Dr Rosalind Hewett, Social Policy
Grey Robertson and Joanne Simon-Davies,
Statistics and Mapping
WARNING: The following article includes information
on suicide and mental illness. For help or information contact Beyond Blue on
1300 224 636, or Lifeline on 13 11 14.
Key issue
Prior to the COVID-19 pandemic, it has been estimated that 45% of Australians aged 16–85 years have experienced a mental illness during their lifetime. In its recent inquiry, the Productivity Commission estimated that 17% of people experienced an episode of mental illness in the 12 months to September 2019. While most conditions were mild, it estimated that 1.5 million people had a moderate or severe condition that can require specialist mental health support (p. 90). Mental ill-health can significantly impact people’s lives and is the largest contributor to years lived in ill-health for people under 50 years in Australia (p. 88).
There have been many reviews into the mental health system, but successful implementation of reforms has proven challenging with people still struggling to access the care and supports they need. In addition, the pandemic has placed significant stress on the mental health system, with workforce challenges and increased demand, that may have impacts for some time to come.
Even before the COVID-19 pandemic, concerns
were raised about the capacity of the mental health system to meet demand
for services. Even with recent commitments from federal, state and territory
governments, successive natural disasters and the pandemic appear to have
increased demand for mental health services. Some of the changes arising during
the pandemic may have long-term impacts on the sector, such as the exodus of
the workforce following burnout. There may also be long-term effects from post
COVID-19 condition (also known as long COVID) on the mental health of
Australians.
This article provides an overview of the mental
health system, access and workforce issues and the prevalence of mental illness
in Australia, and notes where changes have occurred during the pandemic.
The incidence of mental illness in Australia
The Australian
Institute of Health and Welfare (AIHW), drawing on pre-pandemic data,
estimates that 45% of the population aged 16–85 will experience mental illness
at some point in their life. According to AIHW, the most common mental
illnesses in Australia are:
- anxiety disorders such as panic disorder (14% of the population)
- affective disorders such as depression (6%)
- substance use disorders such as alcohol dependence (5%).
In 2019–20, a total of 310,471
presentations to public emergency departments were mental health-related,
representing 3.8% of all presentations. This proportion was slightly higher
than in 2018–19, when mental health-related emergency department presentations
comprised 3.6% of all presentations.
Funding and responsibility for services
Responsibility for funding, delivering and
regulating mental health services is shared
between the Australian Government and state and territory governments. The
Australian Government funds:
- Primary
Health Networks, which coordinate primary health care in their respective
regions
- Medicare
- the Pharmaceutical Benefits Scheme (PBS).
The Australian Government and state and territory
governments co-fund:
- public hospitals
- helplines, mental health crisis and support services
- the National Disability Insurance Scheme.
The Australian Government also provides some
clinical and non-clinical community-based mental healthcare (such as Adult
Mental Health Centres) and funds non-government organisations such as headspace. The states and territories
administer and deliver hospital, emergency and outpatient services, fund
community-based services, and are responsible for employing the public hospital
workforce.
In 2019–20, national
recurrent spending on mental health-related services was around
$11 billion, or $431 per person in the population. This represented an
annual average increase of 3% since 2015–16 in real terms. Government spending
on mental health-related services in 2019–20 comprised about 7.6% of total
national health expenditure, which represented the same proportion as in
2015–16 and slightly more than the 7.3% in 1992–93 when data collection began.
Spending by state and territory governments increased by an average annual rate
of 2.8% between 2015–16 and 2019–20. Final data on spending during the pandemic
is not yet available.
The Morrison Government committed
in 2021 to providing additional funding of $2.3 billion over 4 years
from 2021–22 for mental health, including measures for prevention, treatment,
workforce and governance. This was expanded in 2022 by an announcement of $547
million committed over 5 years to further address these areas. Policy
initiatives from the Australian Government during the 46th Parliament
include the:
Access and workforce
According to the Australian Bureau of Statistics’
(ABS) First
Insights from the National Study of Mental Health and Wellbeing, 2020–21,
some 3.4 million Australians aged 16–85 years (17%) saw a health professional for
their mental health during 2020–21. It notes in addition to mental
health-related consultations with health professionals, about 612,000
Australians accessed other services for their mental health via phone or
digital technologies, including crisis support or counselling services, mental
health support groups and forums, and online treatment programs and tools to
improve mental health.
The mental health workforce includes:
- GPs, who provide an initial point of contact for many people seeking
assistance with mental illness and can refer patients to more specialised
services through, for example, Mental
Health Treatment Plans
- psychologists
- ounsellors and psychotherapists (who may provide
services that do not attract Medicare rebates)
- psychiatrists
- social workers with specialist
qualifications and training in mental health
- occupational therapists
- nurses and doctors working in hospital emergency departments and
in-patient mental health units
- mental health nurses and other staff working in outpatient services,
community-based ambulatory care services and day clinics
- staff working for mental health crisis and support services, such as
national hotlines.
In 2019–20, some 11%
of Australians accessed Medicare-subsidised mental health specific services
provided by psychiatrists, GPs, psychologists and other allied health
professionals, with 45% of these services provided by psychologists. Figure 1
provides an indication of the full-time equivalent (FTE) number of staff per
100,000 people in some areas of the mental health workforce.
Figure 1 Number and full-time
equivalent of staff per 100,000 people in mental health-related areas
| |
Number |
FTE per 100,000 people |
| Psychiatrists |
3,615 |
13.7 |
| Mental health nurses |
24,111 |
90.2 |
| Psychologists |
28,412 |
95.3 |
| Community mental health care services
staff |
13,948 |
139.6 |
Source: Australian Institute of Health and
Welfare (AIHW), ‘Mental
Health Services in Australia: Mental Health Workforce’, 17 May 2022; AIHW, ‘Mental
Health Services in Australia: Specialised Mental Health Care Facilities’,
17 May 2022.
In 2020, the Productivity
Commission acknowledged ‘substantial shortages’ in some mental
health-related occupations, particularly in regional and remote areas, even
before the pandemic (p. 188). Accessing in-patient services in hospitals
was reported to be especially challenging (p. 424). A literature
review carried out as part of the development of Australia’s National
Mental Health Workforce Strategy also flagged shortages- for example, an
undersupply of 18,500 mental health nurses by 2030- because of an ageing
workforce, high staff turnover, limited new recruits and relatively high rates
of attrition among younger members of the workforce (p. 16).
Since the pandemic began, some
stakeholders have called for Australia to double the number of
psychiatrists, psychologists and mental health nurses to meet additional
demand. The Australian
Psychological Society (APS) reported in February 2022 that 1 in 3
psychologists who responded to its members survey were unable to take new
clients, an increase from 1 in 5 in June 2021. This compared with only 1 in 100
psychologists not taking on new clients pre-pandemic. Of those who were able to
accept more patients, 65% reported worsening wait times (averaging 55 days).
The APS reported that psychologists were working on average 17 unpaid hours
each week and flagged the risk of burnout and a mass exodus.
Staff shortages are an issue across the health
sector, but have
become particularly acute during the pandemic. Issues in attracting and
retaining the mental health workforce include:
Impact of the COVID-19 pandemic
Evidence of the potential additional incidence of
mental illness during the pandemic is mostly drawn from population measures of
psychological distress and changing patterns of service use. These early indicators
suggest a large increase in mental distress compared to before the pandemic,
and that mental health outcomes for some groups may be worse than others,
particularly young people.
According to the ABS’s 'First insights from the National Study of Mental Health and Wellbeing 2020- 21', in 2020-21:
- 15% of Australians aged 16–85 years experienced high or very high
levels of psychological distress
- 20% of Australians aged 16–34 years experienced high or very high levels of psychological
distress.
The
2017–18 National Health Survey found a similar proportion (13%) of adult
Australians experienced high or very high levels of psychological distress.
However, approximately 15% of Australians aged 18–34 experienced high or very
high levels of distress, less than the rates noted above during the pandemic.
The Melbourne
Institute’s Coping with COVID-19 report highlighted the connection between
financial stress and mental distress. The report, using a single item measure
for mental distress (p. 16), showed rates of mental distress were approximately
4 times higher for people experiencing financial stress (42%), compared with
people not experiencing financial stress (11.5%). The report also noted that
pre-pandemic, 8% of parents of children reported high levels of mental
distress, while during the pandemic, this rate had tripled to 24%, and was at a
higher rate than for Australians without children at home
(pp. 15; 18). Findings from the Australian
National University’s COVID-19 Impact Monitoring Survey Program also
pointed to high rates of psychological distress among young adults during the
pandemic.
Mental health services and prescriptions used
during the pandemic
The change in usage of mental health services
during the pandemic provides another indicator of increased demand. For
example, the AIHW
reported that in the 4 weeks to 9 January 2022, 644,690 Medicare Benefits
Schedule (MBS) items related to mental health services were processed, which
was 11.6% higher than the same period 2 years earlier (p. 4). About 30% of
these services were delivered via telehealth, an option that was not widely
available before the pandemic (p. 30).
The number of mental health-related prescriptions
dispensed under the PBS has increased by tens of thousands over the past
several years. Mental health-related prescriptions spiked in the 4 weeks
to 29 March 2020, increasing by 18.5% compared with the same period in
2019 (see Figure 2). There was a 3.9% increase in mental health-related
prescriptions in the 4 weeks to 28 November 2021, compared to the 4 weeks
to 29 November 2020, and prescriptions for antidepressants increased by 5%
during these periods (p. 7).
Figure
2 Number of PBS mental health-related prescriptions dispensed, by
week, January 2019–November 2021
Source: AIHW, Mental
Health Impact of COVID-19, (Canberra: AIHW, March 2022), 8.
As shown in Figure 3, crisis support services
experienced fluctuating demand during the pandemic, with demand peaking from
June 2021 to September 2021. This coincides with a series
of extended lockdowns in NSW, Victoria and the ACT.
Figure 3 Crisis and support
organisation contacts, by week, January 2020–January 2022
Source: AIHW, Mental
Health Impact of COVID-19, (Canberra: AIHW, March 2022), 10.
Research on mental health risks, COVID-19 and
disasters
Many Australians experienced bushfires and their
effects during Australia’s ‘Black
Summer’ of 2019–20 and may still be experiencing ongoing impacts. Parts of
the country have experienced severe flooding in 2021 and 2022. This is in
addition to the global COVID-19 pandemic. As such, in the space of less than 3
years, many Australians have experienced multiple disasters.
There is a growing body of research on the mental health
implications of disasters, which has found that disasters can lead to
short-term and long-term impacts on people’s mental health and indicates that
some people go on to develop clinical mental illness.
Evidence suggests that post-traumatic stress
disorder (PTSD) is the disorder most often associated with exposure to a
traumatic disaster event. The estimates of PTSD prevalence vary greatly, in
part due to the unique factors associated with situations such as the disaster
type, severity of the exposed (for example, the injuries and losses
experienced) as well as the study methods used. Reviews estimate that PTSD may
occur in up to one-third of people highly exposure to a disaster (p. 508).
However, some studies have suggested that PTSD prevalence
can be as high as 100%, as identified in work with children exposed to sudden
and unexpected acts of mass violence (p. 172).
Depression, one of the most common mental illnesses in the general
population, may be the most prevalent condition following a disaster (p.
172). In addition, studies have
shown that people with pre-existing symptoms may be at
increased risk of being negatively affected by disasters, as it may exacerbate
their symptoms (p. 1124).
Longitudinal studies have suggested that psychological symptoms
following a disaster may reach their peak a year after the disaster before
beginning to improve. However, symptoms may persist for some people for months
and years afterwards (p. 173).
The literature shows that one factor that
influences the impacts of a disaster on people’s mental health is their age.
There is evidence that children, particularly those under 8 years of age, are
especially vulnerable, with the most common symptoms and diagnoses following
disasters including anxiety disorders (such as PTSD) and depression (p. 6). Other studies have suggested that middle-aged
people are at the greatest risk of developing mental illness following a
disaster as they have ‘more chronic life stress and burdens and needing to
support others’ (p. 174).
Socio-economic status (SES) has been identified as one of the essential risk factors associated with
psychological symptoms following a disaster. This is partially due to people of
low SES being more vulnerable to being displaced due to housing stress (which,
in itself, is a well-known stressor for mental illness). Additional
issues include having the financial resources to recover, with some evidence
indicating that people with low SES may experience more obstacles in accessing
aid and support to assist with post-disaster recovery (pp. 8–9).
General research on mental illness indicates that
it is common for mental illness to recur years or decades later among those who
have recovered. For example, a
third to half of patients diagnosed with a major depressive disorder may
relapse within a year of discontinuing treatment, while around 36%
of people diagnosed with an anxiety disorder may have their anxiety
disorder recur within 41 years.
Even with this research, we do not know how long or
the extent to which the mental health impacts of the pandemic and recent
natural disasters will persist. We also do not know what the mental health
impacts of long COVID are, although we do know that extended fatigue (a common
symptom of long COVID) and psychiatric
conditions often co-occur, and that fatigue increases the risk of a later
psychiatric disorder. Further, emerging research indicates that people who have
had COVID-19 may also experience poor mental health. For example:
- A large
cohort study published in February 2021 of 62,354 people diagnosed with
COVID-19 in the US found a diagnosis of COVID-19 was associated with
an increased incidence of psychiatric diagnosis in patients with no previous
psychiatric history (particularly anxiety disorders). The incidence of
psychiatric diagnoses in the 14 to 90 days after COVID‑19 diagnosis
overall was 18%, including 6% that were a first diagnosis.
- In a large
retrospective cohort study in the US, researchers found that 17%
of people diagnosed with COVID-19 had a diagnosis of anxiety disorder 6 months
after infection.
- A study
examining data from 11 UK longitudinal studies involving
54,442 participants found that ‘COVID-19 illness was associated with
deterioration in mental health outcomes in the UK population’, although the
authors noted similar associations for both suspected and confirmed cases of
COVID-19. The study ‘did not observe improvements in mental health in the
immediate months post-infection’ (p. 12). It should be noted that this study
had not been certified by peer review at the time of writing of this article.
Suicide and the pandemic
Between 2017 and 2019, suicide was the leading
cause of death for people aged 15–44 in Australia. However, while the data
indicates a greater incidence of mental distress and treatment for mental
illness in 2020 and 2021, it appears that suicide rates did not change
nationally or in the states most affected by lockdowns. Data available in
Victoria and NSW on suspected suicides by month do not show any correspondence between lockdowns
and cases in those states, and nationally, suicide rates per 100,000 people
between 2000 and 2020 have remained relatively stable (Figure 4). Any effects
of the pandemic on suicide risk may have been countered
by protective factors such as income support.
Figure 4 Age-standardised*
suicide rate per 100,000 by sex, 2000–2020
*Standardised death rates enable the
comparison of death rates between populations with different age structures by
relating them to a standard population
Source: Australian Bureau of Statistics (ABS), Causes
of Death, Australia, 2020, (Canberra: ABS, 2021).
It should be noted that while international studies
suggest most
people who die by suicide suffer from mental illness, most people with
mental illness do not die by suicide. Statistics based on the small number of
deaths by suicide should be interpreted with caution and may not provide a
useful indicator of the incidence of mental illness.
Concluding comments
Issues with the mental health system are
well-established and have been noted in for example the Productivity
Commission’s 2020 inquiry into mental health. However, systemic issues have
been compounded by the pandemic through both workforce burnout and increased
demand that, for some groups (particularly young people and those affected by
long COVID) are likely to continue into the future. Recent Australian Government
measures, such as those announced in the 2021–22 and 2022–23 Budgets and the National
Agreement on Mental Health and Suicide Prevention, have been welcomed
by the sector. However, additional reforms and continued commitments across
governments are needed.
Further reading
Joanne Simon-Davies, ‘Suicide and Mental Health During the COVID-19 Pandemic’, FlagPost blog, Parliamentary Library, 1 October 2021.
Rosalind Hewett and Emma Vines, Mental Health Services in Australia: a Quick Guide, Research paper series, 2021–22, (Canberra: Parliamentary Library, 2022).
Australian Bureau of Statistics (ABS), ‘First Insights from the National Study of Mental Health and Wellbeing, 2020–21’, (Canberra: ABS, 8 December 2021).
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