Mental health in the age of COVID-19

06 July, 2020

By Damien Angus and Stuart Babbage

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As the second-order impacts of COVID-19 begin to emerge, the challenge for Australia will be how to nurture and maintain the mental health of our communities nationwide.

Australia has demonstrated incredible leadership and tenacity through the COVID-19 pandemic, which sets a strong path for recovery, uncovering opportunities for innovation that would not have been evident or possible three months ago. So, how can Australia continue leveraging this positive momentum and willingness to act in the post peak phase?

Why does mental health matter?

Despite the richness of its resources, and the bounty of its climate, Australia’s greatest asset is its people. A prosperous Australia depends on both the mental and physical health of its citizens. At the start of 2020, mental ill-health was already one of Australia’s most pressing issues and an area of focus for policy makers and business leaders. And now, following a summer of unimaginable bushfires and the emerging impacts of the COVID-19 pandemic, Australia is likely to face complex social and economic challenges in the years ahead.

Mental health is a major part of how we live our lives. When a person’s mental health is good, they can usually cope with and bounce back from whatever life throws at them. But when mental health is poor, it can be difficult to function day to day and it may take longer to recover. 

Protecting and strengthening the mental health of Australia’s citizens is more critical now than ever to cope with the fast-paced, 24/7 culture of modern-day life. Many people work extended hours, use less sick and annual leave, and feel the impacts of stress and burnout more acutely. The line between work and home life is often blurred. People are constantly bombarded with information. Sleep, exercise and good nutrition feel like luxuries. And, many people feel disconnected from families, friends and neighbours, leading to declining trust across society. 

Some of these challenges have been exacerbated in the last six months by COVID-19 - some of which may continue into the future.

A mental health system in need of change

Australian governments have ramped up their attention and funding on mental health programs and suicide prevention measures in recent years. For example, the federal government announced new suicide prevention and mental health initiatives in early 2020, and state governments are also supporting focused programs (e.g. NSW government’s Towards Zero Suicides).  

Before COVID-19, existing vulnerabilities across the mental health system were known. These are currently being highlighted by the Royal Commission into Victoria’s Mental Health System and the Productivity Commission Inquiry into the social and economic costs of mental health. At the same time there has been an Australian Government Senate Inquiry into the accessibility and quality of mental health services in rural and remote Australia.

While their specific areas of inquiry differ, these reviews all highlight the substantial variation in the access and quality of care delivered across Australia’s mental health support systems. While the final reports are yet to be handed down, these inquiries are already highlighting key opportunities for mental health access and support in Australia:

  • A need to deliver new models of care that design and deliver out of hospital alternatives for mental health care

  • A need to manage the system sustainably, including proactively growing demand

  • A need to develop a diverse and multidisciplinary workforce that is capable, engaged and trauma informed

A vision for the next decade was set in mid-2019 in the Mental Health Commission’s Connections: Vision 2030 report - a blueprint for mental health and suicide prevention through a more responsive, person-led and person centred system.  This vision is just as relevant one year on, but its realisation is now more challenging and more important than ever given the additional impacts of COVID-19.

Preparing for a post-COVID-19 economic downturn

There was a great deal learned from the 2008 global financial crisis (GFC), which are useful to understand as we face into the next set of challenges stemming from the pandemic:

  • Demand for telephone support and crisis services will increase. Beyond Blue and Lifeline are already reporting increases of approximately 30% in demand1,2. Despite this, we know that three in four (74%) Australians have never used counselling services and are not intending to3.

  • Women and youth will be disproportionately impacted by an economic downturn. Women are more likely to work part time and on casual contracts with no paid leave entitlements. They are also more likely to pick up increased schooling and childcare responsibilities, making it difficult to search for, and return to, work. 325,000 women became unemployed in April 2020, making up 55% of all the jobs lost4. Similarly, youth make up a significant portion of Australia’s casualised and gig-economy workforce, and in those industries hardest hit by the pandemic, including retail and hospitality. Youth unemployment is currently sitting at 13.8%5. ‘Under-employment’ is another challenge that young people face - even if they have a job, they may not be able to work the number of hours they would like to earn an adequate income.

  • Young Australians aged 16-34 are at the greatest risk of loneliness, with 42% reportedly feeling isolated and alone during the pandemic6. Young people are known to already be at higher risk of experiencing mental ill-health and are more vulnerable to the impacts of loneliness, joblessness and lack of social engagement post-COVID-19 - without an adequate support structure to manage through life’s ups and downs.

  • Suicide risk is linked to unemployment rates. In the 2008 GFC, suicide rates increased by between 20-30% from pre-GFC levels as unemployment rates increased7. Current day unemployment rates are rising - from 5.2% pre COVID-19 to almost 6.2% in June 20208 - with the total economy expected to contract by 8% in 20209. With the JobKeeper and JobSeeker stimulus currently in place, the true impact of the economic crisis on individuals and households may not be known for some time.   

Australia is currently in a propagation phase of the coronavirus. At some point in coming months Australia will be in a post peak period and will then eventually settle into a post pandemic period. 

Specialist epidemiology and pandemic response will be required to help Australia successfully make this transition. The impacts, however, will be broad across these phases.

As we shift our focus from ‘flattening the pandemic curve’ to ‘flattening the mental health curve’ - the latter being strongly linked to how rapidly and well the economy bounces back - there are a few important design principles to consider in how to take mental health reform forward.

Using data and evidence to tackle the mental health challenge

Australia’s successful response to the COVID-19 pandemic has largely been informed by its use of public health data. To address the mental health challenge, the same evidence-led approach should now be used to map and plan appropriate mental health supports to close gaps and better connect the healthcare system and people to appropriate assistance at the right time. This should include connecting public health data - including self-harm and suicide presentations, GP mental health consultations, demand spikes for online and telephone crisis support - to economic data, such as areas, people and industries. Mapping data to those impacted by bushfires, job loss, underemployment and/or reduced productivity can help predict, plan and deliver services and supports to meet expected community need.  

In preparing for and responding to the COVID-19 pandemic, Australia’s governments and healthcare system used the modelling of ‘what could happen if we don’t act’ to motivate action. The same approach should now be applied to mental health, with at least one institute already investing in this research.

Case study: Brain and Mind Centre systems modelling of suicide

Source: University of Sydney’s Brain and Mind Centre

The University of Sydney’s Brain and Mind Centre has applied a systems model approach to support mental health services planning and suicide prevention in the North Coast NSW region. The model was developed in partnership with the North Coast Primary Health Network and will contribute to work being undertaken by the North Coast Collective, which seeks to embed a regional collaborative model in addressing mental health needs across the continuum.

Systems modelling offers a unique and important tool for systems analysis to support decision making for complex problems. The modelling reveals links between employment, connectedness, and youth mental health and wellbeing and interactions with the mental health systems. 

Applying post COVID-19 scenarios with the following inputs - 11.1-15.9% unemployment rate; 24-34.8% youth unemployment; 10-20% reduction in social connectedness - the modelling predicted the following over five years, with broader flow-on impacts across the whole health system:

  • Suicide deaths in the region would increase by between 23% to 53% 

  • Suicide attempts (self-harm hospitalisations) would increase by between 20% and 47% 

  • Mental health related emergency department presentations in the region would increase by between 15% and 34%

This modelling paints a sobering outlook if translated nationally. But, given the initial COVID-19 infection and hospitalisation modelling also presented a dire prediction for Australia, a systems model approach could similarly help ‘flattened the mental health curve’.

Now is the time to act to prevent poor mental health outcomes

1. Implement integrated and stepped care

The road ahead for mental health reform should continue to build better ways to connect multidisciplinary teams in communities to support early risk identification and intervention. This should include assertive aftercare; community support programs to reduce isolation and improve community connection; and low-acuity support services (e.g. coaching to manage anxiety and/or stress triggers; behaviour and support with managing grief and loss). All models must be supported by clear pathways up into the social and health systems.

2. Focus on the broader impacts of social determinants of health

The social determinants of health, and the flow on impact of housing, welfare dependence, disability, use of social services, education, incarceration and recidivism are strongly linked to mental wellness. There is opportunity to upskill people impacted by job losses following the pandemic and provide pathways for youth to train for roles where there is an expected increased demand in the years to come. 

Developing place-based solutions that are designed (not just informed) by lived experience will also  be critical to meet the needs of communities through recovery efforts.

3. Provide digitally enabled, human-centric mental health care

The broadening of telehealth has now opened the door to a shift in how healthcare can be digitally enabled and delivered post pandemic. Now is the time to review adoption, experience and effectiveness from a patient and healthcare provider perspective to identify areas and opportunities to better integrate digital tools to support self management and care delivery. For mental health services, digitally enabled care has the potential to connect a person in need to the right care at the right time. It also enables people to access support Australia-wide and after hours. The right team of people can then provide care, by coordinating information and touchpoints and measuring progress and outcomes. 

Case study: InnoWell

Innowell, a collaboration between the University of Sydney, PwC and the Australian Government, is underpinned by 10+ years of research and a number of clinical trials. The InnoWell platform is not a substitute for, but augments clinical care. The digital platform enables a more connected care experience, with a strong focus on immediate access and identification of people in the most vulnerable situations.

The InnoWell Platform is designed to put the individual at the centre of the experience. Highlights of the digital platform include:

  • Immediate access: people can access support immediately via tailored apps and e-tools

  • Triage reduction time: reduction in time to identify the right care pathway

  • Assessment reduction time: online screening cuts the time required for assessment while improving the face to face clinical experience

Early identification of people who are at most risk, for follow-up intervention and care

Progressing the mental health reform agenda must start now

The need to create a well-rounded and responsive mental health system is more important now than ever before. Australia requires a system which is contemporary in nature, enabling cohesive delivery of, and timely access to, effective mental health support services for those who need it. It must be a system that is inclusive and responsive to the diversity of Australia’s people. And most importantly, it should be founded on investment in prevention and early intervention, responding to the changing nature of how we live and work.

The good news is that Australia already has much of the research and tools needed to address the coming ‘mental health curve’ - what is now needed is an evidence informed approach. This approach needs to build on the strong foundations already set, look to partnerships and alliances to minimise duplication and maximise cooperation, and take opportunities to explore how digitally enhanced or delivered options may assist with scale and access, whilst growing the capability of the workforce alongside.

1. Lifeline media release, Australian Government provides additional funding to increase access to Lifeline crisis support services through-out COVID-19 outbreak, 29 March 2020

2. Beyond Blue media release, Beyond Blue welcomes funding for new COVID-19 support service, 29 March 2020

3. The Lab and Nature, COVID-19 Special Report - Mental Wellbeing During the COVID-19 Crisis, June 2020

4. Australian Financial Review, Women workers worst hit in COVID job losses, 15 May 2020

5. ABC, Youth unemployment rate rises to 13.8% due to coronavirus crisis, 14 May 2020

6. The Lab and Nature, COVID-19 Special Report - Mental Wellbeing During the COVID-19 Crisis, June 2020

7. The Lancet, Total and cause-specific mortality before and after the onset of the Greek economic crisis: an interrupted time-series analysis, 4 November 2016

8. Australian Bureau of Statistics, 6202.0 - Labour Force, Australia, Apr 2020, 14 May 2020

9. Reserve Bank of Australia, Statement of Monetary Policy - section 6: Economic Outlook, May 2020

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