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)

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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

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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

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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

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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

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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

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

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Prevention Programmes in Rural Areas

• Western Norway Hordaland County Project
• Value of bottom up/topdown approach
• Arvid Skuttle 2002

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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)

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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

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

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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

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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

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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)

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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.

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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

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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

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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)

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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)

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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