Addressing the ‘missing middle’: the next challenge in youth mental health care

It’s now well established that adolescence and young adulthood corresponds with the period of life when mental ill-health is most likely to first onset.[1] If left untreated early experiences of poor mental health can have a significant impact well into adulthood, heightening the risk of severe mental illness, physical health conditions, unemployment and family/relationship breakdown.[2][3] Along with the personal toll, the World Economic Forum has estimated that between 2011 and 2030, mental illness will cost $16 trillion in lost economic output worldwide.[4]

During the past decade, we saw a rising tide of mental ill-health in young people. The understood combination of bio-psycho-social risk factors for young people are now further compounded by uncertainty for their future, including climate anxiety[5], job and financial insecurity and experiences of social injustice and generational inequity.[6] Young people are front and centre among the group in society now termed “the Precariat”.[7]

The COVID19 pandemic has highlighted just how precarious young people’s wellbeing has become[8] with global data indicating a 25 per cent increase in depression and anxiety with young people and females most affected.[9] In Australia, mental health professionals and services are overwhelmed with demand and NSW[10] and Victorian data[11] indicate a surge of presentations among young people to emergency departments in high distress, suicidal risk or following self-harm. There has also been a reported increase in eating disorders [12] which has overwhelmed an already threadbare system of old-fashioned care. The system has failed at a time when young people need it the most. How did this happen when Australia has been leading the world for decades on youth mental health service design and delivery?

headspace centres across Australia are known and trusted by large numbers of young people and their families as a stigma-free, youth-friendly entry point into care and support. headspace was designed to respond to early and milder challenges across mental health, physical health, employment and education support and alcohol and other drug use. headspace also provides stigma free access for young people with moderate to severe and sustained stages of mental illness which is a major advance. In a mature mental health system such young people would then be “upgraded” to more expert, specialised and sustained mental health care provided by multidisciplinary teams including psychiatrists.

A range of new data from the headspace system indicates the scale and extent of this problem.  These data confirm that a substantial proportion of young people accessing the service do not recover sufficiently to achieve good functional outcomes from mental ill-health. This is not to suggest that headspace isn’t beneficial for tens of thousands of young Australians, but that these primary care services are not by themselves the solution for the even more substantial number of young people with more sustained and complex issues who are presenting to the headspace front door and cannot move to a more intensive level of care because there are simply very few options.  They are the “missing middle” and we need to scale up expert multidisciplinary systems of care for these young people too.

How can policy-makers and health advocates work together?

Over a number of years, mental health advocates have articulated the issue, quantified the scale and the impact, and brought to the attention of both the broader public and policy-makers the need to prioritise mental health in funding and system reforms.

Some of the most successful arguments have been made in highlighting the social and economic benefits of early intervention when mental ill-health first onsets. Both the economic argument and the existence of a ‘missing middle’ in the system were both key conclusions from the Australian Government’s Productivity Commission in its final report.[13] Indeed, the Commission found that “too many people are treated too late”. Young are Australians at risk and their families cannot easily access support them. (pp22).

Youth mental health advocates would largely agree that there remain large numbers of young people who are falling through the ‘missing middle’ of Australia’s mental health system. This is where the current policy challenge and opportunity exists. Alongside policy-makers, we must now work together to bridge these known gaps in care with effective, evidence-based and youth-friendly service models.

What do young people need from the future of mental health care?

The solution for the future is going to require more than integration of the existing structures and services of primary care and state-funded tertiary services. State specialist services exist to support the 3 per cent of the population with severe and acute mental health issues yet most states and territories in 2018-19 were still only servicing between 1-2 per cent of the population.[14] They have some heavy lifting to do to provide service access for all people who need this level of care.

Simultaneously, young people need us to fast-track another level of service delivery for the ‘missing middle’. The service model for this cohort has good foundations in the current early psychosis youth service model and the adult community-based hubs funded by the Australian Government.

However, a much greater sense of urgency and rapid execution is needed. Young people and their families, carers and supporters need policy-makers and political leaders to adequately fund and scale up these solutions rapidly. They need them to recognise that the solution doesn’t rest with tinkering around the edges of a broken, fragmented system. That it will take substantial investment and an assumption of responsibility, particularly by the Australian Government, for youth mental health care that goes beyond the current level of primary care and provides services and supports for young people who are missing out.

Portrait of the authorProfessor Pat McGorry AO, Executive Director, Orygen, is a psychiatrist known world-wide for his development of early intervention and youth mental health services and for mental health innovation, advocacy and reform. He is Professor of Youth Mental Health at the University of Melbourne and founding editor of the journal Early Intervention in Psychiatry. He was named Australian of the Year in 2010.

[1] Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry 2005;62:593-602.

[2] McGorry PD. The specialist youth mental health model: strengthening the weakest link in the public mental health system. Med J Aust. 2007;187(7 Suppl):S53-6.

[3] Patton GC, Coffey C, Romaniuk H, Mackinnon A, Carlin JB, Degenhardt L, et al. The prognosis of common mental disorders in adolescents: a 14-year prospective cohort study. Lancet. 2014;383(9926):1404-11.

[4] Bloom DE, Cafiero ET, Jane-Llopis E, et al. The Global Economic Burden of NonComunicable Disease. Geneva: World Economic Forum, 2011.

[5] Hickman, Caroline and Marks, Elizabeth and Pihkala, Panu and Clayton, Susan and Lewandowski, Eric R. and Mayall, Elouise E. and Wray, Britt and Mellor, Catriona and van Susteren, Lise, Young People’s Voices on Climate Anxiety, Government Betrayal and Moral Injury: A Global Phenomenon. Available at SSRN: or


[7] Bessant, Judith. (2018). Young precariat and a new work order? A case for historical sociology. Journal of Youth Studies. 21. 1-19. 10.1080/13676261.2017.1420762.

[8] Sharma, M., Idele, P., Manzini, A., Aladro, CP., Ipince, A., Olsson, G., Banati, P., Anthony, D. Life in Lockdown: Child and adolescent mental health and well-being in the time of COVID-19, UNICEF Office of Research – Innocenti, Florence, 2021.

[9] Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. Santomauro, Damian F et al. 2021. The Lancet, online.

[10] NSW Health report (17 Aug 2021)

[11] Victorian Agency for Health Information, Mental Health and Alcohol and Other Drug Services in Victoria. Report August 2021

[12] Phillipou, A. et al eating and exercise behaviours in eating disorders and the general population during the COVID-19 pandemic in Australia: Initial results from the COLLATE project. International Journal of Eating Disorders. 2020:53(7) pp 1158-1165

[13] Mental Health, Productivity Commission Final Report (No. 95). Canberra: Productivity Commission, 2020.