Suicide in rural Australia: A retrospective study of mental health problems, health-seeking and service utilisation

A 'Vocal Locals' social network campaign is associated with increased frequency of conversations about mental health and improved engagement in wellbeing-promoting activities in an Australian farming community

BACKGROUND

Farmers face numerous barriers to accessing professional mental health services and instead report a preference for informal support systems, such as lay or peer networks. Farmers also experience barriers to investing time in maintaining or improving their wellbeing, stemming from sociocultural norms and attitudes that are widespread in agricultural communities. The Vocal Locals social network campaign is an ifarmwell initiative that aims to promote conversations about wellbeing and challenge attitudes and behaviours that contribute to farmers' poor mental health.

METHODS

The Vocal Locals campaign was underpinned by the socio-ecological model which explains human behaviour as stemming from interactions between the individual, their closest social circle, the community, and broader society. The campaign ran in Loxton, South Australia, from June to August 2022. Ten community members (8/10 farmers) became 'Vocal Locals' and were supported to share 'calls-to-action' to encourage people in their social networks to engage in wellbeing-promoting activities. A broader communications campaign reinforced key messages and amplified Vocal Locals' activities in the community. The intrapersonal and community-level impacts of the campaign were evaluated via pre- and post-campaign surveys of Vocal Locals and community members respectively.

RESULTS

Vocal Locals reported significantly lower psychological distress (p = .014), and higher positive mental wellbeing (p = .011), levels of general mental health knowledge (p = .022), and confidence helping someone with poor mental health (p = .004) following the intervention. However, changes in stigmatising beliefs about mental illness, confidence recognising poor mental health, and confidence and comfort speaking to others about mental health were non-significant. Community members who were familiar with the campaign reported having significantly more wellbeing-related conversations post-campaign compared to before (p = .015). Respondents also reported being more comfortable speaking to others about mental health or wellbeing (p = .001) and engaging more in activities to maintain or improve their wellbeing (p = .012) following the campaign.

CONCLUSIONS

The Vocal Locals social network campaign is an example of how science and community can be brought together to achieve meaningful outcomes. The campaign may serve as a model for others who wish to challenge attitudinal or knowledge-related barriers to help-seeking and improve engagement in wellbeing-promoting activities in difficult-to-reach communities.

This Bloke Who Helps Me With My Tractor, He's Been the Best Psychologist: The Experience of Seeking Mental Health Support in Rural Australia

Mental illness is difficult to discuss among men due to notions of remaining tough, being a man, and societal expectations. In rural communities this is particularly evident which is further exacerbated by poor health care access. The aim of this study is to understand the lived experiences of men and their significant others when seeking mental health support in rural areas. A qualitative study was conducted using purposeful sampling. Data were collected using semi-structured interviews in rural or regional areas of Australia. Open-ended questions were asked but more questions were developed from the responses given. Data analysis was conducted using thematic analysis. Four key themes emerged. These encompassed triggers and help-seeking caused by stressors such as work, family, and poor physical health, with support seeking from professional or informal supports. The second theme included challenges securing professional support appointments, while the third was centered on access to medication and travel time. Finally, the final theme encompassed relationships being impacted by poor mental health or created insights into the need to seek help. The experiences explored throughout this study highlight that as men are impacted, so too are married or romantic partners and children; however, they are the catalyst for help-seeking. The study further highlights even when men are psychologically prepared to seek help, it may be difficult to do so. Improving access goes beyond mere medical professionals in rural areas and must focus on supporting families and loved ones to support men.

Geographic variation in emergency department presentations among youth (10-24 years), New South Wales 2019: An epidemiological study

OBJECTIVE

To characterise ED presentations among youth in New South Wales (NSW) by geographic remoteness for 2019 and determine if intra-regional (inland vs coastal) variations exist.

METHODS

A population-based, retrospective descriptive analysis of 2019 Emergency Department Data Collection registry data for state-wide emergency presentations to NSW public hospitals among NSW residents aged 10-24 years was undertaken. Local government areas of residence were classified as major city, coastal regional, inland regional or remote. Sex and age-adjusted ED presentation rates were modelled according to geographical classification, using negative binomial regression.

RESULTS

In 2019, 178 public ED facilities in NSW received 479 880 presentations from NSW residents aged 10-24 years. ED presentation rates in regional and remote areas were more than twice (incidence rate ratio 2.23, 95% confidence interval 2.08-2.39) and four times (incidence rate ratio 4.32, 95% confidence interval 3.84-4.87) that, respectively, of major cities. Compared to major cities, youth presenting to regional and remote facilities spent 36% and 60% less time in ED, respectively, with presentations less likely to be deemed critical, occur after-hours or result in hospital admission. Variation between inland and coastal regional indicators was minimal.

CONCLUSIONS

Patterns of ED utilisation between major city, regional and remote youth were distinctly different, but not so between coastal and inland regional youth. Further research could better understand ED utilisation among youth and the drivers of higher presentation rates in regional and remote areas.

Online mental health screening for rural fathers over the perinatal period

OBJECTIVE

To determine the feasibility of identifying distressed fathers in rural areas of NSW via a 'light touch' support program (SMS4dads).

DESIGN

A retrospective observational study using self-reported distress and routinely captured help-seeking behaviour over a 14-month period (September 2020-December 2021) comparing rural and urban fathers.

SETTING

Rural and urban Local Health Districts in NSW.

PARTICIPANTS

A total of 3261 expectant and new fathers enrolled in a text-based information and support service (SMS4dads).

MAIN OUTCOME MEASURES

Registrations, K10 score, program engagement, attrition, escalation and referral to online mental health services.

RESULTS

Rural (13.3%) and urban (13.2%) enrolments were equivalent. Rural fathers had higher rates of distress than urban fathers (rural 19%; urban 16%) and were more likely to be smokers, consume alcohol at risky levels and report lower education levels. Rural fathers were more likely to exit the program early (HR = 1.32; 95% CI 1.08-1.62; p = 0.008); however, once adjusted for demographic factors aside from rurality, this increased likelihood was nonsignificant (HR = 1.10; 95% CI 0.88-1.38; p = 0.401). Although engagement with psychological support during the program was equivalent, a greater proportion of rural participants were escalated to online mental health support (7.7%) than urban participants (6.1%); however, this was nonsignificant (p = 0.222).

CONCLUSION

Digital platforms offering text-based parenting information in a 'light touch' format may be an effective way to screen rural fathers for mental distress and connect them to online support.

Preconception factors associated with postnatal mental health and suicidality among first-time fathers: results from an Australian Longitudinal Study of Men's Health

PURPOSE

Prospective evidence about men at risk of postnatal difficulties is rare-particularly for postpartum suicidal ideation. This study aimed to determine the extent to which first-time fathers reported depressive symptoms and suicidal ideation and behaviours in the first postnatal year, and to identify preconception risk factors for postnatal mental health difficulties.

METHODS

Secondary analysis of data from The Ten to Men Study-Australia's population-based prospective study of men's health was conducted. Participants were 205 men who became first-time fathers in the 12 months prior to wave 2 (2015/16). Regression analyses were used to ascertain preconception (mental and physical health, lifestyle) and demographic factors associated with postnatal depressive symptoms.

RESULTS

Postnatally, 8.3% of fathers reported moderate to severe depressive symptoms, 5% had suicidal thoughts, 3% had plans, and less than 1% had attempted suicide. Preconception depressive symptoms was the only factor significantly associated with postnatal depressive symptoms.

CONCLUSION

The transition into fatherhood is marked with significant psychological distress for some men. These results suggest that mental health screening and support in the preconception period is crucial to supporting the mental health of new fathers.

Psychological Autopsy in Small Penis Syndrome: Determining the Manner and Circumstance of Death Following a Vehicular Accident

Road traffic accidents and related deaths are on the rise, especially in developing countries. Even though uncommon and probably under-recognized, predisposing psychiatric states may be contributory, posing the question of whether these could be avoided. Psychological autopsy, despite not being performed routinely, might play a pivotal role in such instances, in reconstructing events leading to the catastrophe and determining the role played by the parties involved. The legal implications, such as the exoneration of the wrongly accused, might be substantial. This case report presents a death of a middle-aged South Asian male with strong history and evidence of small penis anxiety following a direct collision in a road traffic accident. It highlights the careful evaluation of the clinical history of the deceased by a psychological autopsy and reiterates the importance of the former in suspected cases.

Suicide among health professionals in Australia: A retrospective mortality study of trends over the last two decades

OBJECTIVE

To examine the relative risk of suicide among healthcare professionals compared to other occupations and examine changes in suicide rates over time.

METHODS

Suicide cases were identified using the National Coronial Information System and were included if they were recorded as a death by intentional self-harm between 2001 and 2017 and were by an employed adult aged 20-69 with a known occupation at the time of death. Suicide methods were reported descriptively. Workforce data at the population level was extracted from the Australian Bureau of Statistics 2011 Census. Age-standardised suicide rates per 100,000 person-years for each of the four occupational groups were calculated using direct standardisation and using the Australian Bureau of Statistics population-level data from the 2011 Census. Negative binomial regression was used to estimate suicide risk by healthcare employment status and profession, to investigate differences by sex and to examine trends in suicide rates over time, using rate ratios and 95% confidence intervals.

RESULTS

Healthcare professionals were at increased risk of suicide compared to other occupations (rate ratio = 1.30, 95% confidence interval = [1.19, 1.42], p < 0.001), controlling for age, sex and year of death. Nurses and midwives were identified as being at significantly increased risk of suicide (rate ratio = 1.95, 95% confidence interval = [1.73, 2.19], p < 0.001). Suicide rates among female medical practitioners increased substantially over time (p = 0.01).

CONCLUSION

Health professionals are at significantly increased risk of suicide, though the relative risk of different groups is changing over time. There has been a substantial increase in the risk of suicide among female medical practitioners with rates of suicide in this group more than doubling over the last two decades. Findings highlight the need for targeted suicide prevention initiatives for healthcare professionals.

"There's No Sewing Classes, There's No Bedazzling Seminars": The Impact of Masculinity on Social Connectedness and Mental Health for Men Living in Inner-Regional Australia

Regional Australian masculinities are typified by 'traditional' values (e.g., stoicism, self-reliance) known to restrict social connectedness. Thus, these masculinities have been implicated in worsening men's mental health. What remains unclear, however, is how men living in inner-regional communities (i.e., townships on the fringes of major cities) might uniquely experience masculinity, social connectedness, and mental health. We interviewed 29 boys/men and one non-binary participant (M _age = 43.77 years) living in the Macedon Ranges (an inner-regional Australian community). Using reflexive thematic analysis, we generated three themes. Participants described inner-regional masculinities as traditional and rigid, and attributed the Macedon Ranges' comparatively high suicide rate to these masculinities. Conversely, migration from the neighbouring city of Melbourne was implicated in introducing more inclusive masculinities to the area that conflicted with existing masculine norms. Thus, Macedon Ranges men were framed as ultimately lacking a cohesive community identity. Proximity to Melbourne was described as encouraging local men to commute daily for work instead of working locally, thereby further weakening community identity. Overall, these phenomena were implicated in damaging the psychosocial wellbeing of local men via reducing social connectedness. Because men's mental illness is so pervasive within regional Australian communities, these findings have direct implications for policymakers. Namely, policies need to acknowledge that masculinities directly influence mental health and that inner-regional masculinities are impacted by unique place-based considerations distinct from men living in other regional communities.

Prevalence Rates of Depression and Anxiety among Young Rural and Urban Australians: A Systematic Review and Meta-Analysis

Globally, depression and anxiety are major public health concerns with onset during adolescence. While rural Australia experiences overall lower health outcomes, variation in mental health prevalence rates between rural and urban Australia is unclear. The aim of this paper was to estimate the pooled prevalence rates for depression and anxiety among young Australians aged between 10 and 24 years. Selected studies from a systematic literature search were assessed for risk of bias. Random effects model using DerSimonian and Laird method with Freeman-Tukey Double Arcsine Transformation was fitted. Sensitivity analyses were performed. Prevalence estimates were stratified by region and disorder. The overall pooled prevalence of depression and anxiety was 25.3% (95% CI, 19.9-31.0%). In subgroup analysis, anxiety prevalence was 29.9% (95% CI, 21.6-39.0%); depression: 21.3% (95% CI, 14.9-28.5%); and depression or anxiety: 27.2% (95% CI, 20.3-34.6%). Depression and anxiety prevalence were higher in urban 26.1% (95% CI, 17.3-35.9%) compared to rural areas 24.9% (95% CI, 17.5-33%), although the difference was not statistically significant. The heterogeneity was high with an I² score of 95.8%. There is need for further research on healthcare access, mental health literacy and help-seeking attitude in Australia.

Men, suicide, and family and interpersonal violence: A mixed methods exploratory study

Research has shown a link between gender, violence, and suicide. This relationship is complex, and few empirical studies have explored suicide and family and interpersonal violence perpetrated by men. Drawing on a coronial dataset of suicide cases and a mixed methods design, this study integrated a quantitative analysis of 155 suicide cases with a qualitative analysis of medico-legal reports from 32 cases. Findings showed different types and patterns of family and intimate partner violence for men who died by suicide. Men used violence in response to conflict, but also to dominate women. Cumulative, interwoven effects of violence, mental illness, alcohol and other drug use, socioeconomic, and psychosocial circumstances were observed in our study population. However, the use of violence and suicidal behaviour was also a deliberate and calculated response by which some men sought to maintain influence or control over women. Health and criminal justice interventions served as short-term responses to violence, mental illness, and suicidal behaviour, but were of limited assistance.

Rethinking Accessibility in Light of the Orange Declaration: Applying a Socio-Ecological Lens to Rural Mental Health Commissioning

The prevalence of mental illness is a critical public health issue. In Australia, the prevalence of mental illness is similar across all settings, however, people living in rural and remote areas experience worse outcomes than their urban counterparts. Access to mental health services is critical, however, the notion of accessibility needs to be understood in the context of the uniqueness and variability of the rural experience. The Orange Declaration on Rural and Remote Mental Health recognized that rural areas face a series of interconnected challenges and called for place-specific responses and new funding models that reward collaboration and local partnerships. In this paper, we argue that recent mental health planning, policy and service development uses a narrow interpretation of the notion of accessibility that is out of step with current thinking on the heterogeneity of the rural experience. We use some examples of our own research and experience in rural Western Australia to argue that the current commissioning model is not aligned with the Orange Declaration, and remains largely metro-centric and reliant on a narrow conceptualization of service accessibility. We argue that what is needed is a dynamic, responsive, context-sensitive understanding of accessibility that is informed by the distinctiveness of rural adversity, and recognizes the heterogeneity and variability of the rural experience whilst acknowledging rural agency and social capital, and we suggest that applying a socio-ecological approach to the development of new commissioning models provides a way forward.

A sociological autopsy lens on older adult suicide in rural Australia: Addressing health, psychosocial factors and care practices at the intersection of policies and institutions

This paper examines the interrelationship between suicide, health, socioeconomic, and psychosocial factors in contributing to suicide in older adults in rural Australia. Drawing on a coronial dataset of suicide cases and a mixed methods sociological autopsy approach, our study integrated a quantitative analysis of 792 suicide cases with a qualitative analysis of medico-legal reports from 30 cases. The sociological autopsy provided novel insights into the entanglement of policy and service provision at the state-level with individual end-of-life decisions. Particular attention is drawn to age and gendered dimensions of suicide, especially in relation to health and social issues. The study showed a continuity between suicide and the patterning of an individual's life course, including experiences and consequences of inequality and marginality; a desire to meet culturally-normative ideals of autonomy; and a fragmented, under-funded, and intimidating social care system that offered limited options.