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A FOUNDING director of headspace says the organisation is the “front door” for youth mental health care in Australia, with more than 150 centres across the country. Yet many who walk through that door found there was “nowhere to go” once inside.
Professor Ian Hickie, co-Director of the University of Sydney’s Brain and Mind Centre, was commenting on sobering research which found the majority of young people who access mental health services through headspace centres experience no measurable long term improvement in function.
The findings, published in the MJA, have sparked calls for urgent restructuring and investment in youth mental health services, including vital access to second-tier multidisciplinary specialist care for hundreds of thousands of young Australians with complex cases.
“[At present] they might see a registered psychologist or a youth worker – people who are good with relatively simple forms of care – but at least 50% of people coming through headspace need to see people with much greater clinical skill,” Professor Hickie said.
“These kids aren’t getting to see a clinical psychologist, they’re not getting to the multidisciplinary teams, they’re not getting to the functional recovery team, and they’re getting nowhere near a psychiatrist.”
Wait times to see a clinician at headspace were now often 8–12 weeks, Professor Hickie added, saying young people were becoming disengaged from the service.
Headspace began as a major federal government investment in primary care-based youth mental health in 2006, in response to evidence that young people weren’t accessing mental health care. At headspace, youth with subthreshold symptoms – those that do not meet the full criteria for a Diagnostic and Statistical Manual of Mental Disorders (DSM) axis 1 disorder – could access mental health, alcohol and other drug, primary care, and vocational services.
However, Professor Hickie said pathways were never developed for patients with complex needs.
“It was assumed at the time that the specialist services would grow, but the cavalry has never arrived,” he said.
Professor Hickie was the senior author on the latest study, which mapped the trajectories of social and occupational functioning for 1510 people aged 12–25 years attending two headspace centres at the University of Sydney.
The study found two in three young people with emerging mental disorders did not experience meaningful improvement in social and occupational functioning during 2 years of early intervention. The largest group, 49%, had deteriorating and volatile trajectories.
Those with worse trajectories tended to be less well to begin with; for instance, having a history of hospitalisation and comorbidities.
“The whole point of early intervention is to change young peoples’ trajectories toward maximising social, economic and education participation in the long term,” Professor Hickie said.
“But the data shows that this model of care alone – a simplistic brief psychological model – does not deliver good long term functional outcomes, and it’s not been built to do it.”
Professor Hickie called on the federal government to lead reform of the sector, with state cooperation.
“The federal government must make multidisciplinary care services for youth mental health financially attractive,” he said. “We cannot afford for headspace to be run as a rather generic and at times low skilled entity.”
Professor Pat McGorry AO, another headspace founding director, and Executive Director of Orygen, said the findings of the latest study were “sobering”.
“Flooded with demand, headspace urgently needs a much more robust financial model and linked workforce strategy,” Professor McGorry wrote in an accompanying MJA editorial, noting rates of depression and anxiety increased by 25% globally during 2020.
Professor McGorry told, in an exclusive MJA podcast, a “second tier” to headspace was long overdue to cater for the 65% of people who accessed the service but needed more specialised care.
“These are the people with early signs of quite serious eating disorders, psychosis, emerging bipolar and more severe forms of depression that’s not responding to a few sessions of psychological intervention and antidepressants,” he said.
“The only option for those people is to get worse and worse until they get into life-threatening situations and then end up in emergency departments.”
Professor McGorry, who gained international acclaim for his work in early psychosis, said the model his team pioneered in Melbourne could be expanded to accommodate the full range of more complex cases of mental dysfunction.
“This early intervention platform should now be rapidly installed across the nation as an overdue back-up system for assisting the hundreds of thousands of ‘missing middle’ young people, currently locked out of state government services, yet manifestly unable to benefit from primary care alone,” he wrote in his editorial.
Professor McGorry painted a bleak picture of the mental health workforce at present, telling the MJA podcast the system had “imploded across the country”.
“There’s got to be a sense of urgency here,” he said. “In our services in North Western Melbourne we have 1000 young people on our waiting list.
“We have 100 vacancies but with the borders shut and a complete lack of entrepreneurial spirit in terms of recruitment and retention, we’re struggling to find the people,” he added.
A spokesperson for the Department of Health said the government remains committed to headspace, investing in the building of ten new centres at the last budget.
The government is funding an early career program to provide placements for students and graduates within headspace ($22.6 million over 2 years from 2021 to 2022).
It is also funding a “Demand Management and Enhancement Program” to address waiting lists at headspace ($152 million from 2018 to 2025), the spokesperson said.
“In terms of mental health care, the efficacy of headspace reported is broadly similar to other mental health treatments, including antidepressants,” the spokesperson said.
Nevertheless, the Department is currently undertaking an independent evaluation of the national headspace program, due to report in May 2022, which will include consideration of patient outcomes, the spokesperson said.
The authors of the latest MJA study said their findings demonstrated the dynamic nature of youth mental health disorders, where an individual’s trajectory can “oscillate between health and disorder as a function of vulnerability and protective and treatment factors”.
Professor Hickie said this showed the need for a “measurement-based” approach to care, using information technology (IT) to tailor treatments to an individual’s outcomes.
“If we were setting headspace up now, we would have IT-coordinated entry to care,” he said. “We wouldn’t rely so much on the real estate; we would use much more technology to make sure kids went to the right place in the first place, and a lot of kids would go straight into specialist care.”
Thank you for your hard work on this significant study.
Further to the comments above, it would be helpful to have full details on the treatments (the treating clinician, therapies, specialist services, case management, groups, primary care visits, inpatient care, medication types, home visits, involuntary admissions etc) received.
The study notes: “We identified our participants in a research registry of 6743 people aged 12–30 years who presented to the youth mental health clinics at the Brain and Mind Centre (University of Sydney) during 1 June 2008 – 31 July 2018. These clinics provide both primary care services (headspace) and more specialised services.”
Some young people appear to have been seriously unwell, and could have needed step-ups to specialist care at BMC.
Train more clinical psychologists
I think that a third of people on a waiting list would improve. Such is the nature of regression to the mean.
Headspace is full of people who provide SSRI’s and supportive psychotherapy. The former can be provided by GP’s and the latter does not help.
If headspace would just provide services like top-class dialectical behaviour therapy (DBT) for borderline personality disorder that would be great.
As for the commenter who said that someone with vision was needed, well how do you think Headspace got started? Useless thing that it is.
What happened here is what often happens. Someone gets an idea that has good face validity, money is spent setting it up, but evaluation of effectiveness is not baked into the produce, and a lot of money gets wasted.
I think it was Professor McGorry who once said to me – “We don’t measure the harm we do to people accessing Mental Health Services”.
Whilst Professors Hickey and McGorry and many others have had an amazing impact on youth MH services in Australia it remains that they are great clinicians and service modellers. What is missing in the space are strategist with vision and the power of influence. More needs to be done to improve customer service, and mental health could take a leaf out of the MacDonalds or fast food industry on putting the customer first, marketing, selling the product and continuous improvement of the product.
Mental Health has provided its users with ‘lip service’ that does not even come close to what you get and quite frankly is an insult to people with mental health problems.
There have been many issues that have impacted the decline of services provided to people with mental health problems (not to say there still are pockets of excellence). In NSW the lifting of quarantine of mental health funding in LHDs, no authority of mental health division at state level to truely implement models of care and a workforce for the most part who don’t care are a few contributing factors.
We have for many years been concerned about nurturing and retaining a workforce who are basically in it for themselves. You won’t get Clinical Psychologists to work in Headspaces – they mostly will not work for the Medicare fee and claim a gap payment. Nurses who would do well in the youth space , if they can get Medicare payment , it does not go anywhere in matching the award salary in health. There should be more Social Workers , Speechies, dietitians , peer workers and OTs in mental health. There in lies another problem – I once worked in psychiatry and somehow that became mental health. I guess not a great choice for kids who see that as being ‘psycho or mental’ despite the rhetoric we have not come very far in reducing the stigma.
Anyone who has worked in child and youth mental health know what works , but are often exhausted fighting systems that just don’t get it or working with staff who work in a protective system that does not easily allow you to move clinicians, who just don’t fit.
There is a lot of money being allocated to child and youth mental health services and I for one am not confident that giving more to a broken system will necessarily fix the problem.
I agree with grasshopper, we need to invest in improving systems (being honest) and CAPA is one example of how this can be done. I have worked in services where we eliminated wait lists. We need to employ people by skill , not profession and we need to listen to young people about what they want. Working in partnership, stepped care models, wrap around service’s , no wrong door and all the other cliches should underpin the service, but not interfere with service delivery.
If the federal government invested in state funded mental health systems – it would enable young people and their support networks to access multi disciplinary teams and hence the expertise of psychiatrists, occupational therapists, psychologists, peer workers, mental health nurses and social workers.
The clinical governance available in these state funded models would allow for appropriate triage and streaming to evidence informed care.
The team based approach would enable service users to be able to access services regardless of opening hours, waitlists, staff being on leave etc.
The interface that these community services have with facility based care and the possible investment in youth specific employment and recovery programmes would enable families to connect with one service but have most of their needs met.
Currently we expect distressed service users to navigate the quagmire of state and federally funded services.
A quagmire that service providers struggle with daily.
The two tiers of government in this country contributes to the ongoing challenges families encounter when attempting to get care at their most distressed moments.
The federal government investing in a more robust complex care space is merely duplicating what exists in state funded services – why not move money over and get the most bang for buck by building on the economies of scale…. perhaps it will never happen as all the notional “investing in health” is about politics and election promises as opposed to anything else.
Few things.
NGO’s pay lower salary’s to clinicians, so intake assessments are completed by clinicians who are still developing practice. Interesting they put their least experienced clinicians in the front line. This contributes to misdiagnosis and suboptimal treatment planning (emerging personality disorder is commonly missed and treatments delivered are less effective than best practice offered through Project Air). Further to this, the level of pre-screening (phone triage etc) is outdated and not in line with best practice. The system is too confusing for people to navigate so they simply give up.
The Choice and Partnership Approach (CAPA) is an evidence based service delivery model and is considered best practice to handling capacity and demand. Most importantly, CAPA contributes to more person centred, safe/high quality and connected care. This has been introduced to NSW Health and is disappointing this wonderful model has fallen by the waist side.
More money is not the answer, better use of money is. Credentialed Mental Health Nurses would flourish in headspaces but are not hired to deliver psychotherapy as they can not claim on Medicare. Yet time and time again, funding keeps going toward psychologists.
The high turnover rate of staff in headspaces is reflective the current model is not working.
Time to get innovative, move along with contemporary practice and stop doing the same things over & over & over again and expecting a different result.
The lack of access to Child and Adolescent Psychologist and Psychiatrist Services continues to add to the distress of young people seeking support. While GPs and Paediatricians are rapidly upskilling to support young people who are unable to access services there is still a gaping hole for those who are needing crisis support and ongoing complex case coordination. Early intervention is needed for young people under the age of 12 who are too young for Headspaces services. Age appropriate trauma counselling from a young age is essential to address for developmental trauma young people.
Congratulations on this work.
I note that data are reported on only a quarter of the individuals presenting to the Centre. These were the people who engaged with the service for at least 2 years. The authors argue, “We could not assess the longer term functional outcomes for those who did not remain in contact, perhaps biasing our sample towards people who required ongoing care and were accordingly more likely to have poorer outcomes.” This is a generous assumption, as generally, people are likely to engage with a service if they perceive some benefit from it. It would be nice to see outcome data on everyone with at least one outcome measure, irrespective of the duration of follow-up.