Does rural residence limit access to mental health services ?

Introduction: Rural residence may reduce access to specialized mental health services. The objective of this study was to examine the role of rural residence in relation to service utilization. Using Canadian data collected in 2002, service use was examined as a function of the presence of anxiety or mood disorders and rural/urban residence. Use of four different types of professional mental health services was examined in relation to rural residence and additional demographic, social, and health status factors known to predict use of services. Methods: Data were obtained from Statistics Canada's Canadian Mental Health Survey Cycle 1.2. Rural residence was defined as living in a rural community with a population of 1000 or less. For all participants, associations between the presence of anxiety or mood disorders, rural/urban residence, and any service use or use of specialized mental health services (psychiatry and psychology) were examined. For participants who had used professional services, associations were examined between 17 predictor variables, including location of residence, and the use of four types of service providers (family doctor or GP; nurse, social worker, counsellor, or psychotherapist; psychiatrist; or psychologist). Predictors included demographic, social, and health status variables. Cross-tabulated counts and adjusted odds ratios with 99% confidence intervals based on bootstrapped variance estimates were used to evaluate predictors. Results: Among the total sample (n = 35 140), 7.9% had used professional mental health services in the previous year. Among people who were likely to have had anxiety or mood disorders, rural or urban residence was not differentially related to past-year use of any professional services or specialized mental health services. Multivariate logistic regression was used to model factors predicting past year use of four different types of professional services. Location of residence was not a significant predictor of


Introduction:
Rural residence may reduce access to specialized mental health services.The objective of this study was to examine the role of rural residence in relation to service utilization.Using Canadian data collected in 2002, service use was examined as a function of the presence of anxiety or mood disorders and rural/urban residence.Use of four different types of professional mental health services was examined in relation to rural residence and additional demographic, social, and health status factors known to predict use of services.
Methods: Data were obtained from Statistics Canada's Canadian Mental Health Survey Cycle 1.2.Rural residence was defined as living in a rural community with a population of 1000 or less.For all participants, associations between the presence of anxiety or mood disorders, rural/urban residence, and any service use or use of specialized mental health services (psychiatry and psychology) were examined.For participants who had used professional services, associations were examined between 17 predictor variables, including location of residence, and the use of four types of service providers (family doctor or GP; nurse, social worker, counsellor, or psychotherapist; psychiatrist; or psychologist).Predictors included demographic, social, and health status variables.Cross-tabulated counts and adjusted odds ratios with 99% confidence intervals based on bootstrapped variance estimates were used to evaluate predictors.Results: Among the total sample (n = 35 140), 7.9% had used professional mental health services in the previous year.Among people who were likely to have had anxiety or mood disorders, rural or urban residence was not differentially related to past-year use of any professional services or specialized mental health services.Multivariate logistic regression was used to model factors predicting past year use of four different types of professional services.Location of residence was not a significant predictor of

Introduction
Canadian researchers have examined rural and urban residence in relation to mental health services utilization and have found few differences [1][2][3][4][5] .However, the 1994/1995 National Population Health Survey (NPHS) revealed that 3% of urban residents but only 1% of rural residents reported consulting a psychologist in the previous year 6 .In the 2005 Canadian Community Health Survey (CCHS) rural residents were less likely than urban residents to report seeing medical specialists including psychiatrists 7 .This and other evidence suggests that rural residents are less likely than urban residents to receive specialized mental health care [8][9][10] .Some evidence indicates that compared with urban residents, rural residents might experience somewhat lower rates of mental disorders 11,12 .Thus, rural residents might have less need for specialized mental health services than urban residents.However, factors other than rural and urban residence, such as age 7,10 , education 10 , sex 13,14 , social roles 14 , chronic medical conditions 5 , and type of mental condition 2,4,5 are known to predict service utilization, including type of services used 1,5 .Thus, a wide range of demographic, social and health factors must be considered together when evaluating the role of rural versus urban residence in utilization of the various types of mental health services.

Objectives
In the present study, Canadian data collected in 2002 in the CCHS on Mental Health and Well Being Cycle 1.2 15 were analyzed to answer three specific questions: Survey questions designed to detect the presence of specific symptoms were used to identify participants who were likely to have met diagnostic criteria for an anxiety or mood disorder 17 .This method permits estimates of the number of people who have a probable anxiety or mood disorder independent of access to professional diagnostic services, which may be lacking in some communities.The presence of some mental disorders of interest, such as schizophrenia and dementia, cannot be captured accurately using self-report methods, whereas other disorders of interest, such as eating disorders, were assessed via self-report in the CCHS Cycle 1.2 but were not considered in this study due to their low prevalence 17,18 .
Dichotomous outcome variables reflecting participants' use of each of four types of professional services for mental, emotional, and/or alcohol or drug problems were derived from responses to questions about mental health service use.
The outcome variables reflect whether, in the year prior to the survey, the person had a session of counselling or therapy of 15 min or longer with a professional, either in person or by telephone.The categories of mental health professions examined were: (i) family doctor or GP; (ii) nurse, social worker, counsellor or psychotherapist; (iii) psychiatrist; and (iv) psychologist 18 .Nurses, social workers, counsellors, or psychotherapists were grouped together because their mental health services (ie counselling) are similar.They are referred to as 'counsellors' throughout the remainder of this article.Psychiatrists and psychologists were defined as specialists whereas GPs and counsellors were defined as non-specialists.A set of 17 predictor variables was selected for inclusion in regression analyses (Table 1

Results
From among the total sample (n = 35140), 7.9% had sought professional mental health services in the past year.Among the people who sought help from professionals, the weighted percentage that had seen each type of professional was: family doctor/GP 66.4%; counsellor 30.7%; psychiatrist 24.2%; psychologist 24.7% (the values sum to >100% because participants may have seen multiple professional types in the past year).Presence in the past year of symptoms that met DSM-IV diagnostic criteria for any of major depressive episode, manic episode, panic disorder, social phobia, or agoraphobia; based on responses to the World Mental Health version of the Composite International Diagnostic Interview.†For more information see Statistics Canada [17,18].Survey questions about anxiety and mood symptoms revealed that 8.3% of the overall sample were likely to have met the diagnostic criteria for one or more anxiety or mood disorder.
These analyses indicate that rural and urban people with probable anxiety or mood disorders were equally likely to use mental health services, whether these were specialized or not.
Multivariate logistic regression analyses focused on those people who used mental health services in the previous year.These analyses identified factors that significantly predict use of particular types of professional services, given any use.Rural versus urban residence was not a significant predictor for any type of professional mental health services when other demographic, social, and health status characteristics were taken into account (Table 2).People were more likely to see a family doctor/GP regarding mental, emotional, or alcohol/drug problems if they were older or had a probable anxiety or mood disorder in the previous year.People were more likely to see a counsellor if they were not Caucasian or had experienced an usual amount of chronicity of distress (compared with less than usual) in the previous month.Younger people were less likely to see a counsellor.People were more likely to see a psychiatrist if they had completed high school (compared with not completed).
People were less likely to see a psychiatrist if they were younger, were not Caucasian, or used illicit drugs.People were more likely to see a psychologist if they had completed high school (compared with not completed), had a chronic health condition, had greater psychological distress, or had a probable anxiety or mood disorder in the previous year..Involvement of specialists in assessment of complex conditions, treatment planning, and when individuals do not respond to standard care, would reduce demands on specialized services while maximizing benefits.

Limitations
This study has limitations that affect generalization and interpretation of the results.The rural residents represented in this analysis did not live in Aboriginal reserve communities, remote communities, or Canada's northern territories, and the findings cannot be generalized to these communities, which are likely to have more restricted access to mental health professionals.The numbers of rural residents seeking professional help were relatively small, resulting in large confidence intervals.Some of the predictor variables were likely to be correlated with location of residence, but interactions among location of residence and other predictors could not be evaluated due to the relatively small number of rural residents who sought professional care.Residence location was measured at the time the survey was completed and might have changed in the previous year.The professionals identified as nonspecialists are likely to have a wide variety of training and experience in mental health service provision, whereas the specialists might or might not have experience in treating anxiety and mood disorders.Finally, the quality and effectiveness of mental health services were not examined, and if examined, they might reveal important differences between rural and urban Canada.
Future research should focus on identifying elements required for treatment success for particular disorders and whether those elements vary across communities of different sizes.Small scale studies of service models specifically designed for rural communities would further our understanding of how to serve rural residents more effectively.

Table 2 : cont'd
<0.01.OR values were rounded to one decimal place except for ORs involving continuous variables (ie age, psychological distress, social support), where ORs were rounded to two decimal places.One point increase on a continuous variable's scale corresponds to the reported change in the odds of seeking professional mental health services (eg for age, an OR=0.98 means that for each year of increasing age there was 2% less likelihood of using professional services).Cell entries reflect adjusted ORs with bootstrapped variance estimates (99% CI) *Significant at p