The use of mental health services, psychological distress, loneliness, suicide, ambulance attendances and COVID-19

There is a correlation between high levels of psychological distress and common mental health disorders. As a result, instruments such as K10 and K6 can be used in representative sample surveys to track changes in the prevalence of these disorders in the Australian population. This is important, as there is an association between mental health issues and deaths by suicide. Data from the Queensland Suicide Register for 2015–17 based on police and coroners reports, show that 46.1% of people who died from suicide were reported to have a had a mental health problem (Leske et al. 2021). Leske et al. (2021) note that this is likely to be an underestimate. Also, around 66% of people who died by suicide in 2020 had mental and behavioural disorders recorded as an associated cause of death (ABS 2021a).

There are several ways to gain insights into the level of psychological distress in the community, and monitor trends over particular time periods.

One way is to look at trends in the use of mental health services. The AIHW compiled data each week during 2020 and fortnightly in 2021 on the use of mental health services and crisis and support organisations during the COVID-19 pandemic. The most current data are available at MHSA. However, while this approach is useful, it is not a direct measure of the level of psychological distress in the population as it does not capture those who choose not to seek assistance or those who cannot access mental health services or crisis and support organisations.

Another way to analyse trends in the level of psychological distress since the onset of the pandemic is to use sample surveys. This approach has been challenging since the onset of COVID-19 due to the fact that face-to-face surveys are very difficult to undertake at this time and pose a potential health and safety risk to interviewers and interviewees. This has led to a number of online surveys being conducted but many of these surveys are not based on probability sampling. In some cases, samples are drawn by inviting all members of the public above a certain age to respond, with unknown response rates. Other samples are drawn from panels where individuals opt-in online. While this sort of approach can provide some useful information, especially regarding associations between factors that may affect outcomes for respondents, results may not be representative of the Australian population and therefore cannot be used, even with reweighting, to derive estimates for the Australian population. A major report on online panels for the American Association for Public Opinion Research (AAPOR 2010) noted that:

Given the need for representative data, the AIHW collaborated with the Centre for Social Research and Methods at the Australian National University to include questions on loneliness and levels of psychological distress in the ANUpoll surveys, which collect data from  the Life in Australia^TM Panel. Importantly, this panel exclusively uses random probability-based sampling methods and covers both online and offline populations (that is, people who do and do not have access to the internet). In addition, as a panel it is possible to obtain longitudinal data from the same respondents prior to the spread of COVID-19, which provides richer information than a series of cross-sectional snapshots, especially with regards to changes over time. Data on psychological distress were collected in April, May, August, October and November 2020, January, April, August and October 2021 and January 2022.

Pre COVID–19 snapshot

To understand how COVID-19 may have affected Australians’ levels of psychological distress, it is important to look at data from before the pandemic. It is particularly important to consider any existing trends prior to the pandemic—for example, if psychological distress was generally increasing among Australians in the years before COVID-19.

This is possible using results from the Australian Bureau of Statistics’ National Health Survey (NHS), which is conducted approximately every 3 years. Tables 1 to 3 show the proportion of males, females and people with high or very high levels of psychological distress as measured by the Kessler 10 Scale from 2004–05 to 2017–18. While the results vary by age, there is no consistent trend over this period. It is worth noting, however, that young women aged 18–24 generally have higher levels of psychological distress than other age groups. From 2011–12 to 2017–18 there have been small increases in the proportion of both males and females with high or very high levels of psychological distress, albeit with important fluctuations over time.

The National Drug Strategy Household Survey (NDSHS) also showed that the proportion of people who reported experiencing high or very high levels of psychological distress increased from 10% in 2010 to 14% in 2019 (AIHW 2020).

Table 1: Proportion of persons with high/very high psychological distress, by age group and year

	18–24	25–34	35–44	45–54	55–64	65–74	75+	Total
2004–05	15.5	11.8	14.9	13.7	12.2	11.2	10.7	13.0
2007–08	11.8	12.3	11.5	13.2	13.2	9.0	10.8	12.0
2011–12	11.8	10.9	10.9	11.4	10.4	9.3	9.3	10.8
2014–15	15.4	10.9	11.9	12.4	11.0	10.1	9.7	11.7
2017–18	15.2	13.1	11.8	14.3	14.4	10.7	8.8	13.0

Source: ABS 4364.0.55.001 - National Health Survey

Table 2: Proportion of males with high/very high psychological distress, by age group and year

	18–24	25–34	35–44	45–54	55–64	65–74	75+	Total
2004–05	12.4	9.3	11.4	11.0	11.3	9.8	10.8	10.8
2007–08	6.5	10.9	8.8	11.1	11.6	7.4	8.8	9.6
2011–12	10.6	8.2	9.1	8.9	8.8	7.0	7.8	8.8
2014–15	11.1	9.8	10.0	9.2	9.8	9.7	9.0	9.9
2017–18	12.4	11.8	10.3	13.2	12.1	10.0	7.5	11.3

Source: ABS 4364.0.55.001 - National Health Survey

Table 3: Proportion of females with high/very high psychological distress, by age group and year

	18–24	25–34	35–44	45–54	55–64	65–74	75+	Total
2004–05	18.7	14.3	16.6	16.3	13.1	12.5	10.7	15.1
2007–08	17.4	13.9	14.2	15.3	14.7	10.6	12.3	14.3
2011–12	13.0	13.6	12.7	13.8	11.9	11.6	10.5	12.7
2014–15	20.0	11.7	13.7	15.4	12.3	10.3	10.6	13.5
2017–18	18.4	14.7	13.7	15.3	16.9	11.3	9.7	14.5

Source: ABS 4364.0.55.001 - National Health Survey

Psychological distress under COVID-19

The initial results from the Australian Bureau of Statistics’ National Study of Mental Health and Wellbeing, 2020–21 showed that 15% of Australians aged 16–85 experienced high or very high levels of psychological distress as measured by the Kessler 10 scale in 2020–21 (ABS 2021b). However, being from a different survey, these results are not directly comparable with the pre-COVID-19 results from the NHS or NDSHS.

The ANUpoll collected data on psychological distress using the K6 scale prior to and during the COVID-19 pandemic. Data were collected from 2,500 respondents in 2017 (February), and over 3,000 respondents in 2020 (April, August, October and November), 2021 (January, April, August and October) and 2022 (January).

Prevalence of ‘severe’ psychological distress in 2020, 2021 and 2022

The K6 scale can be used to categorise those survey respondents experiencing ‘severe’ psychological distress, consistent with having a ‘probable serious mental illness’ according to their K6 score. Figure 1, below, shows the proportion of people experiencing severe psychological distress for each of wave of the ANUpoll during the COVID-19 pandemic as well as prior to the pandemic in February 2017.

Results of the surveys show that the proportion of the population experiencing severe psychological distress rose from 8.4% (of people aged 18+) in February 2017 to 10.6% in April 2020 (Biddle et al. 2020b) with a subsequent fall to 9.7% in May 2020 followed by an increase to 10.9% in October 2020, and a substantial decrease to 9.4% in January 2021 (Biddle & Gray 2021b). The proportion of people experiencing severe psychological distress in August 2021 (10.1%) was similar to April 2021 (9.7%) and continued to be significantly higher than in February 2017 (8.4%) (Biddle et al. 2021c). Between August and October 2021, there was a large and statistically significant increase in the proportion of Australians experiencing severe psychological distress from 10.1% to 12.5%. At 12.5% in October this proportion was at its highest level recorded since the onset of the COVID-19 pandemic (Biddle et al. 2021d). The Proportion of people experiencing severe psychological distress declined to 11.0% in January 2022, however the change was not statistically significant (Biddle & Gray 2022).

Figure 1: Proportion of Australians aged 18 years and over experiencing severe psychological distress, by survey month from February 2017 to January 2022

Average psychological distress (K6 score) in 2020 and 2021

In February 2017, the average K6 score was 11.2. In April 2020, it increased to 11.9. Between April and May 2020 there was a significant reduction in psychological distress (to an average score of 11.5); however, the score remained above the pre-COVID-19 level of February 2017. The average score rose from 11.5 in May 2020 to 11.7 in August 2020 but showed very little change from August to October 2020 (11.8) (Biddle & Gray 2020). This was followed by a large and statistically significant fall in the average K6 score from October to November 2020 (11.4) (Biddle et al. 2020e). While the average score in November 2020 was quite a bit lower than it was in April 2020 it was higher than it was prior to the onset of COVID-19 in February 2017.

From November 2020 to January 2021, the average K6 score fell from 11.4 to 11.2 and continued to decline to 11.1 in April 2021 (Biddle & Gray 2021b). In August 2021, following the most recent outbreak of COVID-19, the average K6 score increased (worsened) to 11.3 but remained lower than scores recorded in April to October 2020. The increase in psychological distress between April and August 2021 was greater for women than men (after controlling for levels of psychological distress in April 2021). Also, after controlling for other factors, women had higher levels of psychological distress in August 2021 compared with men (Biddle & Gray 2021c).

The average level of psychological distress in August 2021 (11.3) was not significantly different to the pre-pandemic level (11.2) observed in February 2017 (Biddle & Gray 2021c). In other words, the average level of psychological distress had returned to pre-COVID-19 levels. That said, however, there were differences by age (Figure 2).

Between August and October 2021, the average level of psychological distress increased significantly from 11.3 to 11.7 but remained lower than the peaks April and October 2020 (11.9 and 11.8, respectively) (Biddle & Gray 2021d). The worsening of psychological distress between August and October 2021 was due to increases among people aged 18 to 44 years and 75 years and older (Figure 2).  Between October 2021 and January 2022, there was a slight but not statistically significant decline in average psychological distress from 11.7 to 11.6 (Biddle & Gray 2022).

Psychological distress by age

Figure 2 shows average K6 scores by age groups. The chart shows a clear gradient with younger people experiencing higher average levels of psychological distress than people in older age groups (Biddle et al. 2020c,d; Biddle & Gray 2020; Biddle & Gray 2021a,b,c,d). The chart also shows a very distinct pattern over time. For younger people (18–44), average levels of psychological distress were higher in 2020 and 2021 than they were before the pandemic, especially for those aged 18–24, while those aged 45 and above experienced either little change or improvements in their level of psychological distress. As an example, the average levels of psychological distress among those aged 18–24, 25–34 and 35–44 were significantly higher in April 2020 than in February 2017 (Biddle et al. 2020c). However, it is worth noting there were improvements during the course of 2020. For example, the level of psychological distress among those aged 18–24 showed a significant improvement from October to November 2020 (Biddle et al. 2020e).

Figure 2: K6 measure of psychological distress, by age group and selected survey months from February 2017 to January 2022

What contributed to increased levels of psychological distress?

The heightened level of psychological distress in April 2020 coincided with the first wave of COVID-19 infections in Australia and the initial lockdown period, while the improvement from April to May 2020 coincided with the loosening of restrictions. The worsening in the level of psychological distress between May and August 2020 coincided with the second wave of COVID-19 in Victoria and the associated lockdown – with much of the worsening in the average K6 score over this period reflecting changes in Victoria (Biddle & Gray 2020).

To test whether outcomes worsened in Victoria relative to the rest of the country after the reintroduction of lockdowns in July 2020, Biddle et al. conducted a difference-in-difference analysis using linked data for May and August (that is, data across these months for the same people) (Biddle et al. 2020d). This showed a significant worsening in Victoria relative to the rest of the country on several outcomes including: psychological distress, loneliness, life satisfaction, satisfaction with direction of country, likely to be infected by COVID-19 and hours worked). On the other hand, the decrease in levels of psychological distress from October to November 2020 coincided with improvements in Victoria. According to Biddle et al. (2020e):

In 2021, the worsening of psychological distress between April and August was greater for residents of Sydney and Melbourne than those living in the rest of Australia (Biddle & Gray 2021c). The increase in psychological distress from August and October 2021 did not show a clear geographic pattern.

One of the advantages of the data collected through ANUpoll is the fact that longitudinal data are available for a proportion of respondents. This makes it possible to model the factors that appear to be contributing to rises in the level of psychological distress during the pandemic using regression analysis (Biddle et al. 2020c). Modelling of ANUpoll data collected from the same respondents in February 2017, April 2020 and May 2020 showed that the strongest predictor of psychological distress (K6 score) was 'increased (worsened) stress' (this is not surprising as stress is a key predictor of poor mental health outcomes) (Biddle et al. 2020c). 'Increased loneliness' was also a strong predictor of K6 scores even when other factors like changes in employment status were controlled for. This suggests that increased loneliness during the pandemic is of concern and that increases in psychological distress are not only being driven by job loss.

Job loss itself was a predictor of K6 scores in the modelling (Biddle et al. 2020c). Controlling for other factors, people who were employed in February 2020 but not in May 2020 had higher levels of psychological distress than those who were employed. Interestingly, in all the models, those living outside capital cities had lower rates of psychological distress than those living in capital cities, after controlling for other factors (Biddle et al. 2020c). This is probably a reflection of the fact that infection rates and the economic impacts of lockdowns have been higher in major cities than they have been in regional or remote areas.

After controlling for factors such as ‘relationships worsening’, ‘increased stress’ and ‘loss of employment’, there was no significant difference in K6 scores between young people (18–24) and older people. This suggests that these factors were the drivers of higher levels of psychological distress among young people.

One final point worth noting is that in the regression analysis of K6 scores, previous K6 scores in February 2017 had a significant predictive effect on K6 scores for May 2020 (Biddle et al. 2020c). This shows that people who are already experiencing high levels of psychological distress can be particularly vulnerable when the situation worsens.

Loneliness

The ANUpoll also asked respondents whether ‘In the past week, how often have you felt lonely?’ Analysis summarised in Biddle et al. (2020c) shows that those who experienced loneliness had higher rates of psychological distress than those who did not.

Between April 2020 and May 2020, there was a significant decline in experiences of loneliness overall, with 36.1% of the sample saying that they experienced loneliness at least some of the time in May 2020, compared with 45.8% in April 2020 (Biddle et al. 2020c). Declines in loneliness were consistent by age and sex, with the exception of young people (aged 18–24) who did not have a statistically significant reduction in the level of loneliness from April to May 2020 – despite the fact that they had the highest proportion of respondents saying that they felt lonely at least some of the time in April 2020 (63.3%) (Biddle et al. 2020c).

There was a rise in reported loneliness from 36.1% in May 2020 to 40.5% in August 2020 (Biddle et al. 2020d). However, this rise only occurred in Victoria where the proportion of the population who were lonely at least some of the time increased from 35.7% in May 2020 to 44.5% in August 2020; in ‘the other seven States and Territories, there was no significant difference between loneliness in May 2020 (37.1%) and August 2020 (38.8%)’ (Biddle et al. 2020d). The increase in loneliness from May 2020 to August 2020 in Victoria coincided with the lockdown associated with the second wave of COVID-19 infections.

Females were more likely to report experiencing loneliness than males (44.8% of females compared with 35.7% of males in August 2020). The proportion of young people aged 18–24 years who were experiencing loneliness in August 2020 was also higher than for other ages groups (Biddle et al. 2020d).

The proportion of Australians who said that they had experienced loneliness at least some of the time declined from 40.5% in August 2020 to 35.2% in November 2020 (Biddle et al. 2020e). This is the lowest value observed over the COVID-19 period so far. In addition, according to Biddle et al (2020e):

The proportion of Australians who said that they had experienced loneliness at least some of the time remained fairly consistent from November 2020 (35.2%) to January 2021 (36.1%) and April 2021 (35.5%), and increased slightly in August 2021 (37.6%) (Biddle & Gray 2021a & c). However, the increase in loneliness in August 2021 was mainly due to a large increase in Sydney, with the proportion of Sydney residents experiencing loneliness at least some of the time increasing from 35.3% in April 2021 to 44.3% in August 2021, while the rest of Australia reported little change in this period (34.6% in August 2021 compared with 34.0% in April 2021). At the time of the August 2021 survey, Sydney had been in lockdown for the longest amount of time during COVID-19 Delta strain outbreak. The proportion of Australians who said that they had experienced loneliness at least some of the time increased in October 2021 (39.1%) (Biddle 2021) and then decreased in January 2022 (38.1%) (Biddle 2022) but remained above the lows from November 2020 to April 2021 (Biddle & Gray 2022).

Loneliness has a clear impact on levels of psychological distress and life satisfaction. In a regression analysis of data from the November 2020 ANUpoll (that controlled for psychological distress in April 2020) those who felt lonely ‘some’, ‘occasionally’ or ‘most’ of the time all had significantly higher levels of psychological distress than others (Biddle et al 2020e). This suggests that reductions in loneliness may contribute to reductions in levels of psychological distress. Similar results are evident for life satisfaction – that is, after controlling for life satisfaction in April 2020, people who reported feeling lonely at least some of the time had significantly lower levels of life satisfaction than others.

Life satisfaction

Another way of tracking wellbeing is to analyse changes in life satisfaction. In the ANUpoll surveys life satisfaction is measured on a scale of 1 to 10, with higher scores indicating higher levels of satisfaction. Average life satisfaction scores fell substantially during the early stages of the pandemic from 6.9 in January 2020 to 6.5 in April 2020, before rising to 6.8 in May 2020 as infection rates fell and lockdown conditions started to be eased (Biddle et al. 2020d). The average level of satisfaction then fell to 6.6 in August 2020. However, between October and November 2020, life satisfaction improved substantially from an average score of 6.7 to 7.0. Importantly, the average life satisfaction score was no longer significantly different to that recorded in October 2019 (7.1), and was slightly higher than that recorded during the Black Summer Bushfire crisis (6.9 in January 2020) (Biddle et al. 2020e).

Although the overall level of life satisfaction in November 2020 had returned to pre-COVID levels (October 2019) there was a substantial reduction in life satisfaction scores during 2020. A regression analysis conducted in November 2020 using the longitudinal nature of the ANUpoll data, suggested that after controlling for the level of life satisfaction in January 2020, the total loss of life satisfaction over 2020 was:

• significantly higher for people living in Victoria compared with the rest of the Australian population
• lower for those aged 55 years and over compared with those aged 35–44
• lower for those who were living outside the capital cities (Biddle et al. 2020e).

This is consistent with what you would expect given the greater impact of, among other things, lockdowns (through, for example, their impact on employment) for younger people, people in Victoria and people living in capital cities.

Nationally, the average life satisfaction score showed little change from November 2020 (7.0) to January 2021 (7.0), and then declined slightly to 6.9 in April 2021, although the difference was not statistically significant (Biddle & Gray 2021a,b).

In August 2021, the average life satisfaction score in Australia decreased substantially to 6.5, to a level similar to that reported in April 2020 at the peak of the first wave of COVID-19 in Australia and was lower than all other time points measured by ANUPoll (Biddle & Gray 2021c). In order to illustrate the magnitude of the decline in life satisfaction between April and August 2021, Biddle & Gray (2021c) converted the decline into income equivalents, based on the relationship between life satisfaction and household income prior to the pandemic. This model estimated that the decrease in life satisfaction reported between April and August 2021 was equivalent to a loss of $827 in average weekly household income (Biddle & Gray 2021c).

There was a slight increase in life satisfaction between August 2021 and October 2021, from 6.5 to 6.6. The October ANUPoll was conducted in mid-October when COVID-19 restrictions were beginning to be lifted. Life satisfaction remained at 6.6 in January 2022, still lower than the levels observed pre-COVID-19 and from November 2020 to April 2021 (Biddle & Gray 2021d, 2022).

There has been considerable commentary since the start of the pandemic on its potential to impact on the incidence of deaths by suicide. Much of this commentary has been based on modelling using previous experience including the relationship between unemployment and deaths by suicide. However, evidence to-date does not indicate an increase in suicide deaths in Australia during the COVID-19 pandemic. National mortality data published by the Australian Bureau of Statistics show that the rate of death by suicide in Australia was lower in 2020 (12.1 per 100,000 population) than in 2019 (12.9 per 100,000 population), see Deaths by suicide over time. That said, Australian Bureau of Statistics coding of psychosocial risk factors associated with deaths by suicide in 2020 determined that 3.2% of these deaths had the COVID-19 pandemic mentioned in either a police or pathology report or a coronial finding. In most of these cases, other risk factors for suicide were also present, see Psychosocial risk factors and deaths by suicide.

Internationally, a ‘living systematic review’ (John et al. 2021) based on evidence until 19 October 2020, has concluded that:

A study on trends in suicide deaths during the first 4 months of pandemic (1 April to 31 July 2020), which included Australian data from suicide registers in New South Wales, Queensland and Victoria, found that (Pirkis et al. 2021):

Since 2020, suicide registers in Victoria and New South Wales have regularly published data on suspected deaths by suicide in 2019, 2020 and 2021. The Suicide in Queensland: Annual Report 2021 (Leske et al. 2021) included data on suspected deaths by suicide from the interim Queensland Suicide Register (iQSR) from 2018 to 2020. The number of suspected deaths by suicide recorded in suicide registers fluctuates from year to year and, while there have been increases and decreases in some jurisdictions in 2020 and 2021 compared with 2019, there is no evidence to-date that COVID-19 has affected the overall number of suicide deaths. For more information see Suspected deaths by suicide.

While COVID-19 does not appear to have affected suicide rates in Queensland compared with previous reports, the following is worth noting (Leske et al. 2021):

It is true that some key risk factors associated with deaths by suicide did worsen following the onset of COVID-19. For example, there were considerable job losses and rises in the level of psychological distress. On the other hand, it is possible that a general sense of ‘we are all in this together’ could have a protective impact. From February to April 2020 there were rises in the level of trust in others and in governments in Australia (Biddle et al. 2020a). In addition, the vast majority of people who experience unemployment or high levels of psychological distress or mental health issues will never experience a suicide attempt. That said, it is very important to monitor trends in risk factors and trends in deaths by suicide in real time.

Another factor that should be considered is the impact of both JobKeeper and the JobSeeker supplement. This is important given the association between the risk of dying by suicide and socioeconomic outcomes. Modelling undertaken by the ANU suggests that not only were levels of poverty and housing stress lower than they otherwise would have been as a result of these payments, they were also lower than they were prior to the spread of COVID-19 (Philips et al. 2020). Households who mainly relied on the JobSeeker payment prior to COVID-19 and the introduction of the JobSeeker supplement saw their poverty rate fall from 67% prior to COVID-19 to 6.8% (Phillips et al. 2020). On a similar note Biddle et al. (2020d) found that real incomes actually rose for those in the bottom decile of the income distribution from February to August 2020. Using data from the Taking the Pulse of the Nation Survey, Botha et al. (2020) have shown that the level of psychological distress among the unemployed has fallen since May 2020. The ANU modelling suggests that the protective impact of JobKeeper and the JobSeeker supplement on housing stress and poverty were reduced somewhat by the changes to these payments announced in July (Phillips et al. 2020).

A key part of the National Suicide and Self-harm Monitoring Project is the compilation and coding of data from ambulance attendances. The National Ambulance Surveillance System (NASS), established in 2020, provides data on ambulance attendances for suicidal and self-harm behaviours for New South Wales, Victoria, Queensland, Tasmania and the Australian Capital Territory. The NASS is a partnership between Turning Point, Monash University and jurisdictional ambulance services across Australia. Comprehensive data from the NASS are reported in Ambulance attendances: suicidal and self-harm behaviours.

In 2020, prior to the establishment of the NASS, the AIHW asked Turning Point if they could prioritise the coding of data for Victoria. Victoria was chosen as monthly data on ambulance attendances were already being compiled for the Victorian Government and there were concerns about the impact of the Melbourne lockdown on suicide and self-harm behaviours.

Monthly data on the number of ambulance attendances related to suicide attempts in Victoria from 2018 to 2020 are shown in Figure 3. As the figure shows, there is no clear difference from 2018 to 2020. The total number of ambulance attendances related to suicide attempts in Victoria in 2020 was 4% lower than in 2019 but 8% higher than in 2018.

Interestingly, in 2020, there was an 11% increase in the total number of ambulance attendances in Victoria relating to suicidal ideation (thinking about suicide), compared with 2019, with the increase more pronounced in the second half of 2020. There was also an increase in the total number of mental health attendances (16% higher in 2020 than in 2019). This is consistent with the overall greater use of mental health services in 2020 that is evident in other data. This highlights the fact that greater use of, and need for, mental health services does not necessarily equate to trends in the number of suicide attempts. The vast bulk of people who use mental health services will never have a suicide attempt but timely access to mental health services may reduce the number of deaths by suicide. The total number of ambulance attendances for self-injury in Victoria in 2020 was considerably higher (33%) than in 2019. This highlights the fact that self-injury and suicide attempts are not the same thing.

Figure 3: Monthly ambulance attendances for suicide attempts, Victoria, 2018–2020

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