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The adolescent and early adult years are periods of peak prevalence and incidence for most mental disorders. Despite the rapid expansion of Web-based mental health care, and increasing evidence of its effectiveness, there is little research investigating the characteristics of young people who access Web-based mental health care. headspace, Australia’s national youth mental health foundation, is ideally placed to explore differences between young people who seek Web-based mental health care and in-person mental health care as it offers both service modes for young people, and collects corresponding data from each service type.
The objective of this study was to provide a comprehensive profile of young people seeking Web-based mental health care through eheadspace (the headspace Web-based counseling platform), and to compare this with the profile of those accessing help in-person through a headspace center.
Demographic and clinical presentation data were collected from all eheadspace clients aged 12 to 25 years (the headspace target age range) who received their first counseling session between November 1, 2014 and April 30, 2015 via online chat or email (n=3414). These Web-based clients were compared with all headspace clients aged 12 to 25 who received their first center-based counseling service between October 1, 2014 and March 31, 2015 (n=20,015).
More eheadspace than headspace center clients were female (78.1% compared with 59.1%), and they tended to be older. A higher percentage of eheadspace clients presented with high or very high levels of psychological distress (86.6% compared with 73.2%), but they were at an earlier stage of illness on other indicators of clinical presentation compared with center clients.
The findings of this study suggest that eheadspace is reaching a unique client group who may not otherwise seek help or who might wait longer before seeking help if in-person mental health support was their only option. Web-based support can lead young people to seek help at an earlier stage of illness and appears to be an important component in a stepped continuum of mental health care.
The adolescent and early adult years are periods of peak prevalence and incidence for most mental disorders. One in 4 young people will experience a clinically relevant mental health problem within any 12-month period, with 75% of all mental disorders emerging before 25 years of age [
The high prevalence of mental disorder in young people is not matched by a commensurate level of mental health service use. Rather, there is a marked mismatch between the prevalence of disorder and professional help-seeking [
Even for those young people who do seek help, there is often a considerable delay between onset of symptoms and accessing services. This varies according to factors such as type of disorder, gender, population group, and geographical location [
The monetary costs to the Australian economy associated with untreated mental disorders in young people aged 12 to 25 have been estimated at more than AUD$10.6 billion annually (equivalent to US$8.6 billion) [
The reasons young people do not access mental health services in accordance with their level of need are complex. They include: stigma (which includes embarrassment and concern about what others think); negative attitudes to and poor past experiences of treatment; problems recognizing symptoms; lack of awareness of available services; confidentiality concerns; and a preference for self-reliance or drawing on nonprofessional support through family or friends [
Given these substantial barriers to seeking help in-person, it is not surprising that many young people, including those with a probable serious mental illness, are turning to the Internet for information about mental health issues [
In response to demand for Web-based mental health information and support, and in order to address barriers associated with in-person help-seeking, Web-based options are rapidly being developed to enable young people to access information, support, and mental health interventions via communication technologies [
There has been a concerted effort in Australia to make mental health counseling widely available and accessible to young people. In 2006, the Australian Federal Government established headspace, the National Youth Mental Health Foundation [
To extend the reach of headspace and further enable access for young people who do not live near a headspace center or do not want to visit one in person, eheadspace [
Despite the rapid expansion of Web-based mental health care options, supporting evidence is still emerging and there is little research investigating the characteristics of young people accessing Web-based counseling. The current study addresses this gap by presenting the first comprehensive profile of young people who access Web-based counseling (via eheadspace) and comparing them with those who access in-person counseling (via headspace centers). headspace is ideally placed to explore differences between Web-based and in-person clients as it offers both service modes and collects corresponding data from young people accessing each service type.
Participants were all eheadspace clients aged 12 to 25 years (the headspace target age range) who received their first counseling session during the 6-month period November 1, 2014 to April 30, 2015 via online chat or email (n=3414). Clients who received their first counseling session via the phone were not included given the focus of this study is young people who choose to seek Web-based help.
These Web-based clients were compared with all headspace clients aged 12 to 25 who received their first center-based counseling session in a similar 6-month period (October 1, 2014 to March 31, 2015) (n=20,015 clients from across 81 centers). headspace center clients have previously been described in Rickwood et al [
headspace implements a minimum dataset across centers and eheadspace. Part of the minimum dataset is completed by the young person accessing counseling, while another section is completed by their service provider. While data items are completed at every occasion of service, this study examines first-time data recorded at initial presentation.
The data from both young people and service providers are collected via electronic forms. Data are de-identified via encryption and extracted to the headspace national office data warehouse. All headspace clients (eheadspace and center), agree to various terms and conditions including that the data they provide are used at an aggregate level to evaluate, report on, and improve headspace services.
Ethics approval was obtained through quality assurance processes, comprising initial consideration and approval by the headspace Clinical, Research, and Evaluation Committee, and subsequent consideration and approval by the headspace Board of Directors. The consent processes were reviewed and endorsed by an independent body, Australasian Human Research Ethics Consultancy Services.
Demographic measures reported comprise: age in years; gender; Aboriginal and Torres Strait Islander background; country of birth; living situation; location; and work and study situation. Client clinical presentation was measured by self-reported reason for presentation, level of psychological distress as measured by the 10-item Kessler Psychological Distress Scale (K10) [
Descriptive statistics are presented, primarily percentages of young people according to presenting characteristics by mode of service (eheadspace vs centers). National population data comparisons are provided, where available. Pearson’s chi-square tests of contingencies were undertaken to explore whether being an eheadspace compared with a headspace center client was associated with presenting characteristics. Effect sizes are reported as Phi or Cramer’s
The peak age of presentation for eheadspace was the same as that for centers (15-17 years of age). Slightly more eheadspace clients than center clients were in the 15 to 17 and 18 to 20 age brackets. Much fewer eheadspace than center clients were aged 12 to 14, while more eheadspace than center clients were aged 21 to 25. The association between age and type of service was significant (χ21=317.5,
A lower percentage of eheadspace than center clients identified as Aboriginal or Torres Strait Islander; the association was significant (χ21=123.4,
The location of eheadspace clients according to the 2011 edition of the Australian Statistical Geography Standard was largely in line with the location of the Australian population as estimated in 2014 [
More eheadspace than headspace center clients indicated that they had stable accommodation. A slightly lower percentage of eheadspace than center clients reported that accommodation was an issue, they were at risk of being homeless, or that they were currently homeless. This compares with 2011 Census estimates that 0.7% of the Australian population aged 12 to 24 years were homeless or in marginal housing [
A higher percentage of eheadspace than center clients indicated that they were currently at school (55.2% compared with 49.3%), while a similar percentage of eheadspace and center clients indicated they were currently engaged in higher education (18.3% compared with 18.8%). The association between education level (at school or in higher education) and type of service was significant (χ21=7.4,
Demographic characteristics of eheadspace and headspace center clients with national comparison data.
Demographic characteristics | eheadspace (%) | headspace centers (%) | National (%) | |
Female | 78.1 | 59.1 | 48.7a | |
Male | 18.9 | 39.9 | 51.3a | |
Transgender, transsexual, intersex, or another gender | 3.0 | 1.0 | Not available | |
12-14 | 10.2 | 23.6 | 31.2 (10-14)a | |
15-17 | 36.8 | 33.1 | ||
18-20 | 28.8 | 22.9 | 32.4 (15-19)a | |
21-25 | 24.2 | 20.4 | 36.4 (20-24)a | |
3.2 | 8.8 | 3.7b | ||
10.3 | 7.8 | 17.0c | ||
96.0 | 92.8 | 80.3d | ||
Major city | 70.2 | 65.1 | 70.9e | |
Inner regional | 21.4 | 26.3 | 18.1e | |
Outer regional | 7.5 | 6.7 | 8.8e | |
Remote or very remote | 0.9 | 1.9 | 2.2e | |
Stable | 90.4 | 89.1 | Not available | |
An issue | 8.4 | 8.8 | Not available | |
At risk | 1.1 | 1.6 | Not available | |
Homeless | 0.1 | 0.5 | 0.7f | |
15.6g | 27.2g | 27.3h |
a10-24 years [
b12-25 years [
c10-24 years [
d5 years and older [
eAll ages [
f12-24 years [
g18-25 years.
h17-24 years [
Clinical presentation characteristics of eheadspace and headspace center clients.
Presenting characteristics | eheadspace (%) | headspace centers (%) | |
Problems with how they felt | 79.3 | 75.9 | |
Relationship problems | 13.6 | 11.0 | |
Physical health issues | 1.6 | 2.1 | |
School or work problems | 3.6 | 7.8 | |
Alcohol or other drug problems | 1.6 | 2.4 | |
Vocational concerns/assistance | 0.3 | 0.8 | |
86.6 | 73.2 | ||
No mental disorder | 27.5 | 15.7 | |
Mild/moderate symptoms | 53.1 | 43.0 | |
Subthreshold | 13.8 | 19.1 | |
Threshold diagnosis | 4.9 | 16.3 | |
Remission | 0.5 | 1.4 | |
Serious, ongoing | 0.2 | 4.5 | |
46.4 | 44.1 | ||
None | 34.7 | 41.2 | |
1-3 days | 30.0 | 26.3 | |
4-6 days | 15.3 | 13.1 | |
7-9 days | 14.9 | 5.6 | |
10+ days | 5.1 | 13.8 | |
5.0 | 11.7 |
The second most reported reason for seeking help (for both eheadspace and center clients) was for relationship problems. Fewer eheadspace than center clients indicated that their primary reason for seeking help was physical health issues, school/work problems, alcohol or other drug problems, or vocational concerns. The association between reason for contact and type of service was significant (χ21=2619.7,
Across both services the majority of clients presented with high or very high levels of psychological distress, although the percentage of eheadspace clients was higher than the percentage of center clients. Comparatively, the 2007 NSMHW data [
Stage of illness, as estimated by service providers, indicated that more eheadspace clients than center clients presented without a mental disorder or with mild to moderate symptoms. Fewer eheadspace than center clients presented with subthreshold diagnosis, full-threshold diagnosis, periods of remission, or serious and ongoing mental disorder. Importantly, for 46.1% of eheadspace clients and 16.1% of center clients, clinicians recorded that they did not have enough information available to make an assessment of stage of illness and these clients were excluded from these comparisons. The association between stage of illness and type of service was significant (χ21=431.7,
A higher percentage of eheadspace than center clients reported that they had never seen a mental health professional prior to their eheadspace/center visit. The association between prior help-seeking and type of service was significant (χ21=5.9,
Social and vocational functioning scores as assessed by service providers indicated that a lower percentage of eheadspace than center clients experienced serious or major impairment. The association between having a serious or major impairment and type of service was significant (χ21=93.03,
Percentage of eheadspace clients at each level of psychological distress, by age group and gender (males and females only).
Percentage of headspace center clients at each level of psychological distress, by age group and gender (males and females only).
These are the first data to compare the characteristics of young people seeking Web-based mental health counseling and in-person mental health counseling through the headspace service system. headspace is specifically designed to break down the barriers to young people accessing mental health support and the same branding and service promotion is applied to both the Web-based and in-person counseling services. While many similarities were observed between the two groups of clients, important differences were identified.
The most striking finding was the extent of preference by females for Web-based counseling compared with males―close to 80% of the Web-based clients were female. Research from other Web-based services consistently reports a similar gender effect [
In general, males are more likely to be influenced by others, particularly family, to attend mental health services [
For both service types there was the same peak age of presentation at 15 to 17 years, which coincides with the period when the common mental health problems of depression and anxiety develop [
Young people from Aboriginal and Torres Strait Islander backgrounds were less likely to use the Web-based than the in-person service. The percentage of Aboriginal or Torres Strait Islander clients who accessed the in-person service was higher than the percentage of all Australians aged 12 to 25 years who identify as Aboriginal or Torres Strait Islander as indicated in the 2011 census [
The geographical dispersion of center clients reflects the location of centers, which have been set up across Australia to meet community needs. The external evaluation of headspace centers noted a strong relationship between the use of headspace centers and the distance of the center from a client's home, with the majority of clients living within a 10-km radius [
The psychological distress results reveal that young people who use Web-based services are highly distressed, more so than when they present to in-person counseling services, but that they are also earlier in the development of a mental health problem, being at an earlier stage of illness and less likely to have previously accessed mental health care. These results are an important validation of Web-based access as part of stepped-care approaches, revealing that this modality does enable earlier access. Nevertheless, even with earlier presentations, young people are still highly distressed by their symptoms and this distress needs to be a major focus of the initial Web-based counseling response [
Distress is likely to be greater for Web-based clients because service use is closer in time to the symptoms that are distressing. Clients of in-person headspace counseling services have to wait from when they make an appointment to when they receive their service [
The issues that Web-based clients seek help for are also more strongly related to current feelings of depression and anxiety, as well as relationship problems. In contrast, clients of the in-person headspace centers are accessing a wider range of health care options, including for physical health issues. Again, this supports the value of Web-based counselling in addressing current emotional distress─there is clearly a need for this type of support, especially for teenage girls. The Young Minds Matter Australian national survey of young people’s mental health and wellbeing reported high levels of major depressive disorder, psychological distress, self-harm, and suicidal behaviors among adolescents [
The Web-based clients were more likely to be living in stable accommodation, which may suggest that Web-based counseling access is easier for those at home with a computer and Internet connection, and it may be more difficult for young people to go on the Internet in other living situations. While surveys show that almost all young people in Australia have Internet access, for young people who are homeless or couch surfing this can be through public facilities like libraries or drop in centers, or through use of a friend’s computer [
This study has a number of limitations, including the diminishing sample size for eheadspace when broken down by age and gender categories, despite the overall very large sample sizes. The sample for eheadspace was particularly small for some variables, such as stage of illness and psychosocial functioning, with Web-based clinicians having more difficulty making these judgements during first presentation. Better guidance around these issues may be required in order to improve clinicians’ ability to make these assessments.
It is important to acknowledge the possibility that some clients may use both health service types. Unique client codes are used in each service, however, a question in the center dataset asks young people if they have accessed eheadspace, and 5.6% indicated they had. It would be of interest to explore whether clients who access Web-based counseling or in-person counseling exclusively differ from those who access both types, and this is something that could be explored in future research.
Despite these limitations, the study represents an important step in understanding young people who access Web-based counseling. Future research and analysis should investigate the types of interventions that eheadspace clients are receiving and determine whether the approach is making a difference to their mental health and wellbeing. While Web-based counseling certainly has a role in the mental health care continuum, more research is needed to determine how it can best be used to improve access and engage hard to reach young people, as well as its role in stepped care and collaborative approaches between Web-based and in-person services.
During a period when mental health programs and services are being reviewed in Australia [
National Survey of Mental Health and Wellbeing
headspace National Youth Mental Health Foundation is funded by the Australian Government’s Department of Health. The authors would like to thank the young people who contributed data toward this article.
All authors are employed by or directly involved with headspace National Youth Mental Health Foundation.