Youth mental health: building beyond the brand

Youth mental health is a hot topic. How much progress have we made, and what’s next?

Timing in the life cycle is the key difference between physical and mental illness. The fact that mental ill health starts so much earlier in life than other major non-communicable diseases means that it is has a much more devastating public health and economic impact. Seventy-five per cent of mental disorders emerge before the age of 25 years2 and cause premature death, pave the way to a lifetime of social welfare, or erode human potential on a wide scale. Mental illness has double the effect of cancer on the economy, and the costs of the serious underinvestment in its treatment are borne across the whole of society.3

Australia has led the world by initiating reform through investing in a missing element of the health system — holistic mental health care for young people — through headspace, a system of “one-stop shops” aiming for integrated health and social care for young people aged 12–25 years.4 One decade on, it is timely to review how far we have come and what we need to do next. The Supplement accompanying this issue of the MJA looks at these issues in a sophisticated way, seeking to provide information, concepts and strategies to guide the next phase.

Beyond brand: how solid is headspace?

A trusted national brand has been developed by headspace over the past 10 years. While this is only a first step for early intervention in mental health, it represents real progress, since trusted brands in mental health care have proven very elusive due to stigma and discrimination, which has resulted in gross under-resourcing and services that are low in capacity, morale and quality. The independent headspace evaluation has shown that brand awareness and trust is high, and indicates that early access to care for young people has been greatly expanded, combined with very high levels of satisfaction with care among young people and families.5 Community and political support for headspace is consequently very high. Youth participation has been a core feature and key to removing stigma. But what lies behind the brand? How solid is it? While headspace centres aspire to offer through a one-stop shop at least four streams of care — physical and sexual health, mental health, drug and alcohol expertise, and vocational services — it is clear that this has not yet been fully realised in a substantial minority of centres.5 The core headspace grant to centres has never been indexed and hence services have been eroding every year. Defined funding streams for substance use and vocational interventions have not yet been developed. The failure to develop a sound financial model for encouraging general practitioner recruitment means that many centres still do not have on-site GPs. Further, the 10-session cap on allied health funding limits and distorts the provision of care. eheadspace already provides services to 40 000 young people a year but must now be scaled up and integrated with other online platforms and with centre-based face-to-face care. While short-term outcomes improve for about 60% of young people, a significant subgroup of more complex and severe cases fail to improve or may even deteriorate. The review of international one-stop shop models by Hetrick and colleagues6 in the Supplement reveals a similar picture in other jurisdictions.

Building a new system of care

headspace can be seen as the reception and ground floor of the building project that is the new 21st century youth mental health system. We need to expand the pathway to the front door with online technology and community engagement and case detection strategies. We need to increase and index the core headspace grant, and specifically make it financially viable for GPs to practise in a youth mental health setting. We need to meet the needs of the substantial subgroup of more complex and severe cases by:

• lifting the cap on allied health sessions so a longer tenure of care is possible;

• providing more specialised expertise in key diagnostic areas like complex mood disorders, psychosis, and eating, personality and substance use disorders; and

• funding mobile home-based and outreach interventions for young people who cannot access a centre or are hard to engage.

The federal government has a stream of funds entitled “youth severe”, which is intended to respond to the needs of these patients. This stream should be expanded and targeted to fund the above three elements.

Primary Health Networks (http://www.health.gov.au/internet/main/publishing.nsf/Content/PHN-Home) have a crucial responsibility to construct the next stage of the youth mental health model in a way that is predictable and delivers a standard of quality across the nation. headspace is the federal government’s preferred model for enhanced primary care. As the proven blueprint for commissioning enhanced primary care for young people, it must retain and expand its clear service specifications, which are key to reliable evidence-based care. headspace National Office retains the role of accreditation of headspace centres and ensuring fidelity to an essentially simple model of integrated practice.7 Primary Health Networks now have the challenge and opportunity to integrate, via strategic recommissioning, a fragmented system of lead agencies into a regional model of youth mental health care. In a given region, headspace centres should be operated within a cluster model by one lead agency and consortium. This would improve efficiency, workforce issues, integration and interface with state services. State-funded mental health services must always remain a member of these consortia, since the interface with acute care is crucial for saving lives. Patients with complex and severe disorders appropriately find an entry portal through headspace centres, but face a serious bottleneck in accessing state-funded specialist care unless they are in an acute and desperate state. The federal government has recently introduced a welcome new funding scheme focused on such patients, which should be channelled by Primary Health Networks via headspace centres within a regional cluster and expanded progressively to reduce this bottleneck.

The salience of youth mental health as a public health issue means that it must remain in the vanguard of evidence-based reform in health care.