Should we be protecting headspace youth mental health services?

The Australian government set up headspace in 2006 to provide enhanced primary care services to young people aged 12-15, with an emphasis on early intervention for mental health problems. Starting with 10 services initially, the network of shop-front clinics has since expanded to nearly 100 covering much of the country, supported by a national office in Melbourne. 

In response to a report into mental health services by the National Mental Health Commission, the Australian Government decided to devolve control of headspace services to local Primary Health Networks and to reduce the role of the national office. In response to these changes, the CEO of headspace, Chris Tanti, recently resigned and accused the government of “quietly dismantling” this youth mental health initiative, despite “two positive evaluations”. The Sunday Telegraph newspaper has come out in support of Tanti and launched a campaign to protect headspace.

Independent evaluation of headspace shows weak effectiveness

However, Tanti’s claim of positive evaluations is highly misleading. An independent evaluation of headspace, commissioned by the Australian Department of Health, was completed in 2015 and quietly released to the public half a year later.  The evaluation data are anything but positive and do not support retaining the current headspace model.

The evaluation found that only 13% of headspace clients showed “clinically significant improvement” in psychological symptoms, with 4.5% actually showing “clinically significant worsening”. When the outcomes were compared to a matched control group with similar problems who were not receiving treatment, headspace did little better.

To give an indication of the size of the effects, the authors used an ‘effect size’ index, where 0 indicates no effect, 0.2 is generally defined as ‘small’, 0.5 as ‘medium’ and 0.8 as ‘large’. The effect of headspace on psychological symptoms compared to no treatment was 0.16. In other words, the average effect was less than small. The authors of the independent evaluation described the effects as “relatively weak”.

Why isn’t headspace doing better?

Most headspace clients have mental health problems involving anxiety or depression, and receive psychological therapy for these problems. It is surprising that the therapeutic effects of headspace are so weak, given that there is good evidence that psychological therapy can work for these problems. If evidence-based psychological therapy was being provided, we would expect the effects to be medium to large.

A possible reason that the effects of headspace treatment are much less than expected may be that the clients generally get too few sessions of therapy to be effective. ‘Minimally adequate treatment‘ has been defined as 6 or more sessions of 30 minutes duration or longer. Using this criterion, only 28% of headspace clients presenting for mental health problems receive minimally adequate treatment. In fact, 45% only get 1-2 sessions, which is far from being even minimally adequate. While it has been claimed that some young people only require 1-2 sessions to get back on track, the evidence from the evaluation shows little improvement in this group and that they are certainly not getting back on track.

The situation with headspace seems to be that youth-friendly shop-fronts can get young people in the door, but do not keep them coming back to get sufficient help.

The current headspace model should not be protected

Given the evidence of weak outcomes, the Sunday Telegraph’s campaign to protect headspace in its current form is misguided. There is no doubt that mental health problems are the major health issue in this age group and that they can have a disruptive effect on relationships, education, employment and long-term physical health. We need to invest in this area for the future health of the Australian population, but the current headspace model is not the solution. Rather than protection, headspace needs drastic reform.

What should we be doing instead?

The mistake that was made with headspace was to roll out the program nationally before the evaluation data were in. A better approach would have been to rigorously evaluate the initial 10 services and only proceed to roll-out once an effective service model was demonstrated. With the devolution to Primary Health Networks, there may be opportunities for major reform.

I have no simple answer to what should be the alternative, but I will make one suggestion. The problem with headspace has been a failure to engage young people sufficiently to give evidence-based psychological therapy. One reason for this problem may be the stand-alone shop-front model, where the services are separate from the settings where young people spend most of their lives. Evidence from Australia’s recent national survey of child and adolescent mental health showed that schools are major settings for adolescents to receive help for mental health problems.

In a school or other educational setting it is possible to more closely monitor how a young person with a mental health problem is functioning and to follow up if they do not attend an appointment. As well as possibly engaging young people better, these are also settings where it is possible to provide other interventions such as preventive programs and mental health first aid training to students, staff and parents. If the headspace resources were redirected to services in educational institutions, we would be able to take a more of a whole-of-community response to young people’s mental health problems, rather than seeing stand-alone health services as the solution.