2024/11/27 by Jana M Menssink, Caroline X. Gao, Caroline X Gao +8 · 1 citation
Health Professions · Psychology · Social Sciences · #Focus Groups and Qualitative Methods #Mental Health Treatment and Access #Mental Health and Patient Involvement
paper · doi:10.1177/00048674241299221
crossref issued 2024/11/27 · crossref published 2024/11/27 · crossref published-online 2024/11/27 · openalex publication_date 2024/11/27 · crossref created 2024/11/28 · crossref published-print 2025/02/01 · openalex created_date 2025/10/10 · crossref deposited 2026/04/28 · crossref indexed 2026/07/28 · openalex updated_date 2026/08/01
OBJECTIVE: As 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. METHOD: Three 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. RESULTS: Ten 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. CONCLUSIONS: A 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.