Rural/remote communities

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People living in rural/remote communities suffer a variety of social, attitudinal, economic, geographic, and community barriers which means that they are likely to have difficulties accessing treatments and specialist care [1085-1088]. Youth in these communities are at particularly high-risk [1089], and alcohol and rural stressors are likely to play a role in high male suicide rate [1090]. The lack of specialists in these regions tends to result in heavy reliance on primary and AOD health care providers. Compared to major cities, rural areas have significantly less access to specialised mental health care, with per-person supply of employed medical practitioners decreasing according to remoteness [1085]. Although there is a national focus across Australia to increase the supply of health workers to rural and remote areas, it is estimated that rural areas access 33% of psychiatrists, 85% of mental health nurses, and 54% of psychologists compared to major cities, with even poorer access for remote areas [1085, 1086]. Moreover, Medicare expenditure on mental health services in inner regional and remote areas is considerably less than that in major cities [1086]. The health of rural and remote Australians is comparatively poorer than those in major cities [1085], and the lack of resources and health care workers makes working in these settings particularly challenging.

Research has found that people living in remote areas are less likely than major city residents to endorse evidence-based interventions as useful for mental health treatment, and are less likely to perceive psychologists, psychiatrists, GPs, and social workers as helpful in the treatment of mental health conditions [1091]. There is also evidence that people living in remote areas are also more likely than those living in major cities to identify non-evidence-based treatments (e.g., alcohol and painkillers) as helpful interventions for mental health conditions, highlighting the need for effective communication focused on best-practice treatment and management of mental health in rural and remote areas [1091].

Although accessing treatment has been identified as a particular challenge in this population group, recently developed self-guided approaches, such as bibliotherapy or e-health interventions, have proven to be effective as have alternatives to face-to-face methods (e.g., telephone, email, internet) where geographical isolation and lack of specialist services are obstacles [1092]. For example, MoodGYM is a  free online CBT self-help program for depression (www.moodgym.anu.edu.au) that has been shown to be effective in treating symptoms of depression [653], and Anxiety Online comprises five e-therapy programs for GAD, SAD, panic disorder, PTSD, and OCD (www.mentalhealthonline.org.au) [740]. Although definitive evidence regarding the efficacy of Anxiety Online is lacking, a naturalistic study found that the participation in the program was associated with significant reductions in severity of all five disorders, and increased confidence in managing one’s own mental health care.

In terms of feasibility and acceptability of these approaches, there is evidence that clinicians working in rural areas are optimistic about the use of e-health interventions; however, there was a preference for these approaches to be integrated alongside existing services, and used as an adjunct rather than alternative to more traditional face-to-face approaches [1093]. The Rural Mental Health Study found that one in five (18%) people with internet access (75% of the total sample) would consider using e-health interventions, which was associated with being younger, male, a carer, having a 12-month mental health problem, and having used internet-based treatments in the past [1094]. These findings suggest that e-health interventions have the potential to address the limitations of service accessibility among people living in rural and remote areas, and resistance to e-health may be overcome by enhancing community education and program familiarity [1094]. In an RCT examining participants with comorbid depression and AOD use, the efficacy of computerised CBT/MI was compared to face-to-face treatment with both urban and rural participants [1095]. Similar improvements were observed in depression, alcohol, and cannabis use when compared with face-to-face treatment, and the computerised delivery was acceptable to people in both urban and rural locations, even among people who indicated a preference for face-to-face therapy.

Patterns of AOD use and the types of stressors experienced are likely to vary across rural and remote areas. For example, inhalants are a particular problem in some rural and remote areas, especially within Indigenous populations [1034], whereas cocaine is more likely to be used in major cities and inner regional areas [1096]. The proportion of individuals drinking at risky levels increases with increasing remoteness, with certain occupational groups (in particular, farming communities) at particularly high risk, and hospitalisation and mortality associated with alcohol consumption is considerably higher for rural communities relative to urban communities [1097]. Significantly more people living in rural and remote areas smoke tobacco, and whilst smoking rates have fallen over the past 15 years in major cities, outer regional and remote areas have not seen this reduction [1098].

AOD workers need to be aware of the particular issues related to AOD use in their communities. Professional networking with local health providers, and fostering trust, non-judgemental acceptance, and confidentiality with clients, may be particularly important in rural/remote communities. In small rural communities, anonymity is very difficult to maintain, presenting a range of additional challenges for the AOD workers. Therefore issues of confidentiality are particularly crucial.