Finding the ‘missing middle’: those who have fallen through the mental health care cracks

While the Covid burden has fallen more heavily on older Australians, the mental health burden has impacted much more strongly on young Australians and their families.

All global disasters such as world wars and economic depressions, severely damage the fabric of society. The Covid-19 pandemic is no exception and the focus must now turn to how it can be repaired. Australia has come through the pandemic in much better shape than most other nations, with many thousands of lives saved. This is a huge collective achievement. Our political leaders, federal and state, and the Australian people have done extremely well under enormous pressure. The impact or “burden” of disease is measured through the metric Disability Adjusted Life Years, or DALYs, which represents the number of years lost to a particular disease and is therefore a blend of mortality and morbidity. In 2020 the virus resulted in approximately 8400 DALYs being lost to Covid; a modest impact. Conversely, the fully justified, yet highly restrictive, measures required to limit the death toll from the pandemic have unleashed a burden of disease many times higher from other health conditions, with mental ill-health overshadowing everything else. In 2020 alone, we estimate that more than four times as many DALYs were lost to mental ill-health as were lost to Covid. The 2021 mental health burden will be even more substantial and will endure for years. And while the Covid burden has fallen more heavily on older Australians, the mental health burden has impacted much more strongly on young Australians and their families.

The surge in mental ill health is so marked that it has been labelled by The Economist magazine as “the shadow pandemic”. Across the globe anxiety and depression alone has surged by more than 25 per cent. Most countries have ignored this. The Australian government responded early to fund campaigns to promote mental health and boost public morale. Emergency helplines were heavily sandbagged to strengthen capacity. Telehealth was introduced, pop-up mental health hubs were set up, and resources were allocated to strengthen headspace. Some state governments also responded with support for digital mental health and other measures. However, these measures have failed to prevent waitlists from ballooning, and a rising tide of young people surging into emergency departments with a nasty cocktail of intense distress, suicidal behaviour, anorexia and complex mood disorders. This is not transient or mild distress but mostly moderate to severe illness. This is totally unsurprising, since the mental health system even prior to the pandemic, as the Productivity Commission and Victorian royal commission reports finally exposed, is fragile, fragmented and not built to scale. Now it is overrun, and its workforce diluted and exhausted. Oases of innovation have certainly been developed by federal governments in recent years, but a great deal of desert remains, in which the “missing middle”, people with more sustained and complex illnesses, languish in growing numbers.

This means that mental health reform must now be one of the central pillars of the recovery phase from the pandemic, and this must be reflected in the election manifestos of the major parties. This long-deferred national priority now moves to centre stage, and Australians, as a News Corp poll this very week highlighted, are demanding action. The number one priority is to progressively expand the options for the “missing middle”, the million and more Australians with mental ill health beyond the scope and capacity of GPs, high street psychologists and the headspace system. Primary care desperately needs an exit ramp and a back-up system which can deliver evidence-based multi-disciplinary care.

Young people have always borne the major burden of onset of mental ill health and prior to the pandemic their mental health was already declining worldwide. The disruption caused by measures to contain the pandemic has introduced further insecurity and vulnerability to their lives and futures with their support systems of family, peer group, and education and employment all weakened. Yet Australia is in a good position to deliver models of mental health care needed to optimise recovery. Headspace is now embedded in communities across the nation, offering access to a youth-friendly primary care model that works very well for the briefer and less severe forms of mental ill health, which represents about one third of the mental health burden that young people experience. The shadow pandemic surge has blocked its entry ramp, so complementary digital mental health platforms and new waitlist relief options are urgently needed. However, the exit ramp is even more blocked, and more serious than ever. For the remaining two-thirds of young people with more complex and sustained mental illness, for which headspace was never designed, a multidisciplinary specialist back-up system of care is essential.

The good news is that the solution is at hand. Regional youth mental health hubs already exist in six key locations in Australia delivering early intervention and treatment for young people with psychotic illnesses. Funded by the federal government over a decade ago based on Australian research and innovation, these models now represent standard care across the UK, the US, Canada and Western Europe. Evaluation of our Australian centres has shown that they produce superior outcomes and major returns on investment. While they have not yet been scaled up nationally here, they represent the solution to the missing middle since the model is capable of expansion beyond psychotic illness to cover the full range of diagnostic conditions in young people. The complete version of the model has been developed at Orygen in Melbourne in recent years, and is now ready for progressive scaling up to all communities to fill the gap behind headspace and other primary care. Furthermore, modifications of this platform have already been commenced by the federal government as distinct community hubs for older adults and younger children to support primary care and help absorb the missing middle.

So blueprints and proven models exist to address this top public health priority to underpin our recovery from the pandemic, especially for young people where the need and urgency is greatest. Three ingredients are needed. Political will powered by public opinion; federal funding, since the states will always struggle to fund even the most acute and severe stages of illness; and a massive and overdue national strategy to build a workforce to relieve the depleted mental health workforce currently grappling with the shadow pandemic.

Patrick McGorry is a professor of youth mental health at the University of Melbourne.