How does mental health status relate to accessibility and remoteness?

Mental illness contributed to almost 11% of the total world disease burden in 1990, and is predicted to reach 15% by 2020.1 In Australia, nearly one in five individuals suffer from a mental illness such as anxiety, depression or substance use, and almost half of these are affected long term.2,3 Young adults experience the highest prevalence of mental illness, and rates steadily decline with age. Young adult male suicide rates are particularly high in rural areas.4

When comparing the health of rural and urban Australians, there is a tendency to rely on longstanding stereotypes. Rural areas may be portrayed either as idyllic settings in which to escape the many stressors associated with urban living, or as places of isolation and disadvantage where inhabitants suffer from a lack of health services and hence experience poorer health.5 Rural and remote communities have been targeted as priority populations for increased mental health prevention and promotion initiatives.6 However, the perception of rural mental health disadvantage is difficult to confirm or refute because of limited published data on the extent of mental illness in regional Australia.3,7-9 Moreover, most research to support policy decisions is based on population estimates from large rural and urban units of geographical aggregation, a distinction that no longer adequately captures the growing diversity and complexity of rural and remote populations.10

The aim of this study was to determine if the prevalence of mental illness is associated with accessibility and remoteness in South Australia. This is important information for consumer advocacy, health policy and health service planning.

Of the 3989 eligible respondents, 2545 participated in the survey (response rate, 64%). The proportion of Aboriginal people included was one per cent. Residents from the highly accessible areas tended to be more highly educated and engaged in higher-status occupations and were more likely to be never married, born outside Australia, and employed (Box 1).

It is notable and encouraging that we obtained similar overall prevalence estimates using the three different outcome measures. The three instruments measure similar, but not identical, health states. This was the first South Australian survey to include the K10, which prevents direct comparisons with previous state data. However, the prevalence rate for psychological distress reported here is similar to rates reported in other state and national surveys.14,15,22

The prevalence rate for depression was similar to that obtained in an earlier South Australian population survey (11.8%), as were estimates of self-reported mental illness (11.9%).8 Rates of self-reported mental illness were lower in our sample than for Australia as a whole (17.7%); however, direct comparisons are not possible, as different survey tools were used and substance-use disorders are included in the national estimates.14 Similar methodological inconsistencies limit direct comparisons between our findings and those of international studies.23,24

Several limitations should be considered when interpreting our results. Residents who did not have a telephone connected, people in hospitals, nursing homes and other major institutions, and homeless people were not included in our sampling frame. Although individuals from some of these groups may have poorer mental health, it seems unlikely that exclusion would have varied across ARIA categories. Given the low representation of Aboriginal people in this survey, it is unlikely that Aboriginality had a strong influence on our results. The response rate of 64% is within the accepted range for surveys of this type.

To date, the evidence to support rural mental health policy in Australia has been based on crude population estimates using large rural and urban geographical aggregates that have produced inconsistent findings. National survey data found little difference in prevalence of mental illness between rural and urban areas in Australia, and others have found that prevalence estimates were lower in rural areas compared with elsewhere.3,8 In contrast, research conducted in local rural communities reveals higher rates of mental illness.7 A review of international prevalence studies reveals similar inconsistencies.5

The lack of evidence for significant differences in prevalence across ARIA categories does not mean that differences do not exist. Similar non-significant findings have been reported from self-reported health service utilisation research using the ARIA index, despite the fact that certain groups experience higher mortality and morbidity and would be expected to access services more frequently.25,26

After adjusting for age and sex, indicators of socioeconomic status were significantly higher in highly accessible areas, and yet recent research indicates that significant inequities in health outcomes exist between socioeconomically advantaged and disadvantaged groups in both rural and urban areas.27 This suggests that estimates averaged across ARIA regions may obscure local environmental, behavioural and socioeconomic factors that may be important determinants of mental illness.5,6 To describe the full range of factors that affect mental illness at a local level, more sensitive measures may be needed.

There is now good evidence to suggest that Australia’s non-metropolitan population has become more heterogeneous, and sociodemographic and socioeconomic patterns are increasingly mirroring those of large cities.10 We need to move beyond the broad distinction between “city” and “country”, and beyond the stereotype that “health status in the bush is worse than that in the city”. However, our findings are no cause for satisfaction or complacency. Levels of distress and illness are high — too high — across South Australia. More resources are needed to combat this. The response will need to differ depending on the realities of the particular location, building upon an integrated statewide policy and strategy.