ArticleThe Australian and New Zealand journal of psychiatry2025
The missing middle service gap: Obtaining a consensus definition of the 'Missing Middle' in youth mental health.
Article in The Australian and New Zealand journal of psychiatry, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 7 papers.
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Who cites it
7 citing papers in PubMed.
- Occupational therapists' experiences in Australia's primary mental health funding scheme: Navigating complexity in a constrained system.Australian occupational therapy journal · 2026Article
- Predictors of depression outcomes among university students following brief smartphone-based interventions.Npj mental health research · 2026Article
- Understanding the Context and Needs of Adolescents Experiencing Subclinical Anxiety and Depression Symptoms in Wales: Document Analysis and Qualitative Data Collection.School mental health · 2026Article
- Evaluating youth mental health service integration in Australia using the Youth Integration Project framework.BMJ open quality · 2025Article
- "I Believe That AI Will Recognize the Problem Before It Happens": Qualitative Study Exploring Young Adults' Perceptions of AI in Mental Health Care.JMIR mental health · 2025Article
- Increasing Youth Peer Workers' Impact Through Integration: Peer Worker Perspectives on Best Practice in Youth Mental Health.Health expectations : an international journal of public participation in health care and health policy · 2025Article
- Capturing the clinical complexity in young people presenting to primary mental health services: a data-driven approach.Epidemiology and psychiatric sciences · 2024Article
Corrections and comments
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Authors and funding
8 authors.
Funding
Abstract
objectiveAs highlighted in Australia's Productivity Commission Inquiry into mental health, subgroups of individuals are failing to have their needs met, or are 'falling through the cracks' in the current system - a phenomenon increasingly referred to as the 'missing middle'. A barrier to devising solutions is that the term 'missing middle' is not clearly defined. Using the Delphi method, we aimed to define the term and explore acceptability.
methodThree expert groups were recruited: carers and young people with a lived experience of mental ill-health; clinicians and service providers; researchers, policymakers and commissioners of mental health services. Using a three-stage Delphi process, we elicited definitions, refined and developed a consensus definition.
resultsTen subthemes describing the 'missing middle' were identified, with four endorsed across all expert groups from the outset: service gap, inflexibility, inadequate service quality and duration, and social disadvantage. Additional subthemes were later endorsed. Feedback was sought on a consensus-driven definition that encompassed the original four endorsed subthemes. Findings supported a shift to a systemic focus - framing the 'missing middle' as a care gap.
conclusionsA consensus definition was developed, repositioning the term to a systems lens, describing a 'missing middle service gap'. The definition represents the 'missing middle' as a term to describe a gap in care where existing mental health services are not meeting the needs of individuals in a meaningful way. Research was carried out in relation to youth mental health in Australia and the definition may need to be adapted for other contexts.
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