Silver linings: mental health lessons from COVID-19

THE mental health system was knee-deep in trouble way before COVID-19 struck. Many individuals were not getting care and a greater number were not receiving optimised care. However, COVID-19 has ramped the situation up. Early on, the research showed us that in one in two Australians experienced psychological distress (here and here). This is exacerbated in young people, where three out of four reported distress. Call centres and web services, including those at Black Dog Institute, have seen a 40% increase in use.

As the pandemic has continued, the data and evidence have told us that psychological distress and use of online, Lifeline, and COVID-19 lines follows the movement of the lockdown waves. Health care frontline workers are under the pump, with many fearing that they will take the virus home to their families. With countries such as the UK now experiencing similar if not greater levels of COVID-19 cases as in the first wave back in March, health care workers are exhausted and susceptible to experiencing variants of moral injury and post‐traumatic stress disorder.

Young people feel, quite rightly, that their careers, education and jobs are threatened. Data show increased levels of suicide ideation. The bereaved are often upset and angry that they couldn’t attend funerals. New research suggests that some who were affected by the virus will have ongoing cognitive impairments including depression. Waiting lists to see clinicians have lengthened. Emergency mental health support is available in emergency departments 24/7 but not in a form of service that is acceptable to those in crisis. Fortunately, contrary to predictions, no increase in suicide has yet been reported.

Amidst so much uncertainty, are there any positives we can take away from this pandemic? Even when a vaccine becomes available, COVID-19 will be around for a long time and we need to respond wisely. We have an opportunity to improve mental health for the future, and to COVID-19-proof our collective mental health recovery in four key ways:

Blended care is the future

COVID-19 has taught us that a lot can be done online and that care delivered via videoconsultations is trusted. There were 17.2 million consultations for health care services including mental health done via phone or via web. However, through telehealth, all we did was to replicate face-to-face service delivery, rather that amplify it – a missed opportunity that we should now reverse.

Twenty years of research in Australia have shown the use of apps and online programs, in conjunction with a therapist (either face-to-face or via telehealth), allows nine times the number of people seen compared with face-to-face care alone and it is equally as effective. Given Australia has only 4000 psychiatrists and 36 000 psychologists, providing access to care is our biggest problem. We need to expand the power of digital technologies to amplify service delivery.

How? Train and incentivise mental health professionals to deliver blended treatment programs that combine traditional in-person care with online and app-based services.

Policy has a real impact

Second, COVID-19 has taught us to recognise that the government has some of the most effective levers available to lower mental health distress and reduce expected suicide rates. Welfare and employment schemes such as the JobKeeper and JobSeeker payments may help mitigate the pandemic’s financial impact for many Australians. Employment is a protective factor against suicide, and a job may well be better than psychological therapy overall in keeping Australia mentally well.  Other levers include improving homelessness by creating more public housing, and addressing in a holistic way the risk factors that contribute to poor mental health, such as via alcohol pricing and availability.

Prevention is better than cure

Thirdly, we need to reset our attitude to prevention and very early intervention if we are to solve the “access to therapy” problem. Depression and anxiety can be prevented. But up until now, prevention in mental health has largely been ignored or trivialised. COVID-19 has thrown a spotlight on the need for decisive action which goes beyond handwringing and systematically establishes public health prevention programs that are evidence-based.

Let’s introduce these systematically: by screening all young people in schools (using platforms that have already been tested such as Black Dog’s Smooth Sailing service); requiring mental health and wellbeing manager training and apps in all workplaces (as effective programs exist but are not implemented); proactive outreach visiting programs to reach socially isolated people (the elderly, infirm, parents at home, refugees); walk-in clinics, as the French offered in the streets after terrorist bombings; instigate exercise and healthy walking programs, which are effective for depression and physical health

The usual argument against this holistic mental health approach is that “we do not have the resources to do so” or that “our priority is physical health”.

This is absolutely nonsensical and verging on structural stigma: the “societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and wellbeing of the stigmatised”. We have already shown we can mobilise a whole workforce of contact tracers (outreach workers), screen at population levels (drive-through and walk-in COVID-19 assessments) and create systems that monitor and respond to breakout areas in very agile ways. With political will and sustained funding, there is no reason that this cannot be achieved for mental health within months.

We need a COVID-19 preparedness plan for mental health

Historically, we have “preparedness plans” for catastrophes including pandemics and climate events, but they rarely feature the mental health consequences of these disasters. We need a mental health pandemic preparedness plan just as much as a medical pandemic preparedness plan. This should include modelling and articulated intervention scenarios that go beyond the banal and which systematically segment at-risk populations with culturally appropriate responses.

The COVID-19 window for change is beginning to close in Australia and we must commit to making our society a mentally healthier one. Ultimately, these opportunities can help reset the huge problems our mental health system faced before the pandemic hit.

Scientia Professor Helen Christensen AO is Director and Chief Scientist at the Black Dog Institute. This article is based on her address to the Academy of Health and Medical Sciences on 16 October 2020 in Sydney.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.