Chapter 4


Chapter 4

Youth mental health

Introduction

4.1        The Government's 2011–12 Federal Budget mental health reforms focus in part on addressing the needs of people identified as not always receiving adequate mental health services (see Chapter 1).[1] Young people were identified as one of these groups not receiving adequate mental health care.[2] To address their needs, the Budget included expansion of:

  • headspace; and
  • Early Psychosis Prevention and Intervention Centres (EPPIC).[3]

4.2        While much of the commentary about headspace and EPPIC links the two programs, there are fundamental differences between them. EPPIC is an early intervention program specifically targeting young people with a psychotic illness, whereas headspace is a holistic model of providing mental health care to young people. This chapter provides background information about each program, its funding in the 2011–12 Federal Budget, and commentary from submitters about such funding. It then addresses more general concerns raised about the provision of youth mental health funding in the 2011–12 Federal Budget.

headspace

4.3        headspace is a model of delivering integrated mental health services to young people by co-locating specialist and primary health services at headspace centres.[4] headspace's vision is:

To improve the mental and social wellbeing of young Australians through the provision of high quality early intervention services, that are welcoming, friendly and supportive.[5]

4.4        Health professionals at the centres—including GPs, psychologists, social workers, mental health nurses and occupational therapists—are either directly employed through headspace core funding, or self-funded through MBS items or private billing.[6]

4.5        headspace targets 12–25 year olds with a mild to moderate mental disorder, and seeks to assist them across four key areas:

  • General health;
  • Mental health and counselling;
  • Alcohol and other drug services; and
  • Education, employment and other services.[7]

4.6        headspace was established in 2006 with Commonwealth funding and currently delivers services at 30 centres across all states and territories. Its original Foundation Executive Committee was formed with the assistance of Orygen Research Centre, the Australian Psychological Society, the Australian General Practice Network, the Brain and Mind Research Institute at the University of Sydney and the University of Melbourne, all of which are now represented on the headspace board.[8] The board assumed governance of headspace in 2009 when it became a company limited by guarantee, with charitable (not for profit) status.[9] Core funding continues to be provided via the Department of Health and Ageing Youth Mental Health Initiative Program.[10] Funding for individual headspace centres is awarded by the headspace Grants Committee via a competitive process. Tenders are made by lead agencies on behalf of a consortia of government and non-government organisations.[11]

4.7        In 2008–2009, the Social Policy Research Centre at the University of New South Wales (UNSW) conducted an Independent Evaluation of headspace. The Headspace Final Evaluation Report, released in June 2009, commented on the extent to which headspace centres assist young people with mental health issues with respect to the four key areas (above).

4.8        The Report notes that headspace has improved mental health services for young people, especially early-intervention services for people aged 12–17. The Report attributes these positive outcomes to

effective engagement of young people via good CA [Community Awareness] and high quality, youth-friendly services.[12]

4.9        The Report also provided a number of 'lessons and recommendations' suggesting ways in which headspace could improve its service delivery. Some of these are particularly relevant to the present inquiry because they relate to issues that also arose in relation to wider budget changes. These include timeframes for service delivery, the need to engage target groups and funding issues:

  • CYSs [headspace centres] require 9–12 months to become fully operational, including 6–7 months for set-up and establishment and 3–6 months to recruit a full complement of staff and refine policies and procedures.
  • As CYSs have now established themselves as service providers within their communities, it is important that they ensure their services are engaging 'hard to reach groups', for example, young people in the lowest socio-economic status groups, those with limited family support, refugee communities and Indigenous young people.
  • The sustainability of CYSs, which will only be achieved with strong clinical governance, cost-effective models that draw on a diverse range of funding sources, some core [Commonwealth] funding, engagement with the community and demand for the service from young people.
  • CYSs in remote areas will require a very high proportion of core funding.[13]

Budget increases to headspace funding

4.10      In the 2010–11 Federal Budget, the Government funded 30 new headspace centres. The locations of ten of these centres have been determined and these centres are expected to be operational by December 2011.[14]  In the 2011–12 Federal Budget, the Government substantially increased headspace funding. The new measures ($197.3 million over the next five years) provide for the establishment of 30 new headspace centres, and will increase funding across all headspace centres. The Government intends for a total of 90 sustainable headspace centres to be operational by the end of the forward estimates period.[15]

4.11      headspace's submission to the inquiry welcomed the additional funding but noted that the rationalisation of Better Access, particularly the changes to MBS mental health treatment items, is likely to add to existing workforce issues with respect to attracting GPs to headspace centres.

Attracting GPs is already a considerable challenge, particularly in areas of GP shortage. headspace, across its 30 centres, has a full time equivalent of only eight GPs. headspace centres are finding it increasingly difficult to recruit GPs as there are not sufficient incentives for GPs to work in youth mental health. We believe that with the current systems and initiatives in place, it is not financially viable for GPs to work with young people. Many GPs are not comfortable working with this client group in general, and financial disincentives exacerbate this reluctance.[16]

4.12      headspace CEO Mr Chris Tanti expressed concern that GPs may reduce their availability to practice at headspace centres once the proposed cuts are implemented:

Mental health treatment plans are a core activity for GPs working in a headspace centre. For example, analysis of 28 out of our 30 centres showed that in the last financial year item No. 2710, for a 40-minute preparation of a mental health treatment plan, equated to over one quarter of the total GP revenue billed at headspace centres...

The majority of GPs who are working in our centres are very passionate about working with young people...So I suspect they will not leave entirely but they will reduce the amount of time they have available at headspace.[17]

4.13      Rather than a reduction to MBS rebates, headspace suggested that a specific MBS item be introduced for the provision of youth mental health services in order to encourage GPs to work with young people with mental health needs.[18] This would provide an incentive for practitioners to train in headspace models.[19] As Mr Tanti explained:

What they are saying to me is that they are already not remunerated appropriately given that they are often doing well in excess of 60 minutes... An obvious solution would be to have a particular item number in this space—a youth mental health or a youth health item number. I know that in New South Wales they have been arguing for this for some time, and it makes perfect sense to me.[20]

4.14      Prominent mental health policy advocate, academic and headspace board member Professor Ian Hickie also expressed concern about mental health workforce issues in relation to headspace. Professor Hickie supported the budget changes to Better Access—although considered that they do not go far enough—and suggested that a reformed ATAPS might better address workforce issues than the 'old Better Access model [which] is poor spending and poor planning'.[21] Professor Hickie considered that better underlying incentive structures alongside genuine commitment from professionals would address issues that arise in the delivery of headspace services as well as more systemically in the mental health system:

Many of the problems with ATAPS and seemingly with headspace—and I am sure this will happen with the new services—stem from having models that reward GPs, clinical psychologists and mental health nurses for working in those new frameworks instead of working in isolated single practices in the better resourced suburbs in our major cities. At the moment, we do not have the investments of people power under preferential schemes in those areas such as headspace and what will be the new early psychosis programs. That has been the problem with ATAPS. A lot of the criticism of ATAPS, particularly by the professions, is highly self-serving. We need those professions to actually align themselves with the transformational projects and we need a government that is serious about putting the incentives, the allocations of workforces, particularly training workforces in medicine, general medicine, psychiatry and psychology and nursing in those transformational centres.

4.15      Conversely, the Australian Medical Association (AMA) suggested that increased funding to headspace should not come at the expense of Better Access. AMA anticipated that the time likely to elapse before new headspace centres are operational would suggest continued support to other initiatives in the interim is justified.[22]

4.16      Some submitters were opposed to the substantial additional funding for headspace on the basis that a wider range of youth services should have been considered for additional funding. The Australian Clinical Psychology Association (ACPA) submission states:

While additional investment in child and youth mental health is vital, we are concerned that 85% of the $491.7 million funding to boost services for children and young people has been allocated to two models of care—EPPIC and headspace—to the exclusion of other treatment programs which may also be of significant value to the broader community, and which may have a more substantial evidence‐base.[23]

4.17      However, the ACPA submission did not mention the alternative programs it considers of significant value. Similarly, the Psychologists Association (South Australian Branch) expressed concern about headspace funding but did not present a specific alternative for youth mental health care.[24] The Australian Association of Psychologists inc. (AAPi) suggested that headspace and EPPIC received increased funding because they are high profile initiatives, but that Better Access has been more effective:

[W]e agree that EPPIC and headspace are very good programs and that they deserve to be funded. But there is plenty of evidence for Better Access as well...

[G]enerally speaking, there is strong evidence for Better Access to take that; better evidence, I think, than there has been for the other programs.[25]

4.18      This concern about the rationalisation of Better Access was also expressed by witnesses who supported headspace. These submitters drew parallels between the effectiveness of headspace and the availability of MBS items for GPs. The Royal Australian College of General Practitioners (RACGP) and the Australian General Practice Network explained to the committee that cuts to Better Access would reduce the provision of mental health care to young people at headspace centres.[26] These organisations considered that higher MBS items make it viable for GPs to provide care to people who would be unable to make significant gap payments themselves. RACGP considers that Better Access MBS items directly enable GPs to provide mental health services to lower-income target groups via models such as headspace:

headspace...is largely staffed by GPs using the very items that are going to be reduced.[27]

4.19      Several organisations representing health professionals—apart from GPs—and consumers also welcomed headspace funding. These included the Mental Health Council of Tasmania and the Federation of Ethnic Communities' Councils of Australia (FECCA) which further suggested that such funding should in part be directed towards assisting young people from Culturally and Linguistically Diverse backgrounds.[28] The National and NSW Councils for Intellectual Disability and Australian Association of Developmental Disability Medicine suggested that headspace should be better equipped to cater for people with co-occuring intellectual disability and mental health needs.[29]

4.20      Many organisations with direct experience of the headspace model supported the funding increase. The Australian Counselling Association has members who work at headspace centres and EPPIC and welcomed the expansion of the program.[30] The Consumers Health Forum considered that the initiative provides effective early-intervention services to young people, but sought reassurance that ongoing evaluation will take place to ensure services continue to be well-targeted.[31] Other groups supportive of headspace included Mission Australia, the Royal Australian and New Zealand College of Psychiatrists and the Australian Nursing Federation (Victoria Branch).[32]

Early Psychosis Prevention and Intervention Centre (EPPIC)

4.21      The origins of EPPIC date from the 1988 establishment of a ward in the Aubrey-Lewis Unit at Royal Park Hospital dedicated to the treatment of young people hospitalised after their first episode of psychosis. The provision of targeted, early intervention care to young people developed into the EPPIC model which was officially founded in 1992 under the Directorship of Professor Patrick McGorry.[33]

4.22      EPPIC facilitates care to young people (aged 15–24) living in West and North West Melbourne at risk of or exhibiting psychotic illness, and their families and carers. Referrals to the service may be made by any person, and referred young people are subsequently invited to an assessment to determine if EPPIC can most effectively address their needs. If so, an Outpatient Case Manager (OCM) will be assigned to the person, a care plan developed and care services facilitated for a period of two years. The EPPIC model aims to prevent young people from needing to be hospitalised, but if it does become necessary, the Inpatient Psychiatric Unit (IPU) in Footscray can accommodate 16 people.[34] Specialist intervention services provided by EPPIC are modelled on collaborative and continuing care and with a focus on the early 'critical period' considered to be crucial in the management of and recovery from psychosis.[35]

4.23      Over the past 19 years the EPPIC model has grown and expanded in Melbourne and internationally. Orygen Youth Health (OYH) was established in 2001, building on the EPPIC model to provide care to young people experiencing other major (non-psychotic) mental illnesses. EPPIC is now a sub-clinic of OYH.[36] In 1996, the first International Conference on Early Psychosis was held and the International Early Psychosis Association was formed in 1997. Early intervention care based on the EPPIC model is now provided by clinics in North America and Europe.[37]

EPPIC funding in the 2011–12 Federal Budget

4.24      In the 2010–11 Budget, the Federal Government committed to funding four additional EPPIC sites in partnership with interested states and territories.  The 2011-12 budget changes commit the Government to engage the states and territories to share the cost of funding and supporting an additional 12 centres, bringing the total number of centres to 16.[38] The Federal Government commitment amounts to $222.4 million over the next five years.[39]

4.25      While no formal partnership with the states or territories has been announced, the Department of Health and Ageing informed the Community Affairs Legislation Committee during the 2011–12 Budget Estimates hearing that there has been 'strong interest...on the EPPIC rollout' from the states and territories.[40] The Department also indicated that the states and territories had committed to early intervention psychosis services in the National Mental Health Plan 2009–2014.[41]

4.26      The submission from Orygen Youth Health itself welcomed the measure and provided the following specific recommendations that it considers will 'ensure national governance and implementation of the EPPIC measure comprehensively addresses issues of quality, accountability, model fidelity, project selection and workforce and system development':

  • Providing capable, committed and accountable national leadership to drive quality and strong model fidelity across all new EPPIC services;
  • Ensuring new EPPIC services are selected on the basis of being the candidates best equipped for success in terms of impact potential, quality of local leadership and local availability of expertise and resources;
  • Supporting new EPPIC services to develop the skills and culture to provide high quality care consistent with Australian Clinical Guidelines for Early Psychosis; and
  • Ensuring the availability of clear and reliable outcome measures through ongoing evaluation and monitoring.[42]

4.27      In agreement with OYH, Consumers Health Forum supported the expansion of EPPIC on the condition that it—as well as headspace—is subject to regular evaluation:

CHF welcomes the commitment to these services, particularly the significant expansion of the number of EPPIC sites, in recognition of the current poor management of youth psychosis...

Thorough evaluation will ensure that the ongoing administration of these services will be appropriate.[43]

4.28      Submitters supportive of the expansion of EPPIC included South Australia's Office of the Commissioner for Social Inclusion,[44] Mission Australia,[45] and the Royal Australian and New Zealand College of Psychiatrists.[46]

4.29      Other submitters raised concerns about the extent to which EPPIC addresses the needs of people with mental illnesses across the population. As noted above, the Australian Clinical Psychology Association was concerned about the large amount of funds being allocated to just the two programs (headspace and EPPIC).[47] Catholic Social Services Australia considered that early intervention for young people is important, but was concerned about the reach of EPPIC and headspace beyond major cities:

At least some of the proposed new services should be placed in rural and remote locations. In addition, the model needs to be flexible enough to be responsive to local needs and priorities, rather than being developed and imposed in accordance with what has worked in a metropolitan area.[48]

4.30      The Melbourne Children's Psychology Clinic expressed concern that the target group for EPPIC, young people experiencing or at risk of experiencing their first psychotic episode, is a relatively small part of the total youth population with mental health needs:

[I]t is estimated that only 2 per cent of people will experience a psychotic episode at some stage in their life...

This is a significantly small proportion of children and adolescents compared with estimates of anxiety, depression and other common childhood disorders that cause significant distress and significantly impact on daily level of functioning. For example, Dadds et al., (2000) noted twelve month prevalence rates ranging from 17 per cent to 21 per cent in childhood anxiety and furthermore, that around 8 per cent will be significant enough to require treatment...[49]

4.31      The AMA expressed concern about the time it would take to create the new headspace centres, but also queried what will become of the initiative if the states and territories do not enter into a partnership with the Commonwealth as envisaged.

Research on early intervention

4.32      Early intervention for young people at risk of or exhibiting a first psychotic illness is not a settled field of medicine. There is debate within the psychiatry profession, as well as the broader community, about how to approach early intervention for psychosis.

4.33      An Access Economics analysis undertaken on behalf of Orygen Youth Health found that early intervention is effective in the 'critical [early] period':

Access Economics estimated there will be some 5,320 FEP new incidences per year in Australia...

For this cohort, if EI was universally available...the net present value of savings over the critical period would be $212.5 million ($82.5 million in financial savings and $130 million in reduced burden of disease).[50]

4.34      The committee is also aware that there are some in the medical community who have suggested that advocates of early intervention are 'undoubtedly overstating the evidence'.[51] Louise Newman, past president of the Royal Australian and New Zealand College of Psychiatrists, was recently reported saying the 'focus on early intervention was too narrow and could lead to young people being overmedicated, prematurely diagnosed and stigmatised'.[52]

4.35      The current debate over the evidence base supporting early intervention in psychosis is reflected in current discussion about revising the Diagnostic and Statistical Manual of Mental Disorders (DSM). There is currently a proposal to include in the DSM a 'psychosis risk syndrome'.[53] This proposal is fiercely contested. The former chair of the task force that presided over the last revision of the DSM in the 1990s, Professor Emeritus Allen Frances, has said of the proposed revisions that: 'DSM5 would create tens of millions of newly misidentified false positive "patients", thus greatly exacerbating the problems caused already by an overly inclusive DSM4'. Professor Frances is most critical of the proposal for psychosis risk syndrome:

The Psychosis Risk Syndrome is certainly the most worrisome of all the suggestions made for DSM5. The false positive rate would be alarming―70% to 75% in the most careful studies and likely to be much higher once the diagnosis is official, in general use, and becomes a target for drug companies. Hundreds of thousands of teenagers and young adults (especially, it turns out, those on Medicaid) would receive the unnecessary prescription of atypical antipsychotic drugs. There is no proof that the atypical antipsychotics prevent psychotic episodes, but they do most certainly cause large and rapid weight gains (see the recent FDA warning) and are associated with reduced life expectancy―to say nothing about their high cost, other side effects, and stigma.

This suggestion could lead to a public health catastrophe and no field trial could possibly justify its inclusion as an official diagnosis. The attempt at early identification and treatment of at risk individuals is well meaning, but dangerously premature. We must wait until there is a specific diagnostic test and a safe treatment.[54]

4.36      James Phillips, associate clinical professor of psychiatry at the Yale School of Medicine, recently expressed similar concerns regarding:

the controversies surrounding these diagnostic categories, involving the question of creating populations of false-positive patients who would be subjected both to diagnostic mislabeling and unwarranted, potent medications.[55]

4.37      While there may be concerns about the description of disorders and the consequences, there has been for some years now research on early intervention to address psychosis, with some positive results. Nevertheless, a review of the literature in 2010 observed:

Despite initially encouraging results concerning the predictive validity of [psychosis risk syndrome] criteria, recent findings of declining conversion rates demonstrate the need for further investigations. Results from intervention studies, mostly involving second-generation antipsychotics and cognitive behavioral therapy, are encouraging, but are currently still insufficient to make treatment recommendations for this early, relatively non-specific illness phase.[56]

4.38      Underpinning this policy debate are fundamental questions about whether there are identifiable underlying biological processes associated with psychosis or not; and a debate about whether identifying people at high risk of developing psychosis actually helps ensure appropriate intervention.[57] Some suggest, of psychosis, that 'there has never been an underlying disease process to be identified',[58] while others think this to be an open question, worthy of continued research.[59]

4.39      Despite the debate, there are significant points of agreement,[60] and the committee notes that the focus of the EPPIC model is not exclusively on prevention, but represents a broader model. The EPPIC model recognises that:

Preventative intervention can occur in the three key phases of early psychosis:

1. The "at-risk" phase, when symptoms are subtle and can be confused with adolescent development issues

2. The period of frank symptoms of psychosis that remains untreated, which may compound the issues of risk and the development of prolonged disability

3. The critical period after the onset of the first psychotic episode, which can be up to five years in duration, when treatment needs to be comprehensive and phase-specific.[61]

4.40      Early Psychosis Prevention and Intervention Centres address the needs of young people with, or at risk of developing, a psychotic illness. As discussed earlier, service gaps do exist in the care of people with severe mental illness and the Government's commitment to EPPIC is welcome in this context.

4.41      Psychosis can be debilitating and contributes to a heavy disease burden, disproportionately borne by the young. Early intervention is a worthwhile objective, provided it:

  • Is carefully based on published research and evidence;
  • Engages with the full range of views in the research and clinical community;
  • Involves multi-disciplinary teams;
  • Includes a substantial role for psycho-social interventions; and
  • Actively engages patients and families.

4.42      There is some disquiet around the funding of EPPIC, however the committee believes the above conditions are being met. The committee did not receive evidence to suggest that the EPPIC model involved inappropriate prophylactic use of anti-psychotic drugs, which is a particular point of concern in some quarters.

4.43      It will be important for EPPIC to publish regular reports that outline its operations and that there should be an external clinical review after an appropriate period, to help ensure that the EPPIC program reflects the range of results in the research literature of what is a fast-evolving field.

4.44      It is also essential that the significant funding directed to EPPIC demonstrably delivers cost-effective, good health outcomes. In this respect the committee holds some reservations:

  • An independent evaluation of the cost-effectiveness of EPPIC has not been carried out.
  • There is no guarantee that the Government's commitment to EPPIC will be matched by state and territory funding, and therefore no guarantee that the Government will be able to fully deliver its planned expansion to EPPIC.
  • It is likely that EPPIC will be unable, at least in the short term, to deliver services to people outside metropolitan areas. In this respect the committee continues to urge the Government to identify or develop strategies to meet the needs of young people in rural and remote areas.

Recommendation 1

4.45      The committee supports the increased funding to EPPIC and headspace in the 2011–12 Federal Budget on the proviso that this significant policy transformation be evaluated after two years. However, the committee urges the Government to identify or develop strategies that will address the need for early psychosis prevention and intervention in rural and remote areas.

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