COVID‐19 and mental health and well‐being in rural Australia
Clare Fitzmaurice
Abstract
As multiple Australian jurisdictions struggle to control outbreaks of the COVID-19 virus, the likelihood of rural Australians experiencing detrimental effects on their lives and livelihoods increases, whether that be due to the virus itself, the policy measures implemented to control it or associated economic impacts. The potential for the COVID-19 pandemic to influence mental health and well-being was recognised early, given communities’ concerns about contracting the virus, loss of social interaction, restriction to movement, transition to remote work or study and financial impacts.1 In addition, the pandemic has the potential to exacerbate pre-existing mental health conditions.1 While the reported prevalence of mental illness is similar across the nation—around 20%—it has been suggested that these statistics mask inequitable rates of psychological distress and untreated (or undiagnosed) mental illness, with rates of self-harm and death by suicide increasing with remoteness from major cities.2 There are several possible reasons for this geographic disparity. Owing to the nature of the industries that sustain them and the geographic locations of their communities, rural people are more vulnerable to the effects of various factors outside their control, including extreme weather events and long-term changes to climate, commodity prices and changes to global trends in industry practice. These factors, combined with social and economic inequities such as lower incomes, lower educational attainment and higher rates of unemployment, generate a situation of cumulative and ongoing adversity, which can impact mental health and well-being.3 The COVID-19 pandemic adds to these underlying vulnerabilities. Access to health services in rural areas is poor, and this is particularly true for mental health, where data on service utilisation suggest rural people are less likely to access primary health care for their mental health concerns, but more likely to present at an emergency department seeking acute care—indicative of presentation later in the course of an illness or in a more severe state of distress.2 This trend to later presentation to health services by rural people is indicative of a lack of access to primary health care in rural areas. Workforce supply issues contribute significantly to reduced access to services. In general, the mental health workforce reduces with increasing distance from metropolitan centres and is disproportionate to increasing need. There are fewer psychiatrists, psychologists and mental health nurses available with increasing distance from a major city: per capita, 2.7 times as many psychiatrists work in major cities as in outer regional areas and 2.8 times as many psychologists work in major cities compared with remote areas.2 Additionally, access to general practitioners, who are frequently the conduit for people to access key mental health support, is particularly poor in small rural towns throughout Australia.4 There are other additional issues unique to rural living that reduce access to mental health and well-being services. These include attitudinal factors, such as beliefs about the usefulness of seeking help and privacy concerns; the cost of services, associated travel and forgone work; and digital factors, which include access to technology, useability and speed of connectivity.2 It is clear, therefore, that there is significant unmet population need for mental health services and supports in rural Australia, challenges to the provision of a suitable and sustainable workforce, and multiple barriers to access. The pandemic has the potential to further embed this inequity. Deaths due to suicide in our two most populous states, up until the end of February (NSW) and end of March (Vic) 2021, are comparable to numbers prior to the pandemic.1 Yet, usage of mental health crisis and support organisations has increased considerably—with answered contacts in April 2021 (compared to the same period in 2019) up by 57% for Beyond Blue, 32% for Lifeline and 16% for Kids Helpline.1 The effect was most pronounced in Victoria. In August, Lifeline broke its record number of calls in one day, with the new record 40% higher than the average number of calls at the same time before the pandemic.5 Data from the New South Wales Department of Health, reported in the Sydney Morning Herald, highlight the significant impact on young people, with statistics for the year to 29 July 2021 demonstrating a 47% increase in emergency department presentations for self-harm in those aged 0-17 years between 2019 and 2021, and 2000 additional presentations compared with 2020.6 While some experts suggest any effect of the pandemic on mental health and well-being is likely to be occurring on top of a pre-existing long-term trend,7 which might include the bushfires of late 2019 and early 2020, the numbers cannot be ignored. There are reports of overburdened mental health services in metropolitan areas, driven by increased demand for services in combination with staff shortages, owing to the need for staff to quarantine or self-isolate after exposure to, or contracting, COVID.8 This is contributing to burnout in metropolitan mental health professionals, resulting in their need to take time off and further reducing workforce supply. If this is true in major cities, the likelihood of already stretched rural services being overwhelmed is high. The possible impact on mental health and well-being extends not only to mental health professionals, but also to health workers more generally, as evidenced by increased calls to doctors’ health programs in Victoria.8 As the scenario of overstretched rural and regional hospitals and health services looms,9 fatigue, burnout and mental health symptoms will need to be managed in front-line workers placed under stressful conditions for extended periods of time. While mental health is only one facet of overall health and must be considered in the context of broader management of the pandemic in rural areas, it is imperative that policymakers and governments anticipate the potential impact of the ongoing pandemic on the mental health and well-being of rural health consumers, health professionals and communities more broadly and implement appropriate strategies to safeguard them. These strategies must consider the unique needs of rural communities, avoiding the broad-brush application of metropolitan solutions where they might not be fit for purpose. The Alliance suggests that such solutions include consideration of how best to bolster and support the existing mental health workforce, the mental health and well-being needs of the health workforce more generally, and appropriate messaging and communication avenues to target rural people who are less likely to seek help for mental health issues.