Mental health through COVID-19: Linking crisis with lasting reform
There is an urgent concern that the social isolation, economic pressures and health anxieties brought about by COVID-19 will take a heavy toll on the already-fragile mental health of many Australians.
The COVID-19 crisis has followed directly on the heels of Australia’s most destructive bushfire season ever, when thousands of homes were lost and a state of emergency lasted for weeks on end. But even before these twin crises hit, 2020 was shaping up as a major year of reform in mental health. Around 20 percent of Australians experience mental ill-health in a given year, and suicide is consistently the leading cause of death for people aged between 15 and 44. Years of advocacy have crystallised into broad community awareness that mental ill-health touches us all – in our families, neighbourhoods, workplaces, schools and more.
Mental health quick facts
1 in 8
Australians reporting high or very high levels of psychological distress before COVID-19 crisis
1 every 30 seconds
distress calls to Lifeline since COVID-19 lockdowns commenced
per 100,000 people
Annual number of suicides in Australia in 2017
Since 2018 there have been a number of major public inquiries which have revealed the huge scale and scope of need for mental health services in Australia – and how often this goes unmet. These inquiries highlighted that more Australians than ever are struggling with their mental health even in normal times, and our support systems have not been keeping up.
Despite the provision of financial support packages for mental health services including the Mental Health and Wellbeing Pandemic Plan launched by the Prime Minister on 15 May 2020, the ‘Black Summer’ and COVID-19 have added new urgency to conversations about how to protect mental health and strengthen wellbeing across our community. While initial mental health data reports in some states are promising, these conversations won’t end when the current crisis does, because they have been spurred by a much deeper need.
The challenge now is to integrate immediate responses to the current mental health need with the longer-term reform work which was underway when the crisis struck. Achieving this will strengthen our community’s current wellbeing and deliver a lasting improvement to mental health for all Australians.
This is the first in a series of articles which will draw on KPMG’s mental health specialists to explore how governments, service providers and the community sector can work together to achieve this.
COVID-19 makes everyone vulnerable
Governments and service providers are used to thinking about mental health service needs in terms of ‘vulnerable’ or ‘at-risk’ groups. What is truly unprecedented about the COVID-19 crisis is that it has triggered a set of conditions that make our entire community more vulnerable to mental ill-health.
The World Health Organisation has identified a range of risk factors which increase vulnerability to mental ill-health, including loneliness, social exclusion, work stress or unemployment, physical illness, poor access to basic services and bereavement.1 Bushfire-affected communities across Australia’s south-east were already experiencing many of these stressors before COVID-19 triggered national disruption. Now, it would be hard to find a single Australian who has not been touched by one or more of them. The huge uncertainty about how long the current situation will last and what the world will look like on the other side only deepens the strain on mental health and wellbeing.
Recognising that Australians are likely to experience depression, anxiety and grief at a community-wide scale, there are valuable lessons to learn from evidence and practice in post-disaster mental healthcare.
In a disaster recovery context, planning for the delivery of mental health supports often includes the following principles:
- Reducing the stigma that can attach to mental ill-health by emphasising that stress and grief are normal reactions to life-threatening or extreme situations.
- Making proactive outreach a priority as affected individuals may not see themselves as needing mental health services and will not actively seek these out.
- Harnessing the protective power of community – family, community leaders and familiar supportive sites like schools – as the first line of response ahead of formal, clinical interventions.2
These principles could form a strong basis for the coordinated delivery of mental health supports across all levels of government and community in response to COVID-19. Importantly too, approaching the current context through the lens of disaster recovery would foster the sense of shared purpose and focused effort that is often seen across our community after natural disasters.
In the wake of the 2019/20 bushfires, the National Mental Health Commission had commenced work on a national cross-jurisdictional mental health framework to enable a whole of government approach to future natural disasters. The current situation creates an opportunity to accelerate that work, driving a response which properly recognises the community-wide, disaster-like nature of COVID-19’s mental health effects.
COVID-19 creates different stressors and challenges across our community
While the current crisis makes all of us more vulnerable to mental ill-health, there are a number of groups across the community who are likely to be most affected. It is important to recognise that these groups are primarily those who already face the greatest challenges with mental health and wellbeing. COVID-19 greatly exacerbates existing risks.
Our responses today should build towards broader reform to the services and support for these Australians so we don’t just move past this immediate crisis, but build back better.
Frontline workers, first responders and their families
For Australia’s healthcare workers, first responders and other essential workers the COVID-19 crisis presents a rolling series of potential traumas: anxiety about their own personal safety, regular exposure to the suffering and death of others, and long working hours in high-stress environments. Their families also face heightened anxiety about the wellbeing of their loved ones, and in some cases, extended separations due to the need for isolation.
The mental health of Australia’s first responders has been in the spotlight since a 2018 Senate inquiry called out the range of ways their daily work affects their wellbeing – particularly manifesting in higher rates of self-harm and suicide. From Defence, Veterans’ Affairs and the Australian Federal Police to state emergency services bodies, agencies had already begun seeking new strategies and models of care to build employee resilience to traumas at work.
The response to frontline and first responder mental health in the current crisis should recognise that early intervention and prevention supports need to be built into these workplaces in ways that can be sustained well beyond the next few months. Leaders like the Australian Federal Police show how this can be done: by re-designing employee healthcare programs to put mental health on an even footing with physical health.
People at risk of suicide
Around eight Australians a day commit suicide during normal times. Lifeline estimates that for every death by suicide, another 30 people attempt to end their lives.3 There is a great risk that extended social isolation, mass unemployment and disruption to face-to-face mental health supports will lead to a significant increase in suicides during the COVID-19 crisis and recovery. While early data is promising, the impact of COVID-19 may have a lagged effect and will need to be monitored closely.
During the 2003 SARS outbreak in Hong Kong the suicide rate reached an historic high, with older people most likely to take their own lives.4 Research in Australia following the Global Financial Crisis also found unemployed men and women were both significantly more likely to commit suicide than those who kept their jobs through the crisis.5
Suicide prevention has received significant focus from both the Commonwealth and state and territory governments in recent years, with most jurisdictions now working towards zero suicide targets. But COVID-19 has spurred some valuable changes to the delivery of mental health and crisis services which had previously faced resistance – particularly the expansion of bulk-billed e-health consultations for mental health issues.6 Making mental health care more accessible through e-health is especially valuable for rural and regional Australians, who account for a disproportionate share of all suicides because of a lack of local services and supports.7 These services have currently been made available until 30 September 2020.
With COVID-19 providing a circuit-breaker for this important service delivery reform, governments should now consider how to permanently integrate affordable and accessible e-health services into Australia’s ongoing suicide prevention effort.
Children and young people
For young Australians, this year has brought disruption to the familiar routines of school and all the social supports that come with it. Children who are disconnected from their friends and cooped up at home with stressed, distracted adults are now missing out on the daily joys of play, discovery and activity that usually give their lives so much colour.
For many children, school is not only a place for learning and play – it is also where warm and caring adults help them work through challenges they may be facing at home and other problems affecting their wellbeing. With 75 percent of Australians with mental illness first experiencing this before the age of 25, schools provide a crucial point of contact for connecting young people with the supports they need to manage their mental health.
Getting children and young people back to school as soon as it is safe to do so is a top priority for minimising the impact on their wellbeing. But when they get there, they should be greeted by newly-strengthened mental health supports which can identify and respond to the specific needs of these young Australians as they grow and develop.
The Australian Government is already working on a new National Children’s Mental Health & Wellbeing Strategy addressing early intervention and prevention for children ages 0-12. This work could now be folded into broader planning for the post-COVID recovery, to make the mental health supports for our youngest Australians stronger than before.
Regional and remote communities
People living in regional and remote Australia are experiencing the effect of COVID-19 very differently from those in our cities. Because of the need to protect vulnerable Indigenous Australians, some communities are living with extreme restrictions on movement and contact with the outside world. Others have seen their lifelines of essential goods and services all but cut off by disrupted supply chains. These challenges are compounded by a lack of local healthcare services – particularly mental health care. While nationally there is an average of 87 psychologists per 100,000 people, in regional towns this falls to just 29 and drops even further for very remote communities.8
The limited accessibility of services and supports is a major driver of persistently poor mental health outcomes reported by regional Australians across a wide range of indicators.7 But it also means these communities have the most to gain from the rapid scaling up of remote service delivery options and expanded use of e-health. Ironically, the expansion of bulk-billed services delivered by phone or video chat means access to mental health services may actually be better now for regional communities that have decent internet connectivity than it was before COVID-19.
Locking in these gains will mean making remote health care delivery a larger part of Australia’s service mix on an ongoing basis. This doesn’t just encompass the services available through Medicare, but also spans the broader ecosystem of mental health community and peer support programs, crisis outreach, case management and aftercare.
The large-scale shift to digital care prompted by COVID-19 is a genuinely promising development for mental health and wellbeing in regional communities. We should work hard to ensure these service options don’t disappear again when the crisis passes.
Older Australians in residential aged care
With older Australians being most at risk of serious illness and death from the coronavirus, they also have the greatest need to practice strict social isolation. Separation from friends, family and loved ones can be felt particularly keenly when older people do not have other regular points of social contact such as employment. Fear of the illness can also create significant anxiety for older people as they contemplate serious consequences – particularly those living in residential aged care observing the alarming spread through other facilities.
Research by the National Ageing Research Institute prior to the current crisis found up to 50 percent of older people living in residential aged care experience depression, anxiety or both. The Aged Care Royal Commission also highlighted a lack of available mental health supports within residential care settings as an impediment to proper care.9 In 2019 the Australian Government provided $74 million to Australia’s 31 Primary Health Networks to strengthen the delivery of mental health care for Australians living in residential aged care.10
This has given the aged care sector had a head start on stepping up mental health supports for older Australians, but COVID-19 risks slowing this progress because of the more immediate priorities of protecting residents from the virus. The Australian Government, primary health suppliers and providers should collaborate to leverage the most promising models of care developed to date for roll-out more broadly to accelerate this important reform for older Australians living in residential aged care.
There is no doubt that the current pandemic has increased the urgency and scale of need for better mental health supports across each of these priority groups. But it is equally clear that these Australians will continue to experience greater mental health risks after this crisis has passed. That is why the steps we take now must link into longer-term reform, to drive lasting change where it will make the most difference.
Key enablers and opportunities
In seeking to connect the current crisis with longer-term mental health reform, there are a number of important enablers and opportunities that are already coming into focus. These include:
- Embedding mental healthcare where early intervention and prevention can happen as part of transitioning back to normal operations – particularly workplaces, schools and primary healthcare.
- Leveraging the innovations and adaptations spurred by COVID-19 – including scaled-up models of e-health care and stronger channels of coordination between different levels of government and service providers.
- Strengthening non-clinical, community and peer-led mental health supports which do not rely on the infrastructure and resources of our medical systems for delivery – harnessing the protective power of communities to better support each other.
It must be acknowledged that ‘going back to normal’ won’t be good enough for many Australians. Where COVID-19 has accelerated positive changes in the way services and systems work, we need to lock this progress in. Where the crisis has laid bare deep existing inequalities in the mental health and wellbeing of Australians, we need to build back better. And where the huge disruptions of the past few months have created the chance to re-think how things are done, we need to seize this opportunity.
Our shared focus should be on ensuring the work we do now builds towards better mental health and wellbeing for Australians well past the horizon of the current crisis.
- World Health Organisation, 2012, Risks to mental health: an overview of vulnerabilities and risk factors
- Royal College of Psychiatrists, 2014, Principles for responding to people’s psychological and mental health needs after disasters
- Lifeline Australia, 2020, Statistics on suicide in Australia
- Cheung, Chau and Yip, 2008, A revisit on older adult suicides and Severe Acute Respiratory Syndrome (SARS) epidemic in Hong Kong
- Milner, Morrell and LaMontagne, 2014, Economically inactive, unemployed and employed suicides in Australia by age and sex over a 10-year period: what was the impact of the 2007 economic recession?
- Australian Government, 2020, COVID-19 National Health Plan supporting the mental health of Australians through the coronavirus pandemic
- Senate of Australia, 2018, Accessibility and quality of mental health services in rural and regional Australia
- Regional Australia Institute, 2018, Accessibility and quality of mental health services in rural and remote Australia
- Beyond Blue, 2019, Submission to the Royal Commission into Aged Care Quality and Safety (PDF 494KB)
Royal Commission into Aged Care Quality and Safety, 2019, Interim Report, Volume 1
- Australian Government, 2019, $1.45 billion to strengthen mental health services and support job security