Creating headspace for integrated youth mental health care
Authors: Patrick McGorry, Jason Trethowan, Debra Rickwood
Journal: World Psychiatry (2019)

International momentum in global mental health reform is building, responding to overwhelming evidence of unmet need in high, middle and low income countries alike, and powerful economic arguments that mental health care represents the best value for money. Yet adequate investment remains an elusive goal, with the treatment gap as wide as ever1. We have long argued that new paradigms that dispel stigma, open up early access, safeguard hope, and build expertise and quality based on the best available evidence, must be embraced and scaled up in real world settings2. The growing success of prototypical evidence-based early psychosis models in many parts of the world has paved the way for a more definitive reform paradigm, one which links transdiagnostic early intervention with a decisive focus on young people. Early intervention to reduce the impact of potentially serious mental and substance use disorders is an achievable goal if we focus on the period of peak risk of onset. Young people aged between 10 and 24 years make up over a quarter of the world's population, and mental ill-health is their key health issue and leading cause of disability. Virtually all major mental and substance use disorders emerge during the transitional zone between puberty and mature adulthood but, despite being burdened by the highest incidence and prevalence of adult type mental disorders, young people have the worst access to health care. Society as a whole and health systems in particular have comprehensively failed our young people, and at a time when their mental health appears to be deteriorating. This paradox is finally beginning to be recognized, and progressive jurisdictions around the world are designing and scaling up novel youth and family friendly systems of care to address this serious public health problem2. "Integrated youth health care" is an enhanced primary care model offering "soft entry" to care with access barriers minimized. It provides a high capacity first step in stepped or staged care, with other pathways able to flow from this initial low stigma source. It is highly consistent with the global strategy long advocated by the World Health Organization, namely to build and blend mental health expertise within primary care platforms. Reform began in Australia in 2006, with Australian government funding for ten headspace centres4. They have been scaled up through a series of funding rounds, reaching a total of 110 centres in early 2019. Centres are commissioned through a lead agency and local consortia, and have rapidly gained strong local community and political support from all sides and levels of politics. To June 2018, 446,645 young people accessed headspace centres, phone or online (eheadspace) services, with 2.5 million occasions of service delivered. In 2017-8, 88,500 young people accessed face-to-face headspace centre services, and 33,700 accessed online or via phone. headspace also offers suicide postvention services in high schools, and vocational recovery interventions online and face to face. Six early psychosis platforms linked to clusters of local headspace portals build on the primary care model with comprehensive evidence-based care for early psychosis in community settings. Independent evaluation of headspace centres confirmed that they provide much better access to young people, with very high levels of satisfaction and safety5. Outcome studies show that 60% of young people improve significantly either symptomatically, functionally or both6, 7. Despite this tangible success, which has inspired similar models internationally, headspace remains a work in progress. It offers mostly brief episodes of care, and the effect size for improvement in the total sample remains small to modest compared to usual (poorly accessed) care. There are several reasons for this. First, headspace is a treatment delivery system and offers the same treatment content as usual care, albeit more efficiently and in a single location. Second, capped funding and the lack of funding streams for key pillars, notably alcohol and other drug and vocational interventions, mean that tenure of care and model fidelity need to be strengthened. Third, outcomes for the large subset of more complex and unwell young people, whose needs can only be met by more intensive expert services, obscure the benefits for those with earlier presentations who are most likely to do well with this model by not progressing to more severe or persistent illness and functional impairment. headspace currently only provides access to a minority of the young Australians who need it. At least 132 centres could be justified on cost-effectiveness alone, with many more required for full national coverage5. Each region of Australia needs a cluster of headspace entry-level portals seamlessly linked to transdiagnostic specialized care integrating mental and physical health with alcohol and other drugs expertise, vocational interventions and online/digital health platforms. Assertive and intensive home-based care, and clinicians with expertise in complex syndromes (such as borderline, eating, mood and psychotic disorders) are missing elements, and interface with hospital-based services is therefore needed. Strong national oversight to assure integrative commissioning, stronger financial models, additional funding streams, longer tenure and greater depth of expertise will strengthen the capacity of the model. The youth mental health paradigm is in its infancy and will be driven by a dynamic blend of grassroots and professional leadership8. Early adopters, inspiring leaders, philanthropic visionaries and patrons have emerged in progressive regions of the world, notably Ireland, Canada, Denmark, Israel, the Netherlands, France, Singapore, and parts of England and California9. Child and adolescent psychiatry, still a seriously undersized speciality, has begun to recognize the need and opportunity for a paradigm shift, which it has labelled "transitional psychiatry". Momentum within and beyond the mental health field is building and could be decisive in paving the way for a wider revolution in mental health care.