Use of admitted patient care for conditions associated with suicidal behaviour
Key findings
- A higher proportion of ex-serving ADF members were admitted to public hospitals for mental health, alcohol and drug use and intentional self-harm than the Australian population.
- Factors associated with higher likelihood of hospital admission by ex-serving ADF members for mental health, alcohol and drug use and intentional self-harm include service in the Army or Navy, shorter service duration (for males), lower military ranks (for males) and involuntarily leaving the ADF.
- Ex-serving ADF members who died by suicide had higher hospital admissions for mental health and injury than the Australian population who died by suicide between 2010 and 2020.
The focus of this report is on admitted patient care services used by ex-serving ADF members for conditions associated with suicidal behaviour. This includes mental health conditions and the prevalent use of alcohol and other drugs in Australia which are linked to an increased risk of suicide and suicide attempts (Bertolote et al 2014; Fisher et al 2020).
Additionally, hospital-treated self-harm is identified as a potent independent risk factor for suicide (Geulayov et al 2019) with studies reporting between 1.5% and 4% of these patients dying by suicide within five years (Carroll et al 2014, Clapperton et al 2024). Further, it has been estimated that for each suicide in Australia, there are 11 hospitalisations for intentional self-harm (Harrison 2014). Therefore, this report specifically examines admitted patient care for mental health, alcohol and drugs and intentional self-harm as conditions associated with suicidal behaviour.
Previous analysis by AIHW (2021) examined the use of health services (mainly primary care) by ex-serving ADF members who died by suicide. It found that between 2001 and 2018, a similar proportion of ex-serving males (88%) and females (96%) used Medicare-subsidised or Department of Veterans Affairs-funded health services in the year before death compared to Australian males (85%) and females (94%) who died by suicide. However, there was a notable difference in the utilisation of Medicare-subsidised mental health services: 53% of ex-serving males who died by suicide between 2014 and 2018 accessed these services in the year before death, surpassing the 38% among Australian males.
A Victorian study (Clapperton et at 2021) found that 50% of people who died by suicide had hospital contact in the year before their death, with females notably over-represented in these instances of hospital contact. Specifically, 29% of these cases involved hospitalisation for mental health related reasons, and 10% were for intentional self-harm (Clapperton et al 2021). AIHW analysis of admitted care in the year before suicide was previously limited to DVA clients. It showed that among DVA clients who died by suicide, 15% received admitted patient care within 12 months of death; most of whom had at least one mental health-related diagnosis.
This report extends the admitted patient care analysis by including all ex-serving ADF members admitted to participating public and private hospitals between 2010-2020. Understanding the use of hospital services for conditions associated with suicidal behaviour is crucial in the broader context of suicide prevention, as 20% of suicides are linked to a history of self-harm (ABS 2021).
Therefore, monitoring and reporting admitted patient care for intentional self-harm and other conditions associated with suicidal behaviour among ex-serving ADF members is vital for identifying individuals at risk of death by suicide. This includes those who do not seek care, and for developing targeted suicide prevention strategies tailored to the unique needs of ex-serving ADF members.
All states and territories except WA and NT contribute public hospital data to the NHDH; private hospital data is only provided by QLD with some VIC and ACT. Private patients treated in public hospitals in the participating jurisdictions are included.
Mental health
Although over half of people who died by suicide had a diagnosed psychiatric disorder such as severe depression at the time of their death (Lewitzka et al 2022; Harris et al 1997), it is important to note that most people with mental health conditions do not go on to die by suicide. Hospitalisation is often required for patients with severe depression accompanied by acute suicidal ideation to prevent self-harm, and the period immediately following discharge from a psychiatric in-patient facility poses an increased risk for suicidal behaviour and adverse outcomes (Chung et al 2017; Walter et al 2019).
The number of admissions for suicidal crisis (without self-harm) cannot be measured due to the limitations in the current Australian hospital coding system (ICD 10 AM WHO 2018). The coding system allows recording suicidal ideation as the principal diagnosis only in the absence of underlying mental health conditions, confirmed by clinicians (McCarthy et al 2021).
Most adults (83.9%) who present for hospital-treated intentional self-harm (ISH) have an underlying psychiatric disorder, of which depression, anxiety and alcohol use are the most common (Hawton et al 2013).
While not all people who self-harm or contemplate suicide have a mental health condition, these behaviours do suggest the experience of psychological distress.
Mental and behaviour disorders
Overall
A higher proportion of ex-serving ADF males aged 25 to 64 years were admitted for a mental and behavioural disorder in comparison to Australian males in 2019-20. The proportion of ex-serving females admitted for a mental and behavioural disorder was higher in comparison to Australian females but this was mainly driven by those aged 25-34 with similar trends for ex-serving and all Australian females in other age groups.
Table 1 shows the differences across age groups for FY 2019-20. The proportion of patients admitted to a public hospital for mental and behavioural disorders was significantly higher in ex-serving ADF males aged 35-44 years and ex-serving ADF females aged 25-34 years, compared to the corresponding age groups in the total Australian population.
Age | Males | Males | Proportion difference (CI) | Females | Females | Proportion difference (CI) |
|---|---|---|---|---|---|---|
17-24 | 8.3 | 10.8 | -2.5 (-6.2-1.1) | 6.0 | 7.4 | -1.4 (-5.5,2.6) |
25-34 | 13.4 | 11.0 | 2.4 (0.6,4.1) | 6.1 | 4.0 | 2.1 (0.2,4.0) |
35-44 | 13.0 | 10.2 | 2.8 (1.5,4.2) | 5.8 | 5.0 | 0.8 (-0.8,2.4) |
45-54 | 8.5 | 6.8 | 1.7 (1.0,2.4) | 5.6 | 5.1 | 0.5 (-0.7, .6) |
55-64 | 4.0 | 3.4 | 0.6 (0.0, 1.1) | 2.9 | 3.1 | -0.1 (-1.3,1.1) |
65+ | 3.2 | 2.9 | 0.2 (-0.3,0.7) | 2.6 | 3.3 | -0.7 (-2.7,1.3) |
All ages 17+ | 7.1 | 5.7 | 1.4 (1.0,1.8) | 5.0 | 4.2 | 0.8 (0.1, 1.5) |
Source: AIHW analysis of linked Defence Historical Personnel data–PMKeyS–DVA client–NDI–MCD–NHMD-NNAPEDCD–MBS–PBS–RPBS data (2010–2020) and AIHW NHDH (2019-2020)
Notes
n.p. Suppressed due to small numbers, or to prevent subsequent disclosure of cells with small numbers.
Different vetting and release approval practices apply to the different data sources.
Bolding indicates statistical significance was found for the difference between the proportions.
- Includes ADF members with at least one day of service since 1 January 1985 who were ex-serving (separated from permanent and/or reserve ADF service) and alive at any point from 1 July 2010 to 30 June 2020.
- By year of separation from hospital stay, for separations between 1 July 2010 and 30 June 2020.
- Includes hospital stay separations that occurred while ex-serving (for ex-serving members) and where patients were aged 17 years or older at admission.
- By age at admission. Patients may be reported in up to two age groups if a change in age during the analysis period causes them to be assigned into the subsequent age group for later admissions.
- Where a stay includes more than one episode, the principal diagnosis of the initiating episode is used.
- Excludes stays where the principal diagnosis was in the ICD-10-AM chapter 'Certain conditions originating in the perinatal period' or 'Codes for special purposes'.
- Includes public hospital data from New South Wales, Victoria, Queensland, South Australia, Tasmania and the Australian Capital Territory. Additional data for ex-serving members was provided by the Department of Veterans' Affairs (DVA) for DVA-funded admitted patient care in public hospitals in all states and territories, including Western Australia and the Northern Territory.
Military characteristics
Among patients admitted to a public hospital (2019-20), a greater proportion of ex-serving ADF members being admitted for mental and behavioural disorders was associated with the following service characteristics:
- Army (males 7.4%; females 5.3%) or Navy service (males 7.5%; females 6.0%) compared to RAAF service (males 5.3%; females 2.9%)
- length of service for males with less than one year (9.6%), and between 1 and less than 5 years (9.4%) compared to between 5 and less than 10 years (7.3%), and 10 or greater years (5.0%)
- other ranks for males – junior and unspecified (8.1%) compared to officers (5.2%) and senior other ranks (4.3%)
- involuntary separation for males - especially medical (16.7%) compared to voluntary separation (7.1%).
The analysis based on Queensland public and private hospitals showed similar service characteristics were associated with a greater proportion of ex-serving ADF members being admitted for mental and behavioural disorders.
Admission for mental health-related care by diagnostic group
This section presents analysis of the types of mental health-related care for admitted patients. Mental health-related care was defined using the same classification that is used in AIHW reporting conventions when analysing the Australian population. Importantly, this definition also provides categories of types of mental health-related care. The types of conditions within mental health-related care were categorised using diagnostic groups in line with ICD-10-AM codes as defined in Table 14 of the Technical notes.
Mental health-related care is based on a broader definition of mental health admissions than mental and behavioural disorders. For example, mental health-related care includes diagnoses such as problems related to psychosocial circumstances, and insomnia.
Overall
In 2019-20, a higher proportion of ex-serving males were admitted to public hospitals for mental health-related care compared to all Australian males (8.1% vs. 6.6%). This pattern was true for ex-serving males across all age groups from 25 to 64 years in comparison to Australian males (Table 2). The difference was most significant for ex-serving males aged 35-44 years (14.6% vs.11.4%).
The proportion of ex-serving females who were admitted for mental health-related care was higher in comparison to admitted Australian females but this was mainly driven by those aged 25-34 (7.4% vs 4.9%) with similar trends for ex-serving and all Australian females in other age groups (Table 2).
Age group | Males ex-serving | Males Aus | Proportion difference (CI) | Females ex-serving | Females Aus | Proportion difference (CI) |
|---|---|---|---|---|---|---|
17-24 | 13.3 | 12.6 | 0.7 (-3.8,5.2) | 9.0 | 9.3 | -0.4 (-5.2, 4.5) |
25-34 | 15.3 | 12.5 | 2.8 (0.9, 4.6) | 7.4 | 4.9 | 2.4 (0.4, 4.5) |
35-44 | 14.6 | 11.4 | 3.2 (1.8,4.6) | 7.4 | 5.9 | 1.5 (-0.3,3.3) |
45-54 | 9.6 | 7.6 | 2.0 (1.3, 2.8) | 6.5 | 5.8 | 0.7 (-0.5, 2.0) |
55-64 | 4.5 | 3.8 | 0.6 (0.0, 1.2) | 3.6 | 3.5 | 0.1 (-1.2, 1.4) |
65+ | 3.6 | 3.6 | 0.0 (-0.5, 0.5) | 3.0 | 3.9 | -0.9 (-3.1, 1.3) |
All ages 17+ | 8.1 | 6.6 | 1.5 (1.1, 1.9) | 6.1 | 5.0 | 1.1 (0.3, 1.8) |
Source: AIHW analysis of linked Defence Historical Personnel data–PMKeyS–DVA client–NDI–MCD–NHMD-NNAPEDCD–MBS–PBS–RPBS data (2010–2020) and AIHW NHDH (2019-2020)
Notes
n.p. Suppressed due to small numbers, or to prevent subsequent disclosure of cells with small numbers.
Different vetting and release approval practices apply to the different data sources.
Bolding indicates statistical significance was found for the difference between the proportions.
- Includes ADF members with at least one day of service since 1 January 1985 who were ex-serving (separated from permanent and/or reserve ADF service) and alive at any point from 1 July 2010 to 30 June 2020.
- By year of separation from hospital stay, for separations between 1 July 2010 and 30 June 2020.
- Includes stay separations that occurred while ex-serving (for ex-serving members) and where patients were aged 17 years or older at admission.
- By age at admission. Patients may be reported in up to two age groups if a change in age during the analysis period causes them to be assigned into the subsequent age group for later admissions.
- Where a stay includes more than one episode, the principal diagnosis of the initiating episode is used.
- Excludes stays where the principal diagnosis was in the ICD-10-AM chapter 'Certain conditions originating in the perinatal period' or 'Codes for special purposes'.
- Includes public hospital data from New South Wales, Victoria, Queensland, South Australia, Tasmania and the Australian Capital Territory. Additional data for ex-serving members was provided by the Department of Veterans' Affairs (DVA) for DVA-funded admitted patient care in public hospitals in all states and territories, including Western Australia and the Northern Territory.
Of patients in public hospitals (FY 2019-20), compared to all Australians by age group:
- a higher proportion of ex-serving males aged 25-34 years was admitted for stress-related disorders (4.0% vs 1.2%)
- a higher proportion of ex-serving males aged 45-54 years was admitted for depression (1.5% vs 0.9%)
- a similar proportion of ex-serving females was admitted across all mental health-related care and age groups.
Among both ex-serving ADF members and the total Australian population admitted to a public hospital, mental health related to alcohol and other drugs ranked the top mental health diagnosis (Figure 1), followed by stress-related and schizophrenia and other related disorders among ex-serving ADF males, depression among ex-serving ADF females.
Figure 1: Proportion of all admissions for mental health-related care by diagnostic group for male and female ex-serving ADF members and all Australians aged 17 and over to a public hospital, 2019-20.
Source: AIHW analysis of linked Defence Historical Personnel data–PMKeyS–DVA client–NDI–MCD–NHMD-NNAPEDCD–MBS–PBS–RPBS data (2010–2020) and AIHW NHDH (2019-2020)
Notes:
n.p. Suppressed due to small numbers, or to prevent subsequent disclosure of cells with small numbers.
Different vetting and release approval practices apply to the different data sources
- Includes ADF members with at least one day of service since 1 January 1985 who were ex-serving (separated from permanent and/or reserve ADF service) and alive at any point from 1 July 2010 to 30 June 2020.
- By year of separation from hospital stay, for separations between 1 July 2010 and 30 June 2020.
- Includes stay separations that occurred while ex-serving (for ex-serving members) and where patients were aged 17 years or older at admission.
- By age at admission. Patients may be reported in up to two age groups if a change in age during the analysis period causes them to be assigned into the subsequent age group for later admissions.
- Where a stay includes more than one episode, the principal diagnosis of the initiating episode is used.
- Excludes stays where the principal diagnosis was in the ICD-10-AM chapter 'Certain conditions originating in the perinatal period' or 'Codes for special purposes'.
- Includes public hospital data from New South Wales, Victoria, Queensland, South Australia, Tasmania and the Australian Capital Territory. Additional data for ex-serving members was provided by the Department of Veterans' Affairs (DVA) for DVA-funded admitted patient care in public hospitals in all states and territories, including Western Australia and the Northern Territory.
Table 3 provides more detail about the distribution of key diagnostic groups – stress-related, depression and mental health disorder due to alcohol and other drug use – across age groups for males and females.
Age group | Diagnostic group | Ex-serving males (%) | Australian males (%) | Proportion difference (CI) | Ex-serving (%) | Aus (%) | Proportion difference (CI) |
|---|---|---|---|---|---|---|---|
25-34 | Stress-related | 26.2 | 9.2 | 17.0 | 23.9 | 17.4 | 6.5 |
25-34 | Mental health disorder related to alcohol and other drug use | 29.3 | 37.6 | -8.3 | 19.6 | 21.8 | -2.2 |
25-34 | Depression | 11.1 | 9 | 2.1 | 10.9 | 10.6 | 0.3 |
35-44 | Stress-related | 25.3 | 8.9 | 16.4 | 21.7 | 16.2 | 5.5 |
35-44 | Mental health disorder related to alcohol and other drug use | 30.4 | 39.3 | -8.9 | 21.7 | 23.8 | -2.1 |
35-44 | Depression | 11.7 | 8.7 | 3.0 | 18.3 | 10.4 | 8.0 |
45-54 | Stress-related | 18.7 | 9.4 | 9.3 | 11.2 | 10.5 | 0.7 (-5.6, 7.0) |
45-54 | Mental health disorder related to alcohol and other drug use | 29.7 | 37.2 | -7.5 | 19.4 | 25.5 | -6.2 |
45-54 | Depression | 15.4 | 11.6 | 3.8 | 18.4 | 12.8 | 5.5 |
55-64 | Stress-related | 24.3 | 7.9 | 16.4 | n.p. | 8 | n.p. |
55-64 | Mental health disorder related to alcohol and other drug use | 24.8 | 32.6 | -7.9 | n.p. | 19.6 | n.p. |
55-64 | Depression | 14.8 | 13.3 | 1.4 | 17.9 | 13.5 | 4.3
|
Source: AIHW analysis of linked Defence Historical Personnel data–PMKeyS–DVA client–NDI–MCD–NHMD-NNAPEDCD–MBS–PBS–RPBS data (2010–2020) and AIHW NHDH (2019-2020)
Notes
n.p. Suppressed due to small numbers, or to prevent subsequent disclosure of cells with small numbers.
Different vetting and release approval practices apply to the different data sources.
Bolding indicates statistical significance was found for the difference between the proportions. Proportions within brackets represent 95% CI.
- Includes ADF members with at least one day of service since 1 January 1985 who were ex-serving (separated from permanent and/or reserve ADF service) and alive at any point from 1 July 2010 to 30 June 2020.
- By year of separation from hospital stay, for separations between 1 July 2010 and 30 June 2020.
- Includes stay separations that occurred while ex-serving (for ex-serving members) and where patients were aged 17 years or older at admission.
- By age at admission. Patients may be reported in up to two age groups if a change in age during the analysis period causes them to be assigned into the subsequent age group for later admissions.
- Where a stay includes more than one episode, the principal diagnosis of the initiating episode is used.
- Excludes stays where the principal diagnosis was in the ICD-10-AM chapter 'Certain conditions originating in the perinatal period' or 'Codes for special purposes'.
- Includes public hospital data from New South Wales, Victoria, Queensland, South Australia, Tasmania and the Australian Capital Territory. Additional data for ex-serving members was provided by the Department of Veterans' Affairs (DVA) for DVA-funded admitted patient care in public hospitals in all states and territories, including Western Australia and the Northern Territory.
- Proportion difference (or absolute difference) is the simple difference between the proportions for the Australian and ex-serving populations. Relative difference (or risk ratio) is the ratio of the proportions for the ex-serving population and Australian populations and measures the scale of the difference.
Military characteristics
As a proportion of patients admitted to public hospitals (FY 2019-20):
- 9.7% of ex-serving male DVA clients and 7.3% of female DVA clients were admitted for mental health-related care, compared to 6.9% of ex-serving male non-DVA clients and 5.6% of female non-DVA clients
- 19.3% of male and 10.1% of female ex-serving ADF members who had involuntarily separated for medical reasons were admitted for mental health-related care; this compares to 8.1% of male and 4.3% of female ex-serving who separated for voluntary reasons admitted for mental health-related care.
- ex-serving males with a length of service from 5 to less than 10 years (2.4%) and ex-serving females with the same length of service (1.7%) represented a greater proportion of persons admitted for stress-related disorders.
Alcohol and other drug use
What is alcohol and other drug use?
Alcohol and other drug (AOD) use is prevalent within Australian society, with 77.0% of Australians aged 14 and over reporting alcohol consumption in 2019, and 16.8% exceeding lifetime risk guidelines (AIHW 2023d). According to the 2019 National Drug Strategy Household Survey (NDHS), 43% of people aged 14 and over had illicitly used a drug during their lifetime and 16.4% in the previous 12 months (AIHW 2023e). AOD use contributes to both acute and chronic injury and disease, including injuries sustained while intoxicated or unintentional overdose, liver disease, mental disorders, heart disease and some cancers, and is the third leading risk factor for premature death and disabilities (WHO 2014). Chronic stimulant use and opioid consumption increases the risk of mental disorder, and blood borne infections (Degenhardt and Hall 2012).
Alcohol and other drug use is linked to an increased risk of suicidal ideation and behaviours, possibly connected to coping with psychological distress or reducing inhibitions to act on suicidal ideation (Fisher 2020). Alcohol misuse is common in intentional self-harm populations (Hawton et al 2013), contributing to approximately one third of deaths by suicide in this population (Conner et al 2014).
The following analyses include admissions for all physical and mental health conditions associated with AOD use including poisoning, alcoholic liver disease and alcoholic cardiomyopathy – expanding beyond mental health-related conditions as reported previously (see Technical notes for full codes and classification).
Overall
Of admitted patients in public hospitals (FY 2019-20), compared to all Australians:
- a higher proportion of ex-serving ADF males were admitted for alcohol and other drug related conditions (3.8% vs 3.2%), of which a greater proportion were admitted for alcohol use (53.8% vs 46.0%)
- a higher proportion of ex-serving ADF females were admitted for alcohol and other drug related conditions (3.1% vs 1.9%)
- a higher proportion of ex-serving ADF females were admitted for anti-epileptic, sedative-hypnotic and antiparkinsonian drug use (0.6% vs 0.3%).
Table 4 shows that among the substances leading to admission at a public hospital, alcohol was the most common substance. This was more significant for male ex-serving ADF members compared to Australian males. Female ex-serving ADF members were more likely to be admitted for the use of anti-epileptic, sedative-hypnotic and antiparkinsonian drugs compared to Australian females. A greater proportion of male ex-serving ADF members were admitted for conditions related to opioid use compared to Australian males.
Similar findings were seen in those admitted to public or private hospitals in Queensland.
Rank | Principal diagnosis | Ex-serving males (%) | Australian males (%) | Ex-serving females (%) | Australian females (%) |
|---|---|---|---|---|---|
1 | Alcohol | 53.8 | 46.0 | 32.3 | 33.5 |
2 | Anti-epileptic, sedative -hypnotic and antiparkinsonian drugs | 12.0 | 10.9 | 20.5 | 15.6 |
3 | Opioids | 8.7 | 7.8 | 7.9 | 7.3 |
Source: AIHW analysis of linked Defence Historical Personnel data–PMKeyS–DVA client–NDI–MCD–NHMD-NNAPEDCD–MBS–PBS–RPBS data (2010–2020) and AIHW NHDH (2019-2020)
Notes
n.p. Suppressed due to small numbers, or to prevent subsequent disclosure of cells with small numbers.
Different vetting and release approval practices apply to the different data sources
- Includes ADF members with at least one day of service since 1 January 1985 who were ex-serving (separated from permanent and/or reserve ADF service) and alive at any point from 1 July 2010 to 30 June 2020.
- By year of separation from hospital stay, for separations between 1 July 2010 and 30 June 2020.
- Includes stay separations that occurred while ex-serving (for ex-serving members) and where patients were aged 17 years or older at admission.
- By age at admission. Patients may be reported in up to two age groups if a change in age during the analysis period causes them to be assigned into the subsequent age group for later admissions.
- Where a stay includes more than one episode, the principal diagnosis of the initiating episode is used.
- Excludes stays where the principal diagnosis was in the ICD-10-AM chapter 'Certain conditions originating in the perinatal period' or 'Codes for special purposes'.
- Includes public hospital data from New South Wales, Victoria, Queensland, South Australia, Tasmania and the Australian Capital Territory. Additional data for ex-serving members was provided by the Department of Veterans' Affairs (DVA) for DVA-funded admitted patient care in public hospitals in all states and territories, including Western Australia and the Northern Territory.
Age-specific comparisons
While the acute effects of alcohol toxicity (such as poisoning) are found across age groups, the chronic diseases requiring admitted patient care due to long-term alcohol use are more likely to manifest in older age groups. A greater proportion of male ex-serving ADF members aged 65+ were admitted compared to all Australian males for alcohol use, and for any alcohol or drug use (see Supplementary Table S.PUB.3.2).
Military characteristics
Of admitted ex-serving patients to public hospitals (FY2019-20):
- a higher proportion of ex-serving Army (2.1%) and Navy (2.2%) than RAAF (1.6%) members were admitted for alcohol-related conditions
- a higher proportion of ex-serving ADF males with an involuntary medical separation (8.1%) were admitted for an alcohol and other drug related condition than those with a voluntary separation (4.0%)
- a higher proportion of ex-serving ADF males with lengths of service less than 1 year (5.3%) or 1 to less than 5 years (5.5%) were admitted for any alcohol and other drug-related condition than those with more than 10 years of service (2.3%)
- a higher proportion of ex-serving ADF males who separated in ‘other ranks’ (4.6%) were admitted for any alcohol and other drug-related condition than officers (2.6%) and senior other ranks (1.8%).
The analysis of Queensland public and private hospitals showed similar service characteristics were associated with a greater proportion of ex-serving ADF members being admitted for alcohol and other drug related conditions.
Intentional self-harm
What is intentional self-harm?
Intentional self-harm (ISH) is often defined as deliberately injuring or hurting oneself, with or without the intention of dying. ISH comes in many forms, and affects people from different backgrounds, ages and lifestyles. The reasons for self-harm are different for each person and are often complex.
Hospital morbidity provides information on patients admitted to hospital for self-poisoning or self-injury, with or without suicidal intent – and therefore includes both suicide attempts and non-suicidal self-harming behaviours.
Most people who self-harm do not go on to end their lives – but previous self-harm is a strong risk factor for suicide. Therefore, understanding of intentional self-harm is key to suicide prevention.
Admitted patient care for intentional self-harm
People who present to hospital services for ISH represent a minority of those who intentionally self-harm. The number of people who are treated in the community or do not any seek medical treatment for self-harming injury is unknown. Community-treated ISH, often involving self-injury, shows equal prevalence among males and females, tends to be non-suicidal, driven by the need to cope with psychological distress, and has higher repetition rates and lower suicidal mortality than hospital-treated ISH. In contrast, hospital-treated ISH is predominantly by self-poisoning, is more common among females than males, and is associated with suicidal ideation, repetition and deaths by suicide (Carter et al 2016).
While most emergency department presentations for ISH do not result in admission, a minority with serious injuries or mental disorders may require admission to intensive care or psychiatric care. Across Australia ISH accounts for 27,000 admissions to hospital and 90,000 bed days annually (see Intentional self-harm hospitalisations by states & territories).
Hospital-treated ISH is associated with adverse outcomes like repetition of non-fatal ISH, death by suicide, all-cause mortality, mental health morbidity, substance use, diminished quality of life and functioning across physical, psychological and social domains (Carter et al 2016).
Case identification
Records of admitted patient care for ISH are included if they meet the following criteria:
- A principal diagnosis of injury, poisoning and certain other consequences of external causes (ICD-10-AM range S00-T75, T79) and:
- A first reported code for external cause of morbidity (ICD-10-AM range X60-X84, Y87.0)
While this report presents data on patients admitted to hospital for ISH (both suicide attempts and non-suicidal self-harming behaviours), there are limitations to the data source (i.e. the National Hospital and Morbidity Database or NHMD). See limitations in the technical notes.
Improving self-harm data
Only including ISH presentations requiring admission and the reliance on the ‘external’ codes to capture cases means a significant proportion of ISH cases are not captured (McGill et al 2019). However, the NHMD is currently the most comprehensive national data source available. There are additional data sources including the National Ambulance Surveillance System (NASS), which is a new public health monitoring system providing timely and comprehensive data, including ISH with suicidal intent (see Ambulance attendances: suicidal and self-harm behaviours) and some national surveys. Primary care data from general practice and community mental health services currently do not routinely collect ISH data.
The AIHW is working with key stakeholders including mental health services and emergency data custodians to develop nationally consistent suicide-related data.
Overall
Higher proportions of ex-serving ADF members (males and females) who were admitted to a public hospital were admitted for ISH compared to the total Australian population for each year between July 2010 and June 2020. In FY 2019-20, 215 male ex-serving ADF members and 78 female ex-serving ADF members were admitted for ISH. Ex-serving ADF members admitted for ISH used similar mechanisms to self-harm as the total Australian population.
Age-specific comparisons
Table 5 shows the differences across age groups for FY 2019-20. The proportion of patients admitted to a public hospital for ISH was significantly higher for ex-serving ADF males aged 25-34 years and ex-serving ADF females aged 35-44 years, compared to the corresponding age groups in the total Australian population.
Age | Males | Males | Proportion difference (CI) | Females | Females | Proportion difference (CI) |
|---|---|---|---|---|---|---|
17-24 | 5.0 | 2.5 | 2.5 (-0.4,5.4) | n.p. | 3.3 | n.p. |
25-34 | 3.0 | 1.8 | 1.2 (0.3,2.1) | 2.4 | 0.9 | 1.5 (0.3,2.7) |
35-44 | 1.7 | 1.4 | 0.4 (-0.1,0.9) | 2.6 | 0.9 | 1.7 (0.6,2.8) |
45-54 | 1.3 | 0.9 | 0.4 (-0.1,0.7) | 1.8 | 1.1 | 0.7 (0.0,1.3) |
55-64 | 0.7 | 0.4 | 0.2 (0.0,0.5) | 1.2 | 0.6 | 0.5 (-0.2,1.3) |
65+ | 0.1 | 0.2 | 0.0 (-0.1,0.1) | n.p. | 0.2 | n.p. |
All ages 17+ | 1.1 | 0.8 | 0.3 (0.2,0.5) | 1.9 | 0.9 | 1.1 (0.6,1.5) |
Source: AIHW analysis of linked Defence Historical Personnel data–PMKeyS–DVA client–NDI–MCD–NHMD-NNAPEDCD–MBS–PBS–RPBS data (2010–2020) and AIHW NHDH (2019-2020)
Notes
n.p. Suppressed due to small numbers, or to prevent subsequent disclosure of cells with small numbers.
Different vetting and release approval practices apply to the different data sources.
Bolding indicates statistical significance was found for the difference between the proportions.
- Includes ADF members with at least one day of service since 1 January 1985 who were ex-serving (separated from permanent and/or reserve ADF service) and alive at any point from 1 July 2010 to 30 June 2020.
- By year of separation from hospital stay, for separations between 1 July 2010 and 30 June 2020.
- Includes stay separations that occurred while ex-serving (for ex-serving members) and where patients were aged 17 years or older at admission.
- By age at admission. Patients may be reported in up to two age groups if a change in age during the analysis period causes them to be assigned into the subsequent age group for later admissions.
- Where a stay includes more than one episode, the principal diagnosis of the initiating episode is used.
- Excludes stays where the principal diagnosis was in the ICD-10-AM chapter 'Certain conditions originating in the perinatal period' or 'Codes for special purposes'.
- Includes public hospital data from New South Wales, Victoria, Queensland, South Australia, Tasmania and the Australian Capital Territory. Additional data for ex-serving members was provided by the Department of Veterans' Affairs (DVA) for DVA-funded admitted patient care in public hospitals in all states and territories, including Western Australia and the Northern Territory.
Military characteristics
Among ex-serving ADF members admitted to a public hospital for ISH in 2019-20:
- 119 (55.3%) males and 37 (47.4%) females were DVA clients at the time of admission
- a lower proportion of RAAF members were admitted for ISH compared to Army and Navy members (0.6% vs 1.2% and 1.4%)
- a lower proportion of members who had ten or more years of service were admitted for ISH (0.7% vs 1.5% [<1 year], 1.6% [1-<5 years], 1.2% [5-<10 years])
- a higher proportion of members who separated involuntarily due to medical reasons were admitted for ISH compared to other involuntary separation (3.8% vs 1.4%).
Cause of death after ISH hospital admission
The cause of death is recorded in the National Death Index using International Classification of Disease Codes (ICD-10). For the period 2010-20, 195 ex-serving ADF members died following admission for ISH. Of these, the cause of death was:
- ISH – 86 (44.1%)
- deaths from alcohol or drugs (including deaths due to chronic liver diseases and cirrhosis) – 35 (17.9%) (males only).
Of patients admitted for ISH, the proportion of ex-serving members who died by ISH was similar with the Australian population. However, of patients admitted for ISH who died of any cause, ex-serving members had a higher proportion of deaths from ISH compared with the Australian population (males: 43.1% vs. 34.4%; females: 50.0% vs. 29.5%).
Readmission for ISH
For the period 2010-20:
- There were 2,300 ex-serving ADF members admitted to a public hospital for ISH (1,770 for males and 540 for females).
- Most admitted ex-serving ADF males (79.4%) and ADF females (71.8%) only had a single admission for ISH.
- A higher proportion of ex-serving members were re-admitted for ISH compared to all Australians admitted for ISH (males: 20.6% vs 18% and females: 28.2% vs 22.7%).
The Queensland analysis showed a similar pattern to the public hospital-only analysis of readmissions.
Comorbidities of persons admitted for ISH
AIHW has also examined comorbidities relating to conditions associated with suicidal behaviour provided to patients who were admitted for ISH.
Of patients with an admission for ISH in hospitals (FY 2010-20), compared to all Australians:
- a higher proportion of ex-serving ADF members had a concurrent (that is, for the same admission) mental health-related care diagnosis (males 77.5% vs 71.8%; females 74.4% vs 67.8%)
- a higher proportion of ex-serving ADF members had a concurrent stress-related diagnosis (males 29.5% vs 18.3%; females 24.1% vs 18.4%), and more had a subsequent admission for a stress-related diagnosis (males 16.7% vs 10.8%; females 16.6% vs 12.0%)
- a higher proportion of male ex-serving ADF members had a prior (8.6% vs 6.7%), concurrent (29.8% vs 25.6%), subsequent (15.1% vs 12.1%), or any admission for depression 42.0% vs 36.0%).
It is worth noting that US studies have reported that ISH is common among veterans with post-traumatic stress disorder, affecting over half of those seeking treatment (e.g., Calhoun et al 2017).
Of patients with an admission for ISH in public hospitals (FY 2010-20), compared to all Australians:
- a higher proportion of ex-serving ADF members had a concurrent alcohol or other drug diagnosis (males 69.5% vs 65.9%; females 84.1% vs 79.6%)
- a higher proportion of male ex-serving ADF members had a concurrent diagnosis for the effects of anti-epileptic, sedative-hypnotic, or antiparkinsonian drug use diagnosis (26.4% vs 21.7%).
Admitted patient care in the year before suicide
From 1 July 2010 to 30 June 2020, there were 600 ex-serving ADF males and 68 ex-serving ADF females who served since 1 January 1985 who died by suicide. Of these, 275 males and 40 females were admitted to a participating public hospital in the study period. In the year before death, 171 ex-serving ADF males and 26 ex-serving ADF females who died by suicide, received admitted patient care at a public hospital including:
- 73 (42.7%) males and 7 females (26.9%) for mental and behavioural disorders
- 63 (36.8%) males and 15 (57.7%) females for injury, poisoning and the consequences of other external causes.
Of those who died by suicide and were admitted to hospital in the year prior to death, similar proportions of ex-serving ADF males (46.8%) and all Australian males (42.5%) were admitted for any mental health-related care. This was also the case for ex-serving females (42.3%) compared to all Australian females (48.8%).
Of those admitted for mental health-related care in the year before suicide, a higher proportion of ex-serving ADF males (26.2%) were admitted for stress-related disorders, compared to all Australians admitted for mental health-related care (16.5%).
Of those who died by suicide and were admitted in the year prior, 44 (22.3%) ex-serving ADF members were admitted for the effects of alcohol and other drug use.
Of those who died by suicide and were admitted in the year prior, 45 (26.3%) male ex-serving ADF members and 13 female (50%) ex-serving ADF members were admitted for ISH in a public hospital in the year before suicide.
The small numbers prevent further comparisons with the total Australian population who also died by suicide.
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