Response to Jorm: Headspace – A national and international innovation with lessons for redesign of mental health care in Australia

The design, testing and scaling up of youth mental health service reforms in Australia over the past decade provides valuable lessons for the future of health reform in Australia. In particular, the initial successes of headspace in improving access, service satisfaction and outcomes for young people with emerging mental illnesses has established a platform for reorienting mental health care towards earlier, more holistic care that is increasingly being delivered in multi-disciplinary enhanced primary care settings. The influence is obvious of the headspace model on the broader restructure of mental health care announced by the Prime Minister and Minister for Health on 26 November 2015.

Why was headspace needed?

Prior to headspace, young people with mental ill health had the worst access of all to care (as low as 13% for young men) and yet by far the greatest need and capacity to benefit. This meant that one million young Australians on the threshold of productive life were at risk of premature death, the economic scrapheap or substantial underachievement. One thing was certain: spontaneous remission wasn’t working for them; they were not getting better all by themselves (Lawrence et al., 2015). The first priority for young people was to raise levels of access to care. The second priority was, once young people were engaged, to deliver not only the evidence-informed treatments that could be provided in standard primary care, but to add other evidence-informed interventions linked to the core needs of young people; namely, education, employment, substance use and others, within a ‘one-stop shop’ model. That is, to deliver treatments more efficiently than the pre-existing fragmented system.

Access and engagement

The first external evaluation of headspace showed that headspace centres were accessible and acceptable to young people (Muir et al., 2009). Data for 2013–2015 show almost 75,000 unique young people accessed services, with 41% never having sought professional mental health care before. Satisfaction levels were uniformly high, something very rare in mental health care. Importantly, headspace has succeeded in greatly improving access to care for traditionally underserved populations, notably young people from indigenous; lesbian, gay, bisexual, transgender and intersex (LGBTI); and regional and rural backgrounds (Rickwood et al., 2015).

Is headspace effective? Is it more effective?

Perversely, headspace’s success in improving access makes it more difficult to measure its progress in increasing the effectiveness and efficiency of service provision.

One of the challenges for the independent evaluators of headspace has been that because access levels prior to headspace and where headspace does not yet exist are so poor, it has proven very difficult to assemble a comparable control group. In general, headspace clients have more complex needs and the disadvantaged groups that are relatively overrepresented among headspace clients (e.g. young people from regional Australia, indigenous and LGBTI) are underrepresented in other services.

In a recent commentary, Professor Anthony Jorm suggested that the effectiveness of headspace could be assessed by comparison to samples of patients with mild to moderate depression where spontaneous remission can be observed (Jorm, 2015). However, the samples he cites are entirely different in terms of age, diagnostic mix, complexity and socio-demographic variables. Headspace clients are simply not homogeneous samples of patients with mild to moderate depression, whether older or younger.

The notion that spontaneous remission is common and the implication that care is frequently unnecessary is not supported by long-term follow-up studies such as the Christchurch study (Gibb et al., 2010). Untreated mental ill health results in proportionately poor outcomes in a dose–response fashion. Furthermore, although severe endogenous depression in the days prior to antidepressant treatment was known to remit in most cases after many months, these depressions were associated with a 15% suicide rate and unbearable suffering. Similarly, young people with unbearable emotional pain are at significantly elevated risk of self-harm and suicide. Relying on the potential for spontaneous remission is not quite as good as it sounds.

Headspace is also not a single specific intervention, but a complex and variable needs-based mix of interventions provided within a model of care. Spontaneous remission confined to symptomatic levels does not capture behavioural consequences such as self-harm and suicide and social and vocational outcomes – all of which are major components of headspace’s work. These outcomes, notably days out of role and rates of self-harm, are substantially improved in headspace clients. We are unaware of any data suggesting these harder and functional outcomes improve at all in traditional primary care.

How can headspace be improved?

Of course headspace is a work in progress and areas where we feel headspace can do better include a stronger general practitioner (GP) presence and local connection, an evidence-based approach to vocational recovery and substance misuse and a much greater level of support for families and peers. Headspace sites have been scaled up in a series of waves, and they are not all fully mature or ‘evaluable’.

As noted by Professor Jorm, there may also be some potential to achieve greater benefits for headspace clients through increasing the number of psychological treatment sessions. However, further research and analysis of headspace data are required to identify the groups of young people with the greatest potential to benefit from greater engagement and the most cost-effective means of achieving these outcomes. With the wide diversity of presenting issues of headspace clients, some may only require a few sessions to get back on track, while others may need more assertive engagement and support. Young people from more marginalised groups, such as homeless youth and those with substance use, and those living beyond 10–20 km from a centre, may need outreach mechanisms to engage.

Headspace itself is merely an enhanced primary care model and the fact that some young people do not improve is totally expected. For these young people, more, not less, is needed. This seems to be understood by the Federal Government, which now plans to extend expert support for young people with more complex problems, although this must be done in accordance with best available evidence and without undermining the early psychosis commitment that is now solidly based in so many international settings, including the United States.

It is also important that headspace fully integrates with the Government’s new proposals to regionalise health care delivery as contracting devolves from a national level to the Primary Health Networks. Devolution of leadership to local communities has always been an essential feature of the headspace model, but headspace now needs to align better with local health and social services, embed even more strongly within local communities, supported by a uniform and consolidated national structure that facilitates collaborative learning and workforce development, research and evaluation, model fidelity and accreditation, as well as local adaptation. Better linkage with State-funded services is needed too; however, more investment, not less, at State level is urgently required to narrow the gap.

Conclusion

Despite its success at scaling up, headspace still only covers about half of Australian communities, and while it is not intended to be the sole solution for youth mental health, it provides a well-recognised and trusted focal point in a community, a source of expertise and a platform for young people and families to be heard, understood and provided with increasingly evidence-based care. It also enables new interventions to be developed and tested through innovation and research. These are the reasons that Australian communities, local politicians across the nation and five successive Prime Ministers have personally supported headspace and youth mental health reform. To enable young Australians to transition to productive adulthood, those who need evidence-based mental health care must be able to receive it, and in a form that is developmentally and culturally appropriate for their unique needs.