54 year age groups (both at 15.9 per 100,000). Among males, the highest suicide rate was in the 85 years and over group (38.3 per 100,000), followed by the 45–54 group (23.9 per 100,000) and the 35–44 group (23.3 per 100,000). Among females, the highest rate was in the 35–44 year age group (8.5 per 100,000), followed by the age groups 45–54 years (8.0 per 100,000) and 55–64 years (6.9 per 100,000).

In relation to occupational risks, Andersen et al. (2010) found that Australians working in the agricultural, transport and construction industries in Queensland had significantly higher suicide rates than the overall working population in the state between 1990 and 2006 (‘working population’ refers to all individuals in current full- or part-time employment). Risk differed according to gender: males in the agricultural, construction, transport and cleaner groups showed significantly higher rates than the male working population; female artists and nurses also showed significantly increased risk (Andersen et al., 2010).

As well as employment in particular occupations, unemployment has been identified as a major risk factor for suicide in Australia. Milner et al. (2014) found a suicide rate of 57.7 per 100,000 among unemployed or economically inactive males and 20.2 per 100,000 among unemployed or economically inactive females compared with 10.5 per 100,000 and 2.2 per 100,000 among employed males and females between 2001 and 2010 (Milner et al., 2014). These results are supported by research into the general Australian community, which suggests that individuals with low socio-economic status might be at increased risk of suicide mortality compared with the higher SES groups. Page et al. (2006) found a particularly increased risk among young males in the lower SES group—increasing by 8% from 44.8 per 100,000 in 1994 to 1998 to 48.6 in 1999 to 2003—despite declining suicide rates in the middle (a 10% decrease from 37.3 to 33.5 per 100,000) and high SES groups (a 15% decrease from 33.0 to 27.9 per 100,000).

Suicide rates in Australia have also been shown to vary according to location of residence. Sankaranarayanan et al. (2010) found that rural patients using mental health services in the Hunter Valley of New South Wales in 2003 to 2007 were at significantly increased risk of suicide when compared with urban patients in the Newcastle and Lake Macquarie regions (3.1 per 100,000 per year compared with 1.1 per 100,000 per year). In a large-scale study from 2004 to 2008 Cheung et al.

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(2010) supported these findings of difference by location, showing the highest age-standardised suicide rates in remote areas compared with metropolitan and regional areas—a male metropolitan rate of 15.7 per 100,000 person-years compared with 18.2 in rural areas and 30.0 in remote areas and a female metropolitan rate of 4.6 per 100,000 person-years compared with 4.6 in rural areas and 5.5 in remote areas). Possible reasons for this increased risk of suicide in remote areas were said to be socio-economic deprivation, compositional factors, high risks for Indigenous people, and poor access to mental health services (Cheung et al., 2010).

Additionally, research suggests that suicide risk can differ according to country of birth. Ide et al. (2012) found that in Australia between 2004 and 2006 the highest suicide rates were among males born in Eastern Europe (35.3 per 100,000), followed by males born in New Zealand (24.6 per 100,000) and Western Europe (24.2 per 100,000); this compares with a rate of 22.7 per 100,000 among Australian-born males. In females the highest suicide rates for the period were among those born in Western Europe (8.1 per 100,000) and the United Kingdom and Ireland (7.7 per 100,000); this compares with 5.5 per 100,000 among Australian-born females (Ide et al., 2012).

Non-fatal suicidal behaviour and suicidal ideationA number of factors have emerged as posing potential risks for non-fatal suicidal behaviour in the Australian community. The 2007 National Survey of Mental Health and Wellbeing showed that, despite the higher suicide rates in males, females reported a higher prevalence of suicidal ideation, plans and attempts (Slade et al., 2009). Young females (16–24 years) appear to be particularly at risk of suicidality, the prevalence of non-fatal suicidal behaviour declining with age (Slade et al., 2009).

Furthermore, individuals with a diagnosed mental illness were more likely to have been suicidal within the preceding year compared with the rest of the community (8.3% compared with 2.3%) (Slade et al., 2009). An analysis of a South Australian general population sample between 1997 and 2005 showed that the best predictors of suicidal ideation were being separated, divorced or never married; having problems with money; psychosocial stress (K10); a lack of physical activity or insufficient fruit consumption; regular health service use; and mental health service use in the preceding four weeks (Taylor et al., 2007).

Similarly, the WHO SUPRE-MISS community survey found that individuals reporting a suicide attempt or plan often had problems with their partners (40.7%); this was followed by financial difficulties (24.1%), problems with parents (22.8%), and difficulty maintaining and developing social relationships (21.7%) (De Leo et al., 2005). At the time of the suicide attempt 46.1% of subjects were experiencing depression, 26.8% were experiencing anxiety and panic attacks, and 17.2% were suffering from alcohol or drug abuse (De Leo et al., 2005).

Suicidal behaviour and ideation among serving military personnelThe Department of Defence monitors the number of suicides in the Australian Defence Force, but very little information is published on the prevalence of morbidity: most recent figures are available only through Senate Estimates reporting. In 2010 Defence conducted a major study of non-fatal suicidal behaviour among currently serving personnel. This section summarises what is known about suicide mortality, non-fatal suicidal behaviour and ideation in currently serving ADF personnel and then discusses rates among other international militaries and risk factors that have been identified.

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Australian literatureSuicideAs noted, there is only limited published information on suicide among currently serving Australian personnel. As a result, this review relies on two departmental reports and a thesis that deals with the subject. The lack of peer-reviewed papers available adversely affects the quality of the evidence in this section.

In 2000 Gisler and Sadler published the results of their study of suicide rates in the Australian Defence Force from 1985 to 2000. They found that age-standardised suicide rates among 15–24 year old males in the ADF were lower than but still similar to those for the same age group in the general population (19.1 per 100,000 compared with 25.5 per 100,000); rates for the 25–44 year age group were, however, significantly lower among the ADF personnel than in the general population (9.2 per 100,000 compared with 28.8 per 100,000). Suicide rates in the ADF were highest in the Navy (18.3 per 100,000), followed by the Army (17.8 per 100,000) and then the Air Force (11.3 per 100,000).

Because of its year of publication (earlier than 2005), the Gisler and Sadler paper was not officially included in the present review; it is included here in order to provide a comparison with the more recent study by Hadfield and Sheffield (2009). The latter study found that aged-standardised suicide rates in the ADF from 2000 to 2007 were lower than for the male general population (13.8 per 100,000 compared with 23.6 per 100,000). When Kõlves et al. (2012) compared the suicide methods of ADF personnel in the two studies just noted they found that the use of firearms had decreased over time, while use of hanging methods had increased (Kõlves et al., 2012).

These changes are consistent with trends seen in the general population and have been attributed to changes in gun ownership laws (Kõlves et al., 2012). Kõlves et al. presented a similar analysis as part of an AISRAP review of the ADF Suicide Prevention Program in 2011 to 2012. Their report provided an analysis of the ADF suicide database, which holds a record of suicides among ADF personnel since 2000. Between 2000 and 2010 there were 73 suicides among ADF personnel (68 males and five females). Thirty-nine of these suicides (53.4%) were attributable to Army personnel, 23 (31.5%) to Navy personnel and 11 (15.1%) to Air Force personnel (Kõlves et al., 2012). The mean annual crude suicide rate was calculated using the number of service members recorded in the ADF census of 2003 and 2007 and was highest in the Navy (16.6 per 100,000), followed by the Army (14.3 per 100,000) and then the Air Force (7.4 per 100,000). Males in the ADF had considerably lower suicide rates than males in the general population in the 25–29 year age group (13.31 per 100,000 compared with 25.82 per 100,000), the 30–34 year age group (15.08 per 100,000 compared with 28.61 per 100,000) and the 35–39 year age group (2.81 per 100,000 compared with 26.78 per 100,000). There was also a significant decline in the crude suicide rate among male ADF personnel between 1997 and 2010 (data from 1997 to 1999 were obtained from a Senate Estimates brief). The small number of females in the study population limited the ability to calculate female rates (Kõlves et al., 2012).

Non-fatal suicidal behaviour and suicidal ideationIn contrast with the Kõlves et al. results suggesting a lower risk of suicide mortality among currently serving Australian personnel, the 2010 ADF Mental Health Prevalence and Wellbeing Study (McFarlane et al., 2011) found that, in comparison with the general Australian community, ADF personnel reported a significantly higher prevalence of suicidal ideation (3.9% compared with 1.7%) and plans (1.1% compared with 0.4%) in the preceding 12 months. There was no significant difference in the prevalence of suicide attempts between the military personnel and the general community—0.4% compared with 0.3% (McFarlane et al., 2011).

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Female military personnel reported a higher proportion of suicidal ideation than males (5.1% compared with 3.7%). There were no significant differences in relation to suicidal ideation in the preceding 12 months between the Navy (7.2%), the Army (6.6%) and the Air Force (6.5%). Similarly, there were no significant differences in the prevalence of suicide attempts in the preceding 12 months in the Navy (0.5%), the Army (0.4%) and the Air Force (0.4%). ADF personnel who had been deployed were less likely to report suicidal ideation than those who had never been deployed (6.4% compared with 7.3%).

Of the ADF personnel with an ICD-10 psychological disorder, 2.8% had attempted suicide in the preceding year compared with 0.1% with no disorder, meaning that 90% of the ADF personnel who had attempted suicide in the preceding 12 months had a psychiatric disorder (McFarlane et al., 2011). ADF personnel with an affective disorder appeared to be particularly at risk: 8.9% of these personnel reported a suicide plan and 4.3% reported making a suicide attempt in the preceding 12 months (McFarlane et al., 2011).

International literatureSuicideThere are many international papers that analyse the prevalence of suicide among serving military personnel. A New Zealand study was chosen for inclusion in this review because it was assessed as having moderate generalisability to Australia. The New Zealand military is smaller than the Australian military, but the nations have strong cultural and trade links. Both nations are also Australian British Commonwealth Allies. The ABCA organisation provides the framework for the five alliance forces—Australia, New Zealand, Canada, the United Kingdom and the United States—to train, exercise and operate together in the execution of assigned missions and tasks (ABCA, 2016).

The chosen New Zealand study compared the rates of suicide among active military personnel, dentists, doctors, farmers, hunters, nurses, pharmacists, police and veterinarians with the rates of suicide in the overall employed population between 1973 and 2004 (Skegg et al., 2010). It was found that male armed forces personnel had a significantly lower rate of suicide compared with the overall employed population—respectively 11.0 and 29.8 per 100,000 (RR = 0.4; 95% CI 0.3–0.6; p = 0.001) (Skegg et al., 2010). No suicide deaths occurred among female military personnel during the study period.

A more recent paper, from the United States, did include female active military personnel and compared the rates of suicide among currently deployed soldiers with those for never deployed soldiers and previously deployed soldiers from 2004 to 2009 (Street, 2015). This study found a suicide rate of 14.0 per 100,000 person-years in currently deployed women compared with 4.0–4.5 per 100,000 in never or previously deployed women; the equivalent figures for men were 22.6 per 100,000 person-years and 19.1–25.6 per 100, 000 (Street et al., 2015). The odds of suicide among deployed and never-deployed or previously deployed personnel were significantly higher in females (OR = 3.0; 95% CI 1.2–7.4) but not in males.

A report published by the RAND Corporation showed that in the United States the suicide rate among active military personnel rose from 10.3 per 100,000 in 2001 to 15.8 per 100,000 in 2008 (Ramchand et al., 2011). The rates in 2008 were highest in the Marine Corps (19.5 per 100,000) and the Army (18.5 per 100,000); the rates for the Air Force and the Navy were 12.1 per 100,000 and 11.6 per 100,000 respectively. Compared with the US general population, the rate for the armed forces was noticeably higher, the general population suicide rate being about 10 per 100,000. When compared with a segment of the population with a similar demographic profile, however, the suicide

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rate in the military population was lower (information on statistical significance was not provided) (Ramchand et al., 2011).

It should be noted that, although the United States is one of the ABCA members, the size of its military, the operational tempo, the very different models of health care and different firearm laws mean that the US results have limited generalisability to the Australian military.

Non-fatal suicidal behaviour and suicidal ideation: prevalenceMany studies have measured the prevalence of non-fatal suicidal behaviour among serving international military personnel. Papers were selected for inclusion in this review on the basis of the strength of the study and its relevance to Australia. In particular, studies from Canada were chosen for their moderate generalisability to Australia as a result of similarities in characteristics between the Australian and Canadian armed forces. Canada is an ABCA member, the two nations’ militaries are of comparable size, and both have health care systems for veterans.

Belik et al. (2009) analysed non-fatal suicidal behaviour among Canadian active military personnel who had completed the Canadian Community Health Survey: Mental Health and Well-being Canadian Armed Forces Supplement between May and December 2002. They found that 2.2% of men and 5.6% of women reported a suicide attempt at some point in their life. A subsequent study by Belik et al. (2010) analysed the prevalence of suicide attempts in the preceding year among active military personnel compared with the civilian population, also using data from the Canadian Community Health Survey. This study found a notable difference in the prevalence of preceding-year suicide attempts: the civilian population was significantly more likely to report such an attempt (0.6% compared with 0.2% of military personnel). The same study failed to find a significant difference in the prevalence of suicidal ideation in the preceding year: 4% of the active military personnel reported preceding-year suicidal ideation compared with 3.8% of the civilian population.

A US study found that 13.9% of active Army personnel who participated in the Army STARRS All-Army Study in April to December 2011 had experienced suicidal ideation at some time in their life, 5.3% had made suicide plans, and 2.4% had attempted suicide (Nock et al., 2014). This study, although having limited generalisability to Australia, was of high quality and had a large sample size and a limited risk of bias.

Suicide: risk groups and factorsThe literature showed mental illness to be a major risk factor for suicide mortality among serving military personnel (Logan et al., 2015; Skopp et al., 2012). In particular, mood disorders (Skopp et al., 2012) and alcohol and substance abuse (Logan et al., 2015), as well as co-morbidity of mental health diagnoses (Skopp et al., 2012), were associated with increased risk. Among other risk factors were intimate relationship problems, problems with family circumstances (Skopp et al., 2012), recent crises and job problems (Logan et al., 2015). Street et al. (2015) have suggested that currently deployed soldiers—especially currently deployed female soldiers—could be at increased risk of suicide compared with previously or never deployed soldiers.

Non-fatal suicidal behaviour and suicidal ideation: risk groups and factorsStudies from both the United States and Canada have suggested that female serving military personnel might be at increased risk of suicidal ideation (Belik et al., 2010; Nock et al., 2014) and attempts (Belik et al., 2010, 2009) compared with male active military personnel. Among other risk factors for non-fatal suicidal behaviour among serving military personnel were psychiatric problems such as panic disorder, posttraumatic stress disorder and depression (Belik et al., 2010; Nock et al., 2014), excessive drug use (Ejdesgaard et al., 2015), a poor financial situation, a heavy workload, and

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an unhappy childhood (Ejdesgaard et al., 2015). Serving US military personnel experiencing suicidal ideation were at high risk of developing suicidal plans and attempting suicide, particularly in the first year after the onset of ideation (Nock et al., 2014). Belik et al. (2009) found that lifetime sexual trauma or other interpersonal trauma (such as parental abuse as a child, intimate partner abuse, and being kidnapped or assaulted) greatly increased the risk of suicide attempts among male and female Canadian active military personnel, and the risk increased with the number of traumatic events experienced (Belik et al., 2009). Participation in combat or peacekeeping missions was not significantly associated with an increased risk of suicide attempts (Belik et al., 2009).

In contrast with these findings, Vanderploeg et al. (2014) found that military deployment was associated with an increased risk of suicidal ideation among Florida National Guard members (5.5% compared with 3% of non-deployed personnel). The study found differences in risk factors for suicidal ideation between deployed and non-deployed military personnel: specifically, suicidal ideation among non-deployed military personnel was associated with major depression, posttraumatic stress disorder, prior psychological trauma and heavy alcohol consumption, while suicidal ideation in deployed military personnel was associated only with posttraumatic stress disorder and deployment-related mild traumatic brain injury (Vanderploeg et al., 2014). Nock et al. (2014) found that the number of deployments increased the risk of suicide attempts, the greatest risk being in military personnel who had had three or more deployments. The Canadian studies in this regard have moderate generalisability to Australia; the generalisability of the US studies is limited.

Suicidal behaviour and ideation among ex-serving personnelAs with the international literature on suicidal behaviour and ideation among currently serving personnel, there is much more international literature available about both prevalence and risk factors among ex-serving personnel.

Australian literatureThere is at present very limited research information focusing specifically on suicide mortality, non-fatal suicidal behaviour or suicidal ideation among individuals who have left the Australian Defence Force; the consequence is that this section of the review has limited strength in terms of the quantity of information.

Searches covering the period 2005 to 2015 did not reveal any published peer-reviewed papers on suicide mortality in ex-serving Australian personnel. There was, however, one report—published in 2010 by AISRAP for the Department of Veterans’ Affairs—that used the psychological autopsy method (interviews with next of kin and health care professionals) to investigate 2006 to 2008 suicide victims aged more than 35 years from Queensland and New South Wales. The study sample was limited to people who agreed to be interviewed about the death and involved 14 suicides by veterans (12 males and two females). There were no major differences in chosen suicide methods between veterans and the general population: hanging (50% of veterans and 44.6% of non-veterans) and poisoning (21.4% of veterans and 27.7% of non-veterans) were the most common methods in both groups (McKay et al., 2010). Similarly, there were no significant differences in psychiatric diagnosis: 71.4% (n = 10) of veterans had a psychiatric diagnosis compared with 75.1% (n = 184) of non-veterans. Nor were there significant differences in the prevalence of contact with health care providers in the three months before death, a GP being the most common point of contact for both veterans (78.6%, n = 11) and non-veterans (76.8%, n = 179), followed by a psychiatrist (McKay et al., 2010).

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The qualitative analysis of the case studies concluded that the reasons for suicide among veterans are multidimensional and include a range of veteran-specific risk factors such as difficulty returning to civilian life (relationship problems, mental illness, alcohol and drug misuse, employment problems, bereavement, and loss of the routine and structure that characterise a military lifestyle) and veterans’ reluctance to seek help for their problems (McKay et al., 2010).

One peer-reviewed study and two departmental reports that were available dealt with, among other things, non-fatal suicidal behaviour for three specific cohorts—Vietnam veterans, Gulf War veterans and peacekeepers. The peer-reviewed paper, by O’Toole et al. (2015), analysed suicidal ideation, plans and attempts in an ex-serving sample of Australian Vietnam veterans and their partners using structured psychiatric interviews with 448 male veterans and 237 female partners from April 2005 to November 2006. The researchers found that 231 veterans (51.3% of the veterans studied) answered positively to the depression screener questions (a history of two weeks or more of feeling sad, empty or depressed or two weeks of loss of interest in most things, including hobbies and work). Those who answered positively to the depression screener questions were then asked about suicidality.

The results showed that 108 (24%) had experienced lifetime suicidal ideation, 75 (16.7%) had made a suicide plan and 33 (7.3%) had attempted suicide. Compared with the age–sex matched Australian population, the Vietnam veterans in the sample were 7.91 times more likely than the general population to experience suicidal ideation (95% CI 6.61–30.63), 9.73 times more likely to have made a suicide plan (95% CI 7.72–51.20) and 13.82 times more likely to have attempted suicide (95% CI 9.28–138.88). The main predictors of suicidal behaviour in this sample of Vietnam veterans were mental health conditions such as a diagnosis of posttraumatic stress disorder, depression, alcohol dependence, phobia or agoraphobia. The study further suggested that the partners of veterans might be at increased risk of suicidal ideation, plans and attempts compared with the general population.

A Monash University report on the Australian Gulf War Veterans’ Follow Up Health Study compared the incidence of suicidality in the preceding 12 months among veterans who had served in the Gulf War and a group of people who had been employed by the Australian Defence Force at the time of the Gulf War but had not deployed to the conflict (Sim et al., 2015). It should be noted that the study included participants who were still serving in the ADF, although the majority of participants were no longer serving. At baseline, there were 291 serving personnel compared with 421 ex-serving personnel in the participant group and 277 serving compared with 397 ex-serving in the comparison group. By the time of follow-up there were only 116 currently serving personnel in the participant group (16.7%) and 121 in the comparison group (18.4%).

The researchers found that the Gulf War veterans were significantly more likely to report feeling that life was not worth living (17.5% compared with 11.5%) (adj. RR = 1.40; 95% CI 1.07–1.83) and were at significantly greater risk of making a suicide plan (3.6% compared with 1.2%) (adj. RR = 2.44; 95% CI 1.10–5.42). The two groups were comparable in terms of feeling so low that they had thought about suicide (11% compared with 8%) (adj. RR = 1.22; 95% CI 0.87–1.71) and attempting suicide (0.6% compared with 0.5%) (adj. RR = 1.08; 95% CI 0.26–4.43) (Sim et al., 2015).

A similar report from the University of Melbourne examined 12-month suicidality among former Australian peacekeepers 10 to 15 years after deployment (Hawthorne et al., 2014). This group was compared with one civilian group (using data derived from the National Survey of Mental Health and Wellbeing) and an Australian military comparison group (using data derived from the Centre for Military and Veterans’ Health Deployed Health Studies on the East Timor and Bougainville

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deployments, the Australian Gulf War Veterans’ Health Study, and the ‘ever deployed’ group from the ADF Mental Health Prevalence and Wellbeing Study). Hawthorne et al. found a significantly higher level of suicidal ideation (10.7% compared with 2.7%) (χ2 = 51.35, df = 1, p < 0.01), plans (5.8% compared with 0.7%) (χ2 = 42.33, df = 1, p < 0.01) and attempts (1% compared with 0.2%) (χ2 = 5.37, df = 1, p = 0.02) in the former peacekeeper group compared with the civilians. Suicidality was also higher in the former peacekeeper group compared with the ADF comparison group (Hawthorne et al., 2014).

International literatureSuicide: prevalenceTo date, most of the research into suicide mortality among ex-serving personnel has come from the United States (16 studies). The nine US papers chosen for this review were chosen because they are of high quality and involve large samples that are generalisable to the US veteran population. These papers do, however, have limited generalisability to Australia.

There was evidence of significantly higher suicide rates among veterans in seven of the US studies:

The US male veterans were twice as likely to die by suicide between 1986 and 1994 compared with the general male population after adjusting for medical and psychiatric morbidity (adj. HR = 2.13; 95% CI 1.14–3.99) (Kaplan et al., 2007).

Between 2000 and 2006 veterans had an increased risk of suicide compared with the general population. Rates for veterans aged 18–44 years ranged from a high of 47.5 per 100,000 in 2002 to a low of 26.0 per 100,000 in 2006, while population rates remained at about 22.0 per 100,000; ratios were not provided (Maynard & Boyko, 2008).

In 2000 and 2001 veterans using Veterans Health Administration services were at 66% greater risk of suicide compared with the general population (age- and gender-adjusted SMR = 1.66; 95% CI: 1.58, 1.75) (McCarthy et al., 2009).

Between 2003 and 2008 male veterans in all age groups other than the 65 years and over group were at increased risk of suicide compared with their non-veteran peers—18–24 age group, 1.26 (p < .05); 35–44 age group, 1.12 (p < .05); 45–64 age group 1.04 (p = .05); and 65+ age group, 0.98 (p > .05)) (Kaplan et al., 2012).

Between 2000 and 2010 veterans were at increased risk of suicide compared with non-veterans—20% higher than expected in 2000 (SMR = 1.19; 95% CI 1.10–1.28) climbing to 60% higher than expected in 2010 (SMR = 1.63; CI 1.58–1.68) (Hoffmire et al., 2015).

Similarly, veterans of the Iraq and Afghanistan wars who served between 2001 and 2007 and were followed until 31 December 2009 had a significantly higher risk of suicide compared with the general US population—SMR = 1.61; 95% CI 1.53–1.69 for non-deployed veterans and SMR = 1.41; 95% CI 1.26–1.56 for deployed veterans. Nevertheless, all-cause mortality risk was significantly lower for non-deployed veterans (SMR = 0.76; 95% CI 0.74–0.78) and deployed veterans (SMR = 0.75; 95% CI 0.71–0.79) (Kang et al., 2015).

Furthermore, recent veterans of Operation Enduring Freedom and Operation Iraqi Freedom deployed between 7 October 2001 and 31 December 2007 from all four service categories (Army, Air Force, Marine Corps and Navy) had an increased suicide risk regardless of deployment

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status (HR = 1.63; 99% CI 1.50–1.77) after adjusting for age, sex, race or ethnicity, and educational attainment (Reger et al., 2015).

Two of the US studies failed to find a significantly higher risk of suicide in veteran populations:

In 1982 to 2004 suicide rates among middle-aged and elderly US male veterans were not significantly higher than those for the general population—a crude suicide rate of 18.9 per 100,000 for veterans and 21.7 per 100,000 for non-veterans (Miller et al., 2009).

In a later study Miller et al. (2012) initially found that male veterans had a significantly higher risk of suicide than the general population between 1986 and 2000—a crude rate of 26.2 per 100,000 compared with 18.8 per 100,000. This result was, however, not significant after adjusting for differences in age, race and year (HR = 1.11; 95% CI 0.96–1.29). Nevertheless, veterans were significantly more likely to die by firearm-related suicide than males in the general population—19.8 per 100,000 compared with 11.7 per 100,000.

Two papers dealing with suicide mortality among ex-serving personnel outside the United States were chosen for this present review. The first paper, dealing with former Swedish peacekeepers who had served in international UN or NATO peacekeeping missions between May 1960 and December 1999, found that the former peacekeepers had significantly lower suicide rates when compared with the Swedish general population (SMR = 0.67; 95% CI 0.58–0.77) (Michel et al., 2007).

In the United Kingdom, veterans who had left the UK military between 1996 and 2005 showed no significant differences in suicide rates compared with the general population (SMR = 0.97, 95% CI 0.84–1.10) (Kapur et al., 2009). In contrast, male veterans aged 24 years or less had significantly higher rates of suicide than males of the same age in the general population (RR = 1.70, 95% CI 1.34–2.13 in those aged 20–24 years and RR = 2.93, 95% CI 1.85–4.41 in those aged under 20 years). Suicide rates were not significantly different compared with the general population age group 25–29 years (RR = 0.91; 95% CI 0.66–1.22), and they were significantly lower compared with the general population in male veterans in age groups over 30 years (Kapur et al., 2009).

Like the US studies, the Swedish and UK studies had large sample sizes and the results are generalisable to their respective countries. Generalisability to Australian veterans is, however, limited as a result of differences between the sizes and characteristics of the militaries and differences between the countries.

Non-fatal suicidal behaviour and suicidal ideation: prevalenceAs with suicide mortality studies, the majority of the studies dealing with non-fatal suicidal behaviour among veterans originated in the United States. Two US papers were used for this review: both used large samples and were generalisable to the US veteran population but have limited generalisability to Australian veterans.

White et al. (2011) compared US male citizens with a large representative sample of US males who had served in the US armed forces and completed the 2008 National Survey on Drug Use and Health. They found that the prevalence of suicidal ideation (3.0% of ex-military personnel compared with 3.7% of citizens) and plans (0.8% of military personnel compared with 1.0% of citizens) in the preceding 12 months did not differ significantly.

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Apart from the United States, two Canadian studies have recently been published on the subject that might be more generalisable to Australian veterans than the US studies as a result of similarities between the Australian and Canadian militaries.

Richardson et al. (2014) found that 16.8% of veterans and active duty members who were seeking treatment from the Operational Stress Injury Clinic between January 2002 and May 2012 reported suicidal ideation on more than half of the days in question. This study, however, used a relatively small sample of 404 veterans and active duty members. Using a larger, nationally representative sample of Canadian veterans, Thompson et al. (2014) found that 5.8% of veterans who had participated in the 2010 Survey on Transition to Civilian Life and had been released from the forces between 1998 and 2007 reported experiencing suicidal ideation in the preceding year.

Suicide: risk groups and factorsA number of studies chosen for this review analysed various risk factors for suicide mortality among US veterans. Some of the studies found that Caucasian veterans were at increased risk of suicide when compared with veterans of other ethnic backgrounds (Kaplan et al., 2007; Zivin et al., 2007). Additionally, the study results appear to show that, as in the general population, male veterans were at increased risk of suicide when compared with female veterans (Zivin et al., 2007; Kapur et al., 2009; Ilgen et al., 2010; Katz et al., 2012). A number of studies were not able to make this comparison, often because of small numbers of female veterans (Maynard & Boyko., 2008; Miller et al., 2009; Kaplan et al., 2012).

When it came to age, the studies produced mixed results. Maynard and Boyko (2008) found increased risk among male veterans aged 65 years and over; Ilgen et al. (2010) found increased risk among veterans aged more than 29 years. The risk of suicide for different age groups could depend on gender: McCarthy et al. (2009) found that male Veterans Health Administration patients aged 30–79 years were at increased risk, while the females at greatest risk were those aged 40–59 years. Zivin et al. (2007) found that young depressed veterans with co-morbid posttraumatic stress disorder had higher suicide rates than older veterans with posttraumatic stress disorder and depression. This finding was supported by Kaplan et al. (2012), who reported that young veterans who died by suicide were more likely to have had mental health, substance abuse, financial and relationship problems, while older veterans were more likely to have had health problems before their death.

Some of the studies reviewed examined the risk of suicide mortality among veterans according to psychiatric diagnosis. An increased risk of suicide was observed for veterans reporting a diagnosis of any psychiatric disorder (HR = 2.60; 95% CI 2.47–2.74) (Ilgen et al., 2010), with particular risk for those suffering from depression, posttraumatic stress disorder (Kaplan et al., 2012), bipolar disorder and substance use disorder (Ilgen et al., 2010). Increased risk has also been identified for veterans suffering from a traumatic brain injury compared with veteran peers without a similar injury, the extent of the increased risk depending on the severity of the injury; more specifically, those with concussion or a cranial fracture were 1.98 times more likely (95% CI 1.39–2.82) to die by suicide, and those with a cerebral contusion or traumatic intracranial haemorrhage were 1.34 times more likely (95% CI 1.09–1.64) (Brenner et al., 2011).

In addition to demographic variables and diagnosed illnesses, an increased risk of suicide mortality has been observed among veterans who resided in rural areas (McCarthy et al., 2012) and those who did not use Veterans Health Administration services (Katz et al., 2012; Hoffmire et al., 2015). The degree of risk can also depend on the nature of the veteran’s involvement in the military: increased risk has been found for veterans who served in the British Army as opposed to the Naval Service or the Royal Air Force (Kapur et al., 2009), those who had a short period of service, those of lower rank

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(Kapur et al., 2009; Reger et al., 2015) and those who were dishonourably discharged (Reger et al., 2015).

Ilgen et al. (2012) found that US veterans of the Operation Enduring Freedom and Operation Iraqi Freedom conflicts had a higher suicide rate than other veterans—38.0 per 100,000 compared with 36 per 100,000 in other veterans. There are mixed findings in relation to the influence of deployment on suicide risk: one study failed to find any difference in risk assessed on the basis of whether or not veterans had been deployed (Reger et al., 2015); another found that deployed veterans had a lower risk of suicide compared with non-deployed veterans (Kang et al., 2015). In one US study, firearms accounted for 67% of all veteran suicides—69% of male suicides and 40% of female suicides (McCarten et al., 2015)—although differences in gun laws between different countries limit the generalisability of this conclusion.

Non-fatal suicidal behaviour and suicidal ideation: risk groups and factorsIn relation to non-fatal suicidal behaviour among international veterans, the presence of a mental illness was again a major risk factor and was the primary focus of a number of studies. Richardson et al. (2014) found that the main risk factors for suicidal ideation among Canadian veterans and armed forces personnel were generalised anxiety disorder, major depressive disorder, posttraumatic stress disorder and insomnia. Thompson et al. (2014) also found a significant association between suicidal ideation and depression, anxiety and mood disorders; gastrointestinal disorders were also implicated. Further, the risk of suicidal ideation increased according to the number of physical and mental health conditions reported (Thompson et al., 2014).

Using data from the 2010 Behavioral Risk Factor Surveillance System, a study of US veterans found that those aged 60–79 years and those with a lack of social support were at a significantly increased risk of suicidal ideation compared with veterans in the 18–39, 40–59 and 80 and over age groups and those with stronger support networks (Bossarte et al., 2012).

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DiscussionThis review explored the literature dealing with suicide among serving and ex-serving Australian Defence Force personnel. In order to provide context, information about suicidal behaviour in the general Australian community and in international militaries was also examined.

The most recent statistics on suicide in the general Australian community show an overall age-standardised rate of 10.9 per 100,000 individuals in 2013—preliminary rates of 16.3 per 100,000 for males and 5.4 per 100,000 for females (ABS, 2015)—and that about 3.3% of the community have attempted suicide in their lifetime and 0.4% had attempted suicide in the year preceding the 2007 National Survey of Mental Health and Wellbeing (Slade et al., 2009). Research into suicidal behaviour among currently serving Australian personnel suggests that such personnel might die as a result of suicide at a lower rate than people in the general population (about 13 per 100,000 in males) (Hadfield & Sheffield, 2009; Kõlves et al., 2012) although they might experience a higher rate of preceding-year suicidal ideation (3.9% compared with 1.7%) and plans (1.1% compared with 0.4%) and a comparable prevalence of attempts (0.4% compared with 0.3%) (McFarlane et al., 2011).

Monitoring of deaths by suicide in the Australian Defence Force reveals that the prevalence among serving personnel is lower than that for the general community. There are no recently published data on rates of suicide mortality in Australian serving and ex-serving personnel, which affected the quality of the evidence base for this review and constitutes a serious gap in the current literature. It is therefore not possible to say how suicide rates in the ADF compare with those in the general population. It is important to note, however, that the Departments of Veterans’ Affairs and Defence are working with the Australian Institute of Health and Welfare to identify data sets that will allow an estimate of suicide rates among serving and ex-serving personnel.

In contrast with the results suggesting a lower risk of suicide mortality among currently serving Australian personnel, the 2010 ADF Mental Health Prevalence and Wellbeing Study found that, in comparison with the Australian community, ADF personnel reported a significantly higher prevalence of suicidal ideation (3.9% compared with 1.7%) and plans (1.1% compared with 0.4%) in the preceding 12 months (McFarlane et al., 2011). There was no significant difference in the prevalence of suicide attempts between the military personnel and members of the general community (0.4% compared with 0.3%) (McFarlane et al., 2011).

Importantly, the Department of Veterans’ Affairs is continuing to explore rates of suicidal behaviour and ideation as part of the Transition and Wellbeing Research Programme. This initiative is the largest, most comprehensive program of study conducted in Australia to examine the impact of contemporary military service on the mental, physical and social wellbeing of serving and ex-serving personnel and their families. It will expand on the work begun in the 2010 Mental Health Prevalence and Wellbeing Study by exploring prevalence in ex-serving populations as well as changes over time.

Further information on non-fatal suicidal behaviour in Australian ex-serving personnel comes from one peer-reviewed paper and two departmental reports looking at the Vietnam veteran, Gulf War veteran and peacekeeper cohorts. The research with Vietnam veterans has led to the suggestion that, when compared with the general population, these veterans might have an increased risk of non-fatal suicidal behaviour and suicidal ideation, including lifetime suicidal ideation (24%; RR = 7.91), plans (16.7%; RR = 9.73) and attempts (7.3%; RR = 13.82) (O’Toole et al., 2015). Nevertheless, this result might not be easily generalisable to other Australian veterans because of the fact that the

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Vietnam War also involved National Service enlistees and because of the political sensitivities associated with the conflict (Australian War Memorial, n.d). The Vietnam veterans also did not have available to them the support and health treatment services available to contemporary veterans on their return (ADF, 2012; DVA, n.d.). In their report dealing with suicidality among Gulf War veterans, Sim et al. (2015) found that, compared with the comparison group of ADF members who were not deployed to that conflict, Gulf War veterans were significantly more likely to feel that life was not worth living and to make a suicide plan. The authors of the other report on former Australian peacekeepers found that the former peacekeepers had significantly higher levels of suicidal ideation, plans and attempts compared with the civilian comparison group (Hawthorne et al., 2014).

There have been a number of international studies of suicidal behaviour among military personnel, particularly from the United States but also from Sweden and the United Kingdom. The majority of US papers have suggested that individuals who have left service might be at significantly increased risk of suicide mortality when compared with the general population (Kaplan et al., 2007, 2012; Hoffmire et al., 2015; Maynard & Boyko, 2008; McCarthy et al., 2009; Kang et al., 2015; Reger et al., 2015). Nevertheless, a few older studies do not confirm that finding after adjusting for variables such as age, and race (Miller et al., 2009, 2012).

Interestingly, two of the international papers reviewed, one from Sweden and the other from the United Kingdom, found that, overall, ex-serving personnel had either significantly lower (Sweden—Michel et al., 2007) or not significantly different (the United Kingdom—Kapur et al., 2009) suicide rates compared with the general population in the country in question. In spite of this, younger age groups (below 24 years) had significantly higher rates and older age groups (over age 30 years) had significantly lower rates.

Despite the high quality of the international literature on the subject, the generalisability of the international results to the Australian veteran population is limited as a result of a number of differences in the various defence forces and the general community. For example, one important difference between Australia and the United States concerns the availability of firearms. Firearm ownership is less common in Australia than in the United States, and research has shown that the use of firearms as a method of suicide has decreased in Australia since the change in firearm laws in 1996 (Large & Nielssen, 2010) and that this decrease has also been evident in relation to ADF personnel. A comparative analysis of suicide methods from 2006 to 2008 showed that firearms are involved in more than half (60.6%) of all male suicides in the United States compared with 11.5% of male suicides in Australia (Ajdacic-Gross et al., 2008). The increased availability and acceptability of firearms in the United States might partially explain the increased risk for US veterans.

The two countries for which an increased risk of suicide among veterans was not found—Sweden and the United Kingdom—are potentially more comparable with Australia because they too have a low rate of firearm suicide relative to other methods: it was found that 3.5% of male suicides in the United Kingdom and 17.1% of male suicides in Sweden involved firearms (Ajdacic-Gross et al., 2008). It is, however, important to note that there are a number of other differences between the military personnel of differing countries, among them the size of the military, the country’s population and differences in military missions and operational tempo.

A number of studies have analysed the risk of suicidal behaviour among serving and ex-serving military personnel according to factors relating to their military service. The findings of these studies are mixed: some found no differences between the rates of suicidal behaviour in the different services (McFarlane et al., 2011); others found increased risk among active US Army personnel compared with other services (Kapur et al., 2009; Ramchand et al., 2011). In contrast with the

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international results showing increased risk among Army personnel, the Australian research that found increased risk depending on the type of service suggested an increased risk of suicide among active Navy personnel compared with other services (Gisler & Sadler, 2000; Kõlves et al., 2012).

There are also mixed findings in relation to the effect of deployment on suicidal behaviour: some studies have failed to find a difference between deployed and non-deployed personnel (Belik et al., 2009; Reger et al., 2015), while others have found a lower suicide risk among deployed personnel (Kang et al., 2015) and yet others have found an increased risk among deployed personnel (Vanderploeg et al., 2014; Nock et al., 2014). One study found that currently deployed military personnel might be at increased risk compared with their previously deployed or never deployed peers (Street et al., 2015). Among other risk factors specific to veterans and active military personnel are difficulties returning to civilian life and a reluctance to seek help because of the military ‘culture’ (McKay et al., 2010).

Australian veterans appear to have a number of risk factors in common with the general community in terms of suicidal behaviour—particularly psychiatric diagnoses and problems with alcohol and drug abuse (O’Toole et al., 2015)—and these risk factors have also been identified consistently in the international literature (Ilgen et al., 2010; Kaplan et al., 2012). Of particular importance for ex-serving personnel is the high prevalence of posttraumatic stress disorder and traumatic brain injury and the impact these illnesses have on suicide risk (Hoge et al., 2008). Some studies have suggested that older veterans might be less likely to die by suicide as a result of posttraumatic stress disorder and depression (Zivin et al., 2007) or substance abuse (Kaplan et al., 2012) but more likely to have physical illness as a risk factor for suicide (Zivin et al. 2007).

In keeping with the general population, male veterans appear to be at increased risk of suicide compared with female veterans (Zivin et al., 2007; Kapur et al., 2009; Ilgen et al., 2010; Katz et al., 2012), although a number of studies were limited in their analysis by the small number of female veterans. Further research into risk factors for both male and female veterans would be very valuable—especially in view of the potential differences in risk factors arising from demographic factors such as age.

Suicide preventionAction to prevent suicide is imperative for serving and ex-serving personnel, particularly in view of research suggesting that there could be military- or veteran-specific barriers to seeking help for mental health problems, including the perceived stigma associated with seeking help and concerns that records of health care use will appear on military records (Gorman et al., 2011; McFarlane et al., 2011). The majority of research in the area seems to be aimed at currently serving military personnel: a systematic review of suicide prevention programs for military personnel or veterans found that multifaceted interventions offer the best chance of reducing suicide rates among active military personnel but that there is also a need for increased research into suicide prevention among ex-serving personnel (Bagley et al., 2010).

A RAND Corporation report to the US Department of Defense proposed that a comprehensive suicide prevention program for active military personnel have six main elements:

raising awareness and promoting self-care

identifying high-risk individuals

facilitating access to quality care

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providing quality care to those who need it

restricting access to lethal means

responding appropriately to suicides and suicide attempts (Ramchand et al., 2011).

The framers of the review of the Australian Defence Force Suicide Prevention Program, Kõlves et al. (2012), found that the program incorporates the most important components of current best practice for an effective suicide prevention initiative but also highlighted areas where improvements could be made.

In 2007 the Department of Veterans’ Affairs introduced Operation Life, the national suicide prevention strategy for Australian veterans, which originally consisted of face-to-face workshops designed to increase awareness of suicide and assist with prevention. More recently the Operation Life website and app have been designed to offer additional resources for veterans, to help them deal with suicidal thoughts by providing access to emergency professional support and self-help tools (DVA, 2016). In addition, the Australian Defence Force’s Mental Health and Wellbeing Action Plan 2012–2015 (ADF, 2012) and the Department of Veterans’ Affairs’ Mental and Social Health Action Plan 2015 and 2016 (DVA, n.d.) both outline strategies for making current suicide prevention programs more effective.

Limitations of the reviewThis review had a number of limitations. Although the overall quantity of the material reviewed was high as a result of the large number of international papers, the main limitation concerns the small number of studies dealing with serving and ex-serving Australian personnel. In particular, there were few peer-reviewed papers dealing with individuals who had served with the Australian Defence Force. This constitutes a serious shortcoming in current knowledge and is something that should be redressed in future research.

The lack of Australian military papers made it difficult to compare Australian and international military results and draw robust conclusions about the risk of suicidal behaviour among Australian personnel. Further, the international results have limited generalisability to the Australian veteran population. Similarities between the Canadian and Australian armed forces, in terms of size and other main features, suggest that the Canadian results might be most amenable to generalising to the Australian context. Finally, this review was limited to English-language papers published between 2005 and 2015, and there is a possibility that some international grey literature was overlooked.

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ConclusionInternational research suggests that ex-serving military personnel could be at increased risk of suicide compared with the general population. Very limited research has been done in the Australian context, although the results that do exist suggest that both serving and ex-serving Australian personnel might be at increased risk of non-fatal suicidal behaviour and suicidal ideation compared with the general Australian community. There is at present no literature on rates of suicide mortality among ex-serving Australian personnel (between 2005 and 2015), but researchers have found that, despite the higher prevalence of non-fatal suicidal behaviour, currently serving Australian personnel might be at lower risk of suicide mortality compared with the general population. The lack of information about suicide mortality among ex-serving Australian personnel constitutes a serious shortcoming in current knowledge, and the Australian Institute of Health and Welfare in collaboration with the Departments of Veterans’ Affairs and Defence are working to redress the problem.

Risk factors for suicidal behaviour among military personnel appear to be similar to those applying to the general community; they include diagnosed mental health disorders, substance abuse and significant adverse life events. The international literature suggests that a number of risk factors specific to ex-serving personnel might also exist, among them trouble re-integrating into civilian life and factors associated with combat exposure. Research identifying risk factors relevant to Australian military populations could be of use in future refinement of the existing Australian Defence Force and Department of Veterans’ Affairs suicide prevention programs.

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