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MENTAL health advocates agree: young people are looking for more mental health help than ever before and our current system isn’t meeting the demand. How to improve the system is up for debate.
A Perspective published in MJA points the finger at headspace, saying the organisation hasn’t done enough with the millions of dollars of funding they’ve received over the years. According to the article, headspace received $35 million in 2017–18 and a further $263 million over the following 7 years.
“As a result of this financial support, headspace has a significant presence in the delivery of mental health services to young people. For instance, there were 441 914 care episodes in 2020–21 and, since inception, headspace has provided 4.4 million services to more than 700 000 young Australians. This expansion has occurred despite limited evidence of effectiveness, with many studies using either process measures or uncontrolled satisfaction surveys,” the authors wrote.
Perspective co-author Professor Steve Kisely from the University of Queensland told InSight+ that he wants to make sure the small pot of money that goes towards mental health is being spent the right way.
“Every time we have a mental health crisis, governments of both persuasions, the first thing they seem to want to do is throw more money at headspace,” he told InSight+.
“It just seems that we probably need to take a step back and look at what the outcomes are for all the money that’s been being spent on it,” he explained.
What is the goal of headspace?
The MJA article highlighted a study of 1510 young people which was published in late 2021 in the MJA. It found that only 35% had good functional outcomes after 24 months in the period 2008–2018.
Lead author of the article, Dr Frank Iorfino, Senior Research Fellow of the Brain and Mind Centre, told InSight+ that headspace primarily benefits patients in the early stages of illness.
“While the brief psychological interventions are effective for reducing psychological distress, they only marginally improve things like functioning. So, it is lacking in terms of being able to provide the comprehensive type of care to the needs of young people,” he said.
Professor Pat McGorry, Professor of Youth Mental Health at the University of Melbourne, Executive Director of Orygen and founding board member of headspace, said it was important to understand the original intention of headspace.
“Headspace was not set up to solve all the problems of youth mental health. It’s primary care. It was set up because the standard general practice model wasn’t working for young people as an entry point,” he explained.
Chair of the Royal Australian and New Zealand College of Psychiatrists Binational Section for Youth Mental Health, Dr Daniel Pellen, agreed that headspace was never designed for complex mental health problems.
“It is therefore not surprising if a service cannot meet a need it was not set up to address,” he said.
Are we in a youth mental health crisis?
The fact is, there are more young people seeking help and their problems are increasingly complex.
“Just like all systems, at the moment, of health care, it’s struggling. And the reason it is struggling is because we’ve had a 50% increase in need for care as confirmed by the National Mental Health Survey about a month ago. A 50% rise in exactly the age group that headspace is trying to respond to,” Professor McGorry said.
The reasons the mental health of young people is declining is complex. Part of it can be attributed to the COVID-19 pandemic.
“During 2020 and 2021 there were documented increases in presentations to emergency departments by young people with suicidal ideation and self-harming behaviour,” Dr Pellen said.
“Colleagues report that waiting times for young people to see a private psychiatrist or psychologist have blown out to 6–12 months or more, and I have also personally noted an increase in friends and colleagues directly asking me about accessing mental health care for a young person.
“Apart from the pandemic, my opinion is that mental health in general, and youth mental health in particular, now has such an increased profile that young people are more willing to seek help,” Dr Pellen explained.
Professor McGorry agreed that this crisis has been brewing for a while.
“It’s issues like the increasing insecurity of life for young people in every way. The future with climate change, economically, there’s been wealth transfer from younger people to older generations, the commodification of education,” he said.
Mental health issues in youth have always had high prevalence.
“But it’s the only age group where we’ve seen a rise in prevalence over the last 15 years or so. The other age groups are stable, whereas there’s been a 50% increase, which is huge.
“We actually have to treat this as a public health crisis and think about prevention strategies as well,” he highlighted.
Single funding stream or single model of care?
According to Professor Kisely, one way to manage the problem would be to have a single funding stream for youth mental health.
“There should be a single funding stream for all services, which will probably help in many ways to get better integration. If it was a single funding stream, even though the sources might be different, some might come from the states, some might come federally, at least it would lead to better integration,” he suggested.
However, according to Dr Iorfino, the focus for change shouldn’t be on the funding model.
“The focus should be on the model of care and not the model of billing. It’s most likely going to be different in different regions. It’s about drawing upon and filling gaps in services and not duplicating as the authors of that paper suggest,” he said.
“If you want an example of this, we’ve been funded … to provide the right care at the first time, every time, which is a project exactly like this. So we go into local communities, work with the Primary Health Network and the communities on the ground, figure out the service landscape … use modelling as well to try and model these services. And then we work with the services to try and figure out how technology and other tools can be used … to meet the needs of that whole community,” he explained.
How headspace integrates with state-based services
It’s this lack of integration with existing services that has been previously recognised as an issue with headspace.
“Due to funding arrangements, it is impossible or very difficult to shift resources between, say, a headspace and a state Local Health District (LHD), even when the state LHD is the Consortium lead for the headspace.” Dr Pellen explained.
Professor McGorry agreed.
“The one thing I do agree with them about is that those systems … the primary care headspace and the secondary care expanded early psychosis models should be linked better to state systems,” Professor McGorry said.
Dr Iorfino agreed that funding needs to be spent filling in the gaps.
“Either people end up in headspace, which might not be suitable for them, or they end up in an emergency department, which is also not suitable for them. So, I think strengthening how the services work together is a really critical point, not necessarily just throwing more money at individual services to function alone,” he said.
It’s not just the funding. In most states, part of the problem is the way the access models are set up. They’re not aligned with headspace’s 12–25 years age bracket.
“Currently, most state services around the country are still in this obsolete 0–18 paediatric system,” said Professor McGorry.
“That doesn’t align at all with headspace. So, you’ve got to change the age parameters if you’re going to follow that path, which is the right path to follow.”
In Victoria, the Royal Commission mandated for the public mental health system to be organised around a 0–11 years system and a 12–25 years system for emerging adults. Other states are also in discussions.
In one area of Melbourne these changes have meant integration has been possible.
“We have a local system across about a quarter of Melbourne where we run five headspaces. And we are in the process of fully integrating the state services that we run with those headspaces and so that’s the local prototype that we hope to see everywhere,” Professor McGorry explained.
If other states were to change, he sees there could be progress to meet the demand for more complex mental health problems, including the “missing middle” — people who are moderately unwell and need treatment but don’t need crisis services.
“If that were done and resourced, then definitely the state governments would be very good partners in national reform in this space,” he said.
“But the federal government really needs to fund it because state governments will never have enough money to actually cover the whole of the missing middle on their own. We need vehicles like early psychosis platforms, so the Commonwealth and the states can co-invest in solving this missing middle crisis.”
Although the problem is complex, ultimately everyone wants the same thing: a mental health service that meets the needs of all young people.
“It’s basically that [we need to] have the appropriate mix of services that meets the community’s needs. It could be a mix of Medicare-provided headspace and head-to-health state mental health services. But we’re all much better integrated and service configuration is … adapted to the needs of the local community,” Professor Kisely concluded.
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I was working in child psychiatry at the time Headspace was set up and is was seen as a direct competitor to the state services for funding ie for secondary and tertiary care as it was argued that Headspace could better care for this group. I don’t recall Prof Mc Gorry arguing at the time it was primary care and supplementing general practice. Initially also Headspace did have psychiatrists and did take on difficult patients which isn’t the case now. The end result is that the majority of funding goes into “primary care” Headspace and the State Services who are equipped to treat the seriously ill are left stranded. If Headspace is just primary care then funding should be allocated based on this limited role and the secondary and tertiary centers should receive the funding to treat the more seriously ill.
Despite having more and more agencies and mental health services, patients and their GPs can’t still find help when needed.
Also, it seems patients are charged a significant out of pocket fee, despite increased funds resulting in allied health professionals being paid more. Whilst GPs are still expected to cover their expenses, time and extenssive studies with fees lower than trades’ fees!
I agree with the comment that headspace is for middle class young people with parents who are generally motivated and engaged in seeking help. The Maccas model. Works OK in Bondi Junction, but useless in Mt Druitt.
As to the outcomes, it like much of mental health care, is outcome blind.
It is neither relevant or accessible to young people from other backgrounds and more complex needs – and there are tens of thousands of these in desperate need of specialist care who end up in foster care, state care or no care and interactions with criminal justice system. The National Commissioner for children and young people recently pointed to the complete lack of services and alternatives to detention as one dimension of the missing services for youth.
My problem with Headspace is the lack of objective outcome measures. There are standardised and validated instruments for assessing anxiety and depression. Patients should complete an assessment instrument at every consultation – it is the only way you know if your treatment is effective. Headspace is only value for money if it provides effective treatment that results in clinically significant improvements. We measure all other bodily functions, why not in the mental health space?
I’d personally prefer to work in the same building as the people providing therapy. In a “normal GP clinic” was often seeing five mental health patients a day. The same problems with access exist everywhere now so at least this way there is genuine collaborative multidisciplinary care happening. The complexity level is so high now in GP clinics, I felt I needed more support.
So now as someone who does work in a headspace centre, I would like to explain the lack of integration with existing services in our region. As the GP it is part of my role to clinically escalate our young people’s care when they have for example early psychosis or eating disorders. That involves making a referral to the woefully underfunded state community mental health teams, with whom there appears to be a somewhat adversarial relationship pre-dating my employment. I believe they see headspace as the service with all the funding, and don’t understand why I’m referring out. But they have the subspecialist expertise, the links to the hospital, the local in-person psychiatrist and they even told me they are not at capacity (meanwhile we are overflowing) but are reluctant to accept my referrals that meet their criteria.
So yet again the GP is left to coordinate care, and hold onto complexity. See article from a couple of weeks ago from the group of mental health GPs for further insight on that topic…
Headspace: mainly suits young people who are middle class and speak English. And seems to be feel-good funding by the Feds, as hinted at in the article, with lack of meaningful evaluations. MH services for youth need a brave re-think at national (and state/territory) level.