When journalists and others are reporting on the difficulties that people in rural and remote areas face in accessing mental health services, it is important to keep the big picture in mind, says Professor Tim Carey, a mental health academic at the Centre for Remote Health in Alice Springs.
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Behind the headlines on rural and remote mental health
Tim Carey writes:
Problems with access to effective and efficient mental health services in rural and remote Australia have featured recently in the media.
ABC News recently reported that: “Three psychiatrists who regularly visit the major western centre of Dubbo will stop their trips following a decision by the local health district to stop paying for their travel.”
The article highlighted the problems faced in rural and remote areas when large amounts of funding are allocated to travel for visiting specialists at the expense of local clinical services. Without effective and sustainable alternatives, rural and remote residents will either miss out on services or be required to travel to metropolitan centres to access services.
Another article in Australian Doctor magazine began: “A new magnetic brain stimulation therapy should be a first-line option for all Australians with depression, psychiatrists say.”
The therapy is repetitive Transcranial Magnetic Stimulation (rTMS) and it was reported that there is robust evidence for its effectiveness in the treatment of depression. It was suggested that some patients may prefer rTMS as an alternative to antidepressants or when antidepressants fail.
Given that the equipment costs for rTMS are “upward of $100,000” and that a full course of rTMS costs between $8,500 and $10,000, it doesn’t seem reasonable to compare a course of rTMS with the far cheaper option of a course of antidepressants.
When first-line treatment options for “all Australians” are being recommended, it is crucial that rural and remote Australians are not excluded from considerations.
Regardless of its effectiveness, it is unlikely that rTMS would ever become a viable treatment option on a widespread basis for residents in rural and remote Australia. To have to travel to major centres for treatment and be dislocated from important social contexts in the process adds further financial and psychological costs to the treatment.
Both these articles illustrate the way in which the media highlights and emphasises psychiatric care in the treatment of mental health problems. There is no doubt that psychiatric care is an essential component of comprehensive and effective mental health service provision.
Psychiatric care, however, is also the most expensive element of the service package and, in a climate of scarce financial resources, it is important that full consideration, including efficiency and cost-effectiveness, is given to all effective treatment options.
Antidepressants, for example, are not the only treatment option for people with depression, nor the most effective in all cases. Some psychological treatments have strong evidence for effectiveness and, if patients are to be offered alternatives to antidepressants, psychological treatments are likely to be an attractive option in terms of cost-effectiveness.
In seeking to ensure that Australians living in rural and remote areas have adequate access to the full range of mental health services, consideration should be given to all evidence-based treatment options and service provision models.
The first article suggested that a greater focus on telehealth could help in promoting access to services without the expense of travel.
An example of a successful telehealth service in rural South Australia was featured as a case study by the Rural Health Education Foundation. When appropriate, telehealth could enable people in rural and remote locations to benefit from psychiatric services without incurring expensive travel costs.
Other options could also be explored that would improve access to evidence-based, effective, and efficient mental health treatments without requiring rural and remote residents to travel to metropolitan centres or tolerate lengthy waiting times in service provision.
Co-locating mental health clinicians such as psychologists and mental health nurses in primary care GP practices to provide evidence-based psychological interventions would facilitate greater continuity of care and would enable mental health problems to be addressed at an early stage.
Reinstating the maximum of 18 rebatable Medicare sessions for evidence-based psychological treatment through the Better Access initiative may also be a more cost-effective option than other treatment alternatives.
Quarantining time in public mental health services for the provision of evidence-based psychological treatments is another cost-effective option. Given that public mental health services are widespread in rural and remote locations, this is likely to be an attractive option financially since it would only require modifying existing staff roles not the recruitment of extra staff.
An innovative service adopting this approach has been evaluated as effective and efficient in remote Australia (a copy of the paper**, Effective and efficient: Using patient-led appointment scheduling in routine mental health practice in remote Australia, is available upon request to Croakey) where a close working relationship between psychiatry and clinical psychology ensures patients have a more expansive range of treatment options than would otherwise be the case.
Access to effective and efficient mental health treatments for people in rural and remote Australia is an urgent problem that requires innovative and sustainable solutions. The long-term viability of service provision must be part of the equation whenever treatment options are considered so that rural and remote residents can experience the same standard of health care that their metropolitan compatriots enjoy.
It is crucial that affordable and effective mental health treatments are accessible to Australia’s rural and remote citizens without them having to travel to major centres or experience long waiting periods for services.
Policy makers and health service managers need to courageously explore the full range of evidence-based psychiatric, psychological, and social treatments to make a significant and sustained impact on the burden of mental health problems for individuals and communities in rural and remote Australia.
When journalists and media outlets are reporting on problems with access to mental health services in rural and remote areas, it would be useful if they could also help their audiences to keep this bigger picture in mind.
• Professor Tim Carey is Deputy Director and Head of Research at the Centre for Remote Health, a joint centre of Flinders University and Charles Darwin University, in Alice Springs. He is a member of the Centre of Research Excellence in Rural and Remote Primary Health Care.
** Carey, T. A., Tai, S. J., & Stiles, W. B. (2013). Effective and efficient: Using patient-led appointment scheduling in routine mental health practice in remote Australia. Professional Psychology: Research and Practice, 44, 405-414.
