In the midst of polycrises such as the COVID pandemic, climate change, financial precarity and the rise of artificial intelligence, there has been growing global momentum for early intervention in the mental health of young people.
Driven by research and systemic reform across countries like Australia, the United Kingdom, Singapore and Canada, a new generation of youth mental health and substance use services has emerged that is:
- Co-designed by and friendly for young people;
- Co-located with additional developmentally appropriate services like vocational or educational supports and physical and sexual health care;
- Not restricted to one or more diagnoses, or requiring a diagnosis at all;
- Composed of multiple portals of entry, including walk-in and direct access;
- Engaging peer supporters who share their own lived experiences with mental health and recovery;
- Located outside of hospitals and institutions, and in community settings to improve access.
These interlocking components have led them to be called “enhanced primary care” or “integrated youth services” (IYS) for youth mental health.
In Canada, transformation began with ACCESS Open Minds, a national research and evaluation initiative across 14 sites in six provinces and territories and has continued with provincial and territorial networks rapidly expanding.
So now is the time to start asking whether these services achieve their objectives – improving timely access to care for more youth while reducing reliance on costly emergency departments and hospitals to optimize public resources.
First, ACCESS Open Minds successfully increased the number of youths seeking help, and reduced wait times to the first evaluation appointment and the first service(s).
Second, evaluations show that these hubs reached many underserved youth. They served a much higher percentage of these individuals than live in the surrounding area. Other IYS in Canada and Australia report similar findings.
Community-based (rather than institutional) care delivered through flexible, multidisciplinary teams has many benefits: it aligns with the priorities of young people and families/carers, who understandably want to access stigma-free care close to where they live, and is important to funders and policymakers, who know that even intensive care delivered in community settings can be more resource-efficient than emergency departments or hospitals. Until recently, there has been surprisingly little evidence about whether IYS-like services deliver on the promise of more efficient and effective care delivery. Establishing this evidence is critical to helping governments decide if these services should be sustained, scaled and whether they truly deliver value for money.
We recently conducted the first data-based economic evaluation of an enhanced primary youth mental health service, examining nearly 1,500 young people who received care through ACCESS Open Minds Edmonton and comparing them with more than 9,000 youth with broadly similar demographics and clinical needs receiving traditional community mental health services.
The findings were striking.
Young people receiving care through ACCESS Open Minds experienced greater reductions in hospitalizations, physician visits and publicly funded residential services than comparable youth receiving traditional services. After accounting for all implementation and operating costs (setting up the service and site, hiring/training and paying clinicians, outreach to bring more people into care), the net savings from this shifting of care from institutional to community settings was substantial: $4,355 per young person per year, amounting to $9.7 saved for every dollar invested.
For governments grappling with health-care budgets, those numbers should attract attention. Even with the usual grains of salt that sceptics should ingest – such as this analysis being limited to urban settings – they represent substantial cost savings. For comparison, housing first strategies save $2 for every dollar invested, early childhood education programs between $4-$9, endovascular therapy for suspected strokes $1.6 and comprehensive foot care for diabetes $7.4.
Another equally important finding emerged from the study. A common criticism of primary care- or community-based mental health programs is that they succumb to “cream-skimming” – incurring fewer expenditures by serving less severe cases. If that were true here, the savings would perhaps be less impressive and less relevant to broader system reform.
In fact, we found the opposite. In the year prior to their referral, young people referred to ACCESS Open Minds had received more intensive services – higher rates of hospitalization, emergency department and residential care use – and had greater symptom and functional difficulties than comparable youth during the year before they started receiving traditional services.
This finding matters because some IYS are positioning themselves as services primarily or solely for young people with mild-to-moderate concerns. However, this assumption does not hold when considering real-world data. ACCESS Open Minds, British Columbia’s Foundry and some nodes of the Australian headspace network have reported that a majority of youth presenting for care have high levels of severity, distress, social and work/school difficulties and complex needs. In many cases, these same youth also use high-intensity care settings like emergency departments or hospitals after their follow-up at IYS.
All young people – including those with mild or emerging difficulties – deserve timely support. But the Edmonton findings suggest that the public benefits of IYS may depend on their ability to engage young people with more complex and persistent needs before those needs result in repeated crises and costly institutional care. In other words, we can only save money if we are being inclusive of those on whom we were spending it in the first place.
The lesson is not that every IYS needs to offer every young person the full spectrum of services they might need, including specialized treatment, in a single building. Rather, IYS should welcome young people across the entire severity spectrum; systematically assess and document their needs; use that information to guide care; provide appropriate care in-house to the extent possible; and maintain coordinated pathways to more specialized local and regional services when necessary.
Youth mental health services reform does not have to be a zero-sum game. It is possible to address two urgent imperatives simultaneously: addressing growing youth mental health problems and managing increasing pressures on public health systems.
We now see that enhanced youth services with intensive, flexible community-based interventions can be highly cost-effective and therefore viable for wider scaling. However, their potential will only be realized if these services remain accessible to the young people whose needs are the greatest. Will governments heed that lesson?
