Myths and Myths and Challenges of Challenges of Mental Disorders Mental Disorders in Communities: in Communities: Rural v Urban Rural v Urban How do we provide an How do we provide an appropriate service appropriate service response? response? Dr Denise Coia Dr Denise Coia
35
Embed
Myths and Challenges of Mental Disorders in Communities: Rural v Urban
Myths and Challenges of Mental Disorders in Communities: Rural v Urban. How do we provide an appropriate service response? Dr Denise Coia. 5 of 10 leading causes of disability world wide are mental disorders. - PowerPoint PPT Presentation
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Myths and Challenges Myths and Challenges of Mental Disorders in of Mental Disorders in Communities: Communities: Rural v UrbanRural v Urban
How do we provide an How do we provide an appropriate service appropriate service
response?response?
Dr Denise CoiaDr Denise Coia
5 of 10 leading causes of 5 of 10 leading causes of disability world wide are mental disability world wide are mental disordersdisorders
Major Depression (predicted the second Major Depression (predicted the second most prevalent health problem most prevalent health problem worldwide by 2020)worldwide by 2020)
In Established Market In Established Market Economies Economies (Australia, Europe & (Australia, Europe & America)America)
Mental Disorders account for Mental Disorders account for
43% disability43% disability
22% total burden of disease22% total burden of disease Burden of mental disorders in USA is Burden of mental disorders in USA is
more than burden associated with all more than burden associated with all forms of cancer forms of cancer (Murray and Hopez) 1996(Murray and Hopez) 1996
Depression in Australia 4Depression in Australia 4thth most most common problem in General Practice common problem in General Practice 2000- 20012000- 2001
Mental Health DisordersMental Health Disorders
High Level of Unmet NeedHigh Level of Unmet Need Most people who seek help do so Most people who seek help do so
from GP (75%)from GP (75%)
Are the prevalence rates for Are the prevalence rates for mental health disorders different in mental health disorders different in rural versus urban areas?rural versus urban areas?
Difficult to assessDifficult to assess Rural populations are not Rural populations are not
heterogeneousheterogeneous Rural issues change over time Rural issues change over time
(employment, foot and mouth)(employment, foot and mouth)
So what is the Rural So what is the Rural Context Affected byContext Affected by
Distribution of different types of Distribution of different types of people (compositional effects)people (compositional effects)
Place or location itself Place or location itself
(contextual effects)(contextual effects)
Diversity of Rural Diversity of Rural Populations IncludePopulations Include
Population densityPopulation density Ethnic Composition/cultural heritageEthnic Composition/cultural heritage Socio economic status and stress Socio economic status and stress
(eg in farming, mining and fishing (eg in farming, mining and fishing communities) and predominant communities) and predominant occupationsoccupations
Remoteness – distance from large Remoteness – distance from large settlementssettlements
What Aspects of Rural Life What Aspects of Rural Life and Place Contribute to:and Place Contribute to:
Positive Mental HealthPositive Mental Health Increased Likelihood of mental Increased Likelihood of mental
health problems or/andhealth problems or/and Support, resilience and recoverySupport, resilience and recovery
The MythThe MythUrban Ghetto versus Rural Urban Ghetto versus Rural HavenHaven
Removing the Focus of Removing the Focus of Control from rural Control from rural CommunitiesCommunities
Leading toLeading to Relative poverty, poorer educationRelative poverty, poorer education Negative life experiencesNegative life experiences Lack of control over life and work Lack of control over life and work
in general in general Marmot 1998Marmot 1998
Potential Mental Health Potential Mental Health Consequences of Rural DeclineConsequences of Rural Decline
USA Berson 2000USA Berson 2000
1.1. Impact on IndividualImpact on Individual Psychological distress and multiple stress related Psychological distress and multiple stress related
symptomssymptoms risk of suiciderisk of suicide risk of depressionrisk of depression risk from accidents and injuryrisk from accidents and injury2.2. Impact on FamiliesImpact on Families Intergenerational conflictIntergenerational conflict Marital DiscordMarital Discord Domestic ViolenceDomestic Violence Difficulties in adjusting to urban settingsDifficulties in adjusting to urban settings3.3. Impact on ChildrenImpact on Children Adjustment DisordersAdjustment Disorders Poor ParentingPoor Parenting Children internalise problems leading to depressionChildren internalise problems leading to depression Substance AbuseSubstance Abuse
Potential Mental Health Potential Mental Health Consequences of Rural DeclineConsequences of Rural Decline
USA Berson 2000USA Berson 2000
4.4. Impact on CommunitiesImpact on Communities Depression affects whole communityDepression affects whole community Social disintegration and Social disintegration and
disorganisation disorganisation Violence to OthersViolence to Others5. Reactions5. Reactions Adjustment (grief) reactionsAdjustment (grief) reactions HelplessnessHelplessness Social IsolationSocial Isolation More vulnerable to anti government More vulnerable to anti government
Paykel and Jenkins 1997Paykel and Jenkins 1997
UK National Morbidity Study. UK National Morbidity Study. Urban- Rural DifferencesUrban- Rural Differences
In General Practice Alcohol and In General Practice Alcohol and Drug Dependence Higher in Urban Drug Dependence Higher in Urban settingssettings
Recent Changes in Rural Recent Changes in Rural Mental HealthMental Health
Rural residents experience higher Rural residents experience higher levels of depression, alcohol abuse, levels of depression, alcohol abuse, domestic violence, incest and child domestic violence, incest and child abuse than urban counterparts abuse than urban counterparts (Baume 1997, Bushy 2000, Haustein 1994. Olson 2000)(Baume 1997, Bushy 2000, Haustein 1994. Olson 2000)
They view mental illness more They view mental illness more negatively and the stigma is negatively and the stigma is magnified which prevents them magnified which prevents them seeking healthcareseeking healthcare
60% rural areas lacking mental health 60% rural areas lacking mental health professionalsprofessionals
56.9% of families below poverty line56.9% of families below poverty line Suicide rate 3 times higher than urban Suicide rate 3 times higher than urban
ratesrates
Prevalence ProblemsPrevalence Problems
““How are differences in the How are differences in the characteristics of various types of characteristics of various types of rural and urban communities rural and urban communities functionally relevant to differences functionally relevant to differences in the type and level of disorders in the type and level of disorders observed”observed”
Beeson 1992Beeson 1992
Determinants of Resilience and Determinants of Resilience and Positive Mental Health IndicatorsPositive Mental Health Indicators
CategoryCategory IndicationsIndicationsHopeHope
Sufficient ResourcesSufficient Resources
Location in SocietyLocation in Society
Connectedness with Connectedness with CommunityCommunity
SelfSelf
FamilyFamily
Primal Human ValuesPrimal Human Values
See a futureSee a future
Sufficient income, family Sufficient income, family resource, resource,
Meaningful WorkMeaningful Work
Sense of BelongingSense of Belonging
Sense of Wellbeing in Sense of Wellbeing in CommunityCommunity
Know who you are and how Know who you are and how you fit inyou fit in
Emotional support network Emotional support network of family and communityof family and community
Happiness, relationships, Happiness, relationships, sense of caring, abhorrence sense of caring, abhorrence of suffering, devotion to of suffering, devotion to familyfamily
Determinants of Resilience and Determinants of Resilience and Positive Mental Health IndicatorsPositive Mental Health IndicatorsCategoryCategory IndicationsIndicationsAutonomy/EffectivenessAutonomy/Effectiveness
Sense of EfficacySense of Efficacy
Valuing DiversityValuing Diversity
Physical EnvironmentPhysical Environment
Physical HealthPhysical Health
Feeling of Safety in Home Feeling of Safety in Home and Environmentand Environment
Control over environment Control over environment (work and home)(work and home)
Not being overwhelmed by Not being overwhelmed by external eventsexternal events
Self determination at work Self determination at work and with familyand with family
Basic freedom to live in an Basic freedom to live in an accepting societyaccepting society
Connection with earth and Connection with earth and seasons, beauty exercise, seasons, beauty exercise, nutrition, relaxation, nutrition, relaxation, balanced lifestylebalanced lifestyle
Ability to deal confidently Ability to deal confidently with conflicts that arise. with conflicts that arise. Freedom from fear in home Freedom from fear in home and communityand community
Good Mental Health Good Mental Health 3 Streams of Intervention3 Streams of Intervention
1.1. Improving positive mental health Improving positive mental health through Health Promotion and through Health Promotion and preventionprevention
2.2. AssessmentAssessment
3.3. TreatmentTreatment
Health Promotion/Prevention Health Promotion/Prevention StrategiesStrategies
Understand the mechanisms that Understand the mechanisms that account for rural urban differences account for rural urban differences in prevalence of mental disordersin prevalence of mental disorders
Understand proximal and distal Understand proximal and distal influencing factors in preventioninfluencing factors in prevention
Optimally preventative Optimally preventative interventions are implemented in interventions are implemented in response to specific problems in response to specific problems in specific rural settingsspecific rural settings
Prevention Programmes in Prevention Programmes in
Rural AreasRural Areas
Western Norway – Hordaland Western Norway – Hordaland County ProjectCounty Project
Value of bottom up/topdown Value of bottom up/topdown approachapproach
Arvid Skuttle Arvid Skuttle 20022002
Developing Mental Health ServicesDeveloping Mental Health ServicesIssues to be considered in service Issues to be considered in service deliverydelivery
i.i. Diversity of Rural populationsDiversity of Rural populationsii.ii. Inconsistencies in the term ruralInconsistencies in the term ruraliii.iii. What is functional relevance of rural What is functional relevance of rural
residence in the aetiology of specific residence in the aetiology of specific disordersdisorders
iv.iv. Suitability of ServiceSuitability of Servicev.v. Do you design interventions Do you design interventions
specifically for rural populationsspecifically for rural populationsvi.vi. How do you engage rural residentsHow do you engage rural residentsvii.vii. AccessAccessviii.viii. Increasing CostsIncreasing Costs (Farell and (Farell and
McKinnon 2003)McKinnon 2003)
Challenges to Designing Challenges to Designing Rural Intervention Rural Intervention ServicesServices
1.1. Shortages of staff, particularly specialist to Shortages of staff, particularly specialist to provide a range of interventionsprovide a range of interventions
2.2. Lack of service outreach infrastructureLack of service outreach infrastructure
3.3. Distances required to travel to places Distances required to travel to places where services are offered – inaccessiblewhere services are offered – inaccessible
4.4. General distrust of Mental Health SystemGeneral distrust of Mental Health System
But are they so But are they so different in their different in their requirements or is this requirements or is this another myth?another myth?
System Wide ApproachSystem Wide ApproachThe Stepped Collaborative Care Model The Stepped Collaborative Care Model
Level 2 - Care for milder or uncomplicated Level 2 - Care for milder or uncomplicated disordersdisorders
Interventions in L1/L2 provided by primary Interventions in L1/L2 provided by primary care clinicianscare clinicians
Level 3 – Collaboration ie secondary or Level 3 – Collaboration ie secondary or specialist consultant and shared carespecialist consultant and shared care
Level 4 – Skilled specialist for more severe Level 4 – Skilled specialist for more severe and complex disorders, components of this and complex disorders, components of this level would include CMHT, Crisis Teams, level would include CMHT, Crisis Teams, Assertive Outreach, Partial Hospitalisation Assertive Outreach, Partial Hospitalisation and Early Intervention Servicesand Early Intervention Services
Social CareSocial Care
Tier 1 – Support volunteered by Tier 1 – Support volunteered by family and friendsfamily and friends
Tier 2 – Community and religious Tier 2 – Community and religious organisations local emergency organisations local emergency servicesservices
Tier 3 – Formal Services providing Tier 3 – Formal Services providing social supportsocial support
What are the Specific Rural What are the Specific Rural Issues that Affect Service Issues that Affect Service DeliveryDelivery
Stigma and help seeking behaviourStigma and help seeking behaviour Dual Roles/Staff Recruitment and Dual Roles/Staff Recruitment and
retentionretention Access to careAccess to care
Dual Relationship in Dual Relationship in Mental Health Practice Mental Health Practice (Scopelli, (Scopelli,
Judd 2005)Judd 2005)
IssuesIssues Pressure to be always on dutyPressure to be always on duty Pressure to deal with community Pressure to deal with community
tragedytragedyoften have to provide care and often have to provide care and support when equally support when equally upset/unrealistic expectationsupset/unrealistic expectations
3 main features of rural 3 main features of rural communities that impact upon communities that impact upon the capacity of mental health the capacity of mental health workers to maintain clear workers to maintain clear professional boundariesprofessional boundaries
1.1. Size of communitySize of community
2.2. Isolation of communityIsolation of community
3.3. Community expectations (to Community expectations (to support community activities etc)support community activities etc)
Boundary Management is Boundary Management is EssentialEssential
ii For Patients: proper boundaries For Patients: proper boundaries provide a foundation for an provide a foundation for an effective therapeutic allianceeffective therapeutic alliance
iiii For staff – prevents “burnout” – For staff – prevents “burnout” – require psychological space as an require psychological space as an individual to functional and thrive.individual to functional and thrive.
Solutions Solutions
1.1. Acknowledge that multiple Acknowledge that multiple relationships are unavoidable in relationships are unavoidable in small and remote communitiessmall and remote communities
4.4. Be mindful of confidentialityBe mindful of confidentiality
Solutions to Delivering Rural Solutions to Delivering Rural Mental Health ServicesMental Health Services
II Enhanced Primary CareEnhanced Primary Care Improving detectionImproving detection Improving Effective TreatmentImproving Effective Treatment
IIII Training and Education Programme for Training and Education Programme for
Primary CarePrimary Care
IIIIII Novel ApproachesNovel Approaches Rooming-In Facilities in Western AustraliaRooming-In Facilities in Western Australia
IV IV TelehealthTelehealth
VV Training in Rural Psychiatry for SpecialistsTraining in Rural Psychiatry for Specialists
Telehealth Telehealth Is technology a help? Is it acceptable? Is it Is technology a help? Is it acceptable? Is it feasible?feasible?
““Early on psychiatry was perceived as Early on psychiatry was perceived as the ideal specialty for the application the ideal specialty for the application of telemedicine owing to the fact that of telemedicine owing to the fact that assessment and treatment relies more assessment and treatment relies more on audiovisual information than on the on audiovisual information than on the use of lab tests and procedures”use of lab tests and procedures”
(Boer, Elford & Cukor 1997)
Telehealth Telehealth Is technology a help? Is it acceptable? Is it Is technology a help? Is it acceptable? Is it feasible?feasible?
Issues of contractual relationshipIssues of contractual relationship PrivacyPrivacy Medical Legal PrudenceMedical Legal Prudence May challenge deeply embedded May challenge deeply embedded
constraints of the therapeutic constraints of the therapeutic relationshiprelationship
Practical problems Practical problems
(Jablonowski 2003)(Jablonowski 2003)
More Research is Required More Research is Required to Dispel the Mythsto Dispel the Myths The examination of the nature and extend of The examination of the nature and extend of
mental health problems in different (geographic, mental health problems in different (geographic, socio demographic,economic) rural communitiessocio demographic,economic) rural communities
Identifying the mechanisms by which rural place Identifying the mechanisms by which rural place contributes to mental wellbeing or mental contributes to mental wellbeing or mental disorderdisorder
Implementation and evaluation of mental health Implementation and evaluation of mental health promotion/prevention strategiespromotion/prevention strategies
Design and evaluation of a range of models of Design and evaluation of a range of models of mental health service deliverymental health service delivery
Identify which models of service delivery best Identify which models of service delivery best suit different rural settingssuit different rural settings