Psychological distress of rural parents: Family influence and the role of isolation

Objective: Research regarding psychological distress has often underestimated the importance of contextual social factors. This research aims to investigate patterns of psychological distress within the family system (parent dyads) across rural and remote communities and the influence of remoteness on such distress. Design: Self‐report survey data from the Australian Rural Mental Health Study was used to examine the distress levels of cohabitating parental figures in rural and remote Australia. Setting: The survey was conducted across rural and remote communities within New South Wales. Participants: The sample consisted of 129 adult couples (mean age = 42.66 years, SD = 8.11), 43 from Inner Regional areas, 48 from Outer Regional areas, 24 from Remote areas and 14 from Very Remote areas. Main outcome measure: Distress levels (Kessler‐10). Results: A significant association was detected between the levels of psychological distress among parents within a household. The strength of this relationship increased with increasing remoteness of residence. Conclusions: Identifying the influence of spousal factors on mental health in rural and remote areas allows health services in such regions to be aware of the needs of rural couples and families. These results support the need to consider partner/spouse mental health in clinical assessment and support the importance of household factors especially in remote communities.     

Psychological distress is associated with a range of high‐priority health conditions affecting working Australians

Background: Psychological distress is growing in prevalence in Australia. Comorbid psychological distress and/or depressive symptoms are often associated with poorer health, higher healthcare utilisation and decreased adherence to medical treatments. Methods: The Australian Work Outcomes Research Cost‐benefit (WORC) study cross‐sectional screening dataset was used to explore the association between psychological distress and a range of health conditions in a sample of approximately 78,000 working Australians. The study uses the World Health Organization Health and Productivity Questionnaire (HPQ), to identify self‐reported health status. Within the HPQ is the Kessler 6 (K6), a six‐item scale of psychological distress which strongly discriminates between those with and without a mental disorder. Potential confounders of age, sex, marital status, number of children, education level and annual income were included in multivariate logistic regression models. Results: Psychological distress was significantly associated with all investigated health conditions in both crude and adjusted estimates. The conditions with the strongest adjusted association were, in order from highest: drug and alcohol problems, fatigue, migraine, CVD, COPD, injury and obesity. Conclusions: Psychological distress is strongly associated with all 14 health conditions or risk factors investigated in this study. Comorbid psychological distress is a growing public health issue affecting Australian workers.     

Improving mental health capacity in rural communities: mental health first aid delivery in drought-affected rural New South Wales

Objective: To assess the effectiveness of mental health first aid (MHFA) training in drought‐affected rural and remote Australia, as part of a strategy to improve capacity among farming communities to provide early intervention for mental health problems. Methods: Data were obtained from 99 participants recruited across 12 New South Wales towns, before and after delivery of MHFA seminars emphasising the role of front‐line workers from agricultural‐related services. Surveys assessed knowledge of, confidence in dealing with, and attitude towards people experiencing mental illness, along with the impact of training on response to mental health problems among target population of farmers and farming families. Results: Rural support workers and community volunteers attended MHFA seminars because of perceived mental health needs in the workplace. A majority of responses reflect a concern with giving appropriate advice and support well outside narrow job definitions. Participants' ability to identify high prevalence disorders and endorse evidence‐based interventions for both high and low prevalence disorders increased following MHFA training, as did their confidence in their ability to provide appropriate help. Conclusions: MHFA training can form an effective part of a strategy to improve systems of care and pathways to early intervention in rural communities by using local networks to provide mental health support.     

Subjective well-being, sociodemographic factors, mental and physical health of rural residents

Objective: To ascertain the relationship between subjective well‐being and sociodemographic factors, mental and physical health of a sample of rural residents. Design: Cross‐sectional survey with stratified random sampling of persons based on the 2000 State Electoral Role. Questionnaire was forwarded to 23 000 residents throughout a rural area. Setting: Households within Gippsland. Participants: Five thousand three hundred and ninety‐one adults aged 18 years and above. Main outcome measures: Residents completed a self‐reported questionnaire assessing life satisfaction/subjective well‐being, psychological distress, sociodemographic factors, physical and mental health problems. Results: Completed survey indicated that participants with lower levels of psychological distress, physical disability and mental disability had higher odds of being satisfied with their life. Participants with severe mental disability had the lowest odds of being satisfied with life. On average, participants were satisfied with their life (mean score of 21, SD = 5.9), are within the normal range of the Kessler‐10 (mean score = 16.31, SD = 5.85), had no mental disability (mean score = 51.8, SD = 7.36) on the mental component of the Short Form‐12 Health Survey, but are mildly physically disabled (mean score = 48.9, SD = 7.74). Conclusions: The results of this study indicate that sociodemographic factors, psychological distress, physical health and mental health contribute to subjective well‐being. Compared with other age groups, those aged 66 years and above had the highest level of life satisfaction. Those living with partner/spouse without children, with no mental or physical disability and no psychological distress had highest level of life satisfaction. Women also had higher levels of life satisfaction compared with men.     

Healthy minds for country youth: Help‐seeking for depression among rural adolescents

Objective: To assess depression recognition, barriers to accessing help from health professionals and potential sources of help for depression among rural adolescents. Design: Cross‐sectional survey. Setting: Two rural secondary schools in south‐east South Australia. Participants: Seventy‐four secondary school students aged 14 to 16 years. Main outcome measure(s): Depression recognition was measured using a depression vignette. Helpfulness of professionals, barriers to seeking help and help‐seeking behaviours for depression were assessed by self‐report questionnaire. Results: Depression was identified in the vignette by 73% (n = 54) of participants. Participants indicated that it would be more helpful for the vignette character to see other health professionals (98.6%, 95% CI, 92.0–100.0%) than a doctor (82.4%, 72.1–89.6%). Barriers to seeking help from doctors and other health professionals were categorised into logistical and personal barriers. Participants agreed more strongly to personal (mean = 2.86) than logistical barriers (mean = 2.67, P < 0.05) for seeing a doctor. Boys and girls responded differently overall, and to personal barriers to seeing an other health professional. Sources of help were divided into three categories: formal, informal and external. Informal sources of help (mean = 4.02) were identified as more helpful than both formal (mean = 3.66) and external sources (mean = 3.72, P < 0.001). Gender differences were observed within and between the three sources of help categories. Conclusions: Recognising symptoms of depression was demonstrated in this study. Helpfulness of professionals, barriers to seeking help and potential sources of help for depression were identified. More work is required for improving depression literacy and providing effective interventions specifically for rural adolescents.     

Using cohort studies to investigate rural and remote mental health

This paper, presented at the 2010 rural health researchers' National Scientific Symposium on Rural and Remote Health, provides an overview of large Australian population mental health cohort studies which have a focus on climate-related and environmental adversity, social factors and mental health. These studies highlight the value of exploiting multiple exceptional datasets to better understand the drivers of rural health, including how to use population-level research to improve health resources in non-metropolitan areas. We show how the key characteristics of rural and remote mental health might be explored by exploiting the following cohort studies: Household, Income and Labour Dynamics in Australia Survey; Australian Rural Mental Health Study; Hunter Community Study; and Extending Treatments, Education and Networks in Depression study. Existing cohort studies that focus on significant rural and regional characteristics can be creatively analysed to better understand geographic variation in mental health. They have the potential to move understanding beyond simple prevalence to building knowledge about the trajectories of psychological distress and determinants of mental disorders and outcomes over time.     

Rural adolescents' help-seeking intentions for emotional problems: the influence of perceived benefits and stoicism

Objective: This study explores the factors that influence adolescents' help‐seeking intentions. Specifically, the study investigates the extent to which perceived benefits of help seeking, stoicism, gender and symptoms of psychological distress are associated with intentions to seek professional help for emotional problems. Design and setting: A cross sectional self‐report questionnaire was administered to adolescents recruited from seven high schools in rural towns in the Riverina region of New South Wales. Participants: A total of 778 adolescents were recruited. The sample included 373 male and 404 female participants between 13 and 18 years of age. Main outcome measure(s): Participants completed an anonymous self‐report questionnaire designed to measure help‐seeking intentions in the advent that they were to experience emotional problems, psychological distress symptoms, perceived benefits of help seeking and stoicism. Results: In all, 17% of male participants and 29% of female participants reported they would be likely to seek help from doctors if they were to experience emotional problems. In total, 15% of male participants and 23% of female participants reported they would be likely to seek help from other health care professionals. Multiple regression analysis suggested that adolescents are more likely to seek help from professionals if they perceive help seeking as beneficial (t = 12.91; P < 0.001). Female particpants reported that they were more likely to seek help than male participants (t = 2.69; P = 0.01). Conclusions: Findings suggest that adolescents are reluctant to seek professional help if experiencing emotional problems, because they do not believe professional help seeking is beneficial. Improving adolescents' beliefs about the benefits of professional help seeking might be a key strategy for increasing their use of professional health services to address mental health problems.     

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.     

A Participatory Workplace Intervention for Employees With Distress and Lost Time: A Feasibility Evaluation Within a Randomized Controlled Trial

Introduction Little is known about feasibility and acceptability of return to work (RTW) interventions for mental health problems. RTW for mental health problems is more complicated than for musculoskeletal problems due to stigmatization at the workplace. A participatory workplace intervention was developed in which an employee and supervisor identify and prioritize obstacles and solutions for RTW guided by a RTW coordinator. This paper is a feasibility study of this innovative intervention for employees with distress. The aims of this study were to describe the reach and extent of implementation of the workplace intervention, the satisfaction and expectations of all stakeholders, and the intention to use the workplace intervention in the future. Methods Eligible for this study were employees who had been on sick leave from regular work for 2–8 weeks with distress. Data were collected from the employees, their supervisors, RTW coordinators, and occupational physicians by means of standardized matrices and questionnaires at baseline and 3 months follow-up. Reach, implementation, satisfaction, expectations, and maintenance regarding the workplace intervention were described. Results Of the 56 employees with distress eligible to receive the workplace intervention, 40 employees, their supervisors and RTW coordinators actually participated in the intervention. They identified 151 obstacles for RTW mostly related to job design, communication, mental workload and person-related stress factors. The 281 consensus-based solutions identified were mostly related to job design, communication and training. Of those solutions, 72% was realized at the evaluation with the employee and supervisor. Overall, employees, supervisors and occupational health professionals were satisfied with the workplace intervention and occupational health professionals rated it with a 7.1. Time-investment was the only barrier for implementation reported by the occupational health professionals. Conclusions The results of this study indicate a high feasibility for a broad implementation of a participatory workplace intervention for employees with distress and lost time, and their supervisors.     

Mental health problems among young people on remand: has anything changed since 1989?

Objectives: To determine whether the prevalence of mental health problems among adolescents on court ordered remand in South Australia has changed since 1989. To compare the prevalence of mental health problems reported among adolescents on remand in 1989 and 2008/09 with the prevalence among adolescents in the general community. Method: Mental health problems were identified using the Youth Self‐Report (YSR), which was completed by 11–17 year olds on remand in South Australia in 1989 (n=100) and in 2008/09 (n=197), and 13–17 year olds (n=1,283) in the national survey of mental health problems among Australian adolescents conducted in 1998. Results: Although adolescents on remand reported somewhat fewer mental health problems in 2008/09 than were reported in 1989, the prevalence of problems in both groups of adolescents on remand was significantly higher than that reported for adolescents in the general community. Conclusion: Adolescents on remand have a much higher prevalence of mental health problems than other adolescents in the community, with little change evident over the past 20 years. Implications: To reduce the high levels of mental health problems experienced by adolescents on remand, interventions need to provide effective management and treatment both during the time adolescents are on remand and after they return to the general community.     

Perceived inability to help is associated with client‐related burnout and negative work outcomes among community mental health workers

Community mental health is a vital service, but it faces ongoing challenges from its high staff‐turnover rates. The current study provides a preliminary test of a novel explanation for employee disengagement in community mental health. It is proposed that providing assistance to clients, while simultaneously feeling that only limited progress is being made, is associated with client‐related burnout among community mental health providers, leading to negative work outcomes. Employees (N = 349) from three non‐governmental community mental health organisations in Australia completed a survey assessing their perceptions of client improvement from treatment, client‐related burnout and a range of organisational outcomes. Analyses revealed that perceptions that clients are not improving was associated with burnout, which in turn is related to lower job satisfaction, decreased job engagement, poorer workplace well‐being, and increased turnover intentions. These findings suggest that interventions that highlight positive changes among clients could reinforce the important service provided by community mental health employees and may minimise burnout and negative work outcomes.     

Mental Health and Substance Use Care Among Young Adults Before and After Affordable Care Act (ACA) Implementation: A Rural and Urban Comparison

Purpose

Rural young adults experience greater unmet need for mental health (MH) and alcohol or drug (AOD) treatment and lower health insurance coverage than urban residents. It is unknown whether Affordable Care Act (ACA) reforms in 2010 (dependent coverage extended to age 26) or 2014 (Medicaid expansion) closed rural/urban gaps in insurance and treatment. The present study compared changes in rates of health insurance, MH treatment, and AOD treatment for rural and urban young adults over a period of ACA reforms.

Methods

Young adult participants (18‐25 years) in the National Survey on Drug Use and Health (2008‐2014) with past‐year psychological distress or AOD abuse were included. Difference‐in‐differences logistic regression models estimated rural/urban differences in insurance, MH, and AOD treatment pre‐ versus post‐ACA reforms. Analyses adjusted for gender, race, marital status, and health status.

Results

Among 39,482 young adults with psychological distress or AOD, adjusted insurance rates increased from 72.0% to 81.9% (2008‐2014), but a significant rural/urban difference (5.1%) remained in 2014 (P < .05). Among young adults with psychological distress (n = 23,470), MH treatment rates increased following 2010 reforms from 30.2% to 33.0%, but gains did not continue through 2014. Differences in MH treatment over time did not vary by rural/urban status and there were no significant changes in AOD treatment for either group.

Conclusions

Although rates of insurance increased for all young adults, a significant rural/urban difference persisted in 2014. Meaningful increases in MH and AOD treatment may require targeted efforts to reduce noninsurance barriers to treatment.     

‘I need help’: Reasons new and re‐engaging callers contact the PANDA—Perinatal Anxiety and Depression Australia National Helpline

In Australia, the PANDA—Perinatal Anxiety & Depression Australia National Helpline (the Helpline) offers support to callers impacted by emotional health challenges in the perinatal period. Callers receive counselling from professional staff and peer support from volunteers. An understanding of factors that contribute to callers’ experiences of emotional distress, as well as potential barriers and facilitators to help‐seeking, can be used to inform future service design and delivery. A caller intake form is completed by Helpline staff when an individual contacts the service for the first time, or re‐engages after a period of non‐contact. We analysed all intake forms of individuals calling about their own emotional wellbeing from the middle month of each season in 2014: January, April, July, and October. Content analysis was undertaken, focusing on caller profile, patterns of help‐seeking, and reasons for caller engagement. Of the 365 calls, the majority were from women (n = 358, 98%) who were pregnant (n = 59, 16%) or had a child ≤12 months of age (n = 241, 75%). Many were seeking support regarding depression (n = 186, 51%) or anxiety (n = 162, 44%), with a number seeking help for both (n = 71, 20%). Almost a third were identified as being ‘at risk’, including a number who were experiencing thoughts of suicide or self‐harm. Complex interrelating factors contributed to callers’ emotional distress, including: stressful life events; pregnancy, birthing and parenting experiences; social isolation; and histories of mental health difficulties. Significant numbers of parents experience emotional health challenges in the perinatal period, but many do not receive adequate treatment. Complex factors contribute to callers’ distress, highlighting the need for health professionals to undertake thorough psychosocial assessments during the perinatal period so those that need additional support are identified, and appropriate care provided. Telephone Helplines like PANDAs assist overcoming barriers to care and provide specialised perinatal mental health support to families.     

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.     

Prevent 2nd Stroke: a pilot study of an online secondary prevention program for stroke survivors

Objective: The prevalence of modifiable health risk factors and psychological distress following a stroke is high and markedly increase the chance of a second stroke. This study aimed to examine the usability and acceptability of an online secondary prevention program addressing modifiable psycho‐behavioural risk factors for stroke survivors. Methods: A pre–post pilot study was conducted in Australia between 2016 and 2017. Participants were recruited through the Australian Stroke Clinical Registry and completed measures of health‐related quality of life, physical activity, smoking status, depression and anxiety, alcohol status, nutrition and internet use. Participants also used an online secondary prevention program (Prevent 2^nd Stroke) over a two‐week period. At follow‐up, acceptability and usability of the program were assessed. Results: A total of 18 out of 19 participants reported engaging in multiple health risk behaviours. Participants reported that they were interested in receiving an online program that provided health information (73.7%). Participants indicated Prevent 2^nd Stroke was easy to use (63.1%) and that they would recommend the program to other stroke survivors (63.1%). Conclusions: The results indicated that online programs are an acceptable way to address these health outcomes. Implications to public health: Further research is needed to assess the effectiveness of these interventions using powered trials.     

Distress among rural residents: Does employment and occupation make a difference?

Objective:  This study investigates the relationship between levels of mental health and well-being (in terms of self-reported levels of distress) with employment and occupational status of rural residents, to better inform the provision of mental health services to those in greatest need in rural communities.
Method:  A stratified random sample of community residents in rural and remote New South Wales with over-sampling of remote areas as first stage of a cohort study. Psychological distress was measured using Kessler-10, inclusive of additional items addressing functional impairment (days out of role). Occupational data were classified using Australian and New Zealand Standard Classification of Occupations categories.
Results:  A total of 2639 adults participated in this baseline phase. Among them, 57% were in paid employment, 30% had retired from the workforce, 6% were permanently unable to work and 2% were unemployed. The highest levels of distress and functional impairment were reported in those permanently unable to work and the unemployed group with rates of 'caseness' (likely mental health disorder) varying from 57% to 69%, compared with 34% of farmers and farm managers and 29% of health workers ( P <  0.01).
Conclusion:  The rural unemployed suffer considerable psychological distress and 'disability', yet they are not the target of specific mental health promotion and prevention programs, which are often occasioned by rural adversity, such as drought, and delivered through work-based pathways. Policy-makers and health service providers need to consider the needs of the rural unemployed and those permanently unable to work and how they might be addressed.     

Cross-sectional associations between sitting at work and psychological distress: Reducing sitting time may benefit mental health

ProblemEvidence is emerging of adverse associations between prolonged sitting at work and physical health, yet little is known about occupational sitting and mental health. This study examined associations between occupational sitting and psychological distress in employed adults, independent of leisure-time physical activity.MethodsA survey of 3367 state government employees (mean age 46.2 years, 71.9% women) was conducted in Tasmania, Australia, during 2010 as part of an evaluation of workplace health and wellbeing programs. The Kessler Psychological Distress Scale (K10) was used to measure psychological distress, and participants reported time spent sitting at work on a typical day. Physical activity was assessed using the International Physical Activity Questionnaire (IPAQ). Ratios of prevalence (PR) for categories of psychological distress were estimated by log multinomial regression separately for men and women, and with adjustment for age, marital status, effort-reward imbalance and leisure-time physical activity.ResultsAverage reported occupational sitting time was 4.8 (Standard Deviation SD = 2.5) hours for men and 4.2 (SD = 2.7) hours for women. Compared to those sitting at work less than 3 h/day, men sitting more than 6 h/day had increased prevalence of moderate psychological distress (adjusted PR = 1.90, 95%CI 1.22, 2.95), and women sitting more than 6 h/day had an increased prevalence of moderate (adjusted PR = 1.25, 95%CI 1.05, 1.49) and high (adjusted PR = 1.76, 95%CI 1.25, 2.47) distress.ConclusionThe current study found an association between occupational sitting and intermediate levels of psychological distress, independent of leisure-time physical activity. Reducing occupational sitting time may have mental health benefits.     

Prison health and public health responses at a regional prison in Western Australia

Objective: To describe the health of inmates in a Western Australian regional prison and evaluate the coverage of public health interventions. Design: Cross‐sectional audit of all paper‐based and electronic medical notes of inmates at one regional prison in Western Australia. Setting: A mixed medium‐security prison in regional Western Australia. Participants: 185 prisoners, 170 men and 15 women Main Results: The prisoners were mainly young (70% < 35 years of age) and Indigenous (84%). Fifty two percent of prisoners had at least one chronic health condition. There was a significantly higher prevalence of diabetes to that found in the general Indigenous population (15% vs 6% p=0.001), and a significantly lower prevalence hepatitis C (4.5%) compared with both national (29–61%) and State (20%) data. Screening for sexually transmitted infections and blood borne viruses within the first month of incarceration was achieved for 43% of inmates. Vaccination coverage for influenza (36%) and pneumococcal disease (12%) was low. Conclusion: This study makes visible the burden of disease and reach of public health interventions within a largely Indigenous regional prisoner population. Our study demonstrates that the additional risks associated with being Indigenous remain in a regional Australian prison but also shows that interventions can be delivered equitably to Indigenous and non‐Indigenous inmates. Implications: Ongoing monitoring of prisoner health is critical to take advantage of opportunities to improve public health interventions with timely STI and BBV screening and increased vaccinations rates.     

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.