Determinants of mental health and well‐being in rural communities: Do we understand enough to influence planning and policy?

This issue presents some initial results from the Australian Rural Mental Health Study (ARMHS).1,2 ARMHS will serially measure of a range of mental health determinants including physical health, individual characteristics and family and community cohesion and distress in a large cohort over five years. In addition where a participant shows significant distress a structured diagnostic interview (CIDI) will be used to assess clinical severity and anticipate recommendations about service needs. The sampling method has particular emphasis on people living in remote and very remote areas. It complements the 2007 National Survey of Mental Health and Wellbeing (NSMHWB)3 that made no specific reference to rural differences but used a similar cross-sectional methodology with no follow up. Information obtained should inform policy direction as well as increase our understanding of high prevalence disorders in rural and remote places. How much do we know now? Are all of the mental health problems faced by people in rural Australian the same? Of course not and nobody would expect them to be. Rural Australia is not homogenous.4 However research findings have not always been consistent with this.5 Studies based on rural–urban comparisons and lumping all 'rural' together have been inconclusive. One suggestion has been that the fine graining of rural experience has been insufficiently defined. The ARMHS uses four categories of rurality derived from the geographical classification of ARIA+ to compare groups. This is sensible and it will be interesting to see if this approach, along with detailed information about families, communities and the services they use, captures the changing nature of rural communities over time. Will it for example differentiate the influx of 'sea-changers' and 'tree-changers' versus the migration of welfare recipients in search of cheap housing or define agricultural community versus mining community or even the 'non-community' of fly-in/ fly-out workers? Kelly et al.2 found different levels of psychological distress with significantly lower mean K-10 scores for inner regional and very remote categories. This suggests differences in experiences in different places. The progression of these issues over time especially in relation to community and service involvement will be the most useful findings to inform policy. Almost everything that works in the city has not been evaluated in the country with a few notable exceptions. The findings of Fragar et al.1 that the rural unemployed and those unable to work have greater levels of psychological distress than farmers might not be surprising. However combined with recent policy directions in shifting specific drought-related funding aimed at the mental health of farmers towards broader mental health support programs for all those affected by climate change in rural areas it will offer direction without discarding the lessons learned about specific targeting of help where it is needed. Many people report problems in accessing mental health care such as varying quality, poorly coordinated services and lack of connection to outside agencies such as housing.6 These are often exaggerated in rural and remote areas. It is good to see the strong involvement of Area Health services in this study as it could help with service redesign but what is the best way to go? There remains wide variation in mental health service provision and practices across rural Australia. The best models for service delivery in rural and remote areas are not always clear7 and often determined more by opportunity than forward planning based on evidence. For rural people, engagement with mental health services depends upon the usual help seeking factors – need and gender.8 For those in contact with health services, variations in outcomes might be also explained by differences in practice as well as availability of service or personal or community factors. In the USA, The Dartmouth Atlas of Health Care has shown that reduction in morbidity and mortality is not necessarily related to money spent or access to healthcare but the quality and application of evidence.9 Although these methodologies of rating qualities of outcome and under or over servicing in relation to best practice have not yet been applied to mental health settings, it is important that future research into rural and remote mental health outcomes considers the type and effectiveness as well as simple utilisation of services. Many rural communities are inundated with poorly coordinated services from multiple sources, which might not correctly respond to identified need. In rural communities quality interventions will also include informal networks and social capital. It will be important to consider these factors by including community leaders and service providers in research teams. Researchers will need the capacity and the flexibility to alter their questions or indeed their comparison groupings according to local conditions. The major impediments to improving mental health services in rural and remote areas are the maldistribution of resources, access to appropriate and timely services, burnout and training of health workers and the financial cost of dealing with crisis over prevention. Already some change is occurring in rural New South Wales through new methods of emergency assessment involving telemedicine, primary carers and telephone access lines that are decreasing the stress of emergency responses. This is currently being evaluated. However a better understanding of the determinants of mental health and well-being in rural and remote areas is very important in developing policy to make all the necessary changes. There might not be a whole lot of new money and we will need to concentrate on quality and evidence. We cannot afford to waste time and money on ill-informed models. The opportunities for improved individual, family and community capacities that arise from studies such as the ARMHS could be invaluable.