Mental health in the age of COVID-19

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 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?
 

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. 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 variation in the access and quality of care delivered across Australia’s mental health support systems – some key opportunities to address these challenges include a need to:

• deliver new models of care that design and deliver out of hospital alternatives for mental health care;

• manage the system sustainably, including proactively growing demand;

• 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 still relevant, but its realisation is now more challenging 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) to inform our understanding as we face into a post-pandemic future:

• Demand for telephone support and crisis services will increase. Beyond Blue and Lifeline are already reporting increases of approximately 30 per cent in demand.^{[1] [2]} Despite this, we know that three in four Australians (74 per cent) have never used counselling services and are not intending to^[3].
• 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 per cent of all the jobs lost.^[4] Similarly, youth make up a significant portion of Australia’s casualised and gig-economy workforce, and work in those industries hardest hit by the pandemic, including retail and hospitality. Youth unemployment is currently sitting at 13.8 per cent.^[5] Underemployment 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 per cent reportedly feeling isolated and alone during the pandemic.^[6] 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 per cent from pre-GFC levels as unemployment rates increased.^[7] Current day unemployment rates are rising – from 5.2 per cent pre COVID-19 to almost 6.2 per cent in June 2020^[8] – with the total economy expected to contract by eight per cent in 2020.^[9] 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.   

 

Moving forward

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 ideas and design principles to consider in how to take mental health reform forward.
 

1.Using data and evidence to tackle the mental health challenge

Australia’s use of public health data has informed its successful response to COVID-19. The same evidence-led approach should now be applied to map and plan appropriate mental health supports to close gaps and better connect the healthcare system and people to 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.

2.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.

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

The social determinants of health, and the flow-on impacts 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 increase in 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.

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

Broadening telehealth has opened the door to consider 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 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.

Progressing the mental health reform agenda must start now

The need to create a well-rounded and responsive mental health system is critical. 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 them. It must be a system that is inclusive and responds 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 the research and tools needed to address these challenges – what we need now 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, while growing the capability of the workforce alongside.