Youth mental illness is an important public health problem in Australia and internationally. Early identification of children and young people at risk of mental illness creates opportunities for intervention that can help to avert or ameliorate problems in later life. Primary mental health care services have an important role to play in recognising vulnerable individuals and offering appropriate care and support.
Youth mental health
A series of surveys conducted in Australia, which have considered high prevalence disorders across the age spectrum, can shed light on the extent of mental health problems in young people. The most recent National Surveys of Mental Health and Wellbeing (NSMHWB), conducted in 2007, recruited 8841 individuals aged 16–85 years [
1]. Findings indicated that among those aged 16–24 years, 23% males and 30% females (26% overall) had experienced anxiety, affective or substance use disorders in the previous 12 months [
2], compared to 20% of the overall sample surveyed [
1]. The most recent survey of child and adolescent mental health, conducted in 2013–14, recruited 6310 parents and carers of children aged 4–17 years and 2967 children aged 11–17 years and found that 14% of children and adolescents had a mental disorder (most commonly attention-deficit/hyperactivity disorder followed by anxiety disorders) in the previous year, which was associated with a substantial number of days absent from school [
3].
These surveys also show that young people with mental health problems tend not to access services. The adult survey reported that less than 25% of people aged 16–24 years with mental disorders accessed services in the previous 12 months [
2]. The 2013–14 child and adolescent survey reported 56% of 4–17 year olds with mental disorders had accessed mental health services (e.g., family doctors, psychologists, paediatricians and counsellors/family therapists) in the year preceding the survey [
4], which was an improvement in the rate of service use reported in 1997; 25% in the preceding 6 months [
5]. Furthermore, the adult survey found gender differences in service use among those aged 16–24 years, with only 13% of males and 31% of females with mental disorders accessing any mental health service [
6]. Even when young people do seek help, there is often a significant delay between onset of symptoms and accessing services, which varies according to type of disorder, gender, population group and geographic location [
7]. Personal factors (e.g., stigma and negative attitudes to, and experiences of, treatment) and structural barriers (e.g., location, cost and availability of services) contribute to treatment delays [
8].
The World Mental Health (WMH) Survey Initiative, which encompasses the Australian NSWMHB, is a project of the World Health Organization (WHO) which aims to obtain epidemiological data on mental, substance and behavioural disorders in all WHO regions [
9]. The WMH Survey Initiative found that in 17 countries in Africa, Asia, the Americas, Europe and the Middle East, the median and inter-quartile (IQR) age of onset is very early for some anxiety disorders (7–14, IQR 8–11) and impulse control disorders (7–15, IQR 11–12) [
9]. Given that many mental disorders begin in childhood or adolescence, access to services that focus on early identification and treatment may mitigate the persistence or severity of primary disorders and prevent comorbid disorders [
9].
Primary mental health care in Australia
In response to the public health problem of youth mental ill-health, the Australian Government introduced a suite of reforms to improve access to mental health care for young people, either by targeting them directly or by offering care across the age range.
The Access to Allied Psychological Services (ATAPS) program, funded by the Australian Government from July 2001 to June 2016, provided primary care for common mental disorders across the lifespan. ATAPS enabled general practitioners (GPs) to refer patients with high prevalence disorders (e.g., depression and anxiety) to mental health professionals (predominantly psychologists) for free or low-cost, evidence-based mental health care (most commonly cognitive behavioral therapy, or CBT). This care was typically delivered in up to 12 (or 18 in exceptional circumstances) individual and up to 12 group sessions per calendar year. Review by the referring GP was essential after each block of six sessions and/or the final session [
10]. Over time ATAPS evolved to offer more flexible services to particular at-risk and/or hard to reach populations [
11]. Nationwide, ATAPS has been delivered through regionally-based primary health care organisations: specifically, these have included 31 Primary Health Networks since July 2015, previously 61 Medicare Locals (July 2011–June 2015) and originally over 100 Divisions of General Practice (July 2001–June 2010).
ATAPS has been independently evaluated since its introduction, with findings indicating high program uptake by close to 280,000 clients [
12] in both urban and rural areas [
13,
14] and positive outcomes for clients [
15] and providers [
16]. The introduction of the continuing Better Access to Psychiatrists, Psychologists and GPs (Better Access) initiative in 2006 influenced the nature and direction of ATAPS. Better access facilitates similar access to primary mental health care via fee-for-service rebates under Medicare, Australia’s publicly funded universal health care system, operated by the government authority Medicare Australia [
17]; however, unlike ATAPS, its funding is uncapped. Consequently, following the introduction of Better Access, ATAPS refined its focus to offer more flexible services to particular at-risk populations (e.g., people at risk of suicide, people affected by extreme climatic events, children with mental disorders) that were not available via either the original form of ATAPS, which operated simultaneously, or via Better Access.
headspace National Youth Mental Health Foundation Ltd (
headspace), another Australian Government initiative, introduced in 2006, specifically targeted young people with mental health issues [
18].
headspace aimed to reorient the service system to create highly accessible, youth-friendly, integrated service hubs and networks that provide free or low-cost evidence-based interventions and support to young people aged 12–25 years [
18]. Each local
headspace centre was directed by a lead agency on behalf of a local partnership of organisations responsible for providing more integrated and coordinated responses for young people across primary care, mental health, alcohol and other drugs, and social, educational and vocational issues. The key aim was to improve mental health outcomes for young people through greater access and engagement, earlier intervention, more holistic care, and better service integration [
19]. Between 2006 and July 2014, 67
headspace centres were opened and services were provided to almost 125,000 young people in metropolitan, regional and rural/remote areas across Australia. Bipartisan government support meant that the number of
headspace centres steadily increased, with around 85 centres established by early 2015, and plans to increase to up to 110 centres across Australia in 2016/17 [
20]. The psychological services delivered by
headspace were often funded via the Better Access program (57.4%) and infrequently via ATAPS (7.8%) [
21].
As a result of a major review of all Australian mental health services completed in 2014 [
22], the mental health system is undergoing major reform. The key finding of this review was that Australia’s mental health system is poorly planned and integrated resulting in less than optimal wellbeing and participation, therefore hindering productivity and economic growth. Consequently, recommendations emerged to improve mental health system sustainability based on three key principles: person-centred design in which services are organised around the needs of people, a new system architecture based on a stepped care framework that provides services of varying intensity to match people’s level of need, and shifting funding to more efficient and effective ‘upstream’ services and supports (i.e. population health, prevention, early intervention, recovery and participation) [
22]. To this end, from July 2016, Primary Health Networks became the commissioners of primary care psychological treatment (including both ATAPS and
headspace amongst other programs) within a stepped care approach according to local population mental health needs [
23].
ATAPS and
headspace have differed not only in terms of who they targeted and how their services were delivered, but also in terms of what they offered. Both ATAPS and
headspace provided psychological services and had an overlapping client group but
headspace provided additional health and biopsychosocial services (including physical and sexual health, alcohol or other drug, and vocational services) as well as community awareness and youth engagement activities. Although both programs have separately examined service delivery for young people across different time periods [
19,
24], to date a comparison between the programs and the young people to whom services have been delivered has not been undertaken. Therefore, we examined the uptake of both programs by clients aged 12–25 years, the characteristics of these clients, the types of services delivered and the mental health outcomes produced.