Uptake of a national primary mental health program by young people in Australia

Background The purpose of this study was to examine the uptake of an Australian primary mental health care program (Access to Allied Psychological Services) by young people aged 12 to 25 years and the characteristics of consumers and the treatments received. Data were sourced from a national web-based minimum dataset. Results Between 1 July 2003 and 30 June 2012, 51 716 young consumers received 245 704 sessions via the primary mental health program. Around two thirds were female and the average age was 19 years. The majority had depressive and/or anxiety disorders. Most services were delivered to individuals (including just the young person and/or the young person with one or both parents), in a face-to-face context and free of charge. Cognitive and behavioral strategies were the most common interventions delivered. Conclusions The primary mental health care program has been well utilized by people aged 12 to 25 years. Similar programs in other developed countries may improve access to primary mental health care for young people.


Background
Youth mental health is an important public health problem in Australia and internationally. Approximately one in four young people have mental health problems but tend not to access services [1]. Primary mental health services have an important role to play in recognizing vulnerable individuals and offering appropriate treatment.
The Australian Government-funded Access to Allied Psychological Services (ATAPS) program is an example of a primary mental health care program that may improve access to mental health services for young people. Operating since 2001, ATAPS enables predominantly general practitioners (GPs; the Australian term for family physicians) to refer patients with high prevalence disorders (e.g., depression and anxiety) to mental health professionals (predominantly psychologists) for free or low-cost, evidence-based mental health care (most commonly cognitive behavioral therapy, or CBT). This care is delivered in up to 12 (or 18 in exceptional circumstances) individual and/or up to 12 group sessions. Review by the referring GP is essential after each block of six sessions and/or the final session [2]. Nation-wide, ATAPS is currently implemented by 61 Medicare Locals, which are regionally based organizations that coordinate primary health care delivery whilst striving to address local health care needs and service gaps.
The introduction of the Better Access to Psychiatrists, Psychologists and General Practitioners (Better Access) initiative in 2006 has influenced the nature and direction of ATAPS. Better Access facilitates similar access to primary mental health care via fee-for-service rebates under Medicare, Australia's publicly funded universal health care system, operated by the government authority Medicare Australia [3]; however, unlike ATAPS its funding is uncapped. Consequently, ATAPS has since offered more flexible services to particular at-risk populations (e.g., people at risk of suicide, people affected by extreme climatic events, children with mental disorders) that are not available via either the original form of ATAPS, which operates simultaneously, or via Better Access.
ATAPS has been independently evaluated since its introduction, with findings indicating high program uptake in both urban and rural areas [4,5] and positive outcomes for consumers [6] and providers [7]. To date, however, the ATAPS evaluation has not specifically explored ATAPS' performance in terms of providing care for young people as a particular at-risk population. The current paper, therefore, aims to describe the uptake of ATAPS by young people aged 12 to 25 years, the characteristics of this group of consumers and the interventions delivered to them. This age range was selected in order to be more inclusive given the variations in the definitions 'young people' by different services and researchers internationally, and to facilitate comparisons with other Australian youth mental health services, such as headspace National Youth Mental Health Foundation [8], which targets 12 to 25 year olds.

Method
The ongoing evaluation of ATAPS has received approval from The University of Melbourne's Human Research Ethics Committee.

Data source Minimum dataset
As per contractual requirements with the Australian Department of Health, data were collected by ATAPS service providers and entered by project officers (or providers) into a web-based purpose-designed national minimum dataset. The data includes the numbers of professionals and consumers involved in the program; socio-demographic (e.g., age, gender, level of income) and clinical (e.g., diagnosis, previous psychiatric service use) characteristics of consumers; the number, type and duration of sessions and the nature of the interventions provided. Data were downloaded from the minimum dataset on 29 October 2012.

Data analyses
Consumers were included in the analyses if they were aged between 12 and 25 years at the time of referral. Descriptive analyses of the uptake of ATAPS, and consumer and session profiles were conducted using SPSS v21. The analysis period was 1 July 2003 to 30 June 2012.    Table 1 shows the socio-demographic and clinical characteristics of the 51 716 young people referred to ATAPS who received sessions. Over two-thirds of consumers were female, with an average age of 19 years. Approximately two-thirds of the young people (or their families) were receiving a low income, as determined by their GPs. Only one-third of consumers had previously accessed mental health care. Four percent of young consumers were reported to be of Aboriginal, and less than 1% of Torres Strait Islander, origin. The majority of consumers were diagnosed with depression (55%) and/or anxiety disorders (43%). 'Other' free text diagnoses were reported for 19% of consumers.

Characteristics of sessions
The profile of sessions delivered to young consumers is shown in Table 2. Almost all sessions (92%) were delivered to individuals (including just the young person and/ or the young person with one or both parents) in a face to face context (93%). Sessions of 46 to 60 minutes duration accounted for the vast majority (78%) of services delivered. The most frequently delivered interventions were CBT-cognitive (45%) and CBT-behavioral (35%); however, psycho-education (26%) and interpersonal therapy (21%) were also commonly delivered. Of the 179 852 sessions where payment information was available, the majority (142 840, 80%) were delivered free of charge. Around 9% of sessions were not attended.

Discussion
Substantially, 51 716 people aged 12 to 25 years received mental health care through ATAPS during the nine year analysis period. By comparison, and in the context that ATAPS funding is capped while Better Access funding is not, around 194 901 people aged 15-24 years received psychological therapy and focused psychological strategies in 2007-2009 via the Better Access program [9]. A further 14 548 consumers aged 12 to 25 years were referred to ATAPS but did not take up the service (22% of all referrals), which is similar to the non-uptake rate for the entire ATAPS program, at 21% [10], but lower than that (27%) reported elsewhere [11]. Previous findings have demonstrated that the likelihood of using services increases with symptom severity; [12] therefore it is possible that people referred to ATAPS but who do not take up the service have less severe symptoms. Other possible reasons for not taking up the service which could be further examined are lack of motivation or readiness to change; stigma associated with seeking mental health care; miscommunication with the GP; or access issues, such as the location or cost of the service.
The estimated Australian resident population aged 12 to 25 years in June 2012 was 4 081 058 [13], one quarter  [13], and that the prevalence of mental disorders is higher in younger age groups, the relative access to ATAPS by young consumers seems reasonable. The fact that more females have taken up primary health care services via the ATAPS program is not surprising in the context that females with mental disorders in any group are more likely to use services than males [12]. This in turn may be attributable to multiple factors such as lower levels of stoicism and personal stigma associated with mental health problems in females compared with males [14], masculine norms being negatively associated with men's willingness to seek professional help [15], and the advanced mental health literacy of young female Australians [16].
Most consumers were receiving low incomes or were from low income families and had not previously accessed psychiatric services, suggesting that the ATAPS program is addressing access barriers amongst those in need. Given that Indigenous people comprise 2.5% of the Australian population [17], the finding that around 4% of consumers were of Aboriginal, and less than 1% of Torres Strait Islander, origin indicates that they are appropriately accessing ATAPS. However, in the context that Indigenous people have a higher prevalence of mental disorders [18], their access to ATAPS could be improved. Indeed in July 2010, an ATAPS sub-program targeting Indigenous people was introduced that aims to address this inequity.
Findings based on the minimum dataset are limited by lack of corroboration of data such as diagnosis or intervention and may contain unidentified errors. For example, the 'no show' field was not mandatory until June 2013 and has a high rate of missing data, and so it is likely that this figure is currently underestimated and will increase in the future. However, there are several ways in which the quality of data in the minimum dataset is optimized including restriction of data entry options, mandatory data items, validation of data via code to ensure type of data entered matches type of data required and validation against data self-reported by Medicare Locals to the Department of Health, technical features to enable monitoring of each Medicare Local's data patterns, data analysis checks, introduction of statistical linkage keys [19] to minimize duplicate patient entry, and provision of a helpdesk and website to support data entry. Our findings are policy-relevant for both Australia and other developed countries with a similar primary mental health care system that are considering advancing that system. Our study corroborates previous findings suggesting that depressive and anxiety disorders are the most common mental disorders in young people [20]. The ATAPS model, which is predominantly reliant on a GP referral, is appropriate on the grounds that of the 35% of Australians with mental health problems who seek help, the majority do so from GPs [21]. Although the ATAPS program may not suit all young consumers given that access to services is reliant on their having a GP, ATAPS is a good example of a primary mental health care program which has been delivering services to a substantial number of young people with clinically diagnosable disorders and that facilitates access to free or low-cost treatment. Future evaluation efforts could examine spatial data to determine area-based equity in access to ATAPS by young people.
Abbreviation ATAPS: Access to Allied Psychological Services.