This page was first published in September 2014 and has now been archived.
People outside our main cities may be isolated and unsupported while experiencing symptoms of mental illness. They are more likely to struggle to find the right support because there are fewer mental health professionals and long delays can result.
Peter of Peter Bryant and Eamonn Corvan

People in rural and regional areas feel they are short changed, and do not have the access to basic services considered standard in metropolitan areas.

Read about Eamonn and Peter's story - a community mental health nurse and a GP working together

Beyond the cities
Local people are the experts
More support for more people
No shame
Working it out

Beyond the cities

"Police are a de facto mental health service. Ambulance are a de facto mental health service." Forum participant

People in rural and regional areas feel they are short changed, and do not have the access to basic services considered standard in metropolitan areas. 

Shortages of appropriate supports, networked together to provide service when it is needed by all age groups, areas and times of day, mean people in rural and regional NSW risk being channelled towards forms of care that are not ideal for their circumstances 
or severity of illness.

In particular, emergency services frequently have to step in when community mental health outreach teams – if available – would be better skilled and equipped to support someone experiencing distress. And hospitals or ambulances may be people’s only option out of hours, even for something as simple as needing a new script, if they live in a centre with no out-of-hours medical centre.

The Commission believes in equity for everyone in NSW in terms of the quality and range of mental health support they are able to access.

But we have a problem. NSW is vast and its population widely distributed. A quarter of us live outside the major centres of Sydney, Newcastle and Wollongong. That is nearly 2 million people along the coast, in regional centres, and in rural and remote areas that may be a half day’s drive or more from a town with a hospital or GP clinic.

People who live in regional, rural and remote areas experience mental health problems at about the same rate as those in the cities but they face greater challenges as a result, because of the difficulty of accessing the support they need and to the greater visibility of mental illness in a smaller community, which may lead to stigma and the fear or reality of discrimination.

Social isolation can have a disproportionate effect for country people, who may be less able to reach out for companionship in their area, and may struggle more to find meaningful work and activities in a context of higher unemployment and longer travel distances.

And there is evidence of links between mental illness and prolonged drought, and other adverse environmental factors including floods and fires, the loss of markets for rural produce, economic hardship, climate change and de-population – all key issues affecting people in the bush.

People living in rural and remote NSW are more likely to experience socioeconomic disadvantage, and greater exposure to the risk of physical injury, which can have major psychological consequences. And for Aboriginal people living in country areas, disadvantage and higher risk of distress may be compounded by geographic isolation and lower access to culturally appropriate support services.

Some specific challenges and needs in rural and remote communities include transport issues as well as suicide prevention and response. People in country Australia complete suicide at 1.2 to 2.4 times the rate of city dwellers.

People living in the country may also come from diverse cultures or have other physical or social problems that complicate their experience of mental illness and make it harder to identify appropriate supports, while young and older people also have particular difficulties and needs.

These must be critical considerations as we seek to spread the benefits of good mental health as fairly as we can right across the state.

Local people are the experts

Country NSW is not one entity. It is an endlessly rich collection of unique communities.

The people who live in a town or region – including those who experience mental illness, professionals and the wider community – understand the mental health needs of their town or region better than anyone, but their knowledge has often remained relatively untapped as we have insisted instead on one-size-fits-all solutions designed at head office. 

Towards change

  • We need to power up the ability of local communities to develop their solutions. This does not mean everything will have to be re-invented from scratch. We can develop broad approaches to care and support that may be generally suitable in smaller or more remote communities, and we must insist on certain standards of support. But we must be prepared for people to modify those templates and go off script when they need to, to make the most of resources or respond to particular local situations. And we must get better at promoting locally developed solutions to other communities that might benefit from applying them.
- We must explicitly authorise people to work at a local level across agencies, across tiers of government, and with the community-managed and private sectors, wherever this provides the most rational and effective solution to a local problem. Such relationships are particularly valuable when a community needs to respond to adversity, such as a natural disaster.
  • We must also ensure local services and solutions are communicated clearly to local people, so everyone knows where to go in a crisis and for more long term support.

 

Infographic with statistics around rural and regional areas relating to mental health

  • 1/4 of people in NSW live outside major cities
  • 800,000 square kilometres - the area of NSW
  • 91% of psychiatrists have their main practice in a major city
  • People per square kilometre - UK: 263, US: 34, NSW: 9

More support for more people

We know people outside our main cities are more likely to struggle to find appropriate mental health support.

Mental health professionals are in shorter supply, which results in differences in rates and types of care between rural and urban populations. Delays before seeking help for anxiety and depression appear to be far more prolonged in rural areas compared with urban Australia – implying that people may be isolated and unsupported while they experience symptoms of mental illness.

Even uniform national programs such as the Better Access scheme – which provides Medicare-funded mental health consultations with psychologists and GPs – are less available for people who live in the country. Overall, Better Access has greatly expanded the number of people Australia-wide seeking support from these professionals, but compared with capital cities, people in rural areas used the services 12% less and people living in remote areas used them 60% less, a Commonwealth government analysis found in 2011.

This may be a reflection of the lower availability of GPs and psychologists in country areas, or of the higher co-payments people may need to make to see them – the proportion of professionals who bulk bill is lower in the country. Distortions and unintended consequences of this sort are common, and they undermine people’s ability to seek support.

Towards change

  • We need to do much more to ensure the equitable availability of relevant support for people who seek it outside major towns and cities. This may mean accepting a wider range of support services, provided they are effective. There is growing evidence to support: the development of neighbourhood ‘clubhouses’ – where activities focus on members’ strengths and abilities rather than their illness; the use of peer workers; community wellbeing centres; and outreach services that do not depend on the availability of psychiatrists, psychologists or GPs.
  • Tele-consultations may fill the gap when someone needs access to a particular service that is not available in their area. We should develop a coherent, statewide approach to the delivery of tele-consultations via videoconferencing links to support people who experience mental illness – and create an expectation that city services and professionals will share their expertise. But we accept that this cannot replace face-to-face professional services.
  • Emerging eHealth services, such as mobile phone applications that support people directly to manage their mental distress, may be particularly relevant to people in rural and regional NSW because they are truly universally accessible and may be less stigmatising than using a bricks-and-mortar service. They may also be more acceptable to young people in the country, whose use of services is particularly low. We must be prepared to support the development of e-mental health programs and monitor their quality, as they are likely 
to become an important resource for people outside the main centres.

No shame

Many people who live in country areas pride themselves on their resilience. Rural communities live at the mercy of the elements much more than people in cities. They are more likely to be directly affected by the impact of droughts or floods, as entire local economies – especially those based on agriculture – may depend on the weather.

Living and working to the rhythm of climate cycles requires great personal strength, and this toughness can translate into a reluctance to admit vulnerability or seek help when in trouble. Mental health difficulties may be interpreted as weakness by people who expect themselves and others to push through times of trouble, and who may therefore be hesitant to seek or offer support for psychological distress.

Compounding this reticence, people in small communities avoid seeking help from professionals who are already known to them as neighbours or through local networks. People may fear their difficulty will be revealed, and that this will reduce their standing in their community.

Towards change

  • Stigma and discrimination about mental illness need to be challenged wherever they occur, but a different approach may be necessary in rural and regional NSW. We should involve people in the country in co-designing anti-stigma campaigns that respond to the particular fears and concerns experienced by people in their communities.
  • We should promote helplines and e-mental health services which, because of their anonymity, may be more acceptable to rural people as an initial way to seek help, but accept that they cannot replace face-to-face support services.

Working it out

Mental health professionals are unevenly distributed across NSW and while some country regions are relatively well supplied, people in other areas struggle to see psychiatrists, psychologists and even GPs. In this context, emergency hospital services are frequently used to compensate for a lack of community-based support, which may lead to inappropriate care.

The mental health workforce and its limitations – both in numbers of professionals and the scope of their practice – is one of the most important bottlenecks that prevent people in rural and regional NSW having equitable access to mental health support.

Towards change

  • Peer workers have a particularly important role in rural settings, where geographic isolation may be more intense and the opportunity to share personal experience more limited. We should support the expansion of peer worker training and development in rural areas.
  • We should ensure the mental health system supports links between GPs and acute and other community services to develop GPs’ skills and confidence in helping patients manage their mental health issues. If GPs know there is always someone they can call on for consultation and advice, they will feel more empowered to assist people with more complex mental health conditions, and keep them out of hospital.
  • A comprehensive approach should be developed to attract and retain mental health workers in rural and regional areas. This may include enhanced career pathways and incentives to encourage psychiatrists, psychologists, Aboriginal mental health workers and peer workers to relocate from urban practice.
  • To better meet needs and target resources, we must understand more about investment across government  directed at people with a mental illness.

Related links

Strategic Plan and Report

References

Source material for content on this page is from the Living Well Report

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Last updated: 28 June 2017