Service utilisation by rural residents with mental

PSYCHIATRIC SERVICES

Service utilisation by rural residents with mental health problems Fiona Judd, Henry Jackson, Angela Komiti, Greg Murray and Caitlin Fraser

Objective: To examine the level and type of service utilisation by rural residents for mental health problems, and to explore the influence of level of need, sociodemographic factors and town size on such service use. Method: This was a cross-sectional, community-based study. Subjects were recruited from three locales in rural north-west Victoria: a large regional centre, towns of 5,000 ! 20,000 population and towns of B/5,000 population. Three hundred and ninety-one individuals (54% females) participated. A logistic regression analysis was used to investigate which factors (i.e. need, sociodemographic and town size) predicted lifetime help-seeking for emotional or mental problems from formal health providers in the study sample. Results: Factors that predicted having ever sought help from a formal health provider for emotional or mental health problems were: a lifetime and/or current psychiatric disorder, being female, being separated, divorced or widowed, and living in medium sized towns (population 5,000 ! 20,000). Conclusions: While traditionally known predictors of help-seeking, i.e need and gender, were associated with help seeking in this study, help seeking for mental health problems was also more common amongst individuals living in medium sized rural towns than those living in a large regional city. Possible explanations include availability, accessibility and organisation of services, and individual and/or community attitudes towards help seeking. Key words: general practitioner, mental disorder, mental health professional, rural, service utilization.

Fiona Judd Professor of Rural Mental Health, Centre for Rural Mental Health, Monash University, School of Psychiatry, Psychology and Psychological Medicine and Bendigo Health Care Group, Bendigo, Vic., Australia.

Angela Komiti Research Assistant, Centre for Rural Mental Health, Monash University, School of Psychiatry, Psychology and Psychological Medicine and Bendigo Health Care Group, Bendigo, Vic., Australia. Greg Murray Lecturer, School of Social and Behavioural Science, Swinburne University of Technology, Vic., Australia. Caitlin Fraser Research Assistant, Centre for Rural Mental Health, Monash University, School of Psychiatry, Psychology and Psychological Medicine and Bendigo Health Care Group, Bendigo, Vic., Australia. Correspondence: Professor Fiona Judd, Centre for Rural Health, Bendigo Health Care Group, PO Box 126, Bendigo, Vic. 3552, Australia. Email: [email protected]

There are a variety of reasons for examining service utilisation for mental health problems amongst rural residents. The general health of rural residents is poor compared to those who live in urban areas.6 Reasons suggested for this include high levels of health damaging behaviours,6 poor availability and/or acceptability of services,7,8and a stoic attitude which discourages help seeking.9 All of these may also influence mental health. Further, rural residents are identified as an ‘at risk’ population for mental health problems.10 Suicide is a particular problem amongst rural residents. Notably, high rates have been reported in young males in small rural communities,11,12 and among farmers and farm managers.13 In addition, in smaller sized locales there are fewer providers, and services are delivered in a different fashion to that in larger centres. There are fewer GPs per head

doi: 10.1080/10398560601123724 # 2007 The Royal Australian and New Zealand College of Psychiatrists

Australasian Psychiatry . Vol 15, No 3 . June 2007

Henry Jackson Professor of Psychology, Department of Psychology, University of Melbourne, Parkville, Vic., Australia.

T

he Australian National Survey of Mental Health and Wellbeing (NSMHWB)1 found that about one in five Australian adults met DSM-IV2 criteria for one or more mental disorders in the preceding year. Of concern, only 38% of those with a disorder were seen by health services.3 Most who sought help consulted their general practitioner (GP). Other national surveys have also found high levels of unmet need.4,5

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of population14 and fewer specialist mental health professionals, such as psychiatrists and clinical psychologists.6 In these smaller locales, services are increasingly provided by outreach teams rather than on site facilities.15 Differences in service utilisation by persons with mental health problems by geographic location have been identified. In Australia, the NSMHWB compared prevalence data for urban, rural centres (population size 10,000 ! 100,000) and other rural areas (population size B/10,000) but found no differences for the high prevalence disorders.1 However, overall rates of service utilisation by individuals with a single ICD-10 disorder were different for the three locales, with lowest rates found in ‘other rural’ (population size B/10,000) areas (G. Andrews, personal communication).


More detailed examination of these differences in service utilisation by those participating in the NSMHWB reveals two key findings. First, there was lower use of specialist but not general practitioner services in those living in remote areas (defined as population B/10,000).12 Second, in non-metropolitan areas (population 5/100,000), of those who met criteria for a mental disorder, a smaller proportion accessed professional help than in metropolitan areas.8 The difference was most marked for males aged 18 ! 29 years (25.2% v 11.4%, p B/0.05). Unfortunately, the small number of participants from rural and remote areas did not allow analysis beyond the broad category of ‘non-metropolitan’.

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A second way of examining service utilization for mental health problems has been to study general practitioner service use for mental disorders. Given the lack of specialist providers in rural areas,6 this is of particular interest when examining help-seeking in rural residents. Using data from three sources (the Bettering the Evaluation and Care of Health (BEACH) program data, Medicare data and the Pharmaceutical Benefits Scheme data), Caldwell and colleagues8 found the rate of psychological problems managed by GPs per 1000 population was far less for residents of large rural (population 25,000 ! 99,999), small rural (population 10,000 ! 24,999), other rural (population B/10,000) and remote areas than capital cities. GPs managed less depression problems per 1000 population amongst residents of other rural and remote areas (i.e. rural areas of population B/10,000), and less anxiety problems amongst all rural and remote compared to metropolitan residents. Understanding the extent to which need is met or not, and by whom, is important, particularly if it varies according to location of residence. In rural areas, service availability and accessibility is one obvious factor which may influence help-seeking However, there are a range of other variables which may influence service utilisation. Demographic factors shown to be important include age,16,17 gender,16 ! 18 socioeconomic status19 ! 22 and education.21,23 Whilst

intra-regional variation exists, rural residents are on average of lower socio-economic status, older and experience higher rates of unemployment compared with urban residents.24 In addition, there may be particular issues in smaller towns that influence which type of service is used. Mental health professionals in smaller rural communities are often identified rather than an ‘anonymous’ mental health worker, well known through their other roles in the community, and the effectiveness of their work is more likely to be ‘public knowledge’. Factors shown to predict intention to seek help from a mental health professional include the belief that people would actually be helped by a mental health professional, the belief that they would experience acceptance, understanding and confidentiality, and positive attitudes towards mental health professionals themselves.7 This familiarity may thus affect willingness to seek help. The available data provide a broad overview of service utilisation by rural residents with mental health problems. However, the categories of ‘non-metropolitan’ and ‘other rural’ include a diverse range of towns. In this study, we examined service utilisation by residents of a large regional centre, towns of 5,000 ! 20,000 population, and towns of B/5,000 population. These categories were chosen as services tend to be provided in a different manner in each locale. For example, in towns of B/5,000 population, there are usually only a small number of GPs, one (if any) on site Community Health Service and outreach rather than an on site Mental Health Service. In towns of 5 ! 20,000 population, there are likely to be several GPs, and on site Community Health and Mental Health Services. The aims of the study were to investigate: [1] the level and type of service utilisation for mental health problems by rural residents; and [2] the influence of sociodemographic factors, town size and level of need on help seeking from formal health providers for mental health problems amongst residents of rural communities.

METHOD Procedure The study was conducted in rural Victoria in 2003 ! 2004. The study sample was drawn from a larger sample of adults (n "/7,615) recruited randomly from the electoral roll who participated in an earlier survey.25 Subjects in the original study who indicated their willingness to be involved in future research and who lived in the rural locales of interest (a large regional centre; towns of 5,000 ! 20,000 population; towns of B/5,000 population) were contacted by phone and invited to participate in a face-to-face interview. Interviews were conducted by trained research assistants at local Community Health and Community Mental Health Centres. Analyses conducted here

were based on data drawn from these interviews, collated with data from participants’ original survey responses.

had 12 years or less of formal education, three-quarters were married or in a de facto relationship, and 56% were in some form of paid employment.

Subjects

Diagnosis of mental disorder

One thousand and twenty-three individuals were invited to participate (279 from a large regional centre; 327 from towns with pop. 5,000 ! 20,000; 417 from towns with pop. B/5,000).

Thirty-four percent met criteria for a current or lifetime SCID-IV diagnosis of anxiety, affective or substance use disorder. Ninety-seven individuals had one diagnosis only. Thirty-seven had a comorbid diagnosis.

Assessment

Level and predictors of help-seeking from a formal provider for problems with emotions or mental health

Sociodemographic details collected in the earlier survey included age, sex, marital status, household gross income, level of education attained and employment status. Detailed information on the mental health of each participant in this study was obtained at interview using the Structured Clinical Interview for DSM-IV (SCID-IV).26 Mood, anxiety and substance use disorders were assessed according to DSM-IV criteria. For the purposes of this paper, mental disorder refers to a SCID diagnosis (current and/or lifetime). Information regarding help-seeking was obtained using a modified version of the Use of Mental Health Services Questionnaire from the World Mental Health Survey.27 The questionnaire was used to collect information about whether respondents had ever sought help for emotional or mental health problems, from formal health providers. Formal health providers included GPs and/or mental health professionals (psychiatrist, psychologist, psychotherapist, social worker, counsellor). Statistical analysis

RESULTS Sample characteristics Three hundred and ninety-one individuals (54% females; mean9/SD age 54.49/15.0 years) completed the assessment, an overall response rate of 38%. The response rates from the three locales of interest were similar: large regional centre ! 35%, town size population 5,000 ! 20,000 ! 41%, towns of population less than 5,000 ! 38%. Of the total study sample, a third

Consultation rates with at least one of any of the formal health providers was highest among those with any mental disorder, particularly those with comorbid diagnosis (81.1%), and lowest for those who did not have any mental disorder (34.2%). A bivariate logistic regression was performed to assess the influence of various factors in having sought help from a formal health provider at any time. The criterion variable was having ever consulted a formal health provider for problems with emotions or mental health. Predictor variables were entered in a hierarchical order. Socio-demographic factors (age, gender, education level, marital status, gross household income and employment status) were entered in the first block. Need variable (presence or absence of SCID diagnosis) was entered in the second block and town size ( !/20,000, 5,000 ! 20,000, B/5,000) was entered in the third and final block. Multivariate results When controlling for the effects of all other variables in the model, the factors that independently predicted lifetime help-seeking from formal health providers were: being female, having a mental disorder (SCID diagnosis of anxiety, affective or substance use disorder), and being a resident of a town with a population of 5,000 ! 20,000 inhabitants. The results of the multivariate regression analyses are presented in Table 1. Females were twice as likely as males to have sought help for emotional or mental health problems. Similarly, having been previously married (i.e. divorced/separated or widowed) was associated with a two-fold increase in the likelihood of having sought help, compared to the people who were married. Interestingly, compared to having an annual income of $55,918 or more, all other categories of income were negatively associated with likelihood of seeking help but being in the $33,336 ! $55,918 category reduced the likelihood of having sought help by more than


A logistic regression analysis was used to investigate which factors predicted lifetime help-seeking from formal providers. The predictors were socio-demographic factors (gender, age, education level, gross household income, employment status, marital status), need level (any SCID diagnosis) and geographic location (town size). Multivariate odds ratio (OR) estimates and estimated (95%) confidence intervals (CI) as well as the relevant Wald x2 estimates are provided for these variables. Data analysis was conducted using SPSS (version 12.01) software.

A total of 181 individuals (46.3%) reported they had sought help for emotional or mental health problems from at least one of the formal providers at some point in their lives. Only 15.3% reported consulting any formal provider in the previous 12 months.

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Table 1: Predictors of help-seeking for the total sample (N !/391) in the multivariate regression Predictors

Age 18 !34 35 !44 45 !54 55 !64 65#/ Gender Male Female Education 13#/ yrs 0 !12 yrs

.00 .02 1.9 1.7

1.0 (reference) .99 (.37 !2.6) 1.1 (.42 !2.7) .51 (.20 !1.3) .51 (.18 !1.4)

7.2**

1.0 (reference) 2.0 (1.2 !3.3)

.00

1.0 (reference) 1.0 (.61 !1.7)

4.2* 0.1

2.2 (1.0 !4.6) .97 (.38 !2.5)

Gross household income (per year) $0 !$17,719 $17,720 !$33,335 $33,336 !$55,918 $55,918 or more

.21 1.4 7.7**

.81 (.34 !2.0) .65 (.32 !1.3) .36 (.18 !.74) 1.0 (reference)

.24

1.0 (reference) 1.2 (.63 !2.1)

Has a SCID diagnosis No Yes Australasian Psychiatry . Vol 15, No 3 . June 2007

Exp(B) (95% CI)

Marital status Married or living with someone Previously married Single/never married

Employment status employed unemployed

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Wald x2

Town size !/20,000 5,000 !20,000 B/5,000

1.0 (reference)

1.0 (reference) 32.4*** 4.8 (2.8 !8.2)

6.0* 1.0

1.0 (reference) 2.2 (1.2 !4.1) 1.4 (.74 !2.5)

*p B/ .05; ** p B/ .01; *** p B/ .001

half. Compared to participants from a large regional centre (population !/20,000), participants from town size of 5,000 ! 20,000 were twice as likely to have sought help. The greatest significant predictor of having sought help, however, was illness level, with

those having a lifetime SCID diagnosis being close to five times more likely to have sought help compared to those who did not have a diagnosis.

DISCUSSION Forty-six percent of this sample of residents of rural north-west Victoria had sought help for problems with emotions or mental health problems from at least one formal health provider at some point in their lifetime. One in three (34.3%) had suffered from a mood, anxiety or substance use disorder at any point in their lives. One in six (13.8%) met criteria for a mental disorder in the month preceding the interview. Level and type of service utilisation More than two-thirds (69.4%) of those who had suffered a lifetime mood, anxiety or substance use disorder had sought help for their problems from at least one formal health provider. Individuals who had more than one diagnosis were three times more likely to have sought help for their problems. Among the individuals who met criteria for a current disorder, only 37% had sought help in the previous 12 months. This latter figure is consistent with the national rate of 38% found in the NSMHWB. Consistent with data from the NSMHWB, individuals who had suffered from a mental disorder were more likely to have sought help from a combination of health professionals rather than from a single provider. Socio-demographic variations in help-seeking Women with a current or lifetime mental disorder were five times more likely to have sought help than males with such disorders. This is consistent with findings from other studies.16 ! 18 No relationship was demonstrated between age and service utilisation. However, of note we had only a small number of individuals in the group aged 18 ! 34 years who have previously been identified as less likely to use services.28 Previous studies have also identified that the elderly are less likely to seek help.16,17 Our sample included significant numbers of older persons but we found no relationship between service use and increasing age. While socioeconomic variables did not predict help-seeking, help-seeking tended to be less common in those in the middle income bracket than those with a higher level of income. This mixed finding is consistent with previous studies which have produced inconsistent findings.16,20 Unlike previous studies, we did not find an association between higher education level and service utilisation.21,23 Geographical setting and help-seeking Individuals from towns with a population size of 5,000 ! 20,000 were significantly more likely to have sought help compared to those from a large regional

centre. These results are of interest as they highlight the heterogeneity of rural locales. A variety of factors may explain this finding.

include variable availability, accessibility and organisation of services, individual attitudes towards helpseeking and/or community attitudes.

First, the above finding may relate to availability and accessibility of health service providers. Towns of 5,000 ! 20,000 typically have several resident GPs, multidisciplinary community health services, resident community mental health teams and visiting specialist providers. These services are ‘visible’ and accessible, and may be provided by persons who are known and respected in the community.7 Perhaps in larger centres, where mental health services resemble those of urban areas, services and providers are less visible and pathways to care are less well understood. Thus, living in a medium sized town may confer benefits not enjoyed by residents of larger locales.

These findings emphasise the need to acknowledge the heterogeneity of rural Australia and raise questions about service delivery and service utilisation in rural areas. Further studies, which enable examination of factors such as these in various size and type of rural locations, are required.

Alternatively, the finding may reflect something about communities of 5,000 ! 20,000 size. Perhaps in these communities, greater emphasis on community development and social inclusion results in social networks which enable help-seeking. Individuals with social networks including a range of weak tie partners, such as acquaintances, friends and work colleagues, have access to a broad range of information including health information and practice, with a better chance of accessing services.29 Study limitations

CONCLUSIONS The level of help-seeking by individuals with a current diagnosis of an affective, anxiety or substance use disorder living in rural Victoria was similar to that found in the Australian NSMHWB. Individuals living in medium sized rural towns reported greater service utilisation than those living in a large regional centre. Possible explanations

REFERENCES 1. Andrews G, Henderson S, Hall W. Prevalence, comorbidity, disability and service utilisation. Overview of the Australian National Mental Health Survey. [erratum appears in Br J Psychiatry 2001 Dec;179:561 ! 2.]. British Journal of Psychiatry 2001; 178: 145 ! 153. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Disorders, 4th Edition. Washington: American Psychiatric Association, 1994. 3. Australian Bureau of Statistics. Mental Health and Wellbeing: Profile of Adults, Australia, 1997 Canberra: Australian Government Publishing Service., 1998. 4. Kessler RC, Berglund PA, Bruce ML, Koch JR, Laska EM, Leaf PJ, Manderscheid RW, Rosenheck RA, Walters EE, Wang PS. The prevalence and correlates of untreated serious mental illness. Health Services Research 2001; 36: 987 ! 1007. 5. American Psychiatric Association. Diagnostic and Statistical Manual of Disorders, 3rd revised edition. Washington: American Psychiatric Association, 1989. 6. Australian Institute of Health and Welfare. Health in rural and remote Australia. CAT No. PHE6 Canberra: Australian Government Publishing, 1998. 7. Bayer JK, Peay MY. Predicting intentions to seek help from professional mental health services. Australian & New Zealand Journal of Psychiatry 1997; 31: 504 ! 513. 8. Caldwell TM, Jorm AF, Knox S, Braddock D, Dear KB, Britt H. General practice encounters for psychological problems in rural, remote and metropolitan areas in Australia. Australian & New Zealand Journal of Psychiatry 2004; 38: 774 ! 780. 9. Fuller J, Edwards J, Procter N, Moss J. How definition of mental health problems can influence help seeking in rural and remote communities. Australian Journal of Rural Health 2000; 8: 148 ! 153. 10. Commonwealth Department of Health and Aged Care. Mental Health Promotion, Prevention and Early Intervention Mental Health Plan. Canberra: Commonwealth Department of Health and Aged Care, 2000. 11. Dudley M, Waters B, Kelk N, Howard J. Youth suicide in New South Wales: UrbanRural trends. The Medical Journal of Australia 1992; 156: 83 ! 88. 12. Dudley M, Kelk N, Florio T, Howard J, Waters B, Haski C, Alcock M. Suicide among young rural Australians 1964 ! 1993: A comparison with metropolitan trends. Soc Psychiatr Epidemiol 1997; 32: 251 ! 260. 13. Page A, Fragar L. Suicide in Australian farming 1988 ! 1997. Australian & New Zealand Journal of Psychiatry 2002; 36: 81 ! 85. 14. Australian Medical Workforce Advisory Committee. The general practice workforce in Australia Sydney:AMWAC Report 2000.2, 2000. 15. Judd F K, Jackson H, Komiti A, Murray G, Hodgins G, Fraser C. High prevalence disorders in urban and rural communities. Australian & New Zealand Journal of Psychiatry 2002; 36: 104 ! 113. 16. Parslow RA, Jorm AF. Who uses mental health services in Australia? An analysis of data from the National Survey of Mental Health and Wellbeing. Australian & New Zealand Journal of Psychiatry 2000; 34: 997 ! 1008.


The limitations of this study must be acknowledged. First, the cross-sectional design of the study precludes any causal inferences that can be made about help-seeking behaviour. Second, this was not an epidemiological study. The sample studied here are a sub-group of those who responded to an earlier survey of mental health and wellbeing of rural residents in rural Victoria and New South Wales. These factors combined with the relatively low response rate of 38% mean that limited generalisations can be made from this sample to the greater rural community. Third, the respondents were asked about lifetime help-seeking behaviour. This type of retrospective reporting has inherent potential difficulties, such as inaccurate recall and memory problems. However, the help-seeking questionnaire was completed before the SCID interview took place and it is therefore unlikely that recall of psychological problems would have primed recalled (accurate or otherwise) instances of help-seeking.

ACKNOWLEDGEMENTS This study was in part supported by a grant from beyondblue The National Depression Initiative.

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17. Shapiro S, Skinner EA, Kessler LG, Von Korff M, German PS, Tischler GL, Leaf PJ, Benham L, Cottler L, Regier DA. Utilization of health and mental health services. Three Epidemiologic Catchment Area sites. Archives of General Psychiatry 1984; 41: 971 ! 978. 18. Lin E, Goering P, Offord DR, Campbell D, Boyle MH. The use of mental health services in Ontario: epidemiologic findings. [see comment]. Canadian Journal of PsychiatryRevue Canadienne de Psychiatrie 1996; 41: 572 ! 577. 19. Leaf PJ, Bruce ML, Tischler GL, Holzer CE, III. The relationship between demographic factors and attitudes toward mental health services. Journal of Community Psychology 1987; 15: 275 ! 284. 20. Meadows G, Singh B, Burgess P, Bobevski I. Psychiatry and the need for mental health care in Australia: findings from the National Survey of Mental Health and Wellbeing. Australian and New Zealand journal of Psychiatry 2002; 36: 210 ! 216. 21. Veroff JB. The dynamics of help-seeking in men and women: a national survey study. Psychiatry 1981; 44: 189 ! 200. 22. Wells KB, Manning W, Jr., Benjamin B. A comparison of the effects of sociodemographic factors and health status on use of outpatient mental health services in HMO and fee-for-service plans. Medical Care 1986; 24: 949 ! 960.


23. Greenley JR. Social factors, mental illness, and psychiatric care: recent advances from a sociological perspective. [Review] [96 refs]. Hospital & Community Psychiatry 1984; 35: 813 ! 820.

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24. Wainer J, Chesters J. Rural mental health: neither romanticism nor despair. Australian Journal of Rural Health 2000; 8: 141 ! 147. 25. Murray G, Judd F, Jackson H, Fraser C, Komiti A, Hodgins G, Pattison P, Humphreys J, Robins G. Rurality and mental health: the role of accessibility. Australian & New Zealand Journal of Psychiatry 2004; 38: 629 ! 634. 26. First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSMIV Axis I Disorders-Clinician Version (SCID-CV). Washington,DC: American Psychiatric Press, 1997. 27. Alonso J, Angermeyer MC, Bernert S, Bruffaerts R, Brugha TS, Bryson H, Girolamo G, Graaf R, Demyttenaere K, Gasquet I, Haro JM, Katz SJ, Kessler RC, Kovess V, Lepine JP, Ormel J, Polidori G, Russo LJ, Vilagut G, Almansa J, Arbabzadeh-Bouchez S, Autonell J, Bernal M, Buist-Bouwman MA, Codony M, Domingo-Salvany A, Ferrer M, Joo SS, Martinez-Alonso M, Matschinger H, Mazzi F, Morgan Z, Morosini P, Palacin C, Romera B, Taub N, Vollebergh WA, Investigators ESotEoMDEP. Use of mental health services in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatrica Scandinavica, Supplementum 2004; 47 ! 54. 28. Caldwell TM, Jorm AF, Dear KB. Suicide and mental health in rural, remote and metropolitan areas in Australia. Medical Journal of Australia 2004; 181: S10 ! S14. 29. Rogler LH, Cortes DE. Help-seeking pathways: a unifying concept in mental health care. American Journal of Psychiatry 1993; 150: 554 ! 561.