**1. Introduction**

The global impact of the COVID-19 pandemic on mental health and wellbeing has been significant. The potential for this impact was recognized early in the pandemic and includes the direct health impacts of COVID-19 and fear of contagion, as well as the broader social and economic disruption [1].

In the Australian context, despite having experienced some significant COVID-19 outbreaks, containment measures have meant that the epidemic to date (July 2021) has generally been less severe than in many countries. However, the social, economic and mental health and wellbeing impacts of restrictions have been significant. Social distancing, sudden and protracted 'lockdowns', interruption of physical and mental health service provision, loss of employment, restricted international travel and border quarantine, and remote school and work have all had significant consequences. The impact of the pandemic in Australia started directly after an extreme drought and bushfire season for the country, a time of heightened anxiety for much of the population [2]. Data about the mental health effects of the pandemic at a national and international level are still evolving.

The Australian Institute of Health and Welfare (AIHW) has a long history in reporting mental health data, particularly through the Mental Health Services in Australia report and more recently the National Suicide and Self-harm Monitoring Project, a collaboration between the AIHW, the National Mental Health Commission and the Australian Government Department of Health (DoH), funded by the DoH. One of the key goals of this project is to improve the timeliness of state and territory data on suspected deaths by suicide.

A range of Australian research and reporting has been taking place on the mental health impacts of COVID-19 since early 2020. Some significant efforts include the Australian

**Citation:** Shelly, S.; Lodge, E.; Heyman, C.; Summers, F.; Young, A.; Brew, J.; James, M. Mental Health Services Data Dashboards for Reporting to Australian Governments during COVID-19. *Int. J. Environ. Res. Public Health* **2021**, *18*, 10514. https:// doi.org/10.3390/ijerph181910514

AcademicEditor: RichardMadden

Received: 3 September 2021 Accepted: 30 September 2021 Published: 7 October 2021

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**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

National University's COVID-19 Impact Monitoring Survey Program, a longitudinal survey for which the AIHW provides financial support. This project seeks to monitor the economic and social wellbeing impacts of COVID-19 and is conducted through the ANUPoll, an ongoing quarterly probability-based panel survey of Australian public opinion. The availability of longitudinal pre-pandemic data from the ANUPoll facilitates analysis of the factors that have contributed to pandemic driven changes in psychological distress. The Australian Bureau of Statistics (ABS) has also been conducting surveys to investigate the impacts of the COVID-19 pandemic. From April 2020 to June 2021, the monthly Household Impacts of COVID-19 Survey collected longitudinal data on a range of topics including psychological distress. The Melbourne Institute (University of Melbourne) also commenced the Taking the Pulse of the Nation survey in April 2020.

Data were collected on a broad range of measures of mental health and wellbeing during the pandemic in Australia, including suicide and self-harm [3], life satisfaction, anxiety and worry [4], social connection, personal stressors, self-reported mental health [5] and use of mental health services [6]. One particularly relevant measure to the utilization of mental health services is that of psychological distress, commonly measured using the Kessler Psychological Distress Scale. A higher proportion of Australians have reported severe psychological distress during than pre-pandemic. Psychological distress and related measures tended to show peaks early in the pandemic and in conjunction with lockdowns, with elevated levels around April 2020 and again around August to October 2020 [4,5], the latter peak likely reflecting the impact of the relatively severe second wave in Victoria.

There was significant concern early in the pandemic about its potential impact on deaths by suicide [7], in part based on research linking unemployment to increased suicide rates [8]. Data on suspected deaths by suicide in 2020 for three Australian state suicide registers are included in the National Suicide and Self-harm Monitoring Project. This project seeks to improve the understanding of suicide and self-harm in Australia, to help identify factors that increase risk, to raise awareness and improve support and prevention activities. The AIHW routinely receives data for some states and territories, which is included in the dashboards. A key aim of the project is to establish registers for all Australian states and territories. To date, there has not been evidence of an increase in suspected deaths by suicide in any of these jurisdictions compared to previous years, however, the situation is complex and it remains important to continue to monitor the impact on suicide risk over time [3].

Analysis of ambulance attendances (one month per quarter data snapshots) available for some Australian states and territories from the National Ambulance Surveillance System (part of the National Suicide and Self-harm Monitoring Project) showed slight spikes in the population rate of ambulance attendances for self-injury and suicidal ideation during the outbreak period of the September 2020 quarter in Victoria. There was also a gradual increase in both measures between December 2019 and December 2020, particularly selfinjury (4.7 to 6.5 per 100,000 population), although the rate of attendances for suicide attempts fell from 14.9 to 12.4 in the state over that year. Gradual increases in the rate of attendances for self-injury were also evident in the Australian Capital Territory (6.8 to 10.0) and Tasmania (2.1 to 5.9) over the period [9], however, whether these changes were related to the pandemic is unclear.

The impacts of the pandemic have not been evenly experienced across the Australian population. People with pre-existing mental health conditions [2] and few social supports [1] are at increased risk of distress. In general, younger Australians [10] and women have tended to have worse mental health outcomes than other Australians during the pandemic. Among young people (aged 44 and under), average psychological distress scores were elevated in 2020 compared to 2017, with the greatest increases for those aged 18–24 years. Women and people living in Victoria were the main drivers of an increase in psychological distress from May to August 2020 [11]. High mental distress (defined as 'feeling depressed' and/or 'anxious' 'most or all of the time') among parents also increased, from 8% in 2017 to 24% in 2020 [12].

There is evidence that the economic downturn associated with the pandemic has increased levels of psychological distress, with those employed in April 2020 having significantly lower levels of psychological distress than the unemployed at that time, when considering only those employed in February 2020 [13]. Rates of mental distress were approximately four times higher for people experiencing financial stress (42%) compared to people not experiencing financial distress (11.5%) during April to November 2020 [12].

The OECD has identified a similar range of increased risk factors associated with the pandemic which have contributed to a worsening of mental health, including unemployment and financial insecurity, reduced social connections, difficulties associated with telework, home schooling and education, restricted exercise and reduced access to health services. Peaks of mental distress have been closely related to waves of COVID-19 cases when restrictions have been most stringent [14]. The use of data visualizations in recent OECD reporting clearly illustrates some of the mental health impacts of COVID-19 across nations, particularly regarding depression and anxiety both during the pandemic and in comparison to pre-pandemic periods [14].

The mental health services system in Australia is complex and varies by state and territory, with some services funded by the Australian Government, others by state and territory governments or both. Mental health services are provided through public and private hospitals, residential and community mental health care, by specialist psychiatric and general medical practitioners, mental health nurses, psychologists and other allied health professionals. There are a range of crisis support services, as well as services provided through the National Disability Insurance Scheme and the non-governmen<sup>t</sup> sector [15]. Australia's federated model of health care also means that there is no single 'master' data set relating to health services.

Due to the complexity of the Australian mental health system and the need for timely data collection and analysis to guide the provision of mental health services during the pandemic [16], the AIHW has been providing support to the DoH to report on mental health-related data to Australian governments since April 2020, funded by the DoH. The COVID-19 National Mental Health Services dashboard and later the State and Territory Mental Health Services dashboard, were produced weekly during 2020, and fortnightly in 2021. These reports provide summary statistics of recent data and comparisons with the same data from early and pre-pandemic periods and extensive use of data visualizations of change over time. Data sources include information from the Medicare Benefits Schedule (MBS), Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS), Australian Government-funded crisis and support organizations, and a brief summary of emerging research. A publicly available summary of the data is reported in the AIHW online publication, Mental Health Services in Australia [6], updated quarterly.

The aim of the present paper is to describe the background, development process, key results and learnings from the compilation of the data for the National Mental Health Services and State and Territory Mental Health Services dashboards. The processes that have led to success, and improvements in communication and data sharing within and across governmen<sup>t</sup> and non-governmen<sup>t</sup> organizations have broader implications for future health data, information and policy development.

#### **2. Materials and Methods**

#### *2.1. Environment Scan*

An environment scan and literature review were conducted to determine the range of Australian research and data holdings that were being established in relation to COVID-19 and mental health. During the initial scoping for the dashboard reporting, it was recognized that some of the organizations that would first see the impact of the pandemic on service utilization were those for which there was no national data collection, in particular, crisis and support organizations and online mental health information services.

#### *2.2. Data Sources*

#### 2.2.1. Crisis and Support Organizations and Online Mental Health Information Services

There are a number of Australian phone and online crisis and support services available to people seeking support for mental health issues. Crisis and support organization data include call, web chat, 'app' use, online programs and forums, and/or email data from a range of organizations, including Lifeline, Kids Helpline, Beyond Blue, Smiling Mind's Healthcare Worker Program, Head to Health, Black Dog Institute and ReachOut. Data for HeadtoHelp hubs (Victorian Mental Health Clinics) also include face-to-face contacts.

#### 2.2.2. Medicare Benefits Schedule and Pharmaceutical Benefits Scheme Data

Services Australia collects fee-for-service related MBS claims activity data which it supplies to the DoH [17]. The Australian Government introduced additional MBS telehealth items during the COVID-19 pandemic, including items for mental health services provided by psychiatrists, GPs, allied health professionals and psychologists. MBS subsidized services under the Better Access to Psychiatrists, Psychologists and General Practitioners through the MBS (Better Access) initiative were also expanded [18]. MBS data reported in the dashboards include use of MBS mental health items (services processed), the proportion of services delivered via telehealth, and MBS benefits paid.

The Australian Government subsidizes the cost of prescription medicines through two schemes, the PBS and RPBS for eligible veterans and their dependents. Services Australia processes all prescriptions dispensed under the PBS/RPBS and provides these data to the DoH [19]. PBS/RPBS data reported includes the number of PBS dispensed mental health-related prescriptions.

Further information on these data sources is available at https://www.aihw.gov. au/reports/mental-health-services/mental-health-services-in-australia/ (accessed on 5 October 2021).

### 2.2.3. Emerging Research

Key points from emerging research are provided in each dashboard update, with a more detailed discussion in the Mental Health Services in Australia quarterly online update. This includes key findings from research programs outlined in the introduction to this article.

#### *2.3. Data Access and Analysis*

#### 2.3.1. Data Access and Metric Selection

The data supply from crisis and support organizations and online mental health information services to the AIHW was established in collaboration with the DoH, facilitated through their existing contractual arrangements with the agencies. A prototype data collection template was prepared by the AIHW, with adjustments made as required for individual agency collections. The collection includes daily data on contact volumes and weekly aggregate data on some demographic variables including age, sex, Indigenous status, state or territory and reason for call. Due to data quality issues, reporting of demographic variables (particularly Indigenous status and age) has been limited.

Under an existing arrangemen<sup>t</sup> with the DoH, the AIHW had access to the MBS and PBS/RPBS data via the Department's Enterprise Data Warehouse (EDW) for use in AIHW's regular reporting products. A list of MBS item numbers relating to mental health was identified, based largely on the AIHW's existing Mental health services in Australia reporting. Early analysis identified key metrics for reporting, which have been refined over time. Mental health-related prescriptions in the PBS/RPBS data were identified using Anatomic Therapeutic Chemical (ATC) codes and ongoing trend analysis included from November 2020.

The dashboard was initially funded and prepared for a national view of mental health impacts. Clear gaps became evident early in the process, significantly that the dashboard only included data from Australian Government funded services; it was missing

data from the public mental health system run by state and territory governments. In addition, situations in each state and territory have varied markedly, with the majority of cases occurring in two states, Victoria and New South Wales. On behalf of the DoH, the AIHW established processes to share data across levels of governmen<sup>t</sup> and developed an agreemen<sup>t</sup> to include data at the state and territory level. Data sharing initially focused on the two most populous states of New South Wales and Victoria (together comprising 58% of the total population) which had the largest COVID-19 case numbers (87% of all cases to April 2021) [20]. Agreements were established by the AIHW on behalf of the DoH, for participating states to provide emergency department, community mental health care services and admitted patient (hospitals) data at the required intervals, with the AIHW providing MBS and crisis and support organization data back to these states for their own reporting and monitoring purposes. Queensland subsequently joined the data sharing arrangemen<sup>t</sup> and was included in the State and Territory Mental Health Services dashboard from May 2021. Data for Queensland will be included in AIHW's reporting on Mental health service in Australia from October 2021.
