Gerard F Gill
The recent period of instability and conflict in parts of the world has exposed a new generation of Australian service members to conflict and its associated traumas.
The aim of this article is to assist general practitioners (GPs) in engaging with younger veterans who have served in the Australian Defence Force (ADF) since 1990 and acquired health problems as a result of this service. It provides abbreviated advice on the resources available from the Department of Veterans’ Affairs (DVA), particularly for mental health problems, and how to efficiently access DVA-funded services for newer veterans.
Early detection of and attention to health problems (especially mental ill health) arising from military service, particularly from conflict or peacekeeping missions, has been found to improve veterans’ health, their functioning and family happiness. GPs are ideally situated to arrange and coordinate this care.
Between the end of the Vietnam War in 1975 and fall of the Berlin Wall in 1989, members of the Australian Defence Force (ADF) were not exposed to conflict. Since 1990, the ADF has been heavily involved in peacekeeping and conventional military operations, creating a new generation of Australian veterans.
The new veterans are different from previous veterans. Around 15% of the contemporary veteran population are women, often with dependent children. Many are ADF reservists as 27% of all serving ADF reservists have been deployed on operations.1 Peer and institutional supports for reservists and their families are less well developed than those for full-time personnel.2 Traditional veterans’ services have been geared to middle-aged and older males who served full time, using the assistance of ex-service organisations such as the Returned and Services League (RSL), as previously, women and reserve veterans were uncommon. Newer veterans are less likely to have contact with ex-service organisations, but are heavy users of online information.3
Military mental health
The 2010 ADF Mental Health Prevalence and Wellbeing Study demonstrated that ADF members had a similar prevalence of mental ill health as the wider community.4 Mental health problems arising from military service, particularly from service in conflict zones, are different from those in the wider community. There is an increased lifetime incidence of anxiety, depression and post-traumatic stress disorder (PTSD).4,5 The report also identified a previously unrecognised, marginally higher risk of mental ill health in ADF members who have never been deployed.4 While there is no Australian research to identify the reasons for this increased risk, an American study suggests that the characteristics of those who seek to serve in the military, rather than military experiences, accounts for this increase.5
Significant worsening of mental health symptoms has been observed by military and veterans’ services in some ex-military personnel a few years after they left the military.6 These presentations appear to be precipitated by the loss of military structure and supportive mechanisms. A lack of social support due to frequent moves associated with military service, and difficulties maintaining intimate family relationships occasioned by prolonged deployment, service at sea or training activity separations, may aggravate these mental health problems.7–9 In spite of encouragement to seek help, some ADF members fail to seek mental health assistance while still serving, for fear of lowering their chances of deployment and promotion.10 These delayed presentations of mental health problems in veterans have resulted in strong community and political concern.11 Early identification and engagement of at-risk defence personnel have been shown to significantly improve their health, relationships and the happiness of their families.12
To best care for new veterans when they leave the ADF, general practitioners (GPs) need to be much more attuned to these specific post-military service conditions, and understand how to mobilise and coordinate Department of Veterans’ Affairs (DVA) support. Articles in this issue of Australian Family Physician (AFP) outline the incidence of military-specific problems, and their diagnosis and management. The aim of this article is to assist GPs in mobilising support for new veterans, with an emphasis on mental health support. There are also services available for the widows, widowers or partners of veterans, and their children, but these will not be covered here.
Defence health services and transition to DVA
The average term of service within the ADF is less than 10 years. The vast majority of ex-ADF members are young, healthy, well educated and highly mobile.13 Recent Australian studies have found that criminal behaviour, domestic violence, suicide, at-risk alcohol use and drug abuse are lower in ex-ADF members than in peers of the same age group in the wider population.4,12
The ADF’s Joint Health Command (JHC) supplies high-quality, free healthcare with few restrictions to serving ADF permanent force members, including reservists on continuous full-time service. Rapid access to general practice, investigations, specialists and in-patient care is provided. Entitlement to healthcare is based on the principle of equity with Medicare. Vocationally trained civilian GPs and other health professionals, assisted by a smaller number of uniformed health personnel, provide care.14 The JHC emphasises prevention and regular check-ups. There is a high degree of GP-led case management and referrals are centrally booked. Consequently, many ADF personnel lack experience in managing their health, have not learnt to navigate the Australian civilian health system, are unaware of specialist services access, delays and the out-of-pocket costs of care as their health literacy skills have been underdeveloped.15 GPs may need to be active case managers when veterans first present.
ADF members who become ill or sustain an injury as a result of their service are encouraged to lodge a compensation claim with the DVA as soon as possible. This is to ensure that on discharge they are able to access all their entitlements to benefits and services. When leaving the ADF, members undergo a medical review, which is intended to identify any health problems that could be ascribed to their service, and are encouraged to register the problem with the DVA.
Around 12.5% of all ADF discharges are occasioned by a medical condition that precludes effective service in a military environment.16 Prior to medical discharge, the ADF rehabilitation process attempts to return the individual to their current job. If this is not possible, attempts are made to identify other suitable occupations in the ADF. Should the condition not be compatible with ADF service, emphasis is placed on improving function and preparing the individual for return to the civilian community. Rehabilitation care is transferred in a coordinated way to the DVA after discharge.
The traditional route to entitlement to treatment at the DVA’s expense after the individual has left the ADF was the issuing of a DVA White Card (for specific conditions) or Gold Card (for all medical treatment) following submission and investigation of a claim that the injury or illness was related to the veteran’s service.
DVA entitlements are legislated in three main Acts that cover veterans over different time periods and circumstances.17–19 The DVA has an assessment tool on its website (www.dva.gov.au/esa/wizard?execution=e1s1) that is useful in clarifying entitlements for veterans depending on their circumstances and specific nature of their service. Liability under two of the DVA Acts is determined by reference to Statements of Principles (SoPs),20 developed by an independent statutory authority, the Repatriation Medical Authority. SoPs set out the factors that can connect particular injuries, diseases or death with military service.
The current Act, the Military Rehabilitation and Compensation Act 2004 (Cwlth) (MRCA), reflects changes in compensation arrangements for Australian workers and covers service on or after 1 July 2004. Rehabilitation and improving function are the prime desired outcomes of the MRCA.
If entitlement is established, DVA provides a comprehensive compensation and rehabilitation structure for former ADF members who are injured or ill, including:21
- payment for medical treatment
- incapacity payments for periods of incapacity for work
- permanent impairment compensation, as a lump sum or as ongoing periodic payments, or a combination of both
- rehabilitation programs
- compensation following the death of a member or former member.
To access services under DVA arrangements, members, with the assistance of their chosen advocates, will have to lodge a claim with DVA. Ex-service organisations have individuals who have been trained by DVA to assist claimants in lodging their claims. Veterans are strongly encouraged to access an advocate’s support to guide them through all their claims processes. While there are also instructions and fact sheets on the DVA’s website (Box 1) that enable claimants to complete the claims process themselves, doing this is not advisable, as it may lengthen the process. In the course of a single claim, the DVA may need to:
- establish proof of identity
- search ADF records
- arrange for diagnoses of conditions by medical specialists
- seek additional information from the claimant or their advocate.
This may take some time.
Box 1. Useful phone contacts and websites for new veterans
- DVA health provider line
- 1300 550 457 (metro) or 1800 550 457 (non-metro)
- Veterans and Veterans Families Counselling Service (VVCS)
- Telephone crisis number veterans line
- DVA entitlement assessment tool, www.dva.gov.au/esa/wizard?execution=e1s1
- Military Rehabilitation and Compensation Act information, www.dva.gov.au/benefits-and-payments/compensation/military-rehabilitation-and-compensation-act-mrca
- Non-liability healthcare
- Health assessment of veterans information and forms, http://at-ease.dva.gov.au/professionals/clinical-resources/general-resources/#sthash.p2C7zgvH.dpuf
- At Ease resources for veterans, including apps, http://at-ease.dva.gov.au/professionals/clinical-resources/general-resources/#sthash.p2C7zgvH.dpuf and https://at-ease.dva.gov.au/highres/#!/home
- Veterans and Veterans Families Counselling Service, www.vvcs.gov.au/index.htm
- Veterans and Veterans Families Counselling Service (VVCS), Stepping Out program, www.vvcs.gov.au/Services/GroupPrograms/stepping-out.htm
- Veterans’ MATES therapeutic brief on veteran mental health, www.veteransmates.net.au/topic-41-therapeutic-brief
- Summary of DVA mental health services for GPs, http://at-ease.dva.gov.au/professionals/files/2015/12/DVA-Mental-Health-Services-and-Resources-Dec-2015.pdf
- Phoenix Australia, http://phoenixaustralia.org/for-practitioners/practitioner-resources
In some circumstances, the DVA may also pay for treatment of certain conditions, whatever the cause (it does not have to be related to service). The conditions covered include cancer (malignant neoplasia), pulmonary tuberculosis, anxiety, depression, PTSD, and alcohol-use and substance-use disorders. These arrangements are called ‘non-liability healthcare’. The time taken to process these claims is much shorter as this program is designed to cover treatment costs and facilitate early treatment rather than provide compensation. Those with operational service are eligible for non-liability healthcare, as are many with peacetime service. Eligibility requirements for non-liability healthcare and claim forms are available at the websites described in Box 1.
Until a DVA service-related or non-liability healthcare claim is accepted and a DVA card issued, the veteran should be treated under Medicare arrangements. DVA White Card holders will have received a letter from the DVA specifying their accepted disabilities. DVA will only fund treatments for those conditions; other conditions should be treated under standard Medicare arrangements. In the absence of such a letter, to ascertain what the veteran is covered for, GPs should call the DVA health provider line on 1300 550 457 (metro) or 1800 550 457 (non-metro) and quote the veteran’s file number on the DVA White Card. DVA Gold Card holders are entitled to DVA-supported care for all health conditions.
Medicare-funded health assessment for veterans
All former serving members of either the permanent or reserve forces of the ADF can access a comprehensive health assessment from their GP. It is funded under health assessment items 701, 703, 705 and 707 on the Medicare Benefits Schedule and is claimed through Medicare. The article by Reed, Masters and Roeger22 in this issue of AFP describes this health assessment in more detail. Further details are available at the At Ease website23 indicated in Box 1.
Many veterans with mental health issues do not recognise their condition or they feel that nothing can be done to assist them.10 The comprehensive health assessment may be useful in identifying to the veteran that they have a problem. If problems are identified, the veteran should be encouraged to apply for non-liability healthcare to allow rapid access to treatment support. DVA cardholders can be referred for psychiatry, psychology and mental health social work and occupational therapy services. They can also be referred to the Veterans and Veterans Families Counselling Service (VVCS). A specific DVA mental health website designed for veterans, At Ease, is also available, providing resources such as telephone applications around anxiety management and sensible use of alcohol, and tools to assist with improving resilience (details in Box 1).
The VVCS is a 24/7 counselling service that is free and confidential for eligible members of the veteran community and their families. It offers a wide range of therapeutic options and programs for war-related and service-related mental health conditions including individual, couple and family counselling. VVCS provides:
- group programs to develop skills and enhance support
- support for those with more complex needs
- after-hours crisis telephone support
- self-help resources, including a Facebook page and website.
Where appropriate, VVCS will make referrals to other services or specialist treatment programs.
In addition to a network of counselling centres nationally, VVCS also has a network of more than 1000 outreach clinicians who can provide services to VVCS clients who are unable to easily access a centre. All VVCS counsellors, whether centre-based, outreach provider or telephone crisis line counsellors, have an understanding of the military culture and they work with clients to find effective solutions for improved mental health and wellbeing.
Stepping Out is a transition program for ADF members and their partners who are within 12 months of leaving the ADF, and assists in their transition to civilian life. This program helps members and their partners prepare for unexpected challenges that may arise during the separation process (details in Box 1).
DVA-sponsored resources for GPs on veteran’s mental health
Comprehensive education about mental health problems following military service has been rare in general practice vocational training and continuing medical education.24,25 The DVA has developed a number of resources to assist GPs.
A recent Veterans’ Medicines Advice and Therapeutics Education Services (Veterans’ MATES) topic covered veteran mental health.26 The therapeutic brief for this topic contained much useful information. To assist GPs to manage patients, the DVA has prepared a treatment summary sheet on the services the DVA offers for those with mental health disorders, with links to a very comprehensive list of online resources (Box 1). In particular, the guidelines from Phoenix Australia – Centre for Posttraumatic Mental Health (Box 1) are very useful in engaging veterans and their families, and developing treatment plans. The DVA’s At Ease professionals website (www.at-ease.dva.gov.au/professionals) is a source for clinical resources, including the Mental health advice book,27 which has a dedicated chapter for GPs on screening in primary practice. There is also a DVA-sponsored module on the RACGP’s gplearning covering veteran mental health issues.
Working with veterans is rewarding. Early recognition of problems and appropriate support can significantly alter their lives, and that of their spouses and children. The DVA treatment system is GP-friendly and well resourced. While there are rules, DVA will, without excessive bureaucratic processes, assist GPs to access services to which the patient is entitled.
Gerard F Gill RFD, PhD, FRACGP, FARGP, Professor, Alfred Felton Chair in General Practice in Rural and Regional Victoria, Deakin University, School of Medicine, Geelong, Vic; veteran and the Secretary of the RACGP Chapter of Military Medicine; past member of the national DVA LMO Committee. email@example.com
Roderick Bain OAM, FRCA, FANZCA, JP, member of the RACGP, NSW Returned Services League, State Office, Sydney, NSW
Colonel Isaac Seidl FRACGP, FRACMA, Joint Health Command, Campbell Park Offices, Canberra, ACT; Adjunct Associate Professor, College of Public Health, Medical and Veterinary Sciences, James Cook University.
Competing interests: Gerard Gill has been paid for review activities by the Department of Veterans’ Affairs (DVA). The DVA has also paid his institution in relation to the preparation of this manuscript.
Provenance and peer review: Commissioned, externally peer reviewed.
- Berle D, Steel Z. Families of returned defence force personnel: A changing landscape of challenges. Australas Psychiatry 2015;23(4):399–402.
- Harvey SB, Hatch SL, Jones M, et al. The long-term consequences of military deployment: A 5-year cohort study of United Kingdom reservists deployed to Iraq in 2003. Am J Epidemiol 2012;176(12):1177–84.
- Australian National Audit Office. ANAO audit report No.48: 2011–12 performance audit administration of mental health Initiatives to support younger veterans. Canberra: ANAO, 2012.
- McFarlane A, Hodson SE, Van Hooff M, Davies C. Mental health in the Australian Defence Force: 2010 ADF Mental Health Prevalance and Wellbeing Study: Full report. Canberra: Department of Defence, 2011.
- Rosellini AJ, Heeringa SG, Stein MB, et al. Lifetime prevalence of DSM-IV mental disorders among new soldiers in the U.S. Army: Results from the Army study to assess risk and resilience in servicemembers (Army STARRS). Depress Anxiety 2015;32(1):13–24.
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- Riviere LA, Merrill JC, Thomas JL, Wilk JE, Bliese PD. 2003–2009 marital functioning trends among U.S. enlisted soldiers following combat deployments. Mil Med 2012;177(10):1169–77.
- Lester P, Peterson K, Reeves J, et al. The long war and parental combat deployment: Effects on military children and at-home spouses. J Am Acad Child Adolesc Psychiatry 2010;49(4):310–20.
- Australian Centre for Posttraumatic Mental Health. Australian guidelines for the treatment of adults with acute stress disorder and posttraumatic stress disorder. Melbourne: ACPMH, 2007.
- Biskin, M. Military mental health: From shell-shock to PTSD and beyond. Aust Defence Force J 2015;198:4–10.
- McGuire A, Runge C, Cosgrove L, et al. Timor-Leste family study: Technical report. Brisbane: University of Queensland, Centre for Military and Veterans’ Health, 2012.
- Department of Veterans’ Affairs. Veteran mental health strategy. A ten year framework 2013–2023. Canberra: DVA, 2013.
- Hawthorne G, Korn S, Creamer M. Australian peacekeepers: Long-term mental health status, health service use, and quality of life – Technical Report. Unpublished manuscript, Department of Psychiatry, University of Melbourne, 2015. Available at www.dva.gov.au/sites/default/files/files/consultation%20and%20grants/healthstudies/peacekeepers/pktechnical.pdf [Accessed 20 January 2016]
- Medibank Health Solutions. Garrison Health Services annual report 2013. Wellington, NZ: Medibank Health Solutions, 2013.
- Veterans and Veterans Families Counselling Service (VVCS). Orientation package for provision of services to current serving ADF members and their families. Canberra: VVCS, 2014.
- National Audit Office. ANAO Audit Report No.9 2004–2005: Assistance provided to personnel leaving the ADF 2004.Canberra: Commonwealth of Australia, 2004. Available at www.anao.gov.au/~/media/Uploads/Documents/2004%2005_audit_report_9.pdf [Accessed 2 February 2016].
- Australian Government ComLaw. Military Rehabilitation and Compensation Act 2004 No. 51. Canberra: Commonwealth of Australia, 2015. Available at www.comlaw.gov.au/Details/C2015C00513 [Accessed 2 February 2016].
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- Australian Government ComLaw. Veterans’ Entitlements Act 1986 No. 27, 1986. Canberra: Commonwealth of Australia, 2015. Available at www.comlaw.gov.au/Details/C2015C00569 [Accessed 2 February 2016].
- Repatriation Medical Authority. SOPs. Canberra: Repatriation Medical Authority, 2016. Available at www.rma.gov.au/sops [Accessed 2 February 2016].
- Department of Veterans’ Affairs Factsheet MRC01 – Overview of the Military Rehabilitation and Compensation Act 2004 (MRCA) 2015. Available at http://factsheets.dva.gov.au/factsheets/documents/MRC01%20Overview.pdf [Accessed 20 Jan 2016].
- Reed RL, Masters S, Roeger LS. The Australian Defence Force Post-discharge GP Health Assessment. Aust Fam Physician 2016;45:94–97.
- Cooper J, Metcalf O, Phelps A. PTSD – An update for general practitioners. Aust Fam Physician 2014;43(11):754–57.
- Wallace D, Cooper J. Update on the management of post traumatic stress disorder. Australian Prescriber 2015;38(2):55–59.
- Department of Veterans’ Affairs. Topic 41: ‘At ease’ – Promoting mental fitness: Therapeutic brief. Canberra: DVA, 2015. Available at www.veteransmates.net.au/topic-41-therapeutic-brief [Accessed 7 December 2015].
- Australian Centre for Posttraumatic Mental Health. Mental health advice book for practitioners helping veterans with common mental health problems. Canberra: Department of Veterans’ Affairs, 2012. Available at http://at-ease.dva.gov.au/professionals/files/2014/09/P01621-Mental-Health-Advice-Book.pdf [Accessed 8 January 2016].