Background
Youth mental health is an important public health problem in Australia and internationally. Approximately one in four young people have mental health problems but tend not to access services [
1]. Primary mental health services have an important role to play in recognizing vulnerable individuals and offering appropriate treatment.
The Australian Government-funded Access to Allied Psychological Services (ATAPS) program is an example of a primary mental health care program that may improve access to mental health services for young people. Operating since 2001, ATAPS enables predominantly general practitioners (GPs; the Australian term for family physicians) 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 is delivered in up to 12 (or 18 in exceptional circumstances) individual and/or up to 12 group sessions. Review by the referring GP is essential after each block of six sessions and/or the final session [
2]. Nation-wide, ATAPS is currently implemented by 61 Medicare Locals, which are regionally based organizations that coordinate primary health care delivery whilst striving to address local health care needs and service gaps.
The introduction of the Better Access to Psychiatrists, Psychologists and General Practitioners (Better Access) initiative in 2006 has 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 [
3]; however, unlike ATAPS its funding is uncapped. Consequently, ATAPS has since offered 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 are not available via either the original form of ATAPS, which operates simultaneously, or via Better Access.
ATAPS has been independently evaluated since its introduction, with findings indicating high program uptake in both urban and rural areas [
4,
5] and positive outcomes for consumers [
6] and providers [
7]. To date, however, the ATAPS evaluation has not specifically explored ATAPS’ performance in terms of providing care for young people as a particular at-risk population. The current paper, therefore, aims to describe the uptake of ATAPS by young people aged 12 to 25 years, the characteristics of this group of consumers and the interventions delivered to them. This age range was selected in order to be more inclusive given the variations in the definitions ‘young people’ by different services and researchers internationally, and to facilitate comparisons with other Australian youth mental health services, such as
headspace National Youth Mental Health Foundation [
8], which targets 12 to 25 year olds.
Discussion
Substantially, 51 716 people aged 12 to 25 years received mental health care through ATAPS during the nine year analysis period. By comparison, and in the context that ATAPS funding is capped while Better Access funding is not, around 194 901 people aged 15–24 years received psychological therapy and focused psychological strategies in 2007–2009 via the Better Access program [
9]. A further 14 548 consumers aged 12 to 25 years were referred to ATAPS but did not take up the service (22% of all referrals), which is similar to the non-uptake rate for the entire ATAPS program, at 21% [
10], but lower than that (27%) reported elsewhere [
11]. Previous findings have demonstrated that the likelihood of using services increases with symptom severity; [
12] therefore it is possible that people referred to ATAPS but who do not take up the service have less severe symptoms. Other possible reasons for not taking up the service which could be further examined are lack of motivation or readiness to change; stigma associated with seeking mental health care; miscommunication with the GP; or access issues, such as the location or cost of the service.
The estimated Australian resident population aged 12 to 25 years in June 2012 was 4 081 058 [
13], one quarter of whom had a potential need for mental health services [
1]; given that 9 391 consumers in this age group accessed ATAPS in the 2011–2012 financial year, this equates to around 1% of consumers aged 12 to 25 years in potential need of mental health services accessing ATAPS. This rate needs to be interpreted in the context that ATAPS funding is capped and ATAPS is part of a suite of mental health services available for young people, such as Better Access,
headspace, Orygen Youth Health and Child and Adolescent Mental Health Services. From 1 July 2003 to 30 June 2012, sessions delivered to people aged 12 to 25 years accounted for 20% of all ATAPS services. Given that people aged 12 to 25 years comprise around 18% of the Australian population [
13], and that the prevalence of mental disorders is higher in younger age groups, the relative access to ATAPS by young consumers seems reasonable.
The fact that more females have taken up primary health care services via the ATAPS program is not surprising in the context that females with mental disorders in any group are more likely to use services than males [
12]. This in turn may be attributable to multiple factors such as lower levels of stoicism and personal stigma associated with mental health problems in females compared with males [
14], masculine norms being negatively associated with men’s willingness to seek professional help [
15], and the advanced mental health literacy of young female Australians [
16].
Most consumers were receiving low incomes or were from low income families and had not previously accessed psychiatric services, suggesting that the ATAPS program is addressing access barriers amongst those in need. Given that Indigenous people comprise 2.5% of the Australian population [
17], the finding that around 4% of consumers were of Aboriginal, and less than 1% of Torres Strait Islander, origin indicates that they are appropriately accessing ATAPS. However, in the context that Indigenous people have a higher prevalence of mental disorders [
18], their access to ATAPS could be improved. Indeed in July 2010, an ATAPS sub-program targeting Indigenous people was introduced that aims to address this inequity.
Findings based on the minimum dataset are limited by lack of corroboration of data such as diagnosis or intervention and may contain unidentified errors. For example, the ‘no show’ field was not mandatory until June 2013 and has a high rate of missing data, and so it is likely that this figure is currently underestimated and will increase in the future. However, there are several ways in which the quality of data in the minimum dataset is optimized including restriction of data entry options, mandatory data items, validation of data via code to ensure type of data entered matches type of data required and validation against data self-reported by Medicare Locals to the Department of Health, technical features to enable monitoring of each Medicare Local’s data patterns, data analysis checks, introduction of statistical linkage keys [
19] to minimize duplicate patient entry, and provision of a helpdesk and website to support data entry.
Our findings are policy-relevant for both Australia and other developed countries with a similar primary mental health care system that are considering advancing that system. Our study corroborates previous findings suggesting that depressive and anxiety disorders are the most common mental disorders in young people [
20]. The ATAPS model, which is predominantly reliant on a GP referral, is appropriate on the grounds that of the 35% of Australians with mental health problems who seek help, the majority do so from GPs [
21]. Although the ATAPS program may not suit all young consumers given that access to services is reliant on their having a GP, ATAPS is a good example of a primary mental health care program which has been delivering services to a substantial number of young people with clinically diagnosable disorders and that facilitates access to free or low-cost treatment. Future evaluation efforts could examine spatial data to determine area-based equity in access to ATAPS by young people.
Acknowledgements
Kylie King and Justine Fletcher (Research Fellows at the Melbourne School of Population and Global Health, University of Melbourne), Grant Blashki (Associate Professor at the Nossal Institute for Global Health, University of Melbourne) and Phillip Burgess (Professor at the School of Population Health, Queensland Centre for Mental Health Research, University of Queensland) have made significant contributions to the broader ATAPS evaluation. The evaluation of ATAPS is funded by the Australian Government’s Department of Health.
Competing interests
During the study period, the evaluation of ATAPS was funded by the Australian Government’s Department of Health.
Authors’ contributions
BB was the lead researcher for the study. She conducted the data analysis and interpretation and drafted the manuscript. AN and LR assisted with data interpretation and drafting the manuscript. JP oversaw the project and assisted with drafting the manuscript. All authors read and approved the final manuscript.