Upstream of EDs, downstream of headspace: helping the “missing middle”

THE alarming rise in emergency department (ED) presentations for young people with mental health presentations, highlighted by Hiscock and colleagues in Victoria, is a very serious matter. One of us has already made initial comments in MJA insight on the underlying reasons for this trend when the article appeared.

However, in view of opinions advanced in today’s MJA editorial by Sawyer and Patton, it is necessary to make a more detailed response.

The premise of Sawyer and Patton’s argument is the fundamentally erroneous proposition that ED presentations are “an important test of the success” of recent Federal Government investments in mental health services. This represents a serious misunderstanding or misrepresentation of the target of these recent investments in youth mental health in Australia, which have almost exclusively focused on improving access to primary mental health care for young people. It ignores the most likely explanation for the rise in ED presentations, namely the serious underinvestment in specialist community mental health care by successive state governments in the face of surging population growth.

Data from the Australian Institute of Health and Welfare (AIHW) show that Victorian investment, once the highest per capita in Australia, has declined to approach the lowest level among all states and territories, and particularly in community mental health services. The Duckett report highlighted this in 2016, and the crisis has now been openly acknowledged by the Victorian government, which began to act decisively to reverse this decline in last week’s Victorian budget.

Underinvestment is a serious problem across specialist mental health services, but arguably most serious in child and youth services, which, despite bearing the peak burden for onset of mental ill health across the lifespan, have usually been overlooked for growth funding, relative to adult services. For example, Orygen Youth Health, which covers the north-western catchment of Melbourne, and which directly services the Royal Children’s Hospital ED studied by Hiscock and colleagues, is forced to turn away three out of four complex and acutely ill young people every day. One-quarter of those young people turned away has made a suicide attempt in the past 12 months and nearly all should be offered specialist mental health care. Many will seek alternative points of entry to the health system, such as EDs. Victorian data indicated that the western region of Melbourne, serviced by Orygen and the Royal Children’s Hospital ED referred to by Sawyer and Patton, has among the lowest rates of access to the specialist mental health system for young people in Australia (14 per 100 000, compared with the national average of 28 per 100 000).

Sawyer and Patton claim that there has been substantial new investment across the mental health spectrum proportional to need, and specifically that the investment in enhanced primary care to create the headspace model should somehow have been able to stem the tide of ED presentations.

Headspace has created the model and capacity to intervene with early and mild to moderate primary care level presentations and has enabled many more young people to access stigma-free mental health care. The majority of young people who need it still do not access such care, and building Australia’s youth mental health system is still a work in progress. We know that around 60% of those accessing headspace genuinely benefit from such care. Headspace has also played a role in uncovering unmet needs in the community. The 40% who do not benefit fully from headspace treatment have more complex or acute forms of mental ill-health, which cannot be adequately addressed within headspace centres, to which they have at least gained access.

They do not respond fully due to the failure hitherto to invest in the missing specialised service components that are required downstream from headspace but upstream from acute ED and inpatient care. The capacity to provide more intensive and specialised quality care is lacking and, consequently, they fail to improve. This “missing middle” cohort of patients who are too unwell for headspace but are unable to gain entry to under-resourced specialist mental health services are simply not served. The only option for them and their parents is typically to present to an ED when the situation reaches crisis point, often during the night when other services are unavailable.

Australia’s federal governments have, since 2006, built the base camp of a new and holistic system of care for young people, with special emphasis on mental health, namely headspace. This is regarded worldwide as a major advance and is being widely emulated. However, headspace alone is not a panacea, and the back-up system for the more complex disorders is embryonic or non-existent in most jurisdictions. Headspace is a vital and effective step on a ladder of stepped care, but the ladder is missing several key steps. If these steps are not added, headspace will continue to be under extreme pressure. Headspace is the “thin green line” and urgently needs to be strengthened by new investment upstream from hospitals and EDs.

This failure to invest in community mental health is not unique to young people. It applies across the age range and the entire mental health system. Anyone genuinely connected to frontline care would be well aware of this. Sawyer and Patton laud the value of administrative datasets, yet have clearly failed to draw on the extensive AIHW data on ED presentations that illustrate the increase in severity of mental health presentations to EDs in recent years in Victoria, in parallel with the demonstrable collapse of community mental health care.

Assertive community treatment, home-based treatment and intensive case management, once evidence-based cornerstones of the public mental health system, are now endangered species or extinct. The claim that there have been major investments in mental health care must therefore also be challenged. The modest investments and innovation to date, welcome as they are, have so far have been federal and, consequently, very much at the shallow end of the pool.

It is access to (but not quality of) care for common mental disorders that has increased, but access and quality for more severe and complex disorders have declined. Mental health is allocated around 5% of the health budget but is responsible for nearly 15% of the health burden. Mental health funding, while increasing in absolute terms, is falling as a proportion of the national health budget. The Australian Medical Association has called for action on mental health in a new position statement in early 2018.

Improved crisis lines and online platforms do have a key role to play, and the culture and design of EDs, plus the skills of ED staff, should indeed be enhanced. Currently, patient and family experience is problematic and often traumatic, with long delays, inadequate assessment, and overall rudimentary responses to complex problems from an ill-equipped and under-resourced workforce. The Victorian government has just invested over $100 million in six EDs for this purpose, in order to separate psychiatric emergencies from physical emergencies and to improve the quality of care.

The rise in acute presentations to EDs could have been exacerbated by a variety of other factors that Sawyer and Patton have prematurely dismissed.

An increase in prevalence could be responsible. Sawyer and Patton disregard this because, according to National Mental Health Survey Data, the rates of mental disorders in this age group have not increased during the time frame studied. Methodological differences between these two surveys make this conclusion uncertain. However, even if true, unprecedented population growth, especially in Victoria, means that the absolute number of young people presenting to EDs would be expected to rise between the dates of the two surveys. This partial explanation is supported by the rise in rates in ED presentations for physical disorders, although to a lesser degree. The fact that the rates for mental disorders have risen more than those for physical disorders means that it is not the total explanation. An increase in the severity and complexity of disorders over this period could be an additional factor. The rise in self-harm rates is real. Suicide rates in young females (who are the most frequent presenters to ED for self-harm) are also increasing and a potential indicator of increasing severity. With the advent of better awareness and youth friendly primary care services, notably headspace, more young people are seeking help for self-harm and hidden morbidity has been revealed and mobilised.

In summary, state hospital ED attendances for acute mental health problems are not a test of the value of recent federal investments in primary youth mental health care.

Simple logic, backed by national level data and experience from the frontline of community mental health care, is essential to accurately interpret the Hiscock and colleagues’ findings. Sawyer and Patton state that efforts to buttress ED responses should “not detract from community services”. However, while EDs should indeed be redesigned to better meet the needs of people with acute mental ill-health and crises, the major focus of effort should be further upstream to prevent or divert such last resort presentations.

Professor Patrick McGorry, AO, is the Executive Director of Orygen, professor of Youth Mental Health at the University of Melbourne, and a director of the Board of the National Youth Mental Health Foundation (headspace).

Professor Andrew M Chanen is the Head of Personality Disorder Research at Orygen.

Dr Jo Robinson is a Senior Research Fellow at Orygen.

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