The impact of COVID-19 on the mental wealth of Australia

American architect and systems theorist, Richard Buckminster Fuller, once said: "There is nothing in a caterpillar that tells you it’s going to be a butterfly."

In my youth, these were words that inspired hope, that even from humble beginnings as a daughter of Italian immigrants; in Australia, the land of opportunity, one could hope to reach their full potential and make a unique contribution to science and society. I wonder whether the youth of today will have the same opportunities. In the face of the dual crises of a pandemic and global recession, what price will we pay in lost human potential?  What contributions to civil society, to the arts, to science and technology, to the economy, and to humanity will be lost as hardships increase across communities, and the trajectories for young people, and other vulnerable groups are stifled by diminished opportunity?

We may never be able to quantify the true extent of this loss, but the concept of Mental Wealth (a term coined by UK Professor, John Beddington) provides an important starting point. A nation’s Mental Wealth is defined as the collective cognitive and emotional resources of citizens. It includes people’s mental capital (which is their cognitive ability and emotional intelligence). It also includes mental health and well-being which underpin the ability to work productively, creatively and build and maintain strong positive relationships with others. So, how a nation nurtures mental capital, mental health and wellbeing, through adequate education, economic security, housing, healthcare, psychological and cultural safety, and through equal access to opportunity, will have a significant effect on its economic competitiveness and prosperity, and the collective wellbeing and resilience of communities. 

We don’t have to look too far back to understand the corrosive impacts of recession on human potential. According to a European Commission report eight years after the onset of the 2008 Great Recession, almost one third of young people remained at risk of poverty or social exclusion, facing long-term unemployment, or involuntary temporary or part-time work (European Commission, 2016). In Australia, the July 30 Productivity Commission report confirmed similar ‘scarring’ impacts on our young people; reporting a ‘lost decade’ of income growth, a decline in occupational choices, a decline in employment quality and quantity, and greater exposure to future economic shocks across their lifetimes.

Recessions also impact the developmental trajectories of children through the toll that recessions take on families that can diminish parental emotional investment, and increase domestic violence, child abuse and neglect. Such adverse experiences early in life can have severe and long-term impacts on mental health.

Added to this are the corollaries of the pandemic itself including social isolation and chronic uncertainty that are exacerbating psychological distress and mental health problems among previously healthy people and especially among those with pre-existing conditions. 

So, what can be done to mitigate the impacts of the pandemic and recession on our nation’s Mental Wealth and set us on the best path to recovery? I certainly don’t have all the answers, but I hope today’s address will help broaden the thinking about the approach we need to take to finding the most effective strategies.

Challenges in responding effectively to the crisis:

Quite early in the evolution of the pandemic in Australia, efforts to mitigate the mental health impacts naturally focused on the health sector response. There were national investments to increase the capacity of helplines, provide family support to reduce domestic violence, scale up telehealth, and other psychological supports through online resources; and there have been a range of commitments made since. But will this be enough? Even prior to the current crisis, significant questions were being raised as to the effectiveness of the mental health system with a Royal Commission into Victoria’s mental health system ongoing and the final report of the Productivity Commission Inquiry into mental health handed to the Australian Government on 30 June. 

Over the last decade, despite successive statutory inquiries and hundreds of millions of dollars having been spent on mental health system reforms, rates of mental illness and suicide in Australia had not been decreasing. With such inertia, how can we hope to effectively respond to this current crisis?  

The problem is complex: 

• Research has highlighted the vast array of ‘risk factors’ associated with poor mental health and suicide that provide many potential targets for intervention.
• There are a broad range of interventions, programs, services, and health system solutions being proposed that represent seemingly good investments.
• The system is complicated by the division of roles and responsibilities between Federal, State and Territory governments, regional primary health networks, and private and non-government sectors.
• And there are many, many different views about what should be done.

This complexity has resulted in an approach that promotes broad strategies, based on the rationale that if more evidence-based programs and services are funded, then the impact is simply additive. This simplistic ‘more is better’ perspective is reflected in our National Mental Health Pandemic Response Plan that has 77 priority actions. The 5th National Mental Health and Suicide Prevention Plan released in August 2017 had 32 priority government actions and 82 sub-actions. These sorts of ‘non-strategic’ strategic plans provide no estimates of the scale of impact these actions are likely to have, and could actually be undermining the potential impact of investments by spreading available resources too broadly and inefficiently. This is not a criticism of any one agency or government, nor is it an approach that is limited to mental health, it’s just a natural well-meaning response when the tools are lacking to better focus investments and actions. 

What can we learn from other sectors?

To understand and manage complexity, other fields rely on the analytic techniques of complex systems science. Disciplines as diverse as physics, information theory, computer science, ecology, meteorology, sociology, and biology have harnessed complex systems modelling and simulation to better understand complex phenomena; from the earths global climate, to the human brain, to crowd behaviour, traffic congestion, and racial segregation. In the business, engineering and finance sectors, systems modelling has been deployed to support strategic planning, reduce supply chain instability, improve operational and allocative efficiency, improve public safety, and determine which products and services will deliver the best returns on investment, in which markets, at what time, and at what price. 

In contrast, with the exception of infectious disease control, the design of policy, health system reform, strategic planning, and operational decision-making in the health and social sectors is largely devoid of engagement with these sophisticated tools. This is the case despite the scale of spending on health being in excess of $180 billion per year (2016-2017). The lack of engagement with systems modelling to guide decision making confines us to delayed actions, wrong turns, trial and error, waste and inefficiency, and a lack of agility to be effective in our responses to a rapidly changing world. 

Without these tools to help us see forward, on what basis do governments make decisions about how to effectively respond to the mental health crisis? What combination of initiatives or reforms should be prioritised? What targeting, timing, scale, frequency, and intensity of investments are needed? What impacts should we expect? How long do we need keep programs and initiatives in place? Will there be rebound effects when we remove them? Will there be unintended consequences? Without these tools, we are fumbling around in the dark, trying to make important strategic decisions that will impact people’s lives in fundamental ways.

At the Brain and Mind Centre of the University of Sydney, we have brought together expertise in mathematics, biostatistics, epidemiology, psychology, psychiatry, social science, policy, and economics. We are leveraging best research evidence, data, and local knowledge through inclusive participatory processes, to build systems models that are capable of informing clinical care coordination, mental health policy and planning, and system reform, and that are capable of being rapidly deployed to inform how to effectively mitigate threats to mental health (and mental wealth), just as the infectious disease research community has done in responding to the COVID-19 threat.   To drive forward this approach we have partnered with CSART – an international alliance of centres of excellence in systems modelling, simulation, data science, and global health (spanning Swiss, Canada, US, UK, Colombian, and Australian Institutions) that are sharing advances in tools and technologies and building technical capacity.

We have developed the first prototypic national systems model of mental health and suicide that incorporates the feedbacks between the economy, mental health and policy responses. Dr Adam Skinner, our senior systems modeller deserves a special mention for leading this ground-breaking work. While the course of the virus and extent of economic impact remains uncertain, the model inputs are being updated with revised RBA and treasury outlooks for unemployment. Our most recent simulations estimate that the prevalence of psychological distress across Australia will peak at around 45 percent by April 2022, and among youth at almost 60 percent by November 2021. The proportion of youth not in employment, education or training (NEET) is projected to peak at 38 percent in major cities and 42 percent in regional areas.  Youth mental health-related ED presentations are projected to increase by 26 percent, self-harm hospitalisations by 28 percent, and suicide deaths by 30 percent over the next five years.

The projected cumulative cost of lost productivity associated with psychological distress, hospitalisations, and suicide over the period March 2020 - March 2025 is estimated to be $114 billion, which includes $11.3 billion in lost productivity among the youth population. This mental health related productivity loss is not traditionally accounted for in economic analyses. In addition, over the next five years, the cumulative mental health services costs are projected to be $51.6 billion, which is $874 million above what it would have been had the pandemic not occurred.  

But this trajectory is not inevitable, and the primary purpose of the model is to provide a safe environment to test a range of strategies and initiatives that could help Australia avoid this trajectory. 

Of the interventions we tested, employment programs (like JobKeeper) were the single most effective strategy for mitigating the adverse mental health impacts of the COVID-19 crisis; however, ceasing these programs too early in the trajectory of economic recovery decreases their impact. Approximately 388 lives are projected to be saved by extending JobKeeper to May 2022 – 82 of those lives will be among young people. Large additional investments in health system capacity are also required to flatten the mental health curve. 

The combination projected to deliver the greatest impact is:

• Extending JobKeeper (until May 2022).
• Investing in education support programs.
• Scaling up post suicide attempt assertive aftercare across the country.
• Significantly increasing community-based specialist mental health services capacity; and
• Investing in technology-enabled coordination of team-based care.

This combination is forecast to reduce mental health ED presentations by almost 10 percent (168,655), self-harm hospitalisations by 12 percent (23,112), and save 2,450 (11.2 percent) lives from suicide over the next 5 years, 389 of those among young people. However, the scale of these impacts will only be seen if the investments in mental health system strengthening occurs in early 2021 – so time is critical – delays and underinvestment in national mental health system strengthening, or ceasing investments in employment programs too early will cost lives. These findings also highlight the importance of not being constrained by a health system lens to respond to mental health challenges. Far greater gains in mental health (and our national mental wealth) can be made by coordinating economic, education, and mental health policies and actions. 

Conclusion: 

In closing, there remain many unanswered questions, but the interdisciplinary science of complex systems is shining a light on the darkness. To paraphrase fellow systems scientists in the US, while we might still be fumbling in low light… it’s the low light of dawn. 

Opportunity unlocks potential. 

We have a responsibility to use the best tools available, to better understand how to design and invest in our complex health and social systems to optimise the potential of all Australians, and particularly for young people. It is not only morally and socially fundamental… it is the key to our economic prosperity.

Associate Professor Jo-An Atkinson is head of systems modelling, simulation & data science and co-director of the mental wealth initiative at the University of Sydney’s Brain and Mind Centre. This is the full speech prepared for the National Press Club speech that she delivered today.

If you or anyone you know needs support, please call Lifeline on 13 11 14, Beyond Blue on 1300 22 46 36 or headspace on 1800 650 890.