Exploring the Missing Middle: A qualitative study of youth’s experiences navigating mental health service gaps

Though the majority of mental health challenges emerge in childhood and adolescence, youth consistently report having unmet needs with mental health services. The concept ‘Missing Middle’ has been introduced to highlight the phenomenon in which youth are deemed too well for hospital-based and tertiary mental health services, but too unwell for community-based or primary care services alone. However, there is considerable variation in how this phenomenon is understood. Moreover, there is a dearth of empirical research about how youth experience the Missing Middle. This qualitative description study aims to enhance the conceptual clarity of the Missing Middle by exploring youth’s experiences navigating challenges across mental health services. Individual interviews were conducted with 14 people aged 17 to 37 (including five cisgender women, five cisgender men, and four non-binary and transgender people) who had accessed mental health care as youth in British Columbia, Canada. Narrative analysis approaches were used to examine participants’ stories of navigating the Missing Middle, from which two illustrative vignettes were developed. Findings situate the Missing Middle as reflecting systemic gaps in mental health services and resources, where community-based mental health supports are insufficient or inaccessible, and yet acute care services are not needed or available. Youth navigate three zones of access – community supports, the Missing Middle, and acute care – and move across these zones throughout their mental health trajectories. In discussing these vignettes, we highlight the need for systems-level change to address access barriers and support the development of targeted interventions for youth experiencing the Missing Middle.