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

How do we provide an How do we provide an appropriate service appropriate service

response?response?

Dr Denise CoiaDr Denise Coia

5 of 10 leading causes of 5 of 10 leading causes of disability world wide are mental disability world wide are mental disordersdisorders

Major Depression (predicted the second Major Depression (predicted the second most prevalent health problem most prevalent health problem worldwide by 2020)worldwide by 2020)

Alcohol MisuseAlcohol Misuse Bipolar Affective DisorderBipolar Affective Disorder SchizophreniaSchizophrenia Obsessive Compulsive DisorderObsessive Compulsive Disorder

(WHO (WHO 1996)1996)

In Established Market In Established Market Economies Economies (Australia, Europe & (Australia, Europe & America)America)

Mental Disorders account for Mental Disorders account for

43% disability43% disability

22% total burden of disease22% total burden of disease Burden of mental disorders in USA is Burden of mental disorders in USA is

more than burden associated with all more than burden associated with all forms of cancer forms of cancer (Murray and Hopez) 1996(Murray and Hopez) 1996

Depression in Australia 4Depression in Australia 4thth most most common problem in General Practice common problem in General Practice 2000- 20012000- 2001

Mental Health DisordersMental Health Disorders

High Level of Unmet NeedHigh Level of Unmet Need Most people who seek help do so Most people who seek help do so

from GP (75%)from GP (75%)

Are the prevalence rates for Are the prevalence rates for mental health disorders different in mental health disorders different in rural versus urban areas?rural versus urban areas?

Difficult to assessDifficult to assess Rural populations are not Rural populations are not

heterogeneousheterogeneous Rural issues change over time Rural issues change over time

(employment, foot and mouth)(employment, foot and mouth)

So what is the Rural So what is the Rural Context Affected byContext Affected by

Distribution of different types of Distribution of different types of people (compositional effects)people (compositional effects)

Place or location itself Place or location itself

(contextual effects)(contextual effects)

Diversity of Rural Diversity of Rural Populations IncludePopulations Include

Population densityPopulation density Ethnic Composition/cultural heritageEthnic Composition/cultural heritage Socio economic status and stress Socio economic status and stress

(eg in farming, mining and fishing (eg in farming, mining and fishing communities) and predominant communities) and predominant occupationsoccupations

Remoteness – distance from large Remoteness – distance from large settlementssettlements

What Aspects of Rural Life What Aspects of Rural Life and Place Contribute to:and Place Contribute to:

Positive Mental HealthPositive Mental Health Increased Likelihood of mental Increased Likelihood of mental

health problems or/andhealth problems or/and Support, resilience and recoverySupport, resilience and recovery

The MythThe MythUrban Ghetto versus Rural Urban Ghetto versus Rural HavenHaven

Removing the Focus of Removing the Focus of Control from rural Control from rural CommunitiesCommunities

Leading toLeading to Relative poverty, poorer educationRelative poverty, poorer education Negative life experiencesNegative life experiences Lack of control over life and work Lack of control over life and work

in general in general Marmot 1998Marmot 1998

Potential Mental Health Potential Mental Health Consequences of Rural DeclineConsequences of Rural Decline

USA Berson 2000USA Berson 2000

1.1. Impact on IndividualImpact on Individual Psychological distress and multiple stress related Psychological distress and multiple stress related

symptomssymptoms risk of suiciderisk of suicide risk of depressionrisk of depression risk from accidents and injuryrisk from accidents and injury2.2. Impact on FamiliesImpact on Families Intergenerational conflictIntergenerational conflict Marital DiscordMarital Discord Domestic ViolenceDomestic Violence Difficulties in adjusting to urban settingsDifficulties in adjusting to urban settings3.3. Impact on ChildrenImpact on Children Adjustment DisordersAdjustment Disorders Poor ParentingPoor Parenting Children internalise problems leading to depressionChildren internalise problems leading to depression Substance AbuseSubstance Abuse

Potential Mental Health Potential Mental Health Consequences of Rural DeclineConsequences of Rural Decline

USA Berson 2000USA Berson 2000

4.4. Impact on CommunitiesImpact on Communities Depression affects whole communityDepression affects whole community Social disintegration and Social disintegration and

disorganisation disorganisation Violence to OthersViolence to Others5. Reactions5. Reactions Adjustment (grief) reactionsAdjustment (grief) reactions HelplessnessHelplessness Social IsolationSocial Isolation More vulnerable to anti government More vulnerable to anti government

Paykel and Jenkins 1997Paykel and Jenkins 1997

UK National Morbidity Study. UK National Morbidity Study. Urban- Rural DifferencesUrban- Rural Differences

In General Practice Alcohol and In General Practice Alcohol and Drug Dependence Higher in Urban Drug Dependence Higher in Urban settingssettings

Recent Changes in Rural Recent Changes in Rural Mental HealthMental Health

Rural residents experience higher Rural residents experience higher levels of depression, alcohol abuse, levels of depression, alcohol abuse, domestic violence, incest and child domestic violence, incest and child abuse than urban counterparts abuse than urban counterparts (Baume 1997, Bushy 2000, Haustein 1994. Olson 2000)(Baume 1997, Bushy 2000, Haustein 1994. Olson 2000)

They view mental illness more They view mental illness more negatively and the stigma is negatively and the stigma is magnified which prevents them magnified which prevents them seeking healthcareseeking healthcare

USA (APA Survey 2001)USA (APA Survey 2001)

Rural poverty 15.9% - Urban 13.2%. Rural poverty 15.9% - Urban 13.2%. Gap wideningGap widening

60% rural areas lacking mental health 60% rural areas lacking mental health professionalsprofessionals

56.9% of families below poverty line56.9% of families below poverty line Suicide rate 3 times higher than urban Suicide rate 3 times higher than urban

ratesrates

Prevalence ProblemsPrevalence Problems

““How are differences in the How are differences in the characteristics of various types of characteristics of various types of rural and urban communities rural and urban communities functionally relevant to differences functionally relevant to differences in the type and level of disorders in the type and level of disorders observed”observed”

Beeson 1992Beeson 1992

Determinants of Resilience and Determinants of Resilience and Positive Mental Health IndicatorsPositive Mental Health Indicators

CategoryCategory IndicationsIndicationsHopeHope

Sufficient ResourcesSufficient Resources

Location in SocietyLocation in Society

Connectedness with Connectedness with CommunityCommunity

SelfSelf

FamilyFamily

Primal Human ValuesPrimal Human Values

See a futureSee a future

Sufficient income, family Sufficient income, family resource, resource,

Meaningful WorkMeaningful Work

Sense of BelongingSense of Belonging

Sense of Wellbeing in Sense of Wellbeing in CommunityCommunity

Know who you are and how Know who you are and how you fit inyou fit in

Emotional support network Emotional support network of family and communityof family and community

Happiness, relationships, Happiness, relationships, sense of caring, abhorrence sense of caring, abhorrence of suffering, devotion to of suffering, devotion to familyfamily

Determinants of Resilience and Determinants of Resilience and Positive Mental Health IndicatorsPositive Mental Health IndicatorsCategoryCategory IndicationsIndicationsAutonomy/EffectivenessAutonomy/Effectiveness

Sense of EfficacySense of Efficacy

Valuing DiversityValuing Diversity

Physical EnvironmentPhysical Environment

Physical HealthPhysical Health

Feeling of Safety in Home Feeling of Safety in Home and Environmentand Environment

Control over environment Control over environment (work and home)(work and home)

Not being overwhelmed by Not being overwhelmed by external eventsexternal events

Self determination at work Self determination at work and with familyand with family

Basic freedom to live in an Basic freedom to live in an accepting societyaccepting society

Connection with earth and Connection with earth and seasons, beauty exercise, seasons, beauty exercise, nutrition, relaxation, nutrition, relaxation, balanced lifestylebalanced lifestyle

Ability to deal confidently Ability to deal confidently with conflicts that arise. with conflicts that arise. Freedom from fear in home Freedom from fear in home and communityand community

Good Mental Health Good Mental Health 3 Streams of Intervention3 Streams of Intervention

1.1. Improving positive mental health Improving positive mental health through Health Promotion and through Health Promotion and preventionprevention

2.2. AssessmentAssessment

3.3. TreatmentTreatment

Health Promotion/Prevention Health Promotion/Prevention StrategiesStrategies

Understand the mechanisms that Understand the mechanisms that account for rural urban differences account for rural urban differences in prevalence of mental disordersin prevalence of mental disorders

Understand proximal and distal Understand proximal and distal influencing factors in preventioninfluencing factors in prevention

Optimally preventative Optimally preventative interventions are implemented in interventions are implemented in response to specific problems in response to specific problems in specific rural settingsspecific rural settings

Prevention Programmes in Prevention Programmes in

Rural AreasRural Areas

Western Norway – Hordaland Western Norway – Hordaland County ProjectCounty Project

Value of bottom up/topdown Value of bottom up/topdown approachapproach

Arvid Skuttle Arvid Skuttle 20022002

Developing Mental Health ServicesDeveloping Mental Health ServicesIssues to be considered in service Issues to be considered in service deliverydelivery

i.i. Diversity of Rural populationsDiversity of Rural populationsii.ii. Inconsistencies in the term ruralInconsistencies in the term ruraliii.iii. What is functional relevance of rural What is functional relevance of rural

residence in the aetiology of specific residence in the aetiology of specific disordersdisorders

iv.iv. Suitability of ServiceSuitability of Servicev.v. Do you design interventions Do you design interventions

specifically for rural populationsspecifically for rural populationsvi.vi. How do you engage rural residentsHow do you engage rural residentsvii.vii. AccessAccessviii.viii. Increasing CostsIncreasing Costs (Farell and (Farell and

McKinnon 2003)McKinnon 2003)

Challenges to Designing Challenges to Designing Rural Intervention Rural Intervention ServicesServices

1.1. Shortages of staff, particularly specialist to Shortages of staff, particularly specialist to provide a range of interventionsprovide a range of interventions

2.2. Lack of service outreach infrastructureLack of service outreach infrastructure

3.3. Distances required to travel to places Distances required to travel to places where services are offered – inaccessiblewhere services are offered – inaccessible

4.4. General distrust of Mental Health SystemGeneral distrust of Mental Health System

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

System Wide ApproachSystem Wide ApproachThe Stepped Collaborative Care Model The Stepped Collaborative Care Model

Level 2 - Care for milder or uncomplicated Level 2 - Care for milder or uncomplicated disordersdisorders

Interventions in L1/L2 provided by primary Interventions in L1/L2 provided by primary care clinicianscare clinicians

Level 3 – Collaboration ie secondary or Level 3 – Collaboration ie secondary or specialist consultant and shared carespecialist consultant and shared care

Level 4 – Skilled specialist for more severe Level 4 – Skilled specialist for more severe and complex disorders, components of this and complex disorders, components of this level would include CMHT, Crisis Teams, level would include CMHT, Crisis Teams, Assertive Outreach, Partial Hospitalisation Assertive Outreach, Partial Hospitalisation and Early Intervention Servicesand Early Intervention Services

Social CareSocial Care

Tier 1 – Support volunteered by Tier 1 – Support volunteered by family and friendsfamily and friends

Tier 2 – Community and religious Tier 2 – Community and religious organisations local emergency organisations local emergency servicesservices

Tier 3 – Formal Services providing Tier 3 – Formal Services providing social supportsocial support

What are the Specific Rural What are the Specific Rural Issues that Affect Service Issues that Affect Service DeliveryDelivery

Stigma and help seeking behaviourStigma and help seeking behaviour Dual Roles/Staff Recruitment and Dual Roles/Staff Recruitment and

retentionretention Access to careAccess to care

Dual Relationship in Dual Relationship in Mental Health Practice Mental Health Practice (Scopelli, (Scopelli,

Judd 2005)Judd 2005)

IssuesIssues Pressure to be always on dutyPressure to be always on duty Pressure to deal with community Pressure to deal with community

tragedytragedyoften have to provide care and often have to provide care and support when equally support when equally upset/unrealistic expectationsupset/unrealistic expectations

3 main features of rural 3 main features of rural communities that impact upon communities that impact upon the capacity of mental health the capacity of mental health workers to maintain clear workers to maintain clear professional boundariesprofessional boundaries

1.1. Size of communitySize of community

2.2. Isolation of communityIsolation of community

3.3. Community expectations (to Community expectations (to support community activities etc)support community activities etc)

Boundary Management is Boundary Management is EssentialEssential

ii For Patients: proper boundaries For Patients: proper boundaries provide a foundation for an provide a foundation for an effective therapeutic allianceeffective therapeutic alliance

iiii For staff – prevents “burnout” – For staff – prevents “burnout” – require psychological space as an require psychological space as an individual to functional and thrive.individual to functional and thrive.

Solutions Solutions

1.1. Acknowledge that multiple Acknowledge that multiple relationships are unavoidable in relationships are unavoidable in small and remote communitiessmall and remote communities

2.2. Distinguishing betweenDistinguishing between

- Boundary Violations- Boundary Violations

- Boundary Crossing- Boundary Crossing

3.3. Patient – Clinician distance spectrumPatient – Clinician distance spectrum

4.4. Be mindful of confidentialityBe mindful of confidentiality

Solutions to Delivering Rural Solutions to Delivering Rural Mental Health ServicesMental Health Services

II Enhanced Primary CareEnhanced Primary Care Improving detectionImproving detection Improving Effective TreatmentImproving Effective Treatment

IIII Training and Education Programme for Training and Education Programme for

Primary CarePrimary Care

IIIIII Novel ApproachesNovel Approaches Rooming-In Facilities in Western AustraliaRooming-In Facilities in Western Australia

IV IV TelehealthTelehealth

VV Training in Rural Psychiatry for SpecialistsTraining in Rural Psychiatry for Specialists

Telehealth Telehealth Is technology a help? Is it acceptable? Is it Is technology a help? Is it acceptable? Is it feasible?feasible?

““Early on psychiatry was perceived as Early on psychiatry was perceived as the ideal specialty for the application the ideal specialty for the application of telemedicine owing to the fact that of telemedicine owing to the fact that assessment and treatment relies more assessment and treatment relies more on audiovisual information than on the on audiovisual information than on the use of lab tests and procedures”use of lab tests and procedures”

(Boer, Elford & Cukor 1997)

Telehealth Telehealth Is technology a help? Is it acceptable? Is it Is technology a help? Is it acceptable? Is it feasible?feasible?

Issues of contractual relationshipIssues of contractual relationship PrivacyPrivacy Medical Legal PrudenceMedical Legal Prudence May challenge deeply embedded May challenge deeply embedded

constraints of the therapeutic constraints of the therapeutic relationshiprelationship

Practical problems Practical problems

(Jablonowski 2003)(Jablonowski 2003)

More Research is Required More Research is Required to Dispel the Mythsto Dispel the Myths The examination of the nature and extend of The examination of the nature and extend of

mental health problems in different (geographic, mental health problems in different (geographic, socio demographic,economic) rural communitiessocio demographic,economic) rural communities

Identifying the mechanisms by which rural place Identifying the mechanisms by which rural place contributes to mental wellbeing or mental contributes to mental wellbeing or mental disorderdisorder

Implementation and evaluation of mental health Implementation and evaluation of mental health promotion/prevention strategiespromotion/prevention strategies

Design and evaluation of a range of models of Design and evaluation of a range of models of mental health service deliverymental health service delivery

Identify which models of service delivery best Identify which models of service delivery best suit different rural settingssuit different rural settings