2020: A series of unprecedented events

There is no doubt that 2020 has been an extraordinary year, starting with raging bushfires followed by floods and then the COVID-19 pandemic that has had such a dramatic effect on our way of life. So, it is with a sense of relief, buoyed by the US election result, that we make it to the December issue of the ANZJP. It is perhaps worth pausing to pay tribute to the public health officers who provided good advice to governments in Australia and New Zealand allowing them to take the necessary measures to get control of the pandemic. COVID-19 has dominated everything this year, with decisions needing to be made about the best approach, seemingly choosing between public health and the economy. Some clarity about these types of decisions is provided in a Viewpoint by Mihalopoulos et al. (this issue), who provide us with a framework to consider different courses of action and the ethical dilemmas that are raised. They point out that with increasing unemployment (and inequality) the levels of psychological distress increase as a consequence of job insecurity, financial stress and debt. Added to this are the impact of social isolation, loneliness, complex grief reactions (presumably as a result of ‘lockdowns’) and the stresses experienced by our frontline workers. They discuss the complexity of decision-making to be able to deal with the pandemic and recommend that a dynamic modelling approach is required that takes into account the changing parameters that underpin the overall model.

With the economic downturn triggered by the pandemic, suicide rates are anticipated to increase. Suicide prevention and providing services to those with suicidal intent are critically important. One approach to deal with this is to establish telephone and Internet hotlines. These need to make use of high-quality suicide risk assessment coupled with good communication and counselling skills, as demonstrated in a study by Tong et al. (this issue). These authors describe a hotline established in Beijing and report on a follow-up of high-risk callers. All of the hotline operators had a psychology, or psychiatry, background and underwent 3 months of training before commencing taking calls. Callers to the hotline had their level of hopelessness, psychological distress, suicide intent and overall risk of suicidal behaviour assessed. At-risk callers were provided with a semi-structured psychological intervention that included active listening, showing empathy and respect and providing emotional support. High-risk callers were followed up after 1 day, 1 week, 1 month and 3 months, with suicidal acts being the outcome assessed. All of the calls were recorded and rated on three domains: counselling process, counselling attitude and communication skills. Tong et al. reported that a detailed risk assessment and collaborative problem solving were associated with decreased helplessness, hopelessness and depression by the end of the initial call. When those who had a suicidal act over the follow-up period were compared with those with no suicidal acts, a higher quality counselling process was associated with a lower risk of suicidal acts.

Anxiety in pregnancy has not attracted as much attention as depression, yet it can, like depression have an adverse impact on the developing foetus and is a known predictor of subsequent depression. Viswasam et al. (this issue) measured anxiety levels, using three different measures of anxiety, in each trimester of pregnancy, with the aim of identifying trajectories of anxiety over the course of pregnancy using latent class growth analysis. Overall, levels of anxiety dropped as pregnancy proceeded, particularly from the first to the second trimester. The authors were able to identify two latent classes of trajectory, women with high levels of anxiety throughout the pregnancy and those with a low anxiety trajectory. A previous history of a mental disorder and life stressors were associated with the women in the high anxiety group. This highlights the importance of assessing anxiety among pregnant women and, if the level of anxiety is high, it is likely to persist and requires appropriate intervention to prevent poor outcomes.

A constant frustration for clinicians working in the field is the lack of beds and the seemingly constant ‘access block’. The National Mental Health Service Planning Framework (NMHSPF) brings together epidemiological data and expert opinion to determine how resources should be allocated, in particular, acute and non-acute bed numbers. Allison et al. (this issue) argue that there are insufficient community residential care beds (the numbers are lower than other high-income countries) in Australia that increase the pressure on acute beds. They suggest that there should be more transparency in how expert opinion contributes to the algorithms the NMHSPF use in allocating resources. In response to their debate piece, Whiteford and Diminic (this issue) provide a brief review of the national mental health strategies that have guided how mental health services are planned and the consultation process involved in the formation of the NMHSPF. They point out that the 5th National Mental Health and Suicide Prevention plan aims to move planning to a regional level (involving Primary Health Networks) rather than having a top-down approach. In another response to Allison et al.’s article, Rosen et al. (this issue) highlight the complexity of the mental health system and a focus on bed numbers does not take into account the interrelatedness of various components of the mental health system. These debate pieces provide a valuable background to the much anticipated reforms that will follow the productivity commission report (www.pc.gov.au/inquiries/completed/mental-health/draft).

The Health of the Nation Outcomes Scales (HoNOS) is a routine outcome measure used to assess the outcomes of interventions provided by mental health services. However, interpretation of changes in HoNOS scores over an episode of care can be difficult. Egger et al. (this issue) compare scores on the HoNOS with the Clinical Global Impression (CGI) scales, an intuitively understandable scale widely used in clinical trials, using a technique called equipercentile linking analysis. This essentially equates scores on the CGI severity and improvement scores to the total HoNOS score and the HoNOS change scores. This will make it much easier for clinicians to be able to make sense of the total and change scores of the HoNOS: for example, a HoNOS score of 11 equates to a rating of moderately ill on the CGI severity scale and a fall in the HoNOS score of ⩽12 is equivalent to a clinical impression of ‘much improvement’.

The quality of care in our nursing homes has been under the spotlight with the Australian Royal commission into aged care. What hasn’t been emphasised is the high rate of mental disorders among the older people living in residential care and the fact that it is increasing. Amare et al. (this issue) using data from the National Historical Cohort of the Registry of Senior Australians (ROSA) found that close to 60% had at least one mental disorder, with the most common disorder being depression (42.6%) and a further 14.9% had phobia/anxiety. They noted that the prevalence of mental health disorders increased from 53.8% in 2008 to 64.2% in 2016. Furthermore, half of those with mental health disorders had physical health comorbidity. Polypharmacy was common with close to a quarter of the residents being dispensed up to five medications and a third dispensed 6–10 medications. Provision of good-quality mental health care to our older citizens in residential care is as important as improving the overall quality of care provided to them. Let us hope the Royal Commission covers this in its final report.

A brief return to the topic of the year. Some of the impact of COVID-19 on mental distress has been helped by opening up telehealth that has allowed us to maintain communication with our patients, either using video conferencing or the telephone. While this is clearly an advantage, Zulfic et al. (this issue) point out that not all patients with severe mental illness have access to a phone and clearly depot medications require face-to-face consultations and in-person assessments. They emphasise that careful planning is required for such patients. For those who can access videoconferencing, Perkes et al. (this issue) have provided a useful checklist to assess the readiness for patients to use this.

This issue of the ANZJP has papers that provide food for thought over your summer break. Keep well and keep safe over the festive season.