In Australia, projections and insights from the first COVID-mental health dynamic models have been regularly released since May 2020 by the Brain and Mind Centre, University of Sydney. These national and regional models predicted adverse impacts on mental health and suicide rates over the next five years as a consequence of the economic and social effects of the pandemic.
These predictions were met with considerable scepticism, concerns about possible adverse impacts of public discussion of these sensitive matters, and more active rejection of their validity, largely on the basis of early reports of no increase in service demand or deaths due to suicide in the first phase of the pandemic. Subsequently, as population-based surveys, calls to helplines and other indicators pointed to a significant downturn in mental health, and as these were particularly evident in Victoria, the federal government increased its responses. However, these actions were based on an incomplete picture of the dynamics of what was occurring across communities and across the mental health system.
In contrast, the approach to the physical impacts of the pandemic saw governments leverage dynamic systems models of coronavirus transmission to inform proactive, effective responses that have saved tens of thousands of lives. Despite similarly advanced systems models of COVID-mental health, the federal government is yet to engage actively with these decision support tools. Such engagement would permit authorities to test alternative mitigation strategies and have a stronger empirical basis for shaping their responses to this ‘shadow pandemic’ in mental health. While announced measures (i.e. investments in helplines, expansion of Better Access, and the continuation of Telehealth) appear on the surface to be sound government responses for which there is strong support from national peak bodies, in reality, these measures will do little to mitigate the mental health crisis and represent an abdication of the logic that becomes apparent when all the information is brought together through a systems modelling approach.
The most recent reporting of the latest official data on MBS claims for mental health services was presented as evidence of an effective government response with statements confirming that the increased COVID-related mental health ‘demand is being met’, as evidenced by a 6% increase in funded services between 16th March to 4th October compared to the same period last year. However, even if accurate (as health service delivery has been severely disrupted by COVID19 and year-to-year comparisons may be unreliable this year) this increase is only minimally greater than the average annual growth rate in mental health service contacts over the past decade. It does not represent a dramatic increase in services being provided as a response to the crisis and appears insufficient to meet the scale of need indicated by increased calls to helplines nationally. Existing specialist mental health services are already operating at or near capacity (as evidenced by existing waiting times for care and significant increases in mental health related presentations to emergency departments).
While the significant investments in Telehealth are most welcome, and long overdue, and they may have afforded some efficiency gains within existing capacity (through a reduction in patients that fail to attend appointments), further efficiency gains are unlikely. At this time, the current approach to Telehealth appears to result largely in service substitution rather than genuine expansion or re-orientation to overcome other inequities including age, socio-economic and geographical barriers to care. So, with capacity limited and demand increasing, what will happen to mental health and suicide if there is little further investment in specialist community-based mental health service capacity expansion across Australia?
Systems modelling and simulation represents an advanced approach to exploring such questions by mapping and quantifying the pathways and dynamics of the mental health system (Figure 1). Systems models capture changes over time in the prevalence of psychological distress and its drivers; they capture the movement of psychologically distressed people through service pathways involving (potentially) general practitioners, psychiatrists and allied mental health professionals (including psychologists and mental health nurses), emergency departments and psychiatric inpatient care, community- and hospital-based outpatient care, and online services; and they capture waiting times for services, which are dependent on service capacity and the rate at which people flow into, through, and out of the service system. Finally, systems models capture those that fall through the net or disengage from services as a result of long wait times or the receipt of inadequate or poor quality care from a stretched system.
The BMC COVID-mental health dynamic model projected a 7% increase in rates of help seeking compared to September 2019 under the ‘best case’ scenario and a 7.7% increase under the ‘worst case’ scenario. These projections are largely consistent with the 8% increase recently reported nationally for the same period. Moreover, forward projections indicate that we have not yet seen the peak, with help seeking projected to escalate to a 16% increase by September 2021 as a result of the ongoing recession. While helplines can assist with crisis management, they are not equipped to deliver specialist mental health care and hence the increase in demand will flow on to GPs and subsequently to psychiatrists, psychologists and allied care providers. With existing specialist mental health services operating at or near capacity, by September 2021 this increase in demand for services is projected to increase wait times for GPs by 75% and psychiatrists and allied services by 33% compared to September 2019 (under the worst case scenario). In addition, the prevalence of those that have fallen through the cracks will increase by 17% compared to the same period in 2019. As outlined in a series of reports recently released (Road to Recovery, Revised Projections, Investing in Australia’s Mental Wealth), this escalating increase in demand will result in significant individual, health system, social and economic consequences with increased rates of psychological distress, mental health ED presentations, self-harm hospitalisations, deaths due to suicide, health system costs, and productivity losses.
A dynamic systems perspective delivers insights on the non-intuitive behaviours of complex systems and provides a safe environment to test the likely impacts of government investments and actions before they are implemented. The BMC national COVID-mental health model highlights why recently announced national mental health responses will deliver little impact. For example, the expansion of Better Access in the context of an already stretched service system (i.e. there is limited capacity of existing service providers to see more patients) simply acts to benefit some patients while disadvantaging others with the overall impact being an increase in service wait times unless the initiative is coupled with a substantial increase in service capacity. Depending on the extent to which patients take up the expansion in MBS funded sessions, at best, the initiative will have little impact as a public health response. At worst the increased wait times will have knock-on effects on mental health related ED presentations (people in crisis can’t for many weeks to receive care), and disengagement rates, prolonging psychological distress, and increasing the risk of suicidal behaviour.
Systems modelling supports better public policy and reveals where the smart investments lie. The BMC model indicates that the combination of mental health system investments that would deliver the greatest public benefit are; (i) significant increases in service capacity growth across mental health GPs, psychiatrists, psychologists and allied services (i.e. 8-10% growth per year), (i) investments in post-suicide attempt assertive aftercare, and (iii) better coordination of care across teams of service providers enabled through technology.
As yesterday’s press conference highlights, the reporting of individual pieces of data (without consideration of the broader system and its demand-supply dynamics that influence system performance over time) obscures the inadequacies of the current response to the mental health crisis in this country and denies the real challenges mental health practitioners and patients face and will continue to face in the coming years. There needs to be greater accountability for public sector investments and actions, enabled through systems modelling and simulation to ensure that we rapidly implement the best policy options available and use public funds and capacity wisely.
Figure 1: Mapping and quantifying the pathways and dynamics of the mental health system using systems modelling and simulation