Tragedy is often the most powerful catalyst for change. When 15-year-old Tyler Cassidy was shot dead by police in a Melbourne skatepark in 2008, it highlighted how easily a troubled boy can fall through the cracks.
The agitated teenager, believed to be distressed by the anniversary of his father’s death, had confronted police with two knives before he was gunned down. We’ll never know if early mental health support would have prevented the tragedy but at the 2010 inquest into his death, prominent psychiatrist Patrick McGorry said he could have been helped if Australia had a ”21st-century system”.
Without radical reform, there would be more Tylers, he warned. Young people need early expert help in a youth-friendly setting, not ”rigid, old-fashioned environments”.
Five months after the inquest, McGorry – a passionate, politically shrewd lobbyist who harnessed his 2010 Australian of the Year profile to throw a spotlight on the ”national emergency” of youth suicide – got his wish.
The Gillard government’s 2011 budget committed a record $2.2 billion to mental health. A quarter of it went to a national rollout of headspace – one-stop shops for young people with mild to moderate problems, and specialist early psychosis prevention centres – both services McGorry founded.
It was a policy shift that attracted bipartisan political support and put early intervention at the forefront of Australia’s mental health approach. But will it actually reach the Tyler Cassidys of the future? Can it prevent the onset of mental illness? Or is it, as some critics now claim, a ”hopeful experiment” that’s been oversold by a charismatic leader?
As expansion continues apace – more than 100 headspace centres will be operational by 2016, while the organisation last month opened in Denmark and has plans to sell the brand in the United States, Asia, Israel and the United Kingdom – questions are being asked about its long-term efficacy, cost-effectiveness and potential to ”medicalise” the normal fluctuations of adolescence.
While many in the sector, including headspace chief executive Chris Tanti, have fiercely defended the model, insisting critics misunderstand how it works and that the majority of young people are not given a clinical diagnosis or prescribed drugs when visiting a centre, even he concedes they don’t have data on long-term outcomes or how many young people are being medicated.
Complicating the debate is a backdrop of bitter infighting, coloured by claims of professional envy and divisive personalities, as an underfunded sector goes to war over who should get the biggest slice of a pitifully small pie.
With an estimated one in four 16 to 24-year-olds suffering a mental disorder in any given year, the stakes are high. Nobody wants to jeopardise programs that may ease the burden. But in a highly charged climate, even asking questions of headspace has become a fraught exercise.
”It’s a very emotive issue because there are real concerns about young people who might be self-harming or distressed, and concerns about youth suicide,” says Professor Louise Newman, director of the Monash University Centre for Developmental Psychiatry and Psychology. ”Those issues are hugely important, but questioning a particular approach can be labelled as not caring about those young people, which is not accurate.
”Everyone’s on the same side in wanting an approach that might help, but it’s very worrying that we can’t have a proper, informed debate because people fear they’ll lose funding support or they’ll be publicly attacked, or they’ll be seen as going against what government is supporting,” says Newman, a former president of the Royal Australian and New Zealand College of Psychiatrists.
Division within the sector is not just about what works, it’s partly fuelled by the politics of change. Just as Jeff Kennett raised the profile of beyondblue as its outspoken chairman, galvanising political and public support for tackling depression, Patrick McGorry has almost single-handedly thrust youth suicide and mental illness into the limelight. It’s won him international plaudits and garnered unprecedented local funding to help young people. But just like Kennett, it’s made him enemies.
”Pat has absolutely been on a mission for the past 20 years to get early intervention on the agenda, and he’s the sort of guy who takes no prisoners, so people have been pissed off in the process,” a senior mental-health sector source said.
”His ideas are sound, his motivations are sound, but sometimes the delivery creates problems for him and for others and, importantly, for patients and for families,” said the source, who did not want to be named. ”People start to wonder whether headspace is a good idea, and that’s a real worry because it’s a model that helps a lot of kids.”
McGorry, who founded headspace and remains on the board, declined to comment on the criticisms.
Proponents of early intervention say it’s a ”no brainer” – medically and economically. Treat the signs of mental illness before disorders become full-blown and debilitating, and you’ll not only save money, you may also save lives. Do it in youth-friendly settings and more kids will seek help.
Indeed, headspace’s funky, bright-green drop-in centres, where 12 to 25-year-olds are counselled for a range of issues, from sexual health, anxiety and drug and alcohol problems to bullying, relationship troubles and exam stress, have proved to be popular with young people. They can turn up without a referral or medical records and be seen free of charge by a team of psychologists, social workers, doctors and mental health nurses, in person or online.
More than 100,000 young people have received help since the first centre opened in 2006, with surveys showing 86 per cent were satisfied with their experience, while 56 per cent had a reduction in their psychological distress after three sessions.
Its high profile – politicians have queued up to cut ribbons at centre launches – has made headspace so revered that although Fairfax Media spoke with many clinicians and researchers in the sector – both supporters and critics of the model – few would comment on the record, claiming raising questions publicly would be an unwise career move.
Yet the concerns of those who have reservations are consistent. Seven years since inception, there remains little data on long-term outcomes. While short-term gains are positive, how can we know if the service has altered the trajectory of mental illness without long-term follow-up?
A federal Department of Health evaluation due late next year will look at the clinical outcomes over a nine-month period. But what happens two to five years after visiting headspace? Are those young people any better (or worse) off than those who visited other services, or those who received no intervention?
Whispers in the sector are that the information required to determine whether headspace is fulfilling its remit has simply not been collected. ”My hunch is the federal government will want to release this [evaluation] very, very quietly because it’s a really embarrassing situation for them,” a source close to government said. ”If headspace is effective, nobody will know. If headspace doesn’t work, nobody will know. If headspace does damage, nobody will know. This thing has been rolling along without anyone collecting data.”
While there is general support in the sector for the concept of intervening at an early stage to help young people in distress, the government’s ”eggs in one basket” approach to how that care is delivered is under scrutiny.
Some argue that a mixed approach involving schools, GPs and child and adolescent health services may be more appropriate than channelling the majority of funding into a nationally scaled specialist program that is yet to prove its worth. Even more critical, they say, is the absence, so far, of evidence that socially marginalised groups who are at the highest risk of mental problems – indigenous, homeless, financially disadvantaged, and gay and lesbian youth – are accessing the program in numbers.
Questions also remain over whether building a headspace centre automatically increases the number of young people seeking help in that area – especially in well-serviced metropolitan locations – or whether it ”complicates and divides” mental health care.
”Establishing new healthcare centres probably costs more than building on pre-existing services, so we have to ask about the economics of that,” says Professor George Patton, a senior psychiatrist and director of adolescent health research at Melbourne’s Royal Children’s Hospital. ”That’s fine if the benefits of going to headspace are much greater than going to a paediatrician, a GP or a pyschologist, but we don’t know this. We should really have had answers before headspace went to scale.”
However, Simon Stafrace, director of psychiatry at Melbourne’s Alfred Health, the lead agency for a headspace centre in Elsternwick, maintains that when unmet need is so great, it is legitimate practice to respond first and collect evidence later.
”We know young people have killed themselves in larger numbers than in most age groups,” the associate professor says. ”It’s not unreasonable to put something in place – make an attempt to help – then evaluate it as you go along.”
Stafrace believes history will show headspace greatly improves access to care for those who might otherwise not seek help due to the perceived shame of mental illness.
”If you bring a kid over to a child and youth mental health service and they see the word ‘mental health’ or ‘psychiatric’, you get this kickback. You take them to headspace and because they’ve put so much work into the branding, it’s really destigmatising, so people seem to come forward.”
Part of the problem in finding an approach that works is the nature of mental illness itself. Unlike other areas of health, making a diagnosis is not an exact science. One person’s ”unwell” is another’s ”unconventional”. Measuring mental wellbeing improvements at a population level is challenging, as is assessing whether any one model of care is making an impact.
Patton believes arguments that the scale of unmet need and the economics of early intervention make headspace a ”no-brainer” are flawed. He points to critical-incident debriefing (in which victims or witnesses of trauma are counselled in its immediate aftermath) as a form of early intervention that produced unintended consequences, despite originally being thought of as best practice.
”It seemed perfectly logical to give people who have had a traumatic event a chance to talk about what happened and ventilate their feelings. But most of the evidence has been that this actually leads to more emotional problems in the short to medium term,” Patton says. ”The idea of early intervention is one that most of us would think made a lot of sense, but we do need to test it.”
Chris Tanti acknowledges that headspace’s reach is not yet known, but he says the feedback from young people and their families is overwhelmingly positive. The visible nature of centres, and the fact they don’t need a specialist referral, gives young people autonomy over their mental health and a more appealing option than the ”quick and dirty” model of primary care.
”The GP is a solo practitioner who generally doesn’t have the time to spend with a young person going through a 45-minute session about what they’re going through,” Tanti says. ”It takes time to build up that trust. The primary care model doesn’t lend itself to working with young people in the way they need.”
The question that concerns Patton and others, including US psychiatrist Allen Frances – the former chair of the committee that produced the psychiatric handbook the Diagnostic and Statistical Manual of Mental Disorders, who has been the most vocal critic of what he describes as ”Australia’s reckless public health experiment” in early intervention – is whether the scale of the headspace model has the potential to pathologise adolescence. Does it place healthy young people in the mental health system, encouraging them to view normal, transient life problems as something to be ”fixed”?
”The majority of girls – more than half during the teen years – will go through an emotional crisis at some point, with symptoms of anxiety and depression,” says Patton. ”If you added problems around substance use and abuse, you’re talking more than half of the boys as well. So does this make sense to be setting up what is effectively a specialised mental health service for dealing with more than half the kids in the country?”
Patton argues that many will have a brief, unrepeated episode of mental distress, then they ”just get on with life”. Yet the major investment in mental health has been in youth services, at the expense of those experiencing problems in other critical stages, such as midlife, when people often struggle with the challenges of mortgages, raising families, job stress, and caring for ageing parents.
Jane Burns, head of youth mental health organisation Young and Well Co-operative Research Centre, which partners with headspace, says it’s a false economy not to tackle issues at their onset.
”Often the symptoms don’t simply go away and they don’t just magically improve. You see it manifesting itself in relationship breakdown, in stress, in alcohol abuse and dependence. The evidence is pretty strong that those who are at risk in adolescence and early adulthood are those who go on to have challenges when they’re in their later adult years,” Burns says.
”It’s better that you get a six-week treatment course of cognitive behavioural therapy [a form of mindfulness-based counselling] as opposed to ending up a drug or alcohol statistic in adulthood.”
There are also reservations about Australia’s focus on early intervention for young people with more serious mental health problems. Sixteen early-psychosis prevention and intervention centres (EPPIC) will be operational by 2016, providing support for 15 to 24-year-olds at risk of psychotic illnesses. Critics claim there is little evidence the disorders can be prevented, and that up to 80 per cent of those deemed ”high risk” will never develop the illness yet may still be labelled and medicated.
While headspace is promoted as a non-medical model, there are concerns that the lines will be blurred as EPPIC services begin to be delivered this year through nine ”enhanced” headspace centres.
If acutely unwell young people and those with more moderate problems are treated through a ”single front door”, is there increased potential for more of them to receive a mental illness diagnosis or be prescribed drugs?
”It’s true we’re going to be seeing more kids now who have issues that respond to medication, but I don’t think that’s a bad thing,” Tanti says. ”Anything that reduces the level of distress for young people and reduces some of the symptoms they experience is a good thing. You wouldn’t not medicate in oncology or any other area of medicine. You just have to manage it through guidelines and through informed discussion with young people and their families.”
Burns says division in the sector is unhelpful, and unity is needed for the good of patients.
”This is not an academic debate, this is actually about people’s lives,” she says. ”It’s that dumb debate of ‘I didn’t get enough of the pie’, as opposed to ‘we need more pie’.
”We need to get better at making a very strong case that investing in the mental health of Australia as a society is incredibly important.”