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Suffering in silence

On 19 August 2021, Lifeline, an Australian charity providing twenty-four hour crisis support and suicide prevention to members of the community, received over 3,500 telephone calls in one day—the highest number in its 57 year history. Indeed, the highest 10 days on record have all occurred this year in response to the latest Delta COVID-19 lockdowns. As a comparison, last year, at the start of the pandemic when the number of calls for help was unprecedented, the maximum number was 2,500.1

A common thread to these recent increased calls has been an underlying feeling of uncertainty and anxiousness and a feeling that no one understands. Callers felt a loss of control; they felt they were suffering alone and rang the community helpline to simply talk, to explain, to be listened to. There was a very real fear that they ‘may end up contracting COVID’, become physically ill and then ‘What does that mean for me, and for my family?’ Added to this, was an additional and new financial vulnerability. Unlike last year, when the Australian Government support package JobKeeper provided a non-partisan financial safety net, the latest outbreak of the COVID-19 Delta strain has not been accompanied by governmental financial support, and consequentially callers to Lifeline reported extra stress and worry.

This is backed up by an online YouGov® Australia poll of 3,114 Australian residents aged 18 years and above between 20–25 August 2021.2 Fifty eight per cent of respondents were concerned about business and job security, followed closely by the impact on mental health at 56 per cent. And on 1 September 2021, a confidential Victorian Government report revealed a 57 per cent increase in child mental health issues requiring admission to hospital, and an 88 per cent increase in self-harm and suicidal ideation compared to the same time last year.3

The past 12 months has seen the development of four separate but interwoven social issues that have all impacted us all to varying extents:

  1. The health crisis of COVID-19.
  2. The economic recession associated with the concomitant restrictions and lockdowns.
  3. The social revolution that followed the social injustices of the effect of lockdowns in that some individuals, and companies, have done better than others.
  4. The impact of the lockdown and the COVID-19 pandemic on the mental health of our community.

The fourth point, while not being as well documented in Australia and Aotearoa New Zealand to date, has been quietly devastating. Not only has it confronted and attacked our common values of community and individual wellbeing, of equity and equal opportunity, it has also targeted our beliefs in diversity and inclusion.

The 2021 COVID-19 repeated lockdowns, and the continuation of working from home, has blurred the demarcation between work and the home ‘space’. As such, it has led to longer working hours and an increased inability to shut off from work. Work activity is now part of our family home life, and as a direct consequence, is now omnipresent. Not surprisingly, this has led to an increased level of continuing to work when sick. Combine this change to the home environment with homeschooling, and the impact the lack of school contact has had on our children, and this has yielded a particularly volatile and confronting environment.

Eighteen months ago, when the COVID-19 outbreak rapidly escalated into a global pandemic, it was initially compared to the severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS) that preceded it. As before, COVID-19 rapidly increased in prevalence and overwhelmed the local existing health care resources. Unlike SARS and MERS, however, COVID-19 did so on a global scale.

Like previous pandemics, health care workers represent a unique group at significant risk. And as before, they have ‘…accounted for a large percentage of patients as they themselves became infected due to the demand that they care for confirmed or suspected cases.’4

In the SARS and MERS outbreaks, many reports documented the increased risk of mental health problems among doctors, nurses and hospital-based personnel. These mental health problems tended to involve a constellation of changes in thinking, feeling and/or behaviour, with an increased incidence of anxiety, depression, stress, insomnia and burnout.5-7

Given the well-documented mental health problems confronting health care professionals in any pandemic, how do we cope with this one which is bigger, longer and more devastating?

There is clear evidence that support from supervisors and colleagues leads to a decreased incidence of post-traumatic stress disorder (PTSD) and decreased anxiety. Further, numerous studies document that health care workers receiving social support are more resilient against mental distress with 11 of 13 studies in a 2020 systematic review showing benefit.4 Similarly, Xiao and colleagues found that increased social support for health care workers treating COVID-19 patients was associated with improved self-efficacy, decreased anxiety and decreased stress.8

Hwang and colleagues found that vertical relationships (for example, supervisor support) and horizontal relationships (collegial support), while being fundamentally different, are equally valuable social resources in confronting workplace stress.9 And Cheng and colleagues found that employees who have high-quality relationships with their bosses, and their workplace, have more employment resources to deal with the stress and demands of their work.10 Interestingly, family support, or an ability to talk about your concerns at home, was not statistically significant.

In his interview on the Australian Broadcasting Corporation’s national public radio network, ABC RN Breakfast, one of the key points Mr John Brogden AM, Chairman of Lifeline, wanted to convey was to encourage listeners to ‘reach out—do not suffer in silence’. He went further, saying people ‘crave human contact’, hence a telephone call to a friend, or to your general practitioner, or to an service such as Lifeline, asking for help, is critically important:

One of the big messages is do not suffer in silence—reach out—it will make a difference.1
—Mr John Brogden AM

But this is not always as straightforward as it would first appear, particularly for plastic surgeons. As medical practitioners—as surgeons—we are often looked upon to lead, to provide an exemplar. We are expected to show how resilient and how tough we are. Aren’t we? Would we make that call? Calling out when we aren’t coping?

Additionally, in this new environment of COVID-19 lockdowns, the increased demand for hospital beds and personal protective equipment (PPE) has seen elective surgery significantly curtailed or cancelled altogether. And because most plastic surgery is deemed to be elective, many plastic surgeons have seen their operating lists cancelled and the concomitant daily interaction with colleagues and friends vanish. As a group, we are particularly vulnerable.

To make matters worse, almost all national and international conferences have moved to an online format, meaning that although meetings continue, critical opportunities for talking to fellow surgeons and discussing problems, or sharing experiences, has also been removed. This collegiality is a key component of our mental well-being. Those who regularly travelled interstate or internationally comment on this lack of contact with like-minded peers as being one of the most difficult consequences of the COVID-19 pandemic.

Often you miss things the most when they are gone, and no longer available.

For many of us, the lack of being able to talk to colleagues in person has had a significant impact. To laugh. To chat.

Ultimately the bond of all companionship…is conversation.
—Oscar Wilde

When will we get out of this? There is a feeling now of frustration and anger among the medical workforce that echoes the sentiments of many of the callers to Lifeline on 19 August: ‘I thought we beat this last year, and now we are back in it. This is harder than 2020.’

It is becoming increasingly apparent the borders in Australia and Aotearoa New Zealand will not open until the vaccination rates are significantly improved—to a minimum of 70 per cent (but more likely 80 per cent). On current predictions, that will be a long way away.

In the short and intermediate term, then, it is important that we seek out ways to keep in touch. To ‘reach out’ as Mr John Brogden would say.

If you are feeling low, call a friend.

If you are feeling okay, and are one of the few among us coping with COVID-19, pick up the phone and call a colleague, and a friend.

And do it today.

Editor-in-Chief, Australasian Journal of Plastic Surgery, St Leonards, New South Wales, AUSTRALIA
Clinical Professor of Surgery, Department of Surgery, University of Melbourne, Parkville, Victoria AUSTRALIA
Chairman, Professorial Plastic Unit, Epworth Freemasons Hospital, East Melbourne, Victoria AUSTRALIA

Mark Lee FRACS
Editor-in-Chief, Australasian Journal of Plastic Surgery, St Leonards, New South Wales, AUSTRALIA
Specialist Plastic Surgeon, Subiaco, Western Australia AUSTRALIA


  1. John Brogden, Chairman, Lifeline Australia, interviewed by Fran Kelly, RN Breakfast, Australian Broadcasting Corporation Radio National, program audio, 20 August 2021,
  2. YouGov® AU. Newspoll 30 August 2021 [PDF on the Internet]. Sydney: YouGov® AU [Cited 1 September 2021]. Available from
  3. The Australian. Pandemic’s teen mental health crisis in Victoria worse than feared [Internet]. The Weekend Australian. 28 August 2021 [Cited 1 September 2021]. Available from:
  4. De Brier N, Stroobants S, Vandekerckhove P, De Buck E. Factors affecting mental health of health care workers during coronavirus disease outbreaks (SARS, MERS & COVID-19): a rapid systematic review. PLoS One. 2020 Dec 15;15(12):e0244052 PMid:33320910 PMCid:PMC7737991
  5. Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis. Brain Behav Immun. 2020;88: 901–07. PMid:32437915 PMCid:PMC7206431
  6. da Silva FCT, Neto MLR. Psychiatric symptomatology associated with depression, anxiety, distress, and insomnia in health professionals working in patients affected by COVID-19: a systematic review with meta-analysis. Prog Neuropsychopharmacol Biol Psychiatry. 2021;104:110057. PMid:32777327 PMCid:PMC741138
  7. Salazar de Pablo G, Vaquerizo-Serrano J, Catalan A, Arango C, Moreno C, Ferre F, Shin JI, Sullivan S, Brondino N, Solmi M, Fusar-Poli P. Impact of coronavirus syndromes on physical and mental health of health care workers: systematic review and meta-analysis. J Affect Disord. 2020;275: 48–57. PMid:32658823 PMCid:PMC7314697
  8. Xiao H, Zhang Y, Kong D, Li S, Yang N. The effects of social support on sleep quality of medical staff treating patients with coronavirus disease 2019 (COVID-19) in January and February 2020 in China. Med Sci Monit. 2020;26: e923549. PMid:32132521
  9. Huang L, Lei W, Xu F, Liu H, Yu L. Emotional responses and coping strategies in nurses and nursing students during COVID-19 outbreak: a comparative study. PLoS One. 2020;15(8):e0237303. PMid:32764825 PMCid:PMC7413410
  10. Cheng T, Huang GH, Lee C, Ren X. Longitudinal effects of job insecurity on employee outcomes: The moderating role of emotional intelligence and the leader-member exchange. Asia Pac J Manag. 2012 Sep;29(3):709–28.


Citation: Ashton M, Lee M. Suffering in silence. Australas J Plast Surg. 2021;4(2):1–3.
30 September 2021
Copyright © 2021.
Authors retain their copyright in the article. This is an open access article distributed under the Creative Commons Attribution Licence 4.0 which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited.