Mental Health in the Australian Defence Force CDRE Duncan Wallace RANR Psychiatrist, ADF Centre for Mental Health, 25 May 14

Mental Health in the ADF What is the prevalence of Mental disorders in the ADF? Deployed Vs not Deployed? Which members of the ADF may be at particular risk of developing mental disorders? Compare the management of mental disorders to physical injuries What are the barriers to Mental Health care? What are the strengths and weaknesses of ADF Mental Health services? How well are ADF members supported in their transition to civilian life and how can this be improved?

Timor Leste Solomon Islands Iraq Afghanistan Indonesia Indian Ocean Since 1999 members of the ADF have deployed on Active Service, peace keeping, humanitarian assistance or other operations in the following locations: Timor Leste Solomon Islands Iraq Afghanistan Indonesia Indian Ocean Kuwait Philippines Pakistan Persian Gulf Egypt South Sudan New Zealand Samoa Haiti Kiribati PNG- Bougainville Lebanon Tonga Fiji Syria Border Protection operations: Thousands of ADF personnel have served in these operations- OP RELEX, OP RESOLUTE and OP SOV BORDERS. This is not the full list of countries!

1999- 2011 45,000 members of ADF have served in conflict area or peacekeeping operations 56% of Permanent ADF members deployed on operations 34% of Reserve ADF members deployed on operations 43% have deployed multiple times 19% have deployed once 1. DVA Australian Centre for Posttraumatic Mental Health (2012). Mental Health Advice Book for Practitioners Helping Veterans with Common Mental Health Problems, Department of Veterans’ Affairs, Canberra. 2 and 3. Defence Census 2011. Viewed at <http://intranet.defence.gov.au/People/sites/DefenceCensus/docs/AB8807776.pdf> on 25 Mar 14. 4,5 MILHOP Study

Currently deployed 400 personnel in Afghanistan as instructors, advisors, support staff 800 personnel provide support from other locations in Middle East including at sea 1.

Casualties Afghanistan 40 Killed in Action 261 Wounded in Action (as at 28 Oct 13) Includes 7 members with traumatic limb amputation/s mTBI - 38 cases where mTBI was primary diagnosis mTBI stats: ADF wounded OP CATALYST and OP SLIPPER 2004- 13 Jan 14 [Directorate of Military Medicine] Where members had other injuries e.g. amputations, mTBI may not have been recorded

Casualties East Timor 4 Killed Iraq 2 Killed Bougainville 1 Killed Solomon Is Source: Australian War Memorial

2010 ADF Mental Health Prevalence and Wellbeing Study Prevalence of major mental health disorders in the ADF compared to Aust population (ABS) Affective disorders Depressive episodes; Dysthymia; Bipolar affective disorder; Hypomanic episodes; and Mania Anxiety disorders Panic attacks; Panic disorder; Agoraphobia; Social Phobia; Specific Phobia; GAD; OCD; & PTSD. Alcohol disorders Alcohol harmful use; & Alcohol dependence. Phase I - Self report questionnaires – n=24,481 (48.9% of the ADF) Phase 2 – Telephone CIDI (WHO Composite International Diagnostic Interview) - n=1,789 A. C. McFarlane, S. E. Hodson, M. Van Hooff & C. Davies (2011). Mental health in the Australian Defence Force: 2010 ADF Mental Health and Wellbeing Study: Full report, Department of Defence: Canberra.

Anxiety disorders Anxiety disorders are the most common mental disorder type in the ADF, with higher prevalence among females. PTSD is the most prevalent anxiety disorder, with highest rates among ADF males.

Anxiety disorders 2010 ADF Mental Health Prevalence and Wellbeing Study

MILHOP Study: Affective disorder ADF males experience higher rates of affective disorders than the Australian community sample This is mostly accounted for by the experience of depressive episodes. As per slide 11

MILHOP Study: Affective disorder This graph shows the estimated 12 month prevalence of affective disorders in the ADF. Depressive episodes were defined as Major Depressive disorders- mild, moderate and severe. I suspect Adjustment Disorders with Depressed Mood were caught up in this group. 12

MILHOP Study: Deployed Vs Non-Deployed MILHOP did not find an increased prevalence of mental disorders in personnel who have deployed on operations compared to those who have not. Not the number of deployments but the type of experience on deployment, in particular exposure to trauma or combat, that is a risk factor for PTSD and other disorders. Therefore those personnel at particular risk of developing mental disorders will include: infantry, armoured corps, CER, combat medics and Special Forces.

Why do ADF members delay treatment Why do ADF members delay treatment? (2010 Prevalence and Wellbeing Study)

“Over the last decade the ADF has done a great deal to address mental health and promote greater awareness of the problem, but much of the target audience isn’t listening or can’t bring themselves to admit that the message is aimed at them” MAJGEN John Cantwell (Retd) , 2012

Stigma and Barriers to Care: Denial or ‘Preference for Self-management’? US National Co-morbidity Survey found the most common reason for not seeking help was: ‘wanted to handle problem on own’ Techniques that emphasise self-care may improve uptake of MH services [Mojtabai R, et al. Barriers to mental health treatment: results from the National Comorbidity Survey Replication. Psychol Med 2011; 41(8):1751-61] Mojtabai R, Olfson M, Sampson NA, Jin R, Druss B, Wang PS, et al. Barriers to mental health treatment: results from the National Comorbidity Survey Replication. Psychol Med 2011; 41(8):1751-61. Unpublished work by Adler et al, 2014, suggest that techniques that emphasise or enhance self-care may then improve uptake of MH services.

Barriers to care: Help Seeking in previous 12 months MILHOP Study Almost one in five personnel (17.9%) reported that they had sought help for a stress-related, emotional, mental health or family problem Half the sample with PTSD or depressive episodes reported receiving treatment This is comparable to Australian and US civilian rates, but significantly better than those for US veterans Bryant R et al. The Psychiatric Sequelae of Traumatic Injury. Am J Psychiatry 2010; 167:312–320. Only a minority of Australian civilian injury survivors (33.0%) who met criteria for a psychiatric disorder at 12 months after traumatic injury were receiving mental health treatment for their condition (PTSD, 47.7%; depression, 41.2%; anxiety disorder, 37.7%; substance use disorder, 20.9%). Seal KH, et al. VA Mental Health Services utilization in Iraq and Afghanistan veterans in the first year of receiving new mental health diagnoses. J Trauma Stress 2010; 23, 5-16. Only 9.5 % of 49, 425 US veterans newly diagnosed with PTSD received the recommended number and intensity of VA MH treatment sessions within the first year of diagnosis. Tanielian T and Jaycox L. 2008. Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Corporation. Only 25% of OIF and OEF veterans diagnosed with PTSD and depression received minimally adequate treatment within 12 months of diagnosis. Wang P et al. Twelve-month use of mental health services in the US. Results from the National Comorbidity Survey Replication. Arch Gen Psych 2005, 62, 629-640. 48% of US civilian sample of 9,282 patients with any mental disorder, including PTSD, reported receiving minimally adequate treatment within the first year of diagnosis.

What support is provided to ADF members and their families? Mental health and rehabilitation services are available through Defence and Department of Veterans’ Affairs (DVA): General Practitioners Regional Mental Health Teams (RMHT), Mental Health Psychology Sections (MHPS) and Rehabilitation Consultants Access to additional specialist mental health professionals Accredited PTSD treatment programs Veterans' and their families can access the Veterans and Veterans Families Counselling Service (VVCS) 24-hour telephone help-lines Our health care, rehabilitation programs and mental health initiatives are there to support all of our personnel, no matter the source or cause of their mental or physical health problems We have increased the mental health and rehabilitation workforce and improved policy and training for ADF health professionals Mental health and rehabilitation services available are through Defence and Department of Veterans’ Affairs (DVA) to ensure personnel, serving and ex-serving, are able to access treatment throughout Australia, including: Regional Mental Health Teams (RMHT), Mental Health Psychology Sections (MHPS) and Rehabilitation Consultants have been established across Australia as part of our Garrison Health Services to provide assessment, treatment and rehabilitation for psychological and physical injuries or disorders. Access to additional specialist mental health professionals such as psychiatrists and clinical psychologists is enabled through ‘on base’ and ‘off base’ contract arrangements with Medibank Health Solutions. ADF personnel are also referred and treated through PTSD treatment programs accredited through DVA and the Australian Centre for Posttraumatic Mental health (ACPMH). ADF Personnel returning from operational service and their families are also able to access the Veterans and Veterans Families Counselling Service (VVCS) throughout Australia. Additionally, Defence has an agreement in place with DVA to purchase counselling services for any ADF personnel who do not have existing eligibility for access to the (VVCS). 24-hour telephone helplines include the ‘All hours Support Line’, IM SICK and Defence Family Helpline.

ADF Rehabilitation Joint Health Command (JHC) is a Comcare approved workplace rehabilitation provider 2012-13: 4,438 ADF members met the criteria for referral and undertook a comprehensive rehabilitation assessment Of these rehabilitation referrals, 18% (799 out of 4,438) presented with a primary diagnosis of a mental health condition with Depression being the most common diagnosis.

ADF rehabilitation From rehabilitation programs completed during 2012-13: 40% (172 out of 436) of those with a mental health condition as a primary diagnosis were successfully returned to work nearly 72% (1,726 out of 2,411) of those with a physical health condition as a primary diagnosis successfully returned to work. Defence achieved an overall return to work rate of 71 per cent in 2012-13.

Simpson Assistance Program Consists of a number of projects that are investing in Defence’s overall recovery capability. Individually tailored recovery programs Intensive Recovery Team pilot Meaningful engagement Specialist psychosocial programs Online resource materials and information guides ADF Recovery and Rehabilitation Strategy Research into ADF rehabilitation Individually tailored recovery programs with an emphasis on family and peer support; 230 members have benefited from Intensive Recovery Team pilot programs in Townsville and Sydney since February 2013; Meaningful engagement options that minimise unproductive convalescence leave and support ADF personnel as they prepare to return to work; As of 31 December 2013, Defence has approved 309 individual requests for meaningful engagement options, and ten requests for group engagement options for a total of 92 participants; Specialist psychosocial programs, online resource materials and information guides to support ADF members and their families; and An ADF Recovery and Rehabilitation Strategy is being drafted that will outline the responsibilities and accountability for ADF recovery and rehabilitation, and appropriate governance and key performance indicators to drive service excellence. JHC has engaged Veterans and Veterans Families Counselling Services (VVCS), through the Defence-DVA MoU, to develop and deliver the Families Stronger Together - Living with Disability program later in 2014. A pilot of a Mate-to-Mate Peer Visitation program will soon begin and for training workshops are now underway. JHC has launched a Health and Recovery website containing information for wounded, ill or injured ADF personnel, command and families to assist them to understand the availability of health care, and other support programs. The website is currently available to ADF members and command on the Defence Restricted Network and will soon be available on the defence internet site JHC has identified the following three priority areas for further research on rehabilitation in the ADF: The role of the family in the rehabilitation of wounded injured and ill ADF members; The care continuum provided to members with complex cases who are being transitioned from Defence to DVA; and The use and validation of rehabilitation outcome measures in the ADF population. In December 2013, JHC engaged the Australian Institute of Family Studies to conduct research into the first of these priorities - the role of the family in the rehabilitation of wounded injured and ill ADF members. A report of the research findings is expected to be received by JHC in December 14.

Other Initiatives Mental Health awareness activities Annual ADF Mental Health Day On-line information and SmartPhone Apps Mandatory training Early intervention Mental health screening – Mandatory Resilience programs ADF Paralympic Sports Program ADF Theatre Project ‘The Long Way Home’ Mental health awareness activities such as the Annual ADF Mental Health Day and a range of mental health, alcohol and suicide awareness programs are in place to improve mental health literacy, change the perception that a mental health condition will negatively affect a member’s career in the ADF, and encourage members and their families to seek help as early as possible. e-mental health and mobile phone applications As part of the ADF/DVA collaboration, e-mental health and mobile phone applications are available to defence members and their families to improve access to mental health support and information for individuals and their families on topics such as PTSD, mental health support, alcohol use. JHC are contributing to the content development of further DVA e-mental health and smart phone applications on topics such as Mental Health Practice Advice for Clinicians, Self-Help advice based on BattleSMART concepts. Early intervention Mental health screening is conducted at key times including pre-enlistment, post-deployment and post critical incident and we are reviewing and expanding this program to consider more non-deployment risk factors. A comprehensive psychological resilience building program known as Self Management and Resilience Training (SMART) is in place to develop and enhance the coping skills of personnel. SMART is delivered at a number of key points in a member’s career including during initial training, during pre-deployment training and when transitioning out of Defence. To enhance mental health literacy and address stigma and barriers to care, a mental health peer support program - Keep Your Mates Safe (KYMS) is being developed and trialled with recruits, and junior and senior leaders. In 2013 and now again in 2014 the ADF Paralympic Sports Program sent a team of five ADF members to participate in the Canadian Forces Soldier On Allied Winter Sports Camp in Vancouver Canada. We have achieved this through a partnership and sponsorship with the NSW Returned and Services League for ADF. Additionally, a combined Paralympic sport team of 13 ADF members and 2 DVA veterans have just returned from participating in the United States Marine Corp (USMC) Trials event from 25 February to 16 March 2014. The ADF Theatre Project “The Long Way Home” is a performing arts program aimed at supporting rehabilitation, recovery and retention of defence members who have become wounded, injured or ill. Currently touring around Australia, the production is also providing Australia audiences with a unique insight into some of the impacts and challenges associated with defence operations and the rehabilitation and recovery journey for defence members and their families. Research – ongoing research is being conducted by both Defence and DVA in mental health and rehabilitation, including a focus on the longer term impact of combat and the mental health of personnel transitioning out of full-time service.

Other Initiatives (ctd) Research Proposed DVA and ADF Mental Health and Wellbeing Transition Study and Impact of Combat Study CDF Sponsored Community Workshop ADF, DVA and Ex- Service and Veteran Community-based organisations- met to identify gaps in service delivery and improve continuum of care for those who transition to reserves or separate

Other Initiatives (ctd) Within Army Wounded Injured and Ill Digger Forum Soldier Recovery Centres Within Navy Personnel Support Unit All three Services Member Support Coordinators Individual Welfare Boards Within Army the Chief of Army Wounded Injured and Ill Digger Forum in 2012 Forum focused on PTSD and in 2013, on mental health injuries, specifically depression. Army have also established Soldier Recovery Centres in Darwin, Townsville, Brisbane and Holsworthy. Some of these centres have established relationships with community based veteran’s organisations to broaden the range of psycho- social rehabilitation activities available to injured defence members. Navy have established the Personnel Support Unit located in Sydney. All three Services have created uniformed Member Support Coordinators roles and conduct Welfare Boards to support injured members and improve the coordination of support between Command, health providers, the injured defence member and when required DVA.

DVA Initiatives: 2020 Plan Set up ‘on base’ advisory services at 37 ADF bases Developed On-Line Products to engage clients e.g. PTSD Australia Coach, At Ease, Right Mix, Wellbeing Toolbox Improve links with Ex-Service Organisations e.g. Mates4Mates, Soldier On Promoting Veterans Health Week Implementation of new initiative: Medicare based ADF Post-discharge GP Health Assessment, for veterans not linked to DVA

Conclusion Many ADF members have been exposed to combat and potentially traumatic events during recent years on operations A significant number will develop mental disorders ADF and DVA are working to provide high quality care to serving members and those who transition to civilian life.