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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 MisuseBipolar Affective DisorderSchizophreniaObsessive Compulsive Disorder (WHO 1996). In Established Mark
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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)
7. 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
11. 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
12. 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
15. 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
16. 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
17. Determinants of Resilience and Positive Mental Health Indicators
18. Determinants of Resilience and Positive Mental Health Indicators
19. 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
21. Prevention Programmes in Rural Areas Western Norway – Hordaland County Project
Value of bottom up/topdown approach
Arvid Skuttle 2002
22. 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)
23. 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
24. But are they so different in their requirements or is this another myth?
25. 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
26. 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
28. 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
29. 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)
30. 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.
31. 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
32. 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
33. 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)
34. 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)
35. 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