The impact of COVID-19 on community mental health: lessons learned from Tasmania, Australia

Background . The COVID-19 pandemic had a signi ﬁ cant impact on community mental health globally and widened pre-existing health and social inequities. Tasmania, Australia has one of the highest rates of mental ill health and socioeconomic disadvantage in the country. Whilst Tasmania experienced a delayed and reduced physical presence of COVID-19 compared to other states and territories, mental health impacts remain. It is necessary to understand such impacts to inform policy, practice, and recommendations to enhance the mental health service sector and prevent future mental health burden. This qualitative study aimed to explore expert mental health stakeholders ’ perspectives of the impact of COVID-19 on: (1) the mental health of people living in Tasmania, and (2) mental health services. Method . Semi-structured interviews with 12 expert mental health stakeholders across Tasmania were conducted. This sample was well-positioned to comment on the impact of COVID-19 on community mental health and provide recommendations to enhance the sector. Interviews were thematically analysed. Results . Three subthemes exploring the COVID-19 impact on mental health were included: (1) anxiety, distress, and isolation; (2) varying presentations across age groups; and (3) increased complexity. Four key themes capturing the COVID-19 impact on mental health services were identi ﬁ ed: (1) transition to telehealth; (2) increased service demand; (3) spotlight on service gaps; and (4) local workforce shortages. Conclusions . The pandemic has highlighted existing gaps across the community mental health service sector, and exacerbated existing psychosocial/structural stressors resulting in increased presentations and complexity of mental illness among the community, particularly for youth. Existing treatment gaps and inequities in service access, engagement, and mental health outcomes will persist if not addressed. Recommendations have been provided to inform community mental health service planning


Introduction
The COVID-19 pandemic has undoubtedly had a significant impact on population mental health worldwide (Xiong et al. 2020).Local and international research highlights adverse mental health impacts associated with the pandemic, including increased anxiety, fear, distress, depression, and sadness (Xiong et al. 2020;Botha et al. 2022;Reali et al. 2022).In Australia, the prevalence of psychological distress has significantly increased, from 6.3% pre-pandemic to 17.7% in 2021 at the height of the pandemic, and remained elevated in 2022 (Botha et al. 2022).Young people under 25 years reported the highest levels of increased distress during this period (AIHW 2022a).Mental health services in Australia have been overburdened, with service use rates throughout 2020-2022 significantly exceeding pre-pandemic levels (AIHW 2022b).The increased rates of mental health concerns over this sustained period have been observed across various communities and population groups (Weich 2022).COVID-19 has been associated with the onset of mental health concerns among those without any pre-existing levels, has exacerbated the conditions of those with pre-existing mental ill health, and contributed to additional distress to carers of those with mental illness (Anjum et al. 2020).
Up to 20 December 2022 in Australia, there were a total of 10 975 374 recorded cases of COVID-19 and 16 692 deaths, with variability across states and territories (Department of Health and Aged Care, Commonwealth of Australia 2022).Victoria and New South Wales reported the majority of these cases (i.e. over six million cases combined), and endured multiple prolonged restrictions between 2020 and 2022 (Department of Health and Aged Care Commonwealth of Australia 2022).Specifically, Melbourne experienced the longest lockdown in the world, with a total of 262 days across six separate lockdowns, while Sydney recorded 107 days (Knowlton 2023).In comparison, the state of Tasmania was less affected by the COVID-19 pandemic, in terms of the local direct presence and community transmission of the virus (Department of Health and Aged Care Commonwealth of Australia 2022).The number of cases in Tasmania comprised just 2.5% of all cases in Australia to this date (Department of Health and Aged Care, Commonwealth of Australia 2022; Department of Health, Tasmanian Government 2022).Following the initial nation-wide 6-week lockdown in April-May 2020, Tasmania experienced no community transmission for over 1 year until one case was detected in October 2021, prompting a 3 day snap lockdown in south Tasmania.In April 2022, Tasmania experienced a recordhigh number of daily COVID-19 cases and deaths, followed by a second peak in July 2022.Tasmania had a total of 272 779 cases in 2022, which equates to nearly half of their total population (Department of Health, Tasmanian Government 2022).Whilst state-wide lockdowns and border closures have passed, the delayed presence of COVID-19 in Tasmania continues to affect the mental health of the community more than 2 years after the beginning of the pandemic.
The Tasmanian population experiences high rates of mental ill health across all ages, in comparison to other states and territories in Australia (ABS 2022).There already is, and will continue to be, a significant increase in the burden of mental health related disorders among the general population in Tasmania related to COVID-19 (Ahmed and Shaw 2020).To date, there has been no peer-reviewed published research exploring the mental health impact of COVID-19 in Tasmania, and a dearth of exploration of key mental health stakeholders' perspectives.Understanding the unique impacts of COVID-19 on this population and the local mental health sector is crucial to identify key groups that require support and informing mental health service planning, development, access, and provision.The focus on Tasmania is warranted given their unique experience of COVID-19 in comparison to other parts of the country, and the pre-existing high prevalence of mental ill health.Therefore, the aim of this qualitative study was to explore expert mental health stakeholders' perspectives of the impact of COVID-19 on: (1) the mental health of people living in Tasmania, and (2) mental health services.Given that Tasmania only experienced their highest levels of COVID-19 transmission throughout 2022, the impacts on individuals and services are projected to persist.It is therefore imperative that the lessons learned from this work and expert recommendations are communicated and shared to inform future community mental health service planning, policy, and practice to prevent further mental health burden.

Design
This qualitative study was approved by the Monash Human Research Ethics Committee.Reporting aligns with the Consolidated Criteria for Reporting Qualitative Research (Tong et al. 2007).

Participants
Throughout 2022, purposive sampling was used to recruit key 'expert' stakeholders who had significant expertise, substantial background, or a leadership position working in the Tasmanian mental health sector.This sample was considered wellpositioned to comment on the impact of COVID-19 on community mental health and provide recommendations to enhance the sector.Participants were recruited via email.Fourteen people were identified, and 12 agreed to participate.Participants were not previously known to the researchers.The 12 expert mental health stakeholders were from community mental health services (n = 6), government-run tertiary/acute services (n = 4), and policy/government (n = 2).Key job roles included director of services (n = 4), chief executive officer (CEO) or manager (n = 4), senior clinician (n = 3), or minister (n = 1).The specific job titles and organisations cannot be reported as these participants are likely identifiable by their role/place of employment.Participants were aged 51 years on average (s.d.= 6.06), with 22 years of experience working in mental health (M = 21.9, s.d.= 10.40), and 67% identified as female.This sample was considered representative of the key mental health service providers and leaders across Tasmanian mental health.

Interviews
Interviews with participants were conducted via Zoom (n = 4) or over the phone (n = 7), depending on the personal preference of the participant.One participant completed written answers to a set of semi-structured interview questions.
Participants were asked to reflect on the impact of COVID-19 on the mental health of people living in Tasmania and mental health services, and to provide suggestions for how to mitigate such impacts.Interviews were audio-recorded and were 38 min in duration, on average (mean = 37.76, s.d.= 9.02).Field notes were made during each interview.Interviews were transcribed verbatim and returned to participants for comment/correction.

Analyses
Inductive semantically based thematic analysis was guided by Braun and Clarke's (2006) six steps.Interview transcripts were double-coded.The generated codes were then inductively categorised into two key themes and seven subthemes, which were reviewed, refined, and discussed between the researchers until agreement was reached.Data analysis was conducted concurrently with data collection to assess data saturation, which was fulfilled after the 10th interview.Analysis was conducted using NVivo.

Ethics approval
Ethics approval was obtained from the Monash University Human Research Ethics Committee.

Results
Thematic analysis revealed two overarching themes exploring how COVID-19 in Tasmania had impacted: (1) the mental health of people living in Tasmania, and (2) mental health service access and delivery.Seven subthemes were identified, which explored experts' perspectives of the different impacts and considerations for how such impacts could be mitigated.

Impact of COVID-19 on mental health
Three subthemes described the impact that COVID-19 had on the mental health of the people living in Tasmania: (1) anxiety, distress, and isolation; (2) varying presentations across age groups; and (3) increased complexity.

Anxiety, distress, and isolation
All experts acknowledged that there had been a significant increase in mental health presentations since COVID-19 emerged.Whilst there was minimal COVID-19 community transmission in Tasmania during 2020-2021, mental health trends aligned with other states.
"We learnt that our population reacts to whatever's happening elsewhere.So whilst we didn't really have COVID-19 here for a long time, the impact of what was happening elsewhere was enough to see that mental health response across Tasmania."Key presenting mental health concerns experienced by Tasmanians included anxiety, maladaptive coping, and isolation.Experts described increased psychological distress due to fear of COVID-19, reduced social support, loneliness, and lack of connection."It's predominantly anxiety, but also depression, family violence, substance use, suicidal ideation : : : it's indicative of people not coping."Nine experts explained how the extent of impact depended on existing mental health severity.Previously higher functioning clients experienced significant escalations in their mental health due to the psychosocial impacts and stressors of COVID-19 (e.g.job loss, financial stressors, travel restrictions, and social/community isolation), whereas those experiencing more severe mental illness were less impacted by this.
"It they're already severely affected by mental illness, they're less likely to be out in the community in full-time employment/education, so it's like business as usual for those clients."

Varying presentations across age groups
All experts identified distinct variations in mental health impact across age groups, specifically between youth (aged under 25 years) and older adults (aged 65+ years).Participants agreed that COVID-19 had been felt greatest by young people, due to job loss (i.e.casual employment), social isolation, broader COVID-19 impact on the family system (e.g.financial stress and family violence), greater access to COVID-19 information across social media, increased awareness/identification of mental ill health by family/carers, and ineffective coping strategies to gain control amidst uncertainty (e.g.substance use).
"COVID-19 has affected youth more than it's affected adults.We've been seeing a consistent increasing trend among mental health presentations among youth for 10-12 years, but COVID-19 has definitely increased this." For older adults, key presenting concerns included social isolation and depression, due to loneliness, fears of COVID-19 illness, limited access to health care, and ageism concerns from government messaging.
"They didn't ever have the levels of anxiety that the younger cohort did, but they talked more about social isolation and losing their sense of purpose/connection to community."Experts recognised that community mental health responses need to be better tailored and resourced for these groups, with experts noting limited availability/capacity of existing youth mental health services and no specific responses for older Tasmanians.

Increased complexity
All experts recognised that the pre-existing increasing trends in complexity, severity, and acuity of mental health presentations were escalated by COVID-19.This was attributed to people delaying help-seeking and the underlying psychosocial/contextual factors that perpetuate mental ill health that were exacerbated by the pandemic.
"People are actually receiving more or longer episodes of care, pointing towards a level of complexity that isn't normally there." Seven experts highlighted that increased complexity was particularly apparent among young people, reflecting the broader intergenerational demographics and structures across Tasmania further magnified by COVID-19.
"The complexity is poverty, unemployment, trauma, and lack of housing.The mental health relapses or escalations that we're seeing, especially in younger cohorts, have been facilitated by a failure of social structures and supports." Experts strongly advocated for holistic, tailored, wraparound, one-stop-shop services that can address these underlying contextual factors perpetuating mental illness among youth.

Impact of COVID-19 on mental health services
Four themes capturing how mental health services in Tasmania were impacted by COVID-19, and recommendations to mitigate such impacts, were identified: (1) transition to telehealth; (2) increased service demand; (3) spotlight on service gaps; and (4) local workforce shortages.

Transition to telehealth
Eleven participants recalled that the implementation of telehealth and specific COVID-19 online supports facilitated ongoing support to those with mental illness during the pandemic.
"We didn't stop any of our services.We just changed the way we provided them." "If COVID-19 taught us anything, it's that we can use alternative methods to support people." All experts supported the ongoing use of telehealth to access people living in rural areas of the state where accessible in-person services were lacking, and to support therapeutic outcomes and social connectedness for those with mild to moderate mental health concerns.Seven experts maintained that more severe presentations, particularly among youth, require outreach, in-person, intensive support.
"We have such a highly dispersed population that we can't normally reach, so we really need telehealth to continue to keep supporting those outside the major cities." Experts advocated for greater investment and adequate resources for community mental health services to facilitate the ongoing sustainable use of telehealth, and to ensure support can be delivered flexibly to support clients via their preferred modality (i.e.outreach).

Increased service demand
Ten experts recognised that the elevated prevalence and complexity of mental health concerns had contributed to the rapidly increasing demand for mental health services, which remains above pre-COVID-19 escalations.Specifically, the experts from community service organisations reported that their services had experienced unprecedented demand during the pandemic, with months-long waiting lists, posing barriers to service access and provision.
"Without that continuity of support in the community, we've seen more people presenting to our acute hospitals who are quite unwell or in-crisis." Eight experts also explained how the underlying contextual factors that perpetuate mental ill health that were exacerbated by COVID-19 have also contributed to increased demand and limited service capacity, as clients require longer service engagement or repeat presentations ('churning')."It's the minority taking up the majority of resourcing, money, time, and engagement." "The system is supporting less people than it was a year ago, but those people are actually needing more support."Experts highlighted the importance of better resourcing existing community services and developing complementary services.This would enhance the community sector's capacity to sustainably respond to demand and provide appropriate step-down/step-up options between primary and tertiary care.
"We need one-stop-shop services so people don't go to hospital and don't spend two nights on the emergency department floor.We need a number of experts all in the one place providing that support in the community, to prevent that escalation."

Spotlight on service gaps
All experts agreed that COVID-19 had amplified the preexisting gaps across the Tasmanian mental health service sector, including a lack of community mental health services for youth, under-resourced community services, limited regional/rural supports, and fragmented care.
"We all know that community mental health services in Tasmania are grossly under done, so they were already under stress pre-COVID-19." "The areas that need the services the most, are the ones that still don't have them.In the northwest, there's virtually no community services and very few for youth." Experts maintained that addressing these existing gaps requires increasing the resourcing and availability of community mental health services.This includes implementing services that can address the contextual factors underlying mental ill health and enhance continuity of care between primary and tertiary services.
"Strengthening community services is necessary and needed now more than ever." "We need robust, wrap-around, holistic, rapidly responding, focused, community services to address these underlying structures.Get their psychosocial needs met, then we can see how their mental health goes."

Local workforce shortages
Nine experts discussed how COVID-19 further exacerbated the pre-existing challenges to the recruitment and retention of the Tasmanian mental health workforce.Staffing shortages were attributed to fatigue, burnout, increased pressures/ distress, or staff relocating to other states/territories."We've had unprecedented numbers of staff who have gone home to the mainlandsthey wanted to be back home because of COVID-19, family concerns, and job opportunities." Difficulties recruiting specialist mental health clinicians were attributed to COVID-19 border closures, isolation protocols (i.e.hotel quarantine), and minimal existing local candidates.This highlights unique mental health workforce challenges for Tasmanialimited local staff with the desirable skills and experience, and over-reliance on mainland recruits, including locum specialists.
"We don't train many specialist staff, they all come from the mainland.We have exhausted the local talent and because of COVID-19, people are not relocating here like they used to." Experts agreed that integrated workforce planning was urgently required, including greater capacity building and training opportunities to upskill the existing and emerging local workforce.Five experts also suggested the sustained use of telehealth by locum specialists to continue working remotely.

Discussion
Tasmania has had a unique experience with the COVID-19 pandemic, yet there were significant ramifications on the community's wellbeing and mental health services.This study aimed to explore expert mental health stakeholders' perspectives of the impact of COVID-19 on: (1) the mental health of people living in Tasmania, and (2) mental health services.This qualitative exploration was necessary to inform recommendations that may enhance the community-based mental health service sector and reduce mental health burden across the state.
Despite the delayed and minimal presence of COVID-19 community transmission and associated restrictions/lockdowns in Tasmania, there were increased escalations and prevalence of mental health concerns.The wellbeing of Tasmanians is heavily influenced by events on the mainland, with mental health trends aligned with other states that experienced strict and prolonged lockdowns, including Victoria and New South Wales (Jiang et al. 2022).This is likely due to the impact of social media and other news sources, which saturated COVID-19 content over this time (Price et al. 2022).It has been well-documented that young people were more susceptible to the mental health impacts of the pandemic, which also may be partly due to their high reliance and access to social media (Samji et al. 2022).Furthermore, Tasmania spent a prolonged period in anticipation/a state of arousal regarding the impending threat of COVID-19 (2 years), and prolonged exposure to stress/uncertainty has adverse effects on mental health, particularly for those with pre-existing mental health concerns (Fragkaki et al. 2016).
Increased mental ill health coincided with increased mental health service demand across all services.COVID-19 escalated the complexity, comorbidity, and acuity of presentations to services, particularly among young people.Experts maintained that this largely stemmed from existing clients experiencing psychosocial stressors due to COVID-19 that perpetuated mental ill health.Those with pre-existing mental health conditions and psychosocial stressors experienced the greatest declines in mental health from the beginning of the pandemic (Xiong et al. 2020;Paremoer et al. 2021).This also reflects the broader structural factors in Tasmania, as the state has limited housing and accommodation options, high unemployment rates, and the highest proportion (37%) of people living in the most socioeconomically disadvantaged areas in the country (ABS 2018).COVID-19 disproportionately impacted populations who have been historically marginalised in accessing or receiving appropriate health care, exacerbating existing health inequities (Bernardini et al. 2021;Paremoer et al. 2021).It is necessary that community mental health services are adequately designed, resourced, and implemented to address these underlying psychosocial factors that often precipitate or perpetuate mental illness.
COVID-19 also highlighted other existing gaps within the Tasmanian mental health sector, particularly its underdeveloped and fragmented community mental health sector (i.e.services delivered in the community by non-government organisations or publicly funded services).Experts identified staff shortages due to challenges retaining and recruiting clinicians, limited community-based mental health services for youth and older adults, a dearth of rural/regional services, and under-resourced existing community services.The pandemic placed additional pressures on existing overburdened mental health services worldwide, resulting in barriers to accessing support (Adiukwu et al. 2022).Whilst adaptations to mental health service delivery were made (i.e.telehealth), the sustainability of such approaches needs to be ensured to enable ongoing equitable access to mental health care for all who require it.Ultimately, experts called for greater investment into addressing such gaps in the Tasmanian mental health sector that have been amplified due to COVID-19 to ensure the required range, supply, capacity, and resourcing of community mental health services that can appropriately respond to the demand, complexity, and existing gaps.This requires engagement with relevant stakeholders, including service end-users, to better meet their unique needs.

Implications
This study has provided insight into the mental health impacts of COVID-19 in Tasmania.The context of such impacts were unique in comparison to other Australian states and territories due to the increased mental health burden observed across the population despite the minimal physical presence of COVID-19 in the state.This was attributed to the observation of mainland lockdowns, the prolonged impending threat of COVID-19, and pre-existing psychosocial vulnerability among people living in Tasmania.Furthermore, Tasmania's preexisting under-resourced and fragmented community mental health sector, that is less-developed than in other states (AIHW 2022c), exacerbated existing barriers to mental health service access and delivery.Key recommendations are provided to strengthen Tasmania's community mental health service sector and enhance mental health: Increase resourcing to support equitable and sustainable use of telehealth, including flexible mental health service delivery via multiple modalities (i.e.telehealth, outreach etc.) Adequate design, resourcing, and implementation of community mental health services to: (1) better address the underlying psychosocial and contextual factors underpinning mental ill health, and (2) decrease reliance on acute care Co-design and development of youth mental health services that can support the increasing complexity and psychosocial recovery of youth Provision of tailored community-based mental health responses for older adults Capacity building and training for local mental health workforce to build specialist expertise and sustainable workforce Support the mental health and wellbeing of frontline mental health workers Develop processes and pathways to streamline stepped care/continuity of care, including: (1) greater communication across services and sectors, and (2) strengthen community mental health services to provide alternative step-up/step-down options to tertiary/acute mental health care Meaningful engagement, consultation, and involvement with key target groups to explore needs and co-design, develop, and implement changes that meet their unique needs These recommendations closely align with the Tasmanian Government's Rethink Mental Health 2020-2025 plan to integrate mental health services and enhance continuity of care for people experiencing mental illness (Tasmanian Government 2020).

Limitations
This sample represents a small group of expert stakeholders in one Australian state.Whilst this has provided an in-depth understanding of the unique situation in Tasmania, the findings may have limited generalisability to other areas both within and outside of Australia.Nonetheless, the themes and lessons learned, in terms of increased mental health presentations, service demand, and workforce shortages, align with both local and international data (Xiong et al. 2020;Tsamakis et al. 2021).The provided recommendations for the community mental health sector may therefore be applicable to public health policy makers, practitioners, and researchers outside of Tasmania.Second, this study did not include the voice of mental health consumers/clients.Experts were embedded across various mental health services and could comment on trends observed within each of their services over time.The lack of direct voice of mental health consumers means that deeper insight into the unique lived experiences of this community was not captured.Future research is required to engage various Tasmanian mental health consumers to co-design solutions to the identified gaps.

Conclusion
Despite limited exposure to COVID-19 in comparison to other Australia states, the pandemic had a significant impact on people's mental health status and services across Tasmania.The pandemic exacerbated existing gaps across the sector, particularly the community mental health sector, which may increase existing treatment gaps and inequities in service access, engagement, and mental health outcomes if not addressed.Recommendations have been provided to enhance Tasmania's community mental health service planning, policy, and provision, and improve wellbeing.