A question via Italy: where is the pandemic response to a looming mental health crisis?

Australia faces huge challenges in addressing the mental health impacts of the COVID-19 pandemic, which is bringing trauma, grief, fear, isolation, disruption, loss, and economic hardship, amongst other things.

What can we learn from the experiences of Italy, one of the world’s hotspots?

Dr Sebastian Rosenberg shares some insights from a recent virtual meeting with leading mental health experts from Italy, where more than 105,000 confirmed cases of #COVID-19 have been reported, and more than 12,400 people have died (as of 3pm AEDT, 1 April).

Sebastian Rosenberg writes:

One evening recently, a small group of us had the privilege of a brief Zoom meeting with two leading mental health experts in the Friuli region of Italy.

Our aim was to listen and learn from their experience in attempting to provide mental health care in the time of COVID-19. It was frightening.

The Friuli region encompasses Venice, Udine and Trieste as the main cities, about 1.2 million people. 

They have been affected by COVID-19 much less than the Lombardy region around Milan, but the crisis is impacting everywhere.

Friuli is not like Australia. It is characterised by an exceptionally strong community mental health system, backed up with social cooperatives and day care services that provide places for people with mental illness to go and to work.

The Trieste mental health system is one of the most famous in the world, where psychiatrists led a revolution against inhumane care. 

System impacts

COVID-19 has affected the Friuli regional mental health system in several ways. It has curbed the group meetings that were a feature of their system of care. It has naturally reduced inter-departmental and inter-institutional cooperation. 

Social distancing has made multidisciplinary care much more difficult. They have found their psychiatric workforce not well trained to respond to emergencies. The system is not able to see any new clients, even as issues of anxiety and stress become more prominent across the community.

Importantly, the rate of access to care by existing clients has also fallen considerably. People needing care before COVID-19 are getting less care now. The region, like many areas of Italy, has been affected by a lack of access to Personal Protection Equipment (PPE).

In these circumstances, the Friuli service has been providing daily phone calls to clients and home visits to people with greater needs. Telepsychiatry, almost unheard of before COVID-19, has become popular. It was reported that these teleservices are proving particularly popular with younger clients, familiar with tools such as Skype.

The use of digital or online mental health platforms was rare before and the COVID-19 crisis is not a time for careful development of new services. The social cooperatives, again in accordance with social distancing and business closures, are not operating. The day care services are closed.

In more rural areas of Friuli, away from the main metropolitan mental health centres, responsibility for mental health care has fallen to general practitioners. They generally know who needs help among their local community.

Alarming insights

Our meeting concluded with a series of short statements by Dr Roberto Mezzina, a psychiatrist and one of the key leaders of the Trieste mental health service and world-renowned. 

He stated that the regional approach to mental health care meant each part of Italy was going it alone. The lack of national guidance or governance was debilitating, leaving regions vulnerable, isolated and at risk of pursuing inappropriate strategies.

He stated there were now risks of mental illness and trauma among treating staff as well as issues of suicidality and grief. Mezzina had just published an article presenting a national appeal for action on mental health care.

The Italian system was facing disaster, he said. There was no national emergency plan in relation to the mental health impact of COVID-19. The situation was explosive. People needing help and people trying to provide help were suffering, alone.

Implications for Australia

So what does this frightening situation mean for Australia? 

First, there seems little doubt that the Australian Government’s recent decision to open up Medicare to telehealth for mental health care is useful and most welcome. 

This will go some way to increasing or maintaining access to care, particularly in non-urban areas. This will need to be supported by health professionals, in response to a situation where clients find it difficult or undesirable to physically attend consulting rooms.

But rather than provide individual or spasmodic responses, it may well be useful to consider a specific mental health plan in response to COVID-19, something around which state governments and local regions can organise their resources, planning for the worst while hoping for the best.

There has been considerable recent interest in testing the limits of regional approaches to planning and funding mental health care, something at the heart of the draft report of the Productivity Commission. Disaster planning may be one of those tasks best managed centrally rather than locally.

Australia has focused strongly on ‘flattening the curve’. We have all become overnight epidemiologists. But there is much more to understand beyond the relationship between social distancing and case numbers. As the Italian experience has demonstrated, there is the need for a kind of ‘managerial epidemiology’.

So far and publicly, this has extended to consideration of when the demand for ventilated beds might be exceeded by COVID-19 cases. 

But in relation to mental health, there is an urgent need to consider not only the numbers of cases but also where they occur, the staffing and other resources available to meet this demand and how to shift resources quickly to meet emerging challenges. Mental health planning at this managerial or logistical level has either not occurred or is not in the public realm. 

We cannot afford to leave this to each region to decide. They will need help.

Already in crisis

It should be remembered, of course, that unlike Australia’s world class emergency medicine system, our mental health system is weak. It is typically described as ‘in crisis’. This is the environment in which COVID-19 lands.  

The mental health system received 7.25 percent of the health budget in 1992-93 and 7.6 percent in 2017-18 – almost no change.  Resources are few, staff are stretched. 

Unlike Friuli, non-hospital mental health care is rare and becoming rarer. Our psycho-social rehabilitation services have been run down by the NDIS. Community mental health teams have been withdrawn to the hospital. We do not have a robust system of community mental health care on which to base our response to COVID-19.

And there is one other important issue for us to consider.

There is a strong association in some parts of the consumer and carer movement in Australia between clinical mental health care and harm. This may be a continuation of the anti-psychiatry movement but it has broader implications. 

The push for consumer-led services is often not just couched in terms of their benefit, but also quite clearly as a better and genuinely recovery-focused alternative to the harmful or dangerous services provided by general practitioners, psychologists, nurses, allied health workers and psychiatrists. 

I have no doubt many people have been hurt, traumatised and harmed by mental health care. People want more than pills and beds.

I have no doubt (and the emerging evidence indicates) that consumer-led service would be a useful addition to the psychosocial service landscape. Australia has been slower than other countries (such as the UK) to recognise this.

I am not a clinician. However, the evidence indicates that many people needing mental health care benefit from mixture of clinical and psychosocial support.

We should not be dissuading people from pursuing care. While their own services may be under pressure, health professionals need to unequivocally recognise and advocate the value of psychosocial support.

Our resources are already scarce, stretched and inappropriately allocated. 

But the Italian lesson is that our mental health response, particularly during this time of COVID-19, needs to capitalise on every resource we have available if we are to meet the challenges ahead.

#InThisTogether

• Dr Sebastian Rosenberg was a public servant for 16 years, working in health in state and federal governments. He was Deputy CEO of the Mental Health Council of Australia from 2005-2009. He  works part-time at the ANU and also holds a position as Senior Lecturer at the Brain and Mind Centre at the University of Sydney. He also works privately as a consultant in the area of mental health.

• The virtual meeting described above is one of a series of meetings that The Centre for Mental Health Research at the Australian National University and ConNetica Consulting are jointly hosting with mental health leaders around the world to better understand responses to COVID-19.  A recording of the presentations and discussions is available from either the ConNetica or CMHR websites.