Pre-Budget Submission 2021- 2022 - Science. Compassion. Action - Black Dog Institute, January 2021

Pre-Budget Submission 2021- 2022 - Science. Compassion. Action - Black Dog Institute, January 2021

Pre-Budget Submission 2021-
Black Dog Institute, January 2021
As the only Medical Research Institute in Australia to investigate mental health across the lifespan, we
take a unique translational approach, harnessing the latest technology and other tools to quickly turn
our world-class research findings into clinical services, education, and e-health products that improve
the lives of people with mental illness and the wider community. We distil the best international research
to help inform policy and practice. We focus on key population mental health issues impacting Australia
including suicide prevention, digital mental health, workplace mental health, novel treatments for
depression and anxiety and how mental health disorders can be prevented.

I am pleased to present Black Dog Institute’s 2021-22 Pre-Budget submission.

The first COVID-19 case in Australia was confirmed on the 25th of January 2020. Now, one year on,
Australia and the world have changed dramatically, and the pandemic is not yet over.

At the pandemic onset, the government responded quickly and effectively to close borders and enact
public health orders to curb the spread. The lockdown measures and associated isolation, uncertainty,
economic impacts have created pervasive stressors for many Australians and changed the way we live,
work, and socialise. Unemployment rates have increased substantially since the onset of the pandemic

The pandemic has had a devasting impact on population mental health, exacerbating existing mental
health conditions and creating new ones. Early on, 1 in 2 Australian adults experienced psychological
distress (2, 3). This was exacerbated in young people, where 3 out of 4 reported distress (4). Call centres
such as Lifeline and other online crisis support services have seen a 40% increase in traffic in 2020,
with usage rates following the movement of lockdown waves. Job insecurity and financial uncertainty
are a strong contributor to pandemic-related mental ill health. Evidence shows that people who are
unemployed are at a 2 to 3 times greater risk of suicide (5). Further, evidence from past economic crises
show that spikes in unemployment rates are followed by corresponding surges in population suicide
rates – this can be ameliorated through social welfare measures.

We are thankful for and support the investment by all governments into mental health, and the
recognition that protecting population mental health is essential for Australia’s recovery. We support the
Federal Government’s strong fiscal and public health measures to protect jobs and businesses, including
the JobSeeker and JobKeeper initiatives and MBS-funded telehealth. These responses have been world
leading and are likely to have had protective impacts on population level distress and suicide risk.

Continuing these supports is critical. With physical distancing a continued fixture for the foreseeable
future, we also see the opportunity to expand new models of digital care to at risk groups. COVID-19 has
highlighted that there is a demand for and user acceptance of technology-assisted mental health care,
particularly where traditional services may be inaccessible or less affordable.

Community outbreaks remain a reality while Australian travellers continue to return home from overseas,
creating frequent changes to restrictions and widespread uncertainty. The COVID-19 pandemic is not
over. We think there will be a sustained need for fiscal and policy focus on social welfare, prevention, and
appropriate mental health services, even as restrictions ease in some areas and as we move towards
vaccine rollout. The pandemic has further highlighted the need for crisis preparedness and prevention.

The 2021-22 Budget should also be driven by the landscape for mental health reform in Australia. The
finalisation of two major system reviews – the Productivity Commission Inquiry and the National Suicide
Prevention Taskforce – have highlighted the costs of mental ill health and the benefits of reform. Mental
ill health and suicide cost Australia $220 billion per year, more than $600 million per day (6).

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Governments should act now, in this year’s Budget, to reduce this burden.

Black Dog Institute’s highest priority for the 2021-22 Budget is ensuring that population mental health is
safeguarded through the rest of the pandemic and beyond.

Our recommendations for the 2021-22 Budget are:

•   Recommendation 1: Continue business and employment supports during the COVID-19 pandemic

•   Recommendation 2: Continue telehealth and invest in blended and digital care

•   Recommendation 3: Sustained investment into prevention research via Prevention Hub

•   Recommendation 4: Sustained investment into healthcare workers’ mental health through The
    Essential Network

•   Recommendation 5: Build on existing suicide prevention investment

•   Recommendation 6: Implement the recommendations from the major mental health reviews


Professor Samuel Harvey

Black Dog Institute Chief Psychiatrist & Acting Director

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Recommendation 1: Continue business and
employment supports during the COVID-19
The COVID-19 pandemic is not over. As shown by the recent outbreak of cases in the NSW community,
ongoing financial support is needed for businesses, employees, families, and individuals. We urge the
Government to continue monitoring the impact of stimulus and protective economic measures and
adjust them based on the needs of the population, particularly for at-risk groups such as the recently
unemployed. Despite recent gains near the end of 2020 in employment figures, the unemployment rate
remains high compared to pre-pandemic levels (7), with further pressures to arise if existing programs
like JobKeeper are wound back as planned.

Appropriate social welfare payments during economic downturns not only protect businesses and
the economy but have also been shown to have a protective effect on population mental health and
wellbeing, including helping to alleviate anxiety (8) and suicide risk (1). The Productivity Commission
Inquiry has also highlighted the important links between employment, housing, and mental health (9, 10).

Priority actions required
To continue managing the COVID-19 public health and economic crisis, we recommend that as a priority,
the Government should:

•   Continue support for healthcare workers by providing timely and accurate information about the
    pandemic’s latest global developments, adequate PPE, and mental health supports including through
    digital technology (see Recommendation 4). There is strong evidence that this type of practical
    support is critical in maintaining a functional health workforce. Support for healthcare workers will
    remain crucial during the vaccine rollout period as they are likely to experience higher levels of
    anxiety than the general public (11, 12).

•   Extend and expand JobMaker Hiring Credit. If JobKeeper and JobSeeker are wound back as
    intended, JobMaker should provide the necessary economic support for people of all ages.
    Unemployment during economic downturns is strongly linked with increased rates of suicide, but
    risk can be mitigated by social welfare programs (1) and improved job security (13). Further, middle-
    aged men between 56-64 have seen the biggest increase in suicide rates in Australia between 2006
    and 2019, and middle-aged women 45-54 have the highest suicide rate compared to all other age
    groups of women (14). JobMaker should be expanded to those over 35 who have lost their job or are
    underemployed (not just those who received JobSeeker) and extended beyond October 2021 as

•   Extend JobSeeker supplement or permanently increasing base rates. The temporary increase
    in rates during the COVID-19 pandemic, along with JobKeeper payments, has helped reduce
    poverty and housing stress in Australia (15). Further alleviating poverty and homelessness, known
    determinants of mental illness (13, 16) and suicide risk (17-20), should continue to be a goal of
    economic and social policy during the next phase of the pandemic and during the economy
    recovery as vaccines are rolled out.

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Additional considerations
In addition, we recommend that the Government should also consider:

•   Potential adjustment and extension of JobKeeper beyond March 2021 if there are additional net
    benefits on top of JobMaker Hiring Credit. This should be based on ongoing reviews of the costs and
    benefits of both programs and their interactions.

•   Further fiscal stimulus if the pandemic continues to dampen economic activity throughout 2021,
    including on childcare subsidies, social and affordable housing, infrastructure, and further support
    for women, young people, and highly impacted sectors of the economy.

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Recommendation 2: Continue telehealth and
invest in blended and digital care
The commencement of Medicare Benefits Scheme (MBS) funded telehealth measures have provided
a significant opportunity to further explore the potential for complementing traditional face-to-face
care with evidence-based digital therapies. The pandemic has been a driver of increased psychological
distress (3, 4) and increased demand for mental health services, placing further pressure on the existing
system. The response to the COVID-19 pandemic in particular has emphasised the need to deliver
flexible services, such as telehealth and digital blended care.

Expanded use of digital technology can improve consumer access to higher-intensity services that are
typically accessed face-to-face, such as individual psychological therapy and private psychiatric care.
Traditional in-person care faces ongoing barriers to meeting demand including a limited workforce, the
location dependency of treatment, and out-of-pocket costs. Mental health consultations are ideally
suited to telehealth as physical examinations and physical procedures are not usually needed. In our
experience, patients have embraced telehealth for the mental health care, with many finding it allowed
them to access care for the first time.

From March-November 2020, there have been over 2.5 million MBS-funded telehealth mental health
consultations across Australia. Proportionally more than a third of mental health consultations have
occurred via telehealth (21).

Consistent with the Productivity Commission’s recommendations, expanding access to telehealth
sessions for mental healthcare that are rebated through MBS and investing in supported online
treatment would contribute towards improved population mental health support.

Actions required
Fund telehealth and blended care items as permanent options for mental health consultations in the
MBS (Productivity Commission (PC) Report Recommendation 12.2). As a first step, continuation of the
momentum of this COVID-19-related measure will maintain broad consumer access and choice, and
allow for a thorough evaluation of costs, and the mental health and implementation outcomes over time.

As a priority, government should commission an external evaluation of MBS-rebated psychological
therapy (PC Recommendation 12.3), including trials to test whether consumers would benefit from more
sessions in a year, and to test the value to consumers of feedback-informed practice. The next step
includes providing new MBS items to allow for and encourage clinician-guided, blended care.

Costs and benefits
As estimated by the Productivity Commission, between 200,000 and 400,000 psychiatry consults and
psychological therapy sessions could switch from face-to-face to telehealth, with time and incidental
cost savings equal to anywhere from $4-24 million per year.

On average the telehealth consultations have the same fees (rebate plus co-payment) and provide the
same benefit as face-to-face consultations. We also estimate that 5,000–10,000 people could access
MBS-rebated psychological therapy who otherwise would not seek face-to-face support, costing $3.3-
6.5 million per year, but leading to a yearly benefit of $4-8 million in income (22).

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Recommendation 3: Sustained investment into
prevention research via Prevention Hub
Anxiety and depression are two of the most common mental illnesses, with 50% of Australians
experiencing symptoms of mental ill health in their lifetime. In any one year, over two million Australians
will experience anxiety and a further one million will experience depression. For many Australians,
the last twelve months has been deflating, increasing levels of psychological distress in the general
population (3, 4).

The mental health impact from the pandemic remains significant, and the extent of the long-term effect
is unknown. The Prevention Hub is Australia’s first collaboration focusing on research in depression and
anxiety prevention. Black Dog Institute and Everymind are uniquely positioned to fast-track and scale
interventions with the strongest evidence-based approach to mental health prevention.

In being awarded $2.1 million as part of the 2020-21 Budget, the Prevention Hub has been able to
continue critical work in exploring coordinated preventative interventions as well as initiating new
research pertaining to the mental health impact of COVID-19. The focus on addressing the mental health
impacts of the pandemic by the Australian Government is world leading. However, funding needs to
be sustained so we can maintain mental health preparedness as our country recovers from COVID-19.
The impacts of COVID-19 have accelerated a pattern that was already evident; the cost and personal
disability associated with mental ill health have been rising for many years. Suicide is now the leading
cause of death in young Australians (23). Establishing how this trend can be reversed and how mental ill
health can be prevented at scale is one of the great health challenges of our generation. Discoveries on
how to prevent infections and cardiovascular disease revolutionised physical health care last century.
Now we need to achieve the same for our population’s mental health. Australia has led the world in the
science of mental health prevention, but investment in practical initiatives such as the Prevention Hub
are needed to build our nation’s psychological resilience as we deal with the consequences of COVID-19
and other major events.

Actions required
Co-led by the Black Dog Institute and Everymind and supported by funding from the Australian
Government Department of Health, The Prevention Hub, is Australia’s first collaboration focusing on
preventative research in depression and anxiety. Prevention Hub is a great example of how research can
be rapidly translated into real world initiatives operating at scale. However, its current funding is about
to expire. Black Dog recommends that the Federal Government provide sustainable funding to the only
existing national mental health Prevention Hub. In doing, so this funding would assist to:

•   Support the development of curriculum-based resources to prevent depression and anxiety
    in primary school children as well as mitigating the impact of COVID-19 on Australia’s teacher

•   Progressing innovative and scalable mental health programs for adult Australians, with an emphasis
    on those in remote and regional areas, experiencing mental health distress as a result of the
    COVID-19 pandemic

•   Continue critical research into preventing the onset of depression and anxiety in those experiencing
    unemployment or under-employment as a result of the COVID-19 pandemic

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•   Support the continuation of a large-scale randomised controlled trial examining mental health
    distress in carers

Prevention Hub is a critical piece of research infrastructure. Sustained investment would allow it to
expand, consolidate, and capitalise on the important work already underway in order to develop mature,
evidence-based translational programs across the entire spectrum of mental health prevention. The
distress associated with COVID-19 has made this investment more critical than ever.

Costs and benefits
The potential benefits and savings resulting from this investment in prevention far outweigh the human
and economic costs associated with waiting until treatment is required (24).

Investing $8.5 million over 4 years will ensure that The Prevention Hub continues to expand the
implementation and evaluation of evidence-based prevention strategies for anxiety and depression in a
wide range of practical settings, including workplaces, schools, and healthcare.

2021-22              2022-23              2023-24              2024-25                Total
$2.2 million         $2.1 million         $2.1 million         $2.1 million           $8.5 million

This investment will also ensure that The Prevention Hub continues to bring together researchers,
policymakers, practitioners, schools, workplaces, and other key stakeholders in collaborative
partnerships with the power to transform Australia’s approach to the prevention of anxiety and

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Recommendation 4: Sustained investment into
healthcare workers’ mental health through The
Essential Network
Due to the inherently stressful nature of their jobs, healthcare workers ordinarily have a higher
prevalence of depression, anxiety and stress than the general population (11, 12). The COVID-19
pandemic has exacerbated existing mental health issues within an already high-risk group. Despite high
incidence of mental ill health, healthcare workers are also less likely to seek support than the general
population, increasing the risk of severe illness that requires specialist treatment (25).

The impact of the COVID-19 pandemic is far from over for healthcare workers. They are persistently
experiencing unprecedented challenges including increased personal risk, trauma exposure, and
physical demands (26-28). With a national vaccine roll-out on the way, healthcare workers will be faced
with the stress of administering the vaccine at expedited rates, alongside the risk of future outbreaks.
Continued mental health support for all Australian frontline health workers is essential to cope with the
expected psychological fallout from the pandemic and safeguard the Australian health workforce.

Black Dog Institute recently carried out a rapid meta-analysis of 67 studies which examined the
mental health effects of the current pandemic and previous pandemics (29). Based on this evidence,
we estimate that up to half of all healthcare professionals will experience symptoms of mental ill
health during the COVID-19 pandemic, and more than 1 in 10 will experience post-traumatic stress
disorder 6 months or more after pandemic resolution. In our interviews with healthcare workers, they
communicated that exhaustion, lack of resources, and unsupportive work environments are leading to
burnout and higher stress, impairing their ability to provide excellent care. This is especially concerning
because burnout is associated with absenteeism, workforce attrition (30) and debilitating mental
illnesses (31).

Actions required
Black Dog Institute was awarded funding from the Department of Health to develop and launch a
dedicated blended mental health service for Australian health professionals in partnership with This Way
Up, RANZCP, Hand-n-Hand Network, SAS, Australian Psychological Society, the University of Melbourne,
and the University of New South Wales. The Essential Network (TEN) provides mental health self-
assessment and triaged support, linking health professionals with evidence-based resources, self-help
pathways, peer support, and telehealth consultations, appropriate to their specific needs.

Further, we are also collaborating with the Melbourne research consortium behind the Covid Frontline
Study which will provide the first comprehensive Australian data on the extent of the mental health
impact of COVID-19 on 10,000 Australian healthcare workers and the needs of this workforce. All
participants were linked to the TEN service for specialist care, and the TEN team will provide expert
e-health research consultation as data analysis continues (32).

TEN has serviced more than 28,400 healthcare workers across Australia since its launch in June 2020.
Our data suggest that healthcare workers rely on the TEN service more in times of crisis, with a spike
is usage by over 85% during the Victorian second wave and lockdown, with almost double the users in
Victoria than any other state. We also saw an almost 200% increase in web traffic during the stressful
December holiday period.

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These usage data highlight the unpredictable situational demand for this service as we continue to see
changes in case numbers and corresponding restrictions across states and territories.

Black Dog Institute strongly recommends that the federal Government provide additional funding
to The Essential Network to ensure continuity of the service. An investment of $0.75m will allow the
TEN blended mental health service to continue for another year, providing healthcare workers with
the support they need, when they need it. Coordinated focus on preventative measures and early
intervention for frontline health workers is crucial to mitigate the predicted long-term mental health
fallout of the pandemic.

Costs and benefits
Of the 609,000 people in the Australian healthcare workforce (33), approximately 243,600 are likely to
experience symptoms of mental illness during the COVID-19 pandemic. Further, approximately 61,000
are likely to experience longer term PTSD after the resolution of the pandemic; a condition that requires
specialist psychological treatment. Waiting until treatment is required for this group comes at a far
greater cost than investing in prevention now.

The Productivity Commission’s inquiry report has recently highlighted the economic value of
preventative mental healthcare and the cost-effectiveness of supported digital and blended treatments.
TEN’s online triage platform and blended care delivery ensures that healthcare workers can receive
efficient and tailored support appropriate to their symptom intensity, even while COVID restrictions may
limit the accessibility of face-to-face treatment. It is crucial to invest in supporting healthcare workers
to manage their mental health to lessen the impact downstream productivity costs for this workforce
and the healthcare system.

 2021-22              2022-23              2023-24               2024-25               Total
 $0.75 million        -                    -                     -                     $0.75 million

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Recommendation 5 – Build on existing suicide
prevention investment
Suicide is a persistent social and economic issue in Australia. In 2019, there were 3,318 suicide deaths,
and suicide is the leading cause of death among people aged 15-44 (14). Further, for every death by
suicide, it is estimated that as many as 30 people attempt to end their lives.

The Productivity Commission Inquiry highlights that suicide deaths and attempts cost Australia $30.5
billion every year. The National Suicide Prevention Advisor’s Draft (34) and Final Advice have been
provided to Government, recommending significant reforms to help prevent suicide. Evaluations of the
various suicide prevention trials across the country are critical to inform future program investment.

When the National Suicide Prevention Trials finish in June 2021, funding for systems-based suicide
prevention interventions will end, despite widespread agreement and recommendations in the National
Suicide Prevention Advisor’s advice that a national whole-of-government, multi-sector approach is
needed. There is an imminent threat that people who are at risk of suicide will lose the safety net of
support in their communities. Further, the vital community governance structures and significant local
skills embedded in communities and Primary Health Networks will be lost, and any future programs will
require significant yet avoidable upfront time and costs.

Black Dog Institute has also delivered critical support for the National Suicide Prevention Trials through
the provision of training, resources, webinars and national forums, alongside localised suicide data
analysis reports that include recommendations on evidence-based programs and interventions that
work. Black Dog was initially provided $3 million over two years from the Department of Health in 2017
and an additional $400,000 per annum in 2019-20 and 2020-21. This funding will cease in June 2021,
halting this critical work.

Actions required
At a minimum, we recommend the Government provide additional funding in 2021-22 to ensure the
sustainability of the suicide prevention interventions in communities around the country, and to help
prevent premature mortality. This will allow time for full evaluations of the Lifespan and National Suicide
Prevention Trials to inform the future of suicide prevention program investment, including how systems-
based suicide prevention should be implemented in communities across the country.

$4.5 million in 2021-22 will help maintain critical regional coordination roles and baseline implementation
across each of the 12 national trial sites and allow Black Dog Institute to continue building suicide
prevention expertise and capacity.

This investment will avoid the significantly greater costs and risks of stopping community resourcing
and momentum, the expert support, and access to resources where they are needed most. Funding
the critical roles of the regional coordinators will help ensure the retention of a highly skilled workforce
tackling suicide prevention around Australia.

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Costs and benefits
Transition funding for suicide prevention around the country is critical to help reach the Government’s
zero suicide target. The cost of maintaining local suicide prevention coordination while the full trials
are being evaluated is small – while the potential benefits and protective effects for communities are
substantial. Continuity of the program also will avoid financial and social costs of stopping activities and
restarting later, such as reforming collaboratives and rebuilding local relationships.

 2021-22                2022-23                    2023-24        2024-25               Total
 $4.5 million           -                          -              -                     $4.5 million

Note: excludes other implementation and government costs, such as Department of Health costs. 2021-
22 and future year expenditure should be informed by the trial evaluations.

Initially, $4.5 million in 2021-22 will provide:

•   $1.8 million (or $130,000 plus on costs each) for 12 regional suicide prevention coordinators to
    continue interventions at the local level, maintaining momentum for suicide prevention in each

•   $1.2 million (or $100,000 each) for 12 sites to continue implementing high priority suicide
    prevention initiatives across communities to maintain support and momentum for the most critical

•   $1.5 million for Black Dog Institute’s ongoing expert support and advice, including the latest research
    and resources, implementation support and coordination, detailed suicide data analysis reports and
    ongoing development of the systems-based approach and novel intervention methods

Page 12                                                                         Pre-Budget Submission 2021-2022
Recommendation 6 – Implement the
recommendations from the major reviews
The Productivity Commission (PC) and National Suicide Prevention Advisor (NSPA) have both provided
their final reports to Government (34, 35). We now know the economic and social costs of mental
ill-health and suicide in Australia are in the order $600 million per day, and $220 billion annually.
We support the Government in taking steps to reduce this burden by adopting several of the key
recommendations from these reports as soon as possible.

While many of the recommendations are around structure and governance, there are some key ideas
that require funding through the Commonwealth and state budgets. Public debt should not be a barrier
to funding these critical measures given the return on investment as highlighted by the Productivity
Commission’s analyses.

Actions required
In response to these two reports, we support the Government to increase expenses for:

•   The National Agreement on Mental Health and Suicide Prevention (PC 22.1). The National Agreement
    process is key to improving the effectiveness and efficiency of the mental health system. Given
    the deficits highlighted in the PC report, it is likely significant increases in funding from all levels of
    government is required to improve services and to further prevent mental illness and suicide.

•   A national suicide prevention office (NSPA 5.3)

•   A mental health innovation fund (PC 23.8)

•   Funding the Aboriginal and Torres Strait Islander Suicide Prevention Strategy (NSPA 3.1, PC 9.2) to
    support the new suicide reduction target in Closing the Gap 2020 (Target 14).

•   Addressing the social determinants of mental illness to enhance prevention efforts. Incorporating
    mental health and suicide prevention into all government touchpoints is critical to improve
    prevention of mental illness and suicide, including through social and housing services (PC 20.1),
    increasing housing and homelessness services (PC 20.3), and the justice system (PC 21.1, 21.4, 21.6).

•   Continuing digital mental health reform, including setting up a national digital mental health platform
    and supporting evidence-based digital mental health services (PC 10.4, 11.1). Consideration should be
    made to fund telehealth permanently, invest in the necessary IT infrastructure, and changes to MBS
    to allow for clinician-led, blended digital care treatments that combine elements of face-to-face
    treatment and digital therapies (see also Recommendation 2 above)

•   Further investment in suicide prevention (PC 9; NSPA report; see also Recommendation 5 above)

Costs and benefits
The Productivity Commission’s final report outlines the discounted costs of some of the measures –
profile estimates should be obtained and reviewed by relevant departments.

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Black Dog Institute is pleased to have had the opportunity to make this submission. We hope that
investments into safeguarding population mental health through to pandemic resolution and afterward
are prioritised in the 2021-2022 Budget.

Continued financial support for jobs and businesses, access to mental healthcare including blended
and digital treatment and support for healthcare workers all remain critical. The 2021-22 Budget should
also consider the landscape for mental health reform in Australia. Further investment into preventative
mental health research and the evaluation of national suicide prevention initiatives are needed to inform,
translate, and scale-up best practice care and ensure mental health crisis preparedness.

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