SAMH Research Report Remote and Rural Mental Health

Transcription

1 SAMH Research Report Remote and Rural Mental Health August

2 Introduction In 2012, SAMH launched the Know Where to Go campaign. This aims to enable people in Scotland to get support for mental health problems when they need it. Recognising that some people face additional barriers to getting help for their mental health due to geographical factors, we have chosen to dedicate part of the campaign to rural and remote areas of Scotland. This report forms part of that work and outlines some the available evidence on remote and rural mental health, as well as identifying opportunities to improve it. We believe that everyone should be empowered to know where to go for mental health support - no matter who they are or where they live. Around 5.2 million people live in Scotland, with almost 1 million of them living in rural areas. 1 Over recent years, the population of rural Scotland has grown at a faster rate than the rest of Scotland, mainly due to inward migration. However, mental health services and supports have traditionally been centralised in urban areas. There has also been little work undertaken to help identify the key barriers and opportunities for people in remote and rural areas in accessing help for their mental health. Remote & rural definition There is no universally agreed definition of rural, which has led to some debate over how the terms remote and rural should be defined and understood. The Scottish Government Urban Rural Classification provides a standard definition 2 of rural areas in Scotland. This defines a rural area as a settlement with a population of less than 3,000. By analysing drive times to larger settlements, rural areas are further broken down as shown below: Accessible rural: those with a less than a 30 minute drive time to the nearest settlement with a population of 10,000 or more; Remote rural: those with a greater than a 30 minute drive time to the nearest settlement with a population of 10,000 or more. Remote & rural mental health There is relatively little research into rural mental health in the UK, but some reviews 3 of international literature have concluded that mental health is probably better in rural areas. The evidence in this regard is strongest for psychosis and in particular schizophrenia. International evidence also suggests that the incidence and prevalence of common mental disorders, including depression and anxiety, 1 National Statistics - Rural Scotland Key Facts, Scottish Government, National Statistics - Rural Scotland Key Facts, Scottish Government, Rural Mental Health, Laura Anne Nicolson, Advances in Psychiatric Treatment (2008) 14: 302-2

3 are either lower or the same in rural as in urban areas. Conversely, suicide in men has been consistently shown to be higher in those living in rural areas. 4 However, the mental health of the rural population is affected by a range of challenges, dependent on locality. As such, international research is unable to account for the unique socio-economic aspects of rural life in Scotland, and how they may also impact on mental health. This includes factors such as unemployment, poverty, ethnicity, and drug and alcohol misuse. There is anecdotal evidence that there are high levels of alcohol consumption amongst males in some of the most isolated areas of rural Scotland, and that such consumption is culturally acceptable, or even encouraged. 5 Scottish research 6 has also uncovered that there can be a number of factors specific to rural areas that may contribute to stress, anxiety and depression. These are discussed further in the following sections. Challenges Culture and perception of mental health Before seeking help for mental health problems, people first have to recognise that they are experiencing mental ill-health and understand that support is available. This will depend not only on a person s knowledge of mental health, but also on cultural factors within their community that affect how mental illness is perceived and accepted. There is evidence to suggest that the isolation of remote and rural communities may produce a culture of self-reliance and stoicism towards health problems. 7 Research specific to Scotland 8 has found that although there are many cultural traits that are common to both rural and urban areas, culture can vary between urban and rural communities, and even across rural communities. Physical isolation from social networks and support services, combined with an exaggerated culture of self-reliance, is thought to contribute to stress, anxiety and depression in rural areas. The research also found that common mental health problems are often not recognised by people in rural areas as something that requires treatment and practical support. Stigma Similarly to urban areas, the stigma associated with mental ill-health is present in rural areas. The reputation of having a mental health problem can also stay long 4 Rural Mental Health, Laura Anne Nicolson, Advances in Psychiatric Treatment (2008) 14: Scottish Executive, Poverty and Social Exclusion in Rural Scotland. (2001) 6 Scottish Executive, Poverty and Social Exclusion in Rural Scotland. (2001) 7 Rural Mental Health, Laura Anne Nicolson, Advances in Psychiatric Treatment (2008) 14: Scottish Executive, Poverty and Social Exclusion in Rural Scotland. (2001) 3

4 after a person has recovered. 9 Research comparing the experiences of mental health service users in the Highlands of Scotland with those in rural Alberta (Canada) revealed that, while stigma is a problem in both locations, it is more pronounced in the Highlands. It also showed that stigma can act as a barrier to people accessing services and being accepted in their community. 10 This finding is supported by HUG (a network of people who have experience of mental health problems in Highland Scotland), who have commented that stigma is still a big problem in rural Scotland. This can alienate and isolate people, and prevent them from accepting or seeking help. Furthermore, people can be subject to verbal abuse and through this can be made to feel inadequate and ashamed. 11 Visibility and confidentiality Scottish research has shown that higher visibility in small communities can prevent some people from seeking support for mental ill-health, and cause them to hide problems from the rest of the community. 12 In an urban area it is easier to achieve anonymity when accessing mental health services. In rural areas, people accessing mental health services can be very visible within their communities. Therefore, many people will hide their problems rather then risk being stigmatised or labelled. 13 Some families in rural areas may also try to protect their relatives from loss of anonymity by hiding their mental ill-health, and refusing them access to mental health services. 14 If a mental health worker is well-known in the local community, people may refuse home visits for fear of recognition. Similarly, people may not feel comfortable disclosing mental health concerns to a GP who lives locally, or who is considered to be part of their local community. Access to services Access to healthcare should be as local as possible, for everyone in Scotland, no matter where they live. However, in Scotland, the experience of healthcare for people in rural areas differs from that of people in urban areas in that they often have to travel large distances to receive care. 15 Remote rural areas are the only areas in Scotland which are not within a 15 minute drive time to key services. For 9 Scottish Executive, Poverty and Social Exclusion in Rural Scotland. (2001) 10 Mental Health Services and Social Inclusion in Remote and Rural Areas, Clare Daly, The Views of People With Experience of Mental Health Problems in Highland on the Main Issues That They Have Been Facing in 2011/2012, HUG (Action for Mental Health), Scottish Executive, Poverty and Social Exclusion in Rural Scotland. (2001) 13 Scottish Executive, Poverty and Social Exclusion in Rural Scotland. (2001) 14 Rural Mental Health, Laura Anne Nicolson, Advances in Psychiatric Treatment (2008) 14: Delivering for Remote and Rural Healthcare, The Final Report of the Remote and Rural Workstream,

5 example, 93% of people in remote rural areas live within a 15 minute drive time to a GP compared to 100% of the population of accessible rural areas and of the rest of Scotland. One report has said that hospitals, mental health care and GP provision are all currently being reduced at a local level, with services being centralised in main towns and community services withdrawn. 16 HUG have commented that transport is hugely important to get to services and to attend appointments. They also report that in rural areas it can be almost impossible to reach services or other places by public transport and prohibitively expensive if people don t have bus passes. Over half of the residents of rural Scotland in reported having to spend over 100 a month on fuel for cars, compared to 38% in the rest of Scotland. 17 People have also reported to SAMH that appointments can be arranged for times which are incompatible with public transport timings. For example, someone may be given a 4pm hospital appointment whilst the only bus service which could enable them to attend operates at 9am. Concerns have also been raised 18 about the availability of crisis support for people in rural Scotland. This includes a lack of immediate specialist support, difficulty in identifying local Places of Safety which are required under the Mental Health (Care and Treatment) (Scotland) Act 2003 and delays for people requiring specialist hospital care. HUG have reported 19 that the wait to be admitted to hospital can be deeply unsatisfactory and that sometimes, when help is available, poor knowledge and communication can make it hard to obtain. The Opportunities The rural environment & community Residents of rural Scotland are more likely to rate their neighbourhood as a 'very good' place to live when compared to the rest of Scotland. A higher percentage of residents of remote and accessible rural Scotland particularly like the safe environment and the friendliness of their community. 20 Research has consistently shown that regular contact with the natural environment enhances both physical and mental wellbeing. It reduces stress and improves mood. It also provides a restorative environment for people to relax, unwind and recharge their batteries. 21 Easy access to greenspace could therefore be a significant advantage for people living in remote and rural areas of Scotland. 16 Voices of Women in Rural Scotland, Scottish Women's Convention, National Statistics - Rural Scotland Key Facts, Scottish Government, Remote & Rural Mental Health Services Report, Scottish Government, The Views of People With Experience of Mental Health Problems in Highland on the Main Issues That They Have Been Facing in 2011/2012, HUG (Action for Mental Health), National Statistics - Rural Scotland Key Facts, Scottish Government, Ecotherapy - The green agenda for mental health, Mind,

6 Some research supports the view that the rural community is also stronger or better than the urban community. For example, there may be a stronger sense of community or community spirit in rural areas and people living in rural areas are more likely to feel included in their local community. 22 Belonging to a community is generally considered to be good for mental health and wellbeing but this will only be possible where people feel valued, included and fully able to participate. Employment & Volunteering In rural Scotland, a higher proportion of people give up their time to help as a volunteer or organiser than in the rest of Scotland. The highest rate of volunteering was observed for people aged in remote rural areas (50%). 23 Helping other people is a good way of linking people to their local communities and can be highly rewarding. Furthermore, research has shown that doing an act of kindness once a week over a six-week period can increase your wellbeing. 24 Employment rates are higher for all groups in rural areas compared to the rest of Scotland. 25 Meaningful work is good for everyone s mental health and wellbeing, and can bring considerable financial, health and social benefits to people with mental health problems. In the field of mental health, work is also increasingly being seen as a significant stage in the journey to recovery, rather than recovery as a necessary precursor to work. 26 However, people with mental health problems have the lowest employment rates of any of the main groups of disabled people. 27 Many of the barriers to employment faced by people with mental health problems are attitudinal; arising from people s lack of knowledge or attitudes towards people with mental health problems. HUG have reported that people who can t work due to mental-ill health can find it very hard to explain why this is so, as they don t know how to make their fear of the workplace and the effect it has on them understood. Furthermore, experiences may vary greatly between rural areas with HUG also reporting that in remote areas there is often little or nothing to do and few chances for employment Rural Mental Health, Laura Anne Nicolson, Advances in Psychiatric Treatment (2008) 14: National Statistics - Rural Scotland Key Facts, Scottish Government, Lyubomirsky S, Sheldon KM, Schkade D (2005) Pursuing happiness: The architecture of sustainable change Review of General Psychology 9: National Statistics - Rural Scotland Key Facts, Scottish Government, People with mental health conditions and Pathways to Work, DWP, Research Report No 593, Disability and Employment in Scotland: review of evidence base, Scottish Executive, The Views of People With Experience of Mental Health Problems in Highland on the Main Issues That They Have Been Facing in 2011/2012, HUG (Action for Mental Health),

7 Technology Households in rural Scotland are slightly more likely to have home internet access than those in the rest of Scotland. Households in accessible rural areas of Scotland are more likely to have home internet access and more likely to utilise a broadband connection. 29 This presents an opportunity to ensure that people are able to connect with others and also access information about mental health. This may be particularly useful when considered alongside the challenges posed by visibility in rural communities. Internet-based mental health programs could become a powerful tool in the rural medical kit. Recommendations: The NHS, Local Authorities and other agencies involved in community planning should ensure that people living in remote and rural areas have meaningful opportunities to influence decisions about which mental health services are provided locally and which people will be expected to travel to. This is particularly important given the current financial pressures and resultant service cuts. The Scottish Ambulance Service and local transport service providers should review the provision of non-emergency patient transport services, to ensure that everyone is able to access the services they need and attend appointments. Whenever services are reviewed or established, ensuring that people can reach them by public, NHS or local authority-provided transport should be a main consideration. Contingencies should be better developed by the NHS to support practitioners in remote and rural areas to manage a mental health crisis, and ensure that people receive a prompt response. Crisis services should be provided locally to allow people, as far as possible, to receive support at home or in their community. NHS Boards should also ensure that all relevant staff have received training in the management of mental health crisis and that a 24/7 response can be provided. Anti-stigma work in relation to mental health is crucial. The Scottish Government should consider how existing work on stigma reduction in mental health, such as the see me campaign, could be specifically adapted to achieve maximum impact in remote and rural areas. 29 National Statistics - Rural Scotland Key Facts, Scottish Government,

8 Services within rural communities must be delivered in such a way that prevents service users from feeling stigmatised. For example, mental health outreach services could be delivered at the same time from the same venue as other services, so it is not obvious which services people are accessing. The voluntary sector has an important role to play in the delivery of services in remote and rural communities. Greater use should be made of the voluntary sector to deliver health services and provide information in rural communities. Statutory, non-statutory and voluntary sector organisations should work together with rural communities to develop a coordinated approach to the delivery of services. Advice and information about mental health and mental health promotion activities should be co-ordinated and targeted to achieve maximum impact in rural areas. New technologies should be used wherever possible to maximise the amount of care and information that can be provided locally. For example, talking therapies can be offered via the internet or telephone as well as in person. The Scottish Government and UK Department of Work and Pensions should better promote the supports which are available to help people experiencing mental ill-health to gain or keep employment. This would include the support available from Disability Employment Advisors. The value of volunteering for people with mental health problems should also be publicised. 8