Urgent need to ramp up services for young "missing middle" of mental health

Cate Swannell
Med J Aust
Published online: 8 November 2021

RESEARCH which has again highlighted the reality of mental health care for young people with emerging mental disorders has clearly articulated the urgency of the need to invest in and upgrade Australia’s mental health services beyond primary care-based interventions, according to one of Australia’s leading experts.

Professor Patrick McGorry AO, Professor of Youth Mental Health at the University of Melbourne, and Executive Director of Orygen, wrote, in an editorial published today in the Medical Journal of Australia, that the mental health burden of young people “should arguably be our top health priority”.

“Mental ill health is by far the principal source of burden of disease for people aged 1225 years,2 and at least 50% of young people will experience mental problems,” Professor McGorry wrote.

“Further, the mental health of young people has been steadily undermined in recent decades by a cluster of socio-economic forces.

“This syndemic trend has accelerated during the COVID-19 pandemic, with surveys and health department data documenting the wave of distress, mental ill health, and suicidal behaviour flowing into emergency departments and bloating waiting lists.

“We saw a 25% global increase in anxiety and depression during 2020. This surge or ‘shadow pandemic’ was predicted by Orygen modelling in May 2020.

“The under-resourced mental health system has been overwhelmed in Australia, with general practices and headspaces inundated, emergency departments flooded with demand, and the mental health workforce dwindling and exhausted.”

Professor McGorry said research by Iorfino and colleagues which showed that primary care-based early intervention services such as headspace were only effective for one-third of young people with emerging mental disorders was “not unexpected”.

headspace was designed and works extremely well for the first stage of care, which involves mild to moderate mental health conditions, but also as a stigma-free gateway for more specialised care. So it is only part of the solution.

“While primary care-based models offering soft entry to care for all young people is effective for some, it is clearly insufficient for most young people with more substantial needs, well characterised as the ‘missing middle’,” he wrote.

“They require more sustained, expert, and multidisciplinary care to deal with evolving and ambiguous symptomatology, substantial comorbidity, and social and vocational impairment.”

Professor McGorry and his colleagues developed evidence-based templates for delivering community-based care to the early psychosis component of the “missing middle” 10 years ago, when it was supported by the Australian government, initially in six regions.

“We have shown at Orygen that this model, which has been scaled up in hundreds of locations around the world, is capable of expansion to accommodate the full range of more complex cases of mental dysfunction identified by Iorfino and colleagues,” he wrote.

“In addition to those with emerging psychosis, young people with mood, personality, eating, and substance use disorders or comorbid blends can be offered more sustained evidence-based care in a timely fashion.”

The program in the six regions “has been highly effective, but its extension to the rest of Australia has stalled”.

“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,” Professor McGorry concluded.

“The solution … is to rapidly scale up these platforms of care and to mobilise and expand the skilled workforces to operate them.

“With the additional mental health burden caused by the COVID-19 pandemic, it should arguably be our top health priority. Countless lives and futures will be saved.

“The missing ingredients are acknowledgement of the magnitude of this public health problem and of the shadow pandemic, a sense of urgency, and the capacity to implement reform.”

  • Cate Swannell



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