Improving the mental health of rural New South Wales communities facing drought and other adversities

Objective: NSW has just experienced its worst drought in a century. As years passed with insufficient rain, drought‐related mental health problems became evident on farms. Our objective is to describe how, in response, the Rural Adversity Mental Health Program was introduced in 2007 to raise awareness of drought‐related mental health needs and help address these needs in rural and remote NSW. The program has since expanded to include other forms of rural adversity, including recent floods. Setting: Rural NSW. Design, participants, interventions: Designed around community development principles, health, local service networks and partner agencies collaborated to promote mental health, education and early intervention. Strategies included raising mental health literacy, organising community social events and disseminating drought‐related information. Priority areas were Aboriginal communities, older farmers, young people, women, primary health care and substance use. Results: Over 3000 people received mental health literacy training in the four years of operation from 2007 to 2010. Stakeholders collaborated to conduct hundreds of mental health‐related events attended by thousands of people. A free rural mental health support telephone line provided crisis help and referral to rural mental health‐related services. Conclusion: Drought affected mental health in rural NSW. A community development model was accepted and considered effective in helping communities build capacity and resilience in the face of chronic drought‐related hardship. Given the scale, complexity and significance of drought impacts and rural adjustment, and the threats posed by climate change, a long‐term approach to funding such programs would be appropriate.     

Partnerships to promote mental health of NSW farmers: the New South Wales Farmers Blueprint for Mental Health

Objective: To describe the process and outcome of development of a framework for planning and implementation of a range of interventions aimed at improving the mental health and wellbeing of farmers and farm families in New South Wales (NSW). Design: In response to a major drought in New South Wales (NSW), key agencies were invited to participate in a longer-term collaborative program aimed at improving the mental health and well-being of the people on NSW farms. These agencies became the NSW Farmers Mental Health Network. Setting: The Australian National Action Plan for Promotion, Prevention & Early Intervention for Mental Health 2000 proposed a population health approach base encompassing the range of risk and protective factors that determine mental health at the individual, family and community and society levels. It incorporated three traditional areas of health activity into programs aimed at achieving improved mental health for the Australian population – mental health promotion, prevention activities and early intervention. Although the farming population was not identified as a priority population, research has identified this population to be at high risk of suicide, and of having difficulty in coping with the range of pressures associated with life and work in this industry. Participants: Participants were agencies providing services across rural NSW in the fields of farmer and country women's organisations, financial counselling services, government departments of primary industries and health, mental health advisory and support services, charitable organisations and others. Results: The NSW Farmers Blueprint for Mental Health ( http://www.aghealth.org.au/blueprint ) was developed to be ‘a simplified summary of key issues that need to be addressed, and the major actions that we can be confident will be effective in achieving our purpose’. It has identified ‘steps’ along ‘pathways to breakdown’ from the range of known mental health and suicide risk factors that are relevant to the NSW farming population, and 23 areas of current and potential action that would contribute to improving mental health, as key steps along ‘pathways to health’. For each of the areas of action there is described the rationale and basis for action, and the lead agency or individual who has accepted responsibility for coordinating and reporting further activity to the Network. Conclusion: It is suggested that the NSW Farm Blueprint and the activities being implemented by the NSW Farmers Mental Health Network partners represent a model for implementation of a mental health promotion in identified at-risk Australian populations.     

Securing and retaining a mental health workforce in Far Western New South Wales

OBJECTIVE: To identify strategies local managers can use to optimise recruitment and retention of mental health staff in rural locations. DESIGN: Forty-one staff were interviewed about factors that attracted them to work in remote locations, their initial intentions and factors that encourage them to stay. SETTING: The former Far West Health Area of New South Wales. RESULTS: Overall job satisfaction was high (68%). Key attractors were rural lifestyle and environment. Family reasons, the field of work and the rural lifestyle were factors that keep staff in their positions. Some mentioned the desire to achieve professional goals and see projects completed. Many staff reported that their initial intentions to stay had remained the same (43.9%). Reasons for extended intention to stay were: greater career opportunities; a desire to complete professional goals; extension of positions; and personal factors. The most common reason for leaving was better career opportunities. Other reasons included: changes to personal commitments; heavy workloads or burnout; service management; and workplace politics. A large number of respondents mentioned key differences when comparing rural and metropolitan areas: more travel (greater distances); less service options for referral; greater spectrum of illnesses and conditions; more autonomy and responsibility. CONCLUSIONS: Strategies to recruit and retain staff must take account of personal needs and aspirations. While there is room for state strategies to improve employment incentives, there is also considerable scope for local managers to improve the design and attractiveness of jobs.     

Co-morbid drug and alcohol and mental health issues in a rural New South Wales Area Health Service

Objective: In 2003 the New South Wales (NSW) Centre for Rural and Remote Mental Health (CRRMH) conducted an analysis of co‐morbid drug and alcohol (D&A) and mental health issues for service providers and consumers in a rural NSW Area Health Service. This paper will discuss concerns raised by rural service providers and consumers regarding the care of people with co‐morbid D&A and mental health disorders. Design: Current literature on co‐morbidity was reviewed, and local area clinical data were examined to estimate the prevalence of D&A disorders within the mental health service. Focus groups were held with service providers and consumer support groups regarding strengths and gaps in service provision. Setting: A rural Area Health Service in NSW. Participants: Rural health and welfare service providers, consumers with co‐morbid D&A and mental health disorders. Results: Data for the rural area showed that 43% of inpatient and 20% of ambulatory mental health admissions had problem drinking or drug‐taking. Information gathered from the focus groups indicated a reasonable level of awareness of co‐morbidity, and change underway to better meet client needs; however, the results indicated a lack of formalised care coordination, unclear treatment pathways, and a lack of specialist care and resources. Discussion: Significant gaps in the provision of appropriate care for people with co‐morbid D&A and mental health disorders were identified. Allocation of service responsibly for these clients was unclear. It is recommended that D&A, mental health and primary care services collaborate to address the needs of clients so that a coordinated and systematic approach to co‐morbid care can be provided.     

Improving transfer of mental health care for rural and remote consumers in South Australia

In Australia, it is commonplace for tertiary mental health care to be provided in large regional centres or metropolitan cities. Rural and remote consumers must be transferred long distances, and this inevitably results in difficulties with the integration of their care between primary and tertiary settings. Because of the need to address these issues, and improve the transfer process, a research project was commissioned by a national government department to be conducted in South Australia. The aim of the project was to document the experiences of mental health consumers travelling from the country to the city for acute care and to make policy recommendations to improve transitions of care. Six purposively sampled case studies were conducted collecting data through semistructured interviews with consumers, country professional and occupational groups and tertiary providers. Data were analysed to produce themes for consumers, and country and tertiary mental healthcare providers. The study found that consumers saw transfer to the city for mental health care as beneficial in spite of the challenges of being transferred over long distances, while being very unwell, and of being separated from family and friends. Country care providers noted that the disjointed nature of the mental health system caused problems with key aspects of transfer of care including transport and information flow, and achieving integration between the primary and tertiary settings. Improving transfer of care involves overcoming the systemic barriers to integration and moving to a primary care-led model of care. The distance consultation and liaison model provided by the Rural and Remote Mental Health Services, the major tertiary provider of services for country consumers, uses a primary care-led approach and was highly regarded by research participants. Extending the use of this model to other primary mental healthcare providers and tertiary facilities will improve transfer of care.     

Improving access to and outcomes from mental health care in rural Australia

OBJECTIVE: Rural Australians face particular difficulties in accessing mental health care. This paper explores whether 51 rural Access to Allied Psychological Services projects, funded under the Better Outcomes in Mental Health Care program, are improving such access, and, if so, whether this is translating to positive consumer outcomes. DESIGN AND METHOD: The paper draws on three data sources (a survey of models of service delivery, a minimum dataset and three case studies) to examine the operation and achievements of these projects, and makes comparisons with their 57 urban equivalents as relevant. RESULTS: Proportionally, uptake of the projects in rural areas has been higher than in urban areas: more GPs and allied health professionals are involved, and more consumers have received care. There is also evidence that the models of service delivery used in these projects have specifically been designed to resolve issues particular to rural areas, such as difficulties recruiting and retaining providers. The projects are being delivered at no or low cost to consumers, and are achieving positive outcomes as assessed by standardised measures. CONCLUSION: The findings suggest that the rural projects have the potential to improve access to mental health care for rural residents with depression and anxiety, by enabling GPs to refer them to allied health professionals. The findings are discussed with reference to recent reforms to mental health care delivery in Australia.     

General practitioners' management of patients with mental health conditions: The views of general practitioners working in rural north‐western New South Wales

Objective: To identify the needs of the region's general practitioners concerning diagnosing, treating and referring patients with mental health disorders and major barriers to the general practitioners' management of these patients. Design: Cross‐sectional survey. Subjects: All general practitioners working in rural north‐western New South Wales. Measurements: Self‐assessed levels of confidence (5‐point Likert scale) in diagnosing and treating patients with a mental health condition. Practice data relating to presentation of such patients as well as issues affecting treatment and referral. Results: The three most commonly diagnosed and treated mental health conditions are depression, anxiety and dementia. General practitioners assessed themselves as being confident in diagnosing and treating these three mental health conditions and in diagnosing and treating adults and the elderly. The only form of treatment intervention that the general practitioners self‐assessed as being confident in relates to medication. Referrals to mental health specialists were due mostly to patients needing mental health counselling, the general practitioners seeking clarification of diagnosis as well as having insufficient skills to provide the best possible care. Barriers to being able to refer relate mainly to specialist services not being available and/or accessible as well as patients being reluctant to accept such a referral. Conclusion: Our results indicate that other than for depression, anxiety and dementia, efforts to improve the general practitioners' diagnostic and treatment skills and to diagnose and treat adolescents and children are warranted. Up‐skilling the general practitioners' ability to confidently use treatment options other than medication are worth considering.     

Partnering with communities to address the mental health needs of rural veterans

Purpose: Many veterans who face mental illness and live in rural areas never obtain the mental health care they need. To address these needs, it is important to reach out to community stakeholders who are likely to have frequent interactions with veterans, particularly those returning from Operations Enduring and Iraqi Freedom (OEF/OIF). Methods: Three community stakeholder groups—clergy, postsecondary educators, and criminal justice personnel—are of particular importance for OEF/OIF veterans living in rural areas and may be more likely to come into contact with rural veterans struggling with mental illness or substance abuse than the formal health care system. This article briefly describes the conceptualization, development, initial implementation, and early evaluation of a Veterans Affairs (VA) medical center‐based program designed to improve engagement in, and access to, mental health care for veterans returning to rural areas. Findings: One year since initial funding, 90 stakeholders have attended formal training workshops (criminal justice personnel = 36; educators = 31; clergy = 23). Two training formats (a 2‐hour workshop and an intensive 2.5‐day workshop) have been developed and provided to clergy in 1 rural county with another county scheduled for training. A veteran outreach initiative, which has received 32 referrals for various student services, has been established on 4 rural college campuses. A Veterans Treatment Court also has been established with 16 referrals for eligibility assessments. Conclusions: While this pilot program is in the early stages of evaluation, its success to date has encouraged program and VA clinical leadership to expand beyond the original sites.     

The Orange Declaration on rural and remote mental health

Rural mental health outcomes have been persistently poorer than those in larger cities suggesting that the prevailing investments to improve matters are not working. Mental health researchers and service providers from New South Wales, Victoria, Western Australia and the Australian Capital Territory met in Orange in October 2018 to explore issues pertaining to rural mental health and well‐being. The group recognised and acknowledged that rural residents experience a series of interconnected geographical, demographic, social, economic and environmental challenges which are not addressed adequately by the current mix of services. This declaration has been endorsed by those listed below and we welcome further support. We list ten interrelated problems and ten solutions. As a group, we take this declaration as an opportunity to invite discussion about how we can collectively improve the mental health of rural residents through research, service design and delivery. We invite the reader to consider endorsing this declaration. A short summary of supporting evidence is available online at https://www.crrmh.com.au/ .     

If the land's sick, we're sick:* the impact of prolonged drought on the social and emotional well-being of Aboriginal communities in rural New South Wales

Objective: To report Aboriginal communities' views of how prolonged drought in rural NSW has affected their social and emotional well‐being, and of possible adaptive strategies. Design: Content analysis of issues, priorities and adaptive strategies raised in semistructured community forums. Setting: Rural centres across NSW. Participants: Aboriginal people, service providers and other stakeholders. Voluntary participation by invitation with consent to record discussions. Results: Three themes (containing six issues) emerged: (i) impacts on culture (harm to traditional family structure, culture and place; bringing shame to culture); (ii) sociodemographic and economic impacts (skewing of the population profile; loss of livelihood and participation; aggravation of existing socioeconomic disadvantage); and (iii) loss. In addition to continuing well‐being programs that were already successful, proposed adaptive strategies were: capturing the spirit of Aboriginal knowledge and traditions; knowing your land; and Aboriginal arts. Conclusion: Prolonged drought presented substantial and unique adversity for rural NSW Aboriginal communities, compounding existing, underlying disadvantage. Drought‐induced degradation of and, sometimes, the necessity to leave traditional land drove people apart and disrupted Caring for Country activities. Some people reported despair at not being able to discharge cultural obligations. At the same time, the drought prompted increased love of and concern for land and a renewed enthusiasm for expressing connectedness to land through all forms of art. Modern Aboriginal and wider community well‐being programs helped frame a response to drought alongside traditional Aboriginal dreaming and cultural approaches to emotional health and well‐being.     

农村留守儿童急救知识和健康相关行为综合干预效果评价

目的评价以学校为基础的综合干预模式对农村留守儿童急救知识知晓率和健康相关行为形成率的效果,为提高农村留守儿童健康状况和生活质量提供参考依据。方法在四川省资阳市某乡镇随机抽取2所农村小学分别作为干预学校和对照学校,将2所小学2~5年级全部符合要求的203和121名留守儿童进行干预前和干预后问卷调查,评估干预效果。结果干预前干预学校和对照学校留守儿童5项急救知识知晓率和4项健康相关行为形成率差异均无统计学意义（P >0.05）;干预后干预学校留守儿童5项急救知识知晓率和5项健康相关行为形成率均高于干预前,差异均有统计学意义（P<0.05）;干预后干预学校留守儿童除溺水后急救知识外,烫伤、触电、猫狗咬伤、发生火灾后急救知识知晓率及坚持每天刷牙、打喷嚏遮掩口鼻的行为形成率分别为74.4%、92.6%、80.3%、98.0%及69.1%、69.1%,均高于对照学校留守儿童的64.5%、85.1%、45.5%、93.4%及55.4%、43.0%,差异均有统计学意义（P<0.05）。结论以学校为基础的综合干预模式对农村留守儿童正确掌握急救知识、形成良好的健康相关行为具有促进作用。     

Harnessing the social capital of rural communities for youth mental health: an asset-based community development framework

In Australia, we are facing a period of mental health reform with the establishment of federally funded community youth services in rural areas of the country. These new services have great potential to improve the mental health of rural adolescents. In the context of this new initiative, we have four main objectives with this article. First, we consider the notion of social capital in relation to mental health and reflect on the collective characteristics of rural communities. Second, we review lessons learned from two large community development projects targeting youth mental health. Third, we suggest ways in which the social capital of rural communities might be harnessed for the benefit of youth mental health by using asset-based community development strategies and fourth, we consider the role that rural clinicians might play in this process.     

Caring for depressed patients in rural communities: general practitioners' attitudes, needs and relationships with mental health services

OBJECTIVE: To examine the needs and practices of rural GPs and their relationships with local acute mental health services, particularly in the provision of care to depressed patients. DESIGN: Postal survey. SETTING: Rural general practices. SUBJECTS: Ninety-nine GPs (63 males, 36 females) from the Hunter Valley region of NSW, Australia. MAIN OUTCOME MEASURES: GPs' self-reported contact rates, confidence, needs and beliefs. RESULTS: Depression was the most commonly seen mental disorder, with an average of 1.44 patients per GP per month referred to local acute mental health services, most commonly for suicidality. The preferred form of feedback after the referral of a depressed patient was a follow-up letter, while the most requested type of patient management support was cognitive behavioural therapy (CBT) groups. GPs were most confident in recognising depression, compared to other mental disorders except anxiety, and they were most confident in treating depression, compared to all other mental disorders. The most common barrier to providing care for depressed patients was reported to be 'time constraints' on GPs. CONCLUSIONS: The challenge for mental health services is to develop ways to collaborate more effectively with GPs in the provision of psychological services for depressed patients in rural communities.     

How definition of mental health problems can influence help seeking in rural and remote communities

ABSTRACT: The present study sought to understand the rural and remote influences on people's identification of, and response to, mental health problems. Twenty-two key informants living in northern and western South Australia were interviewed. They included mental health and generalist health professionals, other human service workers and mental health consumers. Three themes are reported here: reluctance to acknowledge mental health problems and the avoidance of appropriate help; stigma and the avoidance of mental health services; and the influence of rural and remote circumstances. Most informants considered that many mental health problems were amenable to help from generalist workers, with backup support from mental health specialists. Informants thought this intervention to be appropriate because a common view of mental health problems as 'insanity' and a culture of self-reliance created a reluctance to seek help from a mental health specialist. These themes need to be taken into account when designing mental health interventions for rural and remote communities.     

Changes in depression‐related mental health literacy in young men from rural and urban South Australia

Objective: To examine rural and urban differences in depression‐related mental health literacy, experience of depression and help‐seeking. Design: Cross‐sectional population‐based survey stratified by rural and urban area. Setting: A random and representative sample of South Australian rural and urban young men aged between 15 and 30 years. Outcome measures: Mental health literacy as determined by recognition and exposure to classical symptoms of depression; perceived helpfulness of various interventions and treatment‐seeking behaviour. Results: Recognition of depression increased significantly in rural and urban young men between 1998 and 2008. More rural young men than urban men identified symptoms of depression in 1998 (odds ratio (OR): 1.53, 95% confidence interval (CI), 1.01–2.40, P < 0.05), but that was not evident in 2008 (OR: 1.32, 95% CI, 0.80–2.25, P = 0.30). Both groups were more likely to have a close friend experience symptoms of depression and to use antidepressant medications in 2008 compared with 1998. Rural young men experienced a significant increase in recognition of personal depressive symptoms (OR: 3.73, 95% CI, 1.72–8.40) and levels of confidence in psychiatrists and psychologists (OR: 2.40, 95% CI, 1.34–4.31) in 2008 compared with 1998. Both rural and urban young men were significantly less likely to rate dealing with problems on their own as helpful in 2008 as in 1998. Conclusions: There has been an increase in both rural and urban young male mental health literacy between 1998 and 2008, especially in rural young men. Whether this will translate into a reduction of depression and associated suicide, with a reversal of the rural/urban suicide differential, remains to be seen.     

Helping and hindering: perceptions of enablers and barriers to collaboration within a rural South Australian mental health network

Objective: To evaluate clinicians’ perceptions of what helps and hinders the delivery of mental health care across a service network in a rural setting. Design: Qualitative, semistructured interviews were conducted with 10 individuals who work in one rural mental health care service network. Setting: A regional centre in rural South Australia involving representatives of the mental health team, general practice, hospital, community health and nongovernment organisations. Results: Clinicians’ perceptions of barriers and enablers to working within their mental health care network were explored. Participants showed a strong shared commitment to effective mental health care delivery and a good understanding of the services that each offers. Interview data suggested that working relationships between local services could be perceived as stronger when a personal or historical element is recognisable. Similarly, the notion of familiarity and community involvement were perceived as facilitators in this network. A perceived barrier for participants was the failure to attract staff with mental health experience, leading to dependence upon the dedication and commitment of existing service providers. Conclusions: Collaboration is especially necessary in rural areas, where access to health care services is known to be difficult. The informality of relationships between service providers was shown to be the main facilitator in the network. This is both a strength as it promotes the communication between services and service providers that is essential for successful collaboration, yet is also a threat to the sustainability of the network based on the difficulties of staff recruitment and retention to rural settings.     

The mental health of rural Australians: developing a framework for strategic research

ABSTRACT: This paper argues that lack of adequate research is a barrier to the long-term improvement of the mental health and well-being of rural Australians. Following from national mental health policy, potential research avenues in four broad domains (prevention and early intervention, pathways to care, outcome of illness and aetiology) are defined. These four broad domains are interdependent and research into them can be brought together into a simple framework or model. This model could be used to guide research into rurality and mental health. The proposed model uses the inclusive concept of place to capture the potential complexities of the rural locale as a variable in mental health and disorder. The model's predictor variables include both risk and resilience factors, and the outcome variables extend beyond morbidity to positive psychological wellness. It is proposed that this provisional model, and the strategic research that it directs, will act as a useful counterpoint to the more immediate evaluation and resourcing needs that confront rural mental health.