This op-ed was first published in The Australian, 3 April, 2020.
Written by Professor Patrick McGorry, executive director of Orygen.
The World Health Organisation stated many years ago that “there is no health without mental health”. This is a statement that will resonate with every Australian as the COVID-19 disaster unfolds. The emotional impact of the pandemic is already profound and will evolve during the coming weeks and months into a second front in the health and socio-economic crisis facing our nation.
The mental health impact of disasters is experienced in a series of overlapping phases.
At first there is shock and disbelief, followed by intense distress and fear. To balance this there is a sense of solidarity and altruism, which evokes nostalgic memories of wartime and whole communities banding together to fight a common threat. This response is vital to nurture and sustain, and it can be enhanced by inspiring leadership.
We know that after a period of initial distress which is normal in crises, most people will not develop mental ill health, however there is always a substantial surge of new episodes. Common mental disorders more than double and people with pre-existing mental illness may relapse. Across many months, most people slowly recover, a process favoured by cohesive communities, good social support networks, preserved family systems, altruistic behaviour of community leaders, religious faith and spirituality.
However, we may be entering another level of disaster with COVID-19 because of its scale and the depth of secondary waves of impact. This is a universal ordeal, affecting the whole world and every human being in it. The closest parallels we have are world wars and the Depression, both outside the experience of most people who are alive today.
COVID-19 is already delivering a double shock: a severe threat to life, and an equally severe threat to the security, prosperity and future of our society and world order. Furthermore, the responses that must be taken to reduce the threat to our lives from the virus create a serious threat to our mental health and to our financial and cultural security. This in turn further undermines mental health and wellbeing and increases the risk of suicide. It is this tension that is making the task of governments in managing the crisis so exquisitely challenging.
The universal nature of the COVID-19 threat means we are likely to see a larger surge in mental ill-health than in more localised disasters. Why is this the case? Even a small shift in the level of a given risk factor for an illness in the whole population substantially affects the number of new cases, even though most people still do not develop the illness. The best example is blood pressure. If the blood pressure of the whole population increases (or decreases) by say five to 10 percentage points, then a substantial rise (or fall) in the number of heart attacks and strokes will follow. By no means in everyone but in the substantial subgroup at risk.
While the rise in anxiety in the face of COVID-19 is certainly not mental illness per se, it does represent a major new risk factor for the later onset of new illness, especially depression, simply because it exerts an effect across the whole population.
Another potent universal risk factor is the sense of helplessness we all feel in the face of the pandemic. This is compounded by other widespread effects that increase risk, including social isolation, job loss or insecurity, loss of freedom of movement, daily routine and social role. This could create a domino effect, fuelled by the loss of key protective factors that we rely on to stay mentally healthy, including a sense of hope, purpose, social connection, holidays, exercise and the scaffolding of education and employment.
In his book Lost Connections, Johann Hari highlights the importance to our mental health of connections with others, with work, with the natural world and with a hopeful and secure future for the world. He shows how the erosion of these connections was a key factor in the rising tide of loneliness and depression even before the COVID-19 crisis.
Young people often are regarded as the “miners’ canaries” of society and have the most intense need for social connection. Yet despite the rise of technology and social media, they experience record levels of loneliness and mental ill-health. One safety net for the loss of connection we are experiencing is the availability of the internet and digital technology, which enables us to be connected even when physically isolated. Will this sustain us and how will an extended period of this interaction affect the way we relate when the crisis is over?
The deeper existential experience of the COVID-19 crisis is one that we are all able to relate to and has been captured in great literature, memorably in The Plague by Albert Camus. Disasters of this scale and depth reveal a lot about ourselves and society, and fundamentally will change everyone who lives through it.
Australia is ahead of the curve in that our government is the first worldwide to recognise the centrality of the mental health challenge we face, and to make rapid and explicit policy changes in response. Scott Morrison and Health Minister Greg Hunt, who before the crisis had placed mental health reform near the centre of their government’s policy agenda, deserve credit for this.
The announcements last Sunday are well targeted as a first pass in responding to the mental health consequences of the pandemic. They are preventive and clinically based. Some focus on key risk factors such as employment, domestic violence and strategies to reduce anxiety and enhance coping.
Dramatic changes to Medicare allow GPs and all MBS-funded mental health professionals to pivot wherever possible to telehealth consultations, reserving face-to-face for essential matters. This allows routine clinical practice to be maintained in a way that is safer for patients and health professionals and reduces overall risk to the community. It also potentially improves access for people in rural and regional Australia to more expert mental healthcare.
As the crisis unfolds, the next stage needs deeper psychiatric expertise to ensure that those with more acute or complex conditions who are at risk of exclusion from care are still able to receive it. There are already concerns that such exclusion may be occurring, with a substantial drop in presentations to emergency departments of acutely ill and suicidal patients who are retreating in fear.
Our mental health system was already struggling with demand even before the crisis, and community outreach especially so. The latter and digital mental health are now top priorities for the second wave of national mental healthcare reform being planned. It is crucial that the new solidarity the disaster has generated unites Australia’s mental health sector, which is working closely with government to meet the challenges ahead.