Myths and Challenges of Mental Disorders in Communities: Rural v Urban

1. Myths and Challenges of Mental Disorders in Communities: Rural v Urban How do we provide an appropriate service response? Dr Denise Coia

2. 5 of 10 leading causes of disability world wide are mental disorders • Major Depression (predicted the second most prevalent health problem worldwide by 2020) • Alcohol Misuse • Bipolar Affective Disorder • Schizophrenia • Obsessive Compulsive Disorder (WHO 1996)

3. In Established Market Economies (Australia, Europe & America) • Mental Disorders account for 43% disability 22% total burden of disease • Burden of mental disorders in USA is more than burden associated with all forms of cancer (Murray and Hopez) 1996 • Depression in Australia 4th most common problem in General Practice 2000- 2001

4. Mental Health Disorders • High Level of Unmet Need • Most people who seek help do so from GP (75%)

5. Are the prevalence rates for mental health disorders different in rural versus urban areas?Difficult to assess • Rural populations are not heterogeneous • Rural issues change over time (employment, foot and mouth)

6. So what is the Rural Context Affected by • Distribution of different types of people (compositional effects) • Place or location itself (contextual effects)

7. Diversity of Rural Populations Include • Population density • Ethnic Composition/cultural heritage • Socio economic status and stress (eg in farming, mining and fishing communities) and predominant occupations • Remoteness – distance from large settlements

8. What Aspects of Rural Life and Place Contribute to: • Positive Mental Health • Increased Likelihood of mental health problems or/and • Support, resilience and recovery

9. The MythUrban Ghetto versus Rural Haven

10. Removing the Focus of Control from rural Communities Leading to • Relative poverty, poorer education • Negative life experiences • Lack of control over life and work in general Marmot 1998

11. Potential Mental Health Consequences of Rural Decline USA Berson 2000 • Impact on Individual • Psychological distress and multiple stress related symptoms •  risk of suicide •  risk of depression •  risk from accidents and injury • Impact on Families • Intergenerational conflict • Marital Discord • Domestic Violence • Difficulties in adjusting to urban settings • Impact on Children •  Adjustment Disorders • Poor Parenting • Children internalise problems leading to depression • Substance Abuse

12. Potential Mental Health Consequences of Rural Decline USA Berson 2000 4. Impact on Communities • Depression affects whole community • Social disintegration and disorganisation •  Violence to Others 5. Reactions • Adjustment (grief) reactions • Helplessness • Social Isolation • More vulnerable to anti government

13. Paykel and Jenkins 1997 UK National Morbidity Study. Urban- Rural Differences • In General Practice Alcohol and Drug Dependence Higher in Urban settings

14. Recent Changes in Rural Mental Health • Rural residents experience higher levels of depression, alcohol abuse, domestic violence, incest and child abuse than urban counterparts (Baume 1997, Bushy 2000, Haustein 1994. Olson 2000) • They view mental illness more negatively and the stigma is magnified which prevents them seeking healthcare

15. USA (APA Survey 2001) • Rural poverty 15.9% - Urban 13.2%. Gap widening • 60% rural areas lacking mental health professionals • 56.9% of families below poverty line • Suicide rate 3 times higher than urban rates

16. Prevalence Problems “How are differences in the characteristics of various types of rural and urban communities functionally relevant to differences in the type and level of disorders observed” Beeson 1992

17. Determinants of Resilience and Positive Mental Health Indicators

18. Determinants of Resilience and Positive Mental Health Indicators

19. Good Mental Health 3 Streams of Intervention • Improving positive mental health through Health Promotion and prevention • Assessment • Treatment

20. Health Promotion/Prevention Strategies • Understand the mechanisms that account for rural urban differences in prevalence of mental disorders • Understand proximal and distal influencing factors in prevention • Optimally preventative interventions are implemented in response to specific problems in specific rural settings

21. Prevention Programmes in Rural Areas • Western Norway – Hordaland County Project • Value of bottom up/topdown approach Arvid Skuttle 2002

22. Developing Mental Health ServicesIssues to be considered in service delivery • Diversity of Rural populations • Inconsistencies in the term rural • What is functional relevance of rural residence in the aetiology of specific disorders • Suitability of Service • Do you design interventions specifically for rural populations • How do you engage rural residents • Access • Increasing Costs (Farell and McKinnon 2003)

23. Challenges to Designing Rural Intervention Services • Shortages of staff, particularly specialist to provide a range of interventions • Lack of service outreach infrastructure • Distances required to travel to places where services are offered – inaccessible • General distrust of Mental Health System

24. But are they so different in their requirements or is this another myth?

25. System Wide Approach The Stepped Collaborative Care Model Level 2 - Care for milder or uncomplicated disorders Interventions in L1/L2 provided by primary care clinicians Level 3 – Collaboration ie secondary or specialist consultant and shared care Level 4 – Skilled specialist for more severe and complex disorders, components of this level would include CMHT, Crisis Teams, Assertive Outreach, Partial Hospitalisation and Early Intervention Services

26. Social Care • Tier 1 – Support volunteered by family and friends • Tier 2 – Community and religious organisations local emergency services • Tier 3 – Formal Services providing social support

27. What are the Specific Rural Issues that Affect Service Delivery • Stigma and help seeking behaviour • Dual Roles/Staff Recruitment and retention • Access to care

28. Dual Relationship in Mental Health Practice (Scopelli, Judd 2005) Issues • Pressure to be always on duty • Pressure to deal with community tragedy often have to provide care and support when equally upset/unrealistic expectations

29. 3 main features of rural communities that impact upon the capacity of mental health workers to maintain clear professional boundaries • Size of community • Isolation of community • Community expectations (to support community activities etc)

30. Boundary Management is Essential i For Patients: proper boundaries provide a foundation for an effective therapeutic alliance ii For staff – prevents “burnout” – require psychological space as an individual to functional and thrive.

31. Solutions • Acknowledge that multiple relationships are unavoidable in small and remote communities • Distinguishing between - Boundary Violations - Boundary Crossing • Patient – Clinician distance spectrum • Be mindful of confidentiality

32. Solutions to Delivering Rural Mental Health Services I Enhanced Primary Care • Improving detection • Improving Effective Treatment II Training and Education Programme for Primary Care III Novel Approaches • Rooming-In Facilities in Western Australia IV Telehealth V Training in Rural Psychiatry for Specialists

33. Telehealth Is technology a help? Is it acceptable? Is it feasible? “Early on psychiatry was perceived as the ideal specialty for the application of telemedicine owing to the fact that assessment and treatment relies more on audiovisual information than on the use of lab tests and procedures” (Boer, Elford & Cukor 1997)

34. Telehealth Is technology a help? Is it acceptable? Is it feasible? Issues of contractual relationship • Privacy • Medical Legal Prudence • May challenge deeply embedded constraints of the therapeutic relationship • Practical problems (Jablonowski 2003)

35. More Research is Required to Dispel the Myths • The examination of the nature and extend of mental health problems in different (geographic, socio demographic,economic) rural communities • Identifying the mechanisms by which rural place contributes to mental wellbeing or mental disorder • Implementation and evaluation of mental health promotion/prevention strategies • Design and evaluation of a range of models of mental health service delivery • Identify which models of service delivery best suit different rural settings