Rural mental health

A romanticised ideal of rural life has been pervasive among the privileged members of our society for at least three centuries. The paintings of Constable and the country house retreats of the urban rich are a historical testimony to this thinking. This view of our society gives rise to assumptions which continue to influence Government policies in a wide variety of areas including transport, employment, education and health. Although one-fifth of the UK population lives in rural areas, health services have tended to concentrate clinical resources and expertise in the larger metropolitan areas and, not surpris ingly, medical research has followed suit. De spite the wealth of literature on the links between urban forms of deprivation and a wide range of health problems, there is not adequate data to support any definitive statements about rural/ urban patterns of physical disease (Watt et al, 1993) and we know even less about rural mental health.

A romanticised ideal of rural life has been pervasive among the privileged members of our society for at least three centuries.The paintings of Constable and the country house retreats of the urban rich are a historical testimony to this thinking.This view of our society gives rise to assumptions which continue to influence Government policies in a wide variety of areas including transport, employment, education and health.Although one-fifth of the UK population lives in rural areas, health services have tended to concentrate clinical resources and expertise in the larger metropolitan areas and, not surpris ingly, medical research has followed suit.De spite the wealth of literature on the links between urban forms of deprivation and a wide range of health problems, there is not adequate data to support any definitive statements about rural/ urban patterns of physical disease (Watt et al, 1993) and we know even less about rural mental health.

Defining rurality
There is no universally agreed definition of rurality.The concept encompasses ideas such as population density, social and physical environment and land use.What constitutes a rural environment is inevitably relative, particu larly internationally -rurality in England is quite different to rurality in Australia.
In the UK, various definitions have been applied using population density (Shucksmith. 1990: Rural Development Commission. 1994).complex indices (Cloke. 1977) and arbitrary judgement by research worker (Meltzer et al, 1995).In such circumstances, it is clear that researchers must select a method of defining rurality which is appropriate to the study being conducted and define this clearly when present ing results.

Psychiatric morbidity
Rapidly increasing homelessness, lack of sup ported housing, social isolation, stigma, poor or non-existent transport and inaccessibility or absence of services are characteristics of rural areas (Bentham & Haynes, 1986: Shucksmith et al 1996) which do not fit comfortably with the popular (and professional) assumptions that the rural environment offers protection from mental illness.
In 1984, Webb critically reviewed the literature and concluded that there was little evidence of significant rural/urban differences in psychi atric morbidity.A major difficulty in evaluating this literature is the complexity of the different factors operating and the over-generalised con cept of a simple rural/urban comparison.The more recent literature allows us to begin to unpick some of the detail and extract more meaningful conclusions by examining the influ ence of factors such as culture/nationality, diagnostic groups, ethnicity/race, occupation/ social class and geographic/clustering effects.

Different countries -different effects
Striking differences between countries emerge in the patterns of overall psychiatric morbidity between towns and countryside and it is clear from the variations between countries that findings from international studies cannot be generalised to the UK(Studies examining general psychiatric morbidity.Urban > Rural, Bowling & Farquhar. 1991 (UK).Lewis & Booth. 1994 (UK): Urban < Rural, Lee et al, 1990 (Korea).Guinness, 1992 (Swaziland): Urban=Rural, Gyllenhammar et al, 1988 (Sweden).Cheng, 1989 (Taiwan).McGee et al, 1991 (NewZealand), Romans et al, 1992 (NewZealand)).

Diagnosis
Finding are no more consistent in studies examining particular diagnoses (Table 1).
However, the fairly robust methodologies of some of the studies give credibility to their individual findings.For example, among the UK studies, the Office of Population Censuses and Surveys survey of psychiatric morbidity in nearly 10 000 adults in private households (Meltzer et al 1995) found significantly higher prevalences in urban areas of depression (Odds ratio (OR) 1.38).anxiety disorder (OR=1.30)and phobia (OR=1.66)but no significant differences in obsessive-compulsive disorder, panic, alcohol and drug dependency or psychosis, although in the latter case numbers were very small.Rurality Psychiatric Bulletin (1998), 22, 273-277 (Brown & Prudo. 1981 (Hebrides v. Camberwell)) Neuroses (Keatinge, 1988 (Eire)) Anxiety and depression (Crowell et al, 1986 (Carolina)) Schizophrenia (Thornicroft et al. 1993 (Italy)) Depression (Cheng, 1989 (Taiwan)) Depression (Orley & Wing, 1979 (Uganda v. Camberwell)) Schizophrenia (Keatinge, 1988 (Eire)) was not defined but left to the impression of the large numbers of interviewers carrying out home-based assessments.The study by McCrea die et al (1997) demonstrates that the prevalence of schizophrenia in a rural Scottish area is half that in deprived inner-city Camberwell.The authors point to the difficulty of generalising these findings even within the UK and replica tions in other parts of the country are required.A study examining the rates of personality disorder presenting to urban and rural general practices in the Nottingham area found a higher rate in urban areas solely accounted for by the explosive/sociopathic category, with similar rates across the areas in all others (Casey & Tyrer, 1990).

Ethnicity /race
The impact of race on the prevalence of schizo phrenia is well-documented (Leff. 1988).McCreadie et al (1997) have demonstrated in their UK study that the large difference in prevalence of schizophrenia between their rural and urban areas was almost entirely accounted for by the high prevalence in urban non-Whites, with little difference between urban and rural Whites (despite socio-economic differences).Although numbers of non-Whites in Britain's rural areas are typically small, the difficulties such individuals face may be considerable (Sherlock, 1994) but little is known about the effects on their mental health.

Occupation /social class
The influence of factors associated with social class on levels of psychiatric morbidity is well described (Thornicroft, 1991).but most studies have been carried out in urban areas.Studies or rural population examining this relationship are rare.Romans-Clarkson et al (1990) found a similar relationship between socio-economic states and morbidity in New Zealand women from rural and urban areas.However, Thorni croft et ai (1993) found no relationship between a variety of service utilisation measures and employment or education levels in a rural population, although a significant association was found in a neighbouring urban sample.
In a UK study.McCreadie et al (1997) found similar levels of gainful employment and educa tional qualifications among people with schizo phrenia in rural and urban areas.
Farmers are an almost exclusively rural occupational group with a particularly high suicide risk, which ranks fourth in order of risk by occupation and now accounts for the second most common cause of death for male farmers under 45 (accidents being the first).In terms of absolute numbers of suicides, farmers have the highest numbers of any occupation in the UK.These high rates are related to depressive illness and access to means, particularly firearms (Malmberg et al, 1997).The Samaritans and National Farmers' Union have recently been targeting preventative efforts at this high-risk group.

Geographical and clustering ejfects
In addition to the international differences in distribution of psychiatric morbidity across rural and urban areas specific clusters of high levels of specific disorder have been described.Taking, for example, the prevalence of schizophrenia, specific areas of very high and very low prevalence have been described throughout the world with up to 20-fold variations in rates (Torrey et al, 1984: Torrey, 1987).The differ ences described do not show any consistent rural-urban patterns, and are on the whole far greater than any differences in morbidity which have emerged from comparisons of rural and urban areas.

Proxy/indicators of morbidity and need
Given the dearth of direct information on morbid ity and service requirements, are there any indirect indicators of mental health needs which can reliably guide us?Indices of deprivation are increasingly applied in resource allocation, but their validity in rural areas has been challenged (Jessop, 1992).The commonly used deprivation indices have been developed in urban areas, and the relationship between these indices or compo nents of them and psychiatric morbidity may be different in rural areas, as found by Thornicroft et al (1993).Several studies have documented differences between rural and urban areas in the relationship between mental illness and factors such as social support, life events and physical illness (Brown & Prudo, 1981: Carpiniello et al 1989;Romans-Clarkson, 1990: Bowling & Farquhar, 1991).

Service provision
More consistent findings emerge from the exam ination of service issues.Primary care appears to be more involved in mental health in the rural areas around Nottingham (Seivewright et al. 1991).Patients had more contact with psychi atrists in urban areas (including more contacts because of physical complaints) and patients in rural areas had more contact with general practitioners.Psychotropic drug use and admis sion rates were higher in the urban area.Very similar findings were reported by Sullivan et al (1996) in Mississippi, who concluded that the results were most likely to be due to the lesser availability and accessibility of services in the rural areas.A study of schizophrenia in indigen ous populations in two areas of Eire (Keatinge, 1988) showed the same incidence in urban and rural areas but the first admissions in the rural group occurring at a later and more chronic stage.Another Irish study (Keatinge, 1987) showed a tendency to under-report neurotic, though not psychotic, symptoms in rural areas and a more negative attitude to psychiatric facilities in rural areas leading to a higher threshold for seeking help.A UK survey of general practitioners' attitudes demonstrated perceived inaccessibility of mental health ser vices in rural areas (Stansfleld et al 1992).Hall (1988) showed that distance from services was a significant predictor of utilisation of mental health services.Cuffel (1994) has shown higher thresholds for admissions to psychiatric hospital in rural than urban areas.A Swedish study (Gyllenhammar et al. 1998) found that, given similar and equally accessible services in rural, suburban and urban areas, the number and nature of emergency psychiatric presentations were the same.
Given the increasing role of primary care in looking after the mentally ill it is important to appreciate the relative inaccessibility of primary care facilities as well as social services and voluntary sector facilities in rural areas (Bentham & Haynes, 1986: Fearn, 1987).Find ings of increased burden on families and in formal carers of people with schizophrenia in rural areas (Martyns-Yellowe, 1992) may also be a reflection of the same service issues.The lack of community facilities for people in rural areas has been highlighted by various non-Govern ment organisations who are beginning to focus particular attention on rural mental health issues (e.g.Ruralminds.Rural Stress Infor mation Network.Samaritans).
The paper by Smith & Ramana (1998) provides further evidence of the unequal distribution of resources which results from historical differ ences in provision and unquestioning urban focus, rather than an analysis of needs.
Resource allocation and service planning must reflect the difficulties and peculiarities of provid ing secondary care service in rural areas.The problems facing users and primary care in accessing services and the difficulties for sec ondary care in providing them are well described (Sherlock, 1994) but the quantitative data and cost implications are lacking (Pullen & Kendrick, 1995) although these may be significant (Watt et al 1994).

Towards a better understanding of rural mental health issues
The international variation in urban/rural patterns of morbidity demonstrates the need to interpret these data in their cultural and social context.In the UK, overall psychiatric morbidity appears to be greater in urban areas.This must be interpreted with caution as we still know little about patterns of individual disorders and there is some evidence of greater hidden morbidity and higher thresholds for reporting symptoms in rural areas.Furthermore, greater accessibility to services in urban areas may lead to resourceled drift of users to those areas.The size of even the largest rural/urban differences is small compared with the effects of other factors such as race, national or more local geographical differences and social class.
The probable lesser prevalence of disorders in rural areas could be due to lower incidence or a more favourable course of disorders, or both.It is impossible to distinguish which process is operating but if there is some "illusive quality about rural environments" (Crowell et ai, 1986) which confers protection or better outcome, we should make efforts to identify it through research and preserve it where it exists.
As the organisational requirements and costs of rural mental health service provision are also inadequately defined, it is inevitable that the already disjointed systems for the funding of community care in rural areas will depend on historical and arbitrary judgements.We need UK-based research giving detailed data on detected and undetected morbidity and associ ations with indices of deprivation in rural areas which could provide valid proxies.This needs to be coupled with quantitative studies of mental health service requirements at primary and secondary care levels to ensure that the mentally ill in rural areas are not forgotten in the drive to improve the mental health of the nation.

Table 1 .
Diagnosis specific studies of rural-urban morbidity