Rural Health
Mental Health in Rural Areas

The Alliance has a separate position paper on suicide prevention1, adopted at its 27 November 2000 Council Meeting. This position paper on mental health complements the suicide prevention one to focus on the broader issues related to the mental health of people living in rural and remote Australia. While there is some overlap between the two papers, each provides a different emphasis.

The National Rural Health Alliance, the peak non-government rural and remote health organisation, notes that:

  1. According to Mental Health and Well-Being Profile of Adults2, one in five Australians aged 18 years and over suffered from a mental disorder during the 12 months prior to the survey in 1997. This equates to over one and a quarter million people living in rural and remote Australia who will at some point in their life experience a mental illness. The most common disorders are major depression and related disorders including anxiety.

  2. The Australian Institute of Health and Welfare estimates that the burden of mental disorders nationally in the Australian community represents 30% of the non-fatal disease burden3. Worldwide the World Health Organisation considers mental illness to be the fourth leading cause of disability and this is predicted to rise to the second in developed nations by 2020.

  3. There are huge economic implications for all Australians from this high prevalence of mental illness, as well as the direct burden on individuals and their families. People with a mental illness are at a greater risk of committing suicide, with 80% of suicides having a pre-existing mental illness.

  4. There is no evidence that in overall terms people in rural and remote areas have higher levels of mental illness than those living in more urban areas. Despite this, people living in rural and remote areas face a number of factors which may exacerbate the problems of mental illness. People in rural areas are poorer, face higher rates of unemployment, and face additional challenges such as isolation, stigma as a result of less anonymity, exposure to environmental hazards, lack of appropriate services and service providers, and the effects of economic restructuring.

  5. Some indicators suggest that the consequences of mental illness might be more severe in rural and remote areas. Rates of suicide are consistently higher in rural towns than in metropolitan and regional areas. In communities with a population of less than 5000, the male suicide rate is one-and-a-half times the capital city rate, and the suicide rate of males aged 15-24 is almost twice that of their city counterparts4. Here the impact of structural adjustment in agriculture and the withdrawal of government and other services, such as banks, has been most dramatic.

    Suicide rates for young Indigenous males are up to 40% higher than the national average. Suicide rates for all young males have increased significantly over the past 30 years.

  6. 33 of the 37 poorest electorates in Australia are rural electorates, with average weekly earnings in rural areas considerably lower than the national average. High youth unemployment is a feature of many of these communities despite out-migration for higher education and work.

  7. Early diagnosis and intervention are keys to effective management of mental illnesses5, yet lack of services is a major issue in rural and remote Australia. Research has indicated that a range of rural health workers identified mental health services as one of the most significant deficiencies in rural and remote Australia6. There is a shortage of mental health nurses, psychiatrists, psychologists and other mental health professionals in rural and remote communities. Lack of access to training, professional isolation, heavy workloads and limited resources affect the recruitment and retention of mental health personnel in rural and remote areas.

    Only 7.5% of psychiatrists are located in rural or remote locations with more than 90% of those in non-metropolitan areas being in major regional centres like Toowoomba. Shortages of clinical psychologists are also evident in rural and remote areas. The situation has been exacerbated by the rationalisation of public services in rural areas that employed psychologists. Lack of access to training, professional isolation, heavy workloads and limited resources affect the recruitment and retention of psychologists to rural and remote areas.

    Few local hospitals have the resources to deal with people in the acute phases of mental illness who often require hospitalisation.

  8. These shortages of mental health professionals undermine the development of intervention and prevention strategies for people at risk. As a consequence of the shortages, non-mental health professionals in rural areas are more likely to be treating people with a mental illness.

    Yet there is a also a shortage of primary health care professionals. For example the current shortfall of GPs in rural and remote areas is estimated to be in the range 500-750 practitioners7. Further, many rural GPs lack specific training in mental health or uicide prevention and/or lack the time that needs to be spent with a depressed or mentally ill person. There is also a growing shortage of nurses in rural and remote areas. Options for referral are all but non-existent in many rural and remote areas

  9. Despite these limitations, there are some positive developments in rural and remote mental health services. Some of the best examples of mental health initiatives have occurred in large regional centres and larger rural environments, though the same research also identified rural and remote communities as having some of the worst services8.

    Information technologies such as telepsychiatry and video-conferencing provide important adjuncts to the services provided by health professionals in rural and remote locations. It can also improve the support and training of local health professionals who provide service to this population. Consultations using telepsychiatry or video-conferencing facilities can reduce the need for a person in a rural area to travel to the capital city for assessment and treatment.

    The Royal Flying Doctor Service (RFDS) plays a vital role in the assessment and evacuation of people with a mental illness. The RFDS has released an educational and interactive CD-Rom for health professionals, aimed at improving the knowledge and awareness of the issues of mental health.

  10. There has been a range of national policies and associated activities supporting improved access to mental health care and better mental health outcomes in rural and remote areas. Healthy Horizons (1999-2003), the strategic framework for rural, remote and regional health, identifies mental health as a key issue. The Healthy Horizon update (2002) provides descriptions of some of the programs operating in Australia's various health jurisdictions. Mental health is also one of the six National Health Priority Areas, along with cardiovascular disease, cancer control, injury prevention and control, asthma and diabetes mellitus.

    The National Mental Health Strategy was adopted by Health Ministers in 1993 and reinforced in 1998 by their adoption of the 5 year Second National Mental Health Plan. Under this broad policy framework there have been several initiatives in rural and remote mental health including:

    • National Demonstration Projects in Psychiatry;
    • pilots of rooming-in services;
    • a project to identify ways to enhance the role of general practitioners in mental health care; and
    • increased numbers of mental health workers and improved services in some rural areas.

  11. There are 6 priority mental health targets for rural and remote communities outlined in the National Action Plan for Mental Health Promotion, Prevention and Early Intervention 1998-20039. These priority targets are:

    • promote family and community cohesion;
    • promote protective factors that impact on the effects of unemployment, environmental hazards, geographical isolation, alienation and loss, building on particular strengths of people in rural and remote communities;
    • reduce the prevalence of risk factors for depression, anxiety, stress and suicide;
    • capacity building of infrastructure and communication technologies to assist improve mental health outcomes for rural and remote communities eg. telehealth/telemedicine;
    • develop and support initiatives as determined by the local community; and
    • increase access to mental health promotion and prevention services.

  12. The Mental Health Council of Australia, a peak body for mental health created through the National Mental Health Strategy, made a number of recommendations for rural and remote mental health in its 2001 Federal Election Submission10 including:

    • additional funding to provide mental health services in rural Australia comparable with those in metropolitan areas;
    • increased incentives and other initiatives to attract and retain multidisciplinary mental health professionals to rural and remote areas and to encourage urban mental health specialists to provide some services in rural and remote areas;
    • expanded recruitment of Indigenous mental health practitioners
    • national accreditation of cultural awareness and sensitivity training for mental health professionals; and
    • the provision of professional development opportunities for mental health professionals in rural and remote areas.

  13. The national depression initiative Beyond Blue, with its emphasis on a population health approach to mental illness has a special task force specifically devoted to rural, remote and Indigenous communities. Its priorities include reducing the stigma of mental illness and increasing community awareness of and knowledge about mental illness.

  14. The complexities of the factors affecting a community's mental health, exacerbated by the ongoing shortages of mental health professionals, suggest that the development of partnerships between consumers, schools, general practitioners, Aboriginal health services and communities, emergency services, police, private mental health sector, Rural Counsellors, non-government and government services and the broader community is an important route to improve metal health of rural and remote communities. Such partnerships will also provide a more supportive network for service providers within the sector and a targeted and preventative program for rural and remote clients.
The National Rural Health Alliance affirms that:
  1. "Total health cannot be achieved without mental health. It is essential therefore, that mental health initiatives be fundamental to the primary care approach11."

  2. Member Bodies of the Alliance strongly support the inclusion of mental health as a national population health priority.

  3. It is important that there be increased inter-agency mental health co-operation in areas such as community education, improved skills of key groups, reducing stigma and providing professional and peer support.

  4. Member Bodies of the Alliance support initiatives that support the provision of mental health information to consumers, including the Commonwealth's telecounselling and internet information service.

  5. Member Bodies of the Alliance support the extension of successful models of innovative mental health services to rural and remote areas which remain underserved by existing mental health services.
The National Rural Health Alliance resolves to:
  1. Encourage Commonwealth, State and Territory Governments to focus some of their mental health funding in rural and remote areas on building partnerships between health and welfare providers and local communities, as well as on other strategies. These partnerships would address locally identified mental health needs, in particular mental health promotion, illness prevention and suicide intervention.

  2. Support, as a priority, initiatives to improve mental health training for GPs, nurses, allied health professionals and Aboriginal Health Workers.

  3. Support incentives to recruit, retain and support rural mental health workers and counsellors, including GPs to small rural communities, and to increase the skills of others, such as teachers, sports coaches and youth workers involved with young people at risk.

  4. Support the expansion of funded telepsychiatry and video-conferencing services as an adjunct to, not a replacement for, face-to-face services in rural and remote communities.

  5. Support the priority mental health targets outlined for rural and remote communities in the Mental Health Promotion, Prevention and Early Intervention National Action Plan 1998-2003.

  6. Maintain close links with Mental Health Branch of the Department of Health and Aged Care in order to provide support to the National Rural Health Alliance's resolutions on mental health and suicide.

  7. Work closely with the Mental Health Council of Australia in its endeavours to achieve implementation of those recommendations in its 2001 Federal Election submission which are most pertinent to mental health in rural and remote Australia.

  8. Seek input to the work of Beyond Blue's special taskforce on rural, remote and Indigenous communities.
References:
  1. National Rural Health Alliance (2001), 2000~ 2001 Position Papers, Canberra
  2. Australian Bureau of Statistics (1998), Mental Health and Wellbeing Profile of Adults, Australia, 1997, Commonwealth of Australia
  3. Australian Institute of Health and Welfare (2001), The Burden of Disease and Injury in Australia, AIHW
  4. Australian Institute of Health and Welfare (2000), Australia's health 2000: the seventh biennial health report of the Australian Institute of Health and Welfare Canberra: AIHW
  5. Myhill K (1999), Innovations in Mental Health Service delivery for Rural Communities. Paper presented at the 5th National Rural Health Conference, 14 - 17 March.
  6. Hodgson L, Jackson J (1997), An interactional model for rural mental health services: the effects on the roles of allied health professionals. Paper presented at the 4th National Rural Health Conference, Perth 9 -12 February.
  7. Mara P, Paper presented in the health theme component of the Regional Australia Summit, 27 - 29 October 1999.
  8. Hickie I, (2001), Beyond Blue: the national depression initiative. Paper presented at the 6th National Rural Health Conference, Canberra 4 -7 March.
  9. National Mental Health Strategy (1999), Mental Health Promotion and Prevention National Action Plan, Commonwealth Department of Health and Aged Care, Canberra
  10. Mental Health Council of Australia (2001), Promoting the mental health of all Australians: a 2001 Federal Election Submission, MHCA, Canberra
  11. Norris G, Beaver C (1992), Aboriginal Health - a primary mental health care approach. Paper presented to the Australian Rural Health Conference, Toowoomba, 12 -15 August.

     

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