Do rural / northern residents have better mental health status?

"In the book, Psychiatric Disorders in America (Robins et al., 1991b), an interesting reference was made to the commission headed by Rosalynn Carter to study the needs for mental health services in the United States. In expressing her desire to start off the work of the commission with sound information, the former First Lady asked some fundamental questions: How many are suffering from mental health illnesses? Who are they and how are they treated? It became obvious that adequate answers to those questions could not be offered at that time.

"Similar problems confront planners and administrators of mental health services in northern Ontario....

"The large-scale collection of data under the Ontario Health Survey (OHS) and the Ontario Health Supplement (OHSupp) and the release of the survey data by the Ministry of Health have, to a certain degree, helped overcome the lack of relevant information. Although the OHS and the OHSupp have their limitations, as will be discussed later on, they allow many service organizations to be able to identify the general and mental health status of the populations they target, to assess health care needs, to know how people use health services, and to have fairly detailed information about health beliefs and behaviors.

"This study examines the mental health status of residents in northeastern or northern Ontario and how they access mental health services....

"....Concerning the extent of mental disorder in the Ontario population, the OHSupp survey shows that almost one in five Ontarians report some symptoms attributable to a mental disorder. Interestingly, this year prevalence rate of approximately 20 percent is similar to that reported by the ECA studies conducted in the US (Robins et al., 1991b). Also, the lifetime prevalence rate of approximately 33 percent reported in the present study is the same as those reported in both the ECA and Edmonton studies (Bland, 1988). If the provincial prevalence rate can be applied to the Network North catchment area, about 24,700 people can be expected to be suffering from some form of mental disorder.

"Contrary to some conventional beliefs, northern Ontario residents do not have higher prevalence rates than residents in the rest of the province. These beliefs may have been based on the fact that northern Ontario is more likely to have conditions that are presumed to be conducive to the development of mental health problems. For example, the catchment area of Network North is characterized by lower educational and income levels, higher adolescent birth rates, a higher proportion of unwed mothers, and higher unemployment rates. However, according to the OHSupp data, these conditions have not translated into an overall higher prevalence rate of mental disorder in northern Ontario.

"The breakdown of the prevalence rate data according to particular disorders is also helpful in determining the types of resources (e.g., treatment specialization) needed. For instance, the ability to treat anxiety disorders would seem to be important, as they occur most frequently among all reported disorders, with a year prevalence of nearly 12 percent. Affective disorders and substance abuse disorders also occur relatively frequently with a year prevalence rate of about 4.5 percent. Another type of specialization that will likely be needed is psychogeriatrics, as 3.6 percent of the over-65 population sampled was found to have symptoms indicating a cognitive impairment disorder. As the population ages, it is likely that the number of older persons with cognitive impairment will increase substantially.

"In contrast, the prevalence rates for the very serious mental disorders such as schizophrenia were found to be very low. Not even 0.5 percent of the individuals sampled were found to be suffering from schizophrenia. The exclusion of institutional residents from the survey partly explains the low rates....

"On the question of how people with mental disorders are treated, the most interesting result emerging from the present study is the substantial proportion of people with mental disorders who did not utilize services. The data show that whereas about 18 percent of the adult population was found to have a mental disorder, only about 8 percent used any kind of mental health service in the one-year period prior to the survey. Only those suffering from an affective disorder were more likely than not to utilize mental health services. Such a finding points to the need to determine why a large proportion of people with mental disorders do not access services. The answer to this question may not be a simple one. Some mental disorders identified by the OHSupp may not be considered serious enough by some people to warrant treatment. Service utilization may not correspond perfectly with needs. It may be affected by the stigmatization of mental health disorders, perceptions about the efficacy of mental health care, the extent to which available services are promoted, difficulties in accessing services, etc. While some of these problems may take a long time to overcome, Network North may, in the meantime, attempt to more effectively promote those mental health services that are, in fact, available and to make such services as accessible as possible, particularly to those living in more remote communities.

"The finding that the overwhelming majority of mental health service users accessed outpatient services and relied less on inpatient care is in line with the provincial goal of reducing the number of hospital beds and shortening the length of stay. The hope has been that unnecessary hospital stays can be avoided by increasing the availability of outpatient services and that outpatient services can play a major preventive role by providing earlier intervention and education. While the overall patterns of service utilization for northern Ontario are generally consistent with those for the rest of the province, the present findings suggest that some work may have to be done in the north to ensure that services are accessible to those in need. The present results show that the proportion of people using outpatient services ranged from a low of 7.0 percent in the north to a high of 9.5 percent in eastern Ontario. There is some reason to believe that accessibility to outpatient services may be a problem in the north, particularly in light of the fact that northerners were more likely than those from other regions to use informal care (2.6 percent of northerners vs. the provincial average of 1.5 percent). It is possible that users in the north relied more on the informal care system in order to make up for perceived or real shortfalls in the formal system. However, such an interpretation can only be offered as speculation at this time.

"As more formal services are being cut back due to financial restraints, increasing references are being made to the need to rely more on informal care. It is, therefore, important to determine outcomes associated with the various types of care. For instance, when enhancement of formal mental health services is proposed, one might be called upon to demonstrate that such services are, in fact, more effective than informal care. From a health human resources perspective, it is equally important to pay more attention to the integration of formal and informal care providers and the appropriate training and orientation of those providing informal care. As Pong et al. (1996) have noted in their study of community-based health care in Canada, health human resources should be seen as a continuum that encompasses formal caregivers, informal caregivers, and those who look after their own health.

"The need for outcome evaluation and health human resources planning also becomes apparent with respect to the types of provider seen on an outpatient basis. The present findings reveal the extent of the burden placed on general practitioners/family physicians to treat people with mental disorders. Half of all individuals with mental disorders visited general practitioners, a proportion that is more than double that for any other type of mental health provider. Furthermore, the overwhelming reliance on general practitioners is a consistent pattern regardless of the type of mental health disorder. These findings are consistent with those from other studies (see, e.g., Wagenfeld et al., 1994). These results indicate that there is a need for general practitioners to receive adequate training in all areas of mental health and/or that some of the burden placed on general practitioners needs to be shared with other types of provider. The finding that 42 percent of all people who utilized services for mental health reasons did not have a classifiable mental disorder suggests that a stronger role for non-physician providers and informal caregivers may be justified. Again, outcome evaluation research will be required to determine what kinds of intervention, by what types of provider, in what types of setting are most efficacious and cost effective for what kinds of users and for what mental health disorder."

From: J.R. Pitblado, T. Managhan, L.G. Houle, R.W. Pong and D. Lapalme (1996). Mental Health Status and Service Utilization in Northeastern / Northern Ontario. Sudbury, Ontario: Centre for Rural and Northern Health Research, Laurentian University.