Suicide and mental health in rural, remote and metropolitan areas in Australia

In Australia, suicide rates have consistently been found to be higher in rural than in metropolitan areas. 1 Adolescent and young adult males,2,3 especially those in rural or remote areas, have particularly high suicide rates. 4-6 Mental health disorders have been described as the strongest risk factor for suicide across all ages7 and in young people. 8 However, only a small body of literature has specifically focused on how mental health differs by age and sex across rural and metropolitan areas.

Judd et al9 conducted a literature review on rural psychiatric morbidity and found few differences in the prevalence of mental health disorders among urban and rural residents. 9 The adult component of the 1997 Australian National Survey of Mental Health and Wellbeing (NSMHWB)10 revealed a slightly increased risk of anxiety disorders in rural centres, but a lower risk of “any mental health disorder” in “other rural” compared with urban areas. However, these differences were not significant after adjusting for a wide array of sociodemographic characteristics. Judd et al9 commented that variation in subgroups may be missed by such broad analyses and that further analysis of the NSMHWB data was needed.

Betts and Thornicroft11 noted that mental health services are generally recognised as being less available in rural and remote areas, where access to qualified specialist staff is often very limited. For instance, there are far fewer psychiatrists (by main place of work) for rural and remote populations (3.3 and 1.8 per 100 000, respectively) than for metropolitan populations (14.2 per 100 000). 12 Service use is not independent of provision, ease, and means of access. However, there are few Australian community-based studies looking at service use and mental health that incorporate area of residence in their analyses. In the NSMHWB, residents of rural centres and “other rural” areas were found to be less likely than metropolitan residents to receive help from psychiatrists and psychologists for a mental health problem, findings which persisted after taking a wide range of characteristics into account, including the prevalence of disorders. 13 However, there was no association between participants’ area of residence and whether or not they accessed help from any mental health professional or from a general practitioner for a mental health problem. 13

Higher suicide rates in rural compared with metropolitan areas, despite similar rates of reported mental disorders, suggest that factors other than mental health (including sociodemographic and service-related factors) may also influence suicide rates. For instance, compared with other age groups, young adults, particularly young men, visit GPs infrequently for general healthcare. 14,15 Andrews et al16 found that men without tertiary education and without family responsibilities were the group least likely to consult a professional for a mental health problem and suggested they may not recognise they have a problem. These investigators argued that mental health literacy programs should specifically target these men. 16

The aim of our study was to determine, using existing datasets, whether age, sex and area differences in the prevalence of mental disorders and the use of professional help parallel differences in suicide rates.

In Australia, deaths are recorded by the state registries of births, deaths and marriages. The Australian Bureau of Statistics (ABS) codes these mortality data according to ICD-10 “X” codes for suicide. 17 Suicide refers to deaths resulting from intentional self-harm (X60–X84), including poisoning; hanging/suffocation; drowning; use of a firearm, explosive material, sharp or blunt objects; motor vehicle crashes; and other or unspecified means.

In our study, we used suicide data collated by the Australian Institute of Health and Welfare over a four-year period (1997–2000). We also analysed data from the NSMHWB to examine regional differences in prevalence of mental health disorders and use of professional help for these disorders.

The NSMHWB was designed to establish the prevalence of common mental health disorders and the utilisation and need for mental health services. The survey was carried out by the ABS using trained interviewers. Households were randomly selected using a stratified, multistage area sample. The ABS provided appropriate weights so that an individual’s chances of selection, which varied by state, territory and region, did not bias the results. 18 About 13 600 private dwellings were approached between May and August 1997. From each household, one resident aged 18 years or over was randomly selected and interviewed. The response rate was 78% (n = 10 641). The survey did not include homeless people or people living in non-private dwellings such as prisons, hospitals or nursing homes. Comprehensive descriptions of the NSMHWB methods have been previously reported. 18,19

In the NSMHWB, a modified version of the Composite International Diagnostic Interview was used to assess past-year prevalence rates for substance use, affective and anxiety disorders according to ICD-10 criteria. 20 All respondents were asked about consultations for mental health problems with a wide range of health professionals, including GPs, psychiatrists, psychologists, social workers, welfare workers, drug and alcohol counsellors, nurses, a mental health team or other health professionals.

The Rural, Remote and Metropolitan Area (RRMA) index was included in both the NSMHWB and the ABS mortality data. It is a seven-category classification system based on statistical local areas (Box 1). 21 First, statistical local areas in capital cities and statistical subdivisions containing an urban centre of 100 000 or more people are identified. 22 Then, other statistical local areas are designated an RRMA category based on population numbers and an index of remoteness. The index of remoteness includes a factor relating to the distance from an urban centre (ie, a centre of > 10 000 people) and a population density factor.

The NSMHWB data available to us had been collapsed into three area divisions: metropolitan (RRMA categories 1 and 2), rural centre (RRMA categories 3 and 4) and other rural/remote area (RRMA categories 5, 6 and 7). 19 The suicide data (classified according to the RRMA designation of the usual residence of the deceased) were grouped according to the three NSMHWB area divisions to enable comparison across datasets.

Age-specific suicide rates per 100 000 population were calculated using the ABS estimate of the population age groups living in the different RRMA divisions between 1997 and 2000.

All analysis of the NSMHWB data was conducted using STATA software23 and applying the weights provided by the ABS. The differences between metropolitan areas and each of the other RRMA divisions were evaluated using z-scores, calculated according to the formula z = Dxy / √(Sx2 + Sy2), where Dxy represents the difference between rates for two RRMA divisions x and y (assumed independent), and Sx2 and Sy2 are the variances of the suicide rate among people in RRMA divisions x and y, respectively. A z-score greater than 1.96 or less than –1.96 indicates a significant difference (P < 0.05).

Our study has many of the shortcomings evident when attempting to investigate aspects of rural health. Although the higher proportion of Indigenous people in rural and remote areas may be an important factor affecting suicide rates, it was not possible to identify Indigenous status in the data we used. The NSMHWB data file did not specify Indigenous status, and suicide rates among Indigenous people were not available for all Australian states. The NSMHWB data reported here did not include adolescents (aged < 18 years), so our analysis cannot explore this population. While this study discusses trends and suggests possibilities, it cannot directly evaluate cause and effect, because the data were cross-sectional. Furthermore, the RRMA classification does not allow for diversity within statistical local areas and combines the concepts of distance and population density. 22 We acknowledge and emphasise that there is considerable variability within and across regions of Australia. It is also important to note that the NSMHWB data reflect self-reported symptoms/disorders and that young men, particularly those in non-metropolitan areas, may have been less likely to report, recognise or be concerned about symptoms than their metropolitan counterparts.

The small number of participants surveyed in non-metropolitan areas has several implications. First, rural and remote RRMA categories needed to be collapsed when reporting service-use patterns from the NSMHWB dataset, so we were unable to compare rural and remote areas. Second, a range of subgroups, specific services, patterns of use and characteristics could not be examined. Third, four years of suicide data (1997–2000) from the ABS needed to be combined to enable a breakdown by age and sex, whereas the NSMHWB was conducted over a single year (1997). Finally, the small sample sizes in rural and remote areas may have meant that some significant differences between groups were not found (eg, in the proportion of mental health disorders among young men in rural and remote areas compared with metropolitan areas).

We were unable to investigate the reasons why professional help is or is not used. Tudiver and Talbot24 argued that men do not seek general healthcare for a range of reasons, including a tendency to use indirect sources of help; the perception that seeking help will show their vulnerability; fear and denial; difficulty relinquishing control; and systematic barriers. Another study indicated that knowledge about depression and its treatments was greater among women and younger people. 25 Mental health literacy may be a particular problem for young men in rural areas, who may be less likely to recognise or report symptoms of distress or know what can be done to help.

Some researchers have argued that a high proportion of suicides among patients with psychiatric disorders may be preventable through appropriate service-system responses. 26,27 While improving suicide prevention strategies for people already in contact with professional help is vitally important, mental health policy and services also need to better incorporate people who currently have little contact with the healthcare system.

Overall, a wide range of factors, including those relating to being male, together with a fundamental lack of services, may help to explain why young men, particularly those in rural areas, do not access professional help.

Given that mental health problems are a major risk factor for suicide, a better understanding of the reasons behind young rural men’s use and non-use of services is of considerable importance. Increasing service use by and for these men, even to a small degree, might reduce their suicide rates.