Comparing the frequency of GP mental health diagnoses between rural and urban communities
Brendan Cantwell BAppSci(Human Biology)*, Kyra Clifton BSc(Hons), GradDipA(Forensic Anthropology)*, Lauren Dickson BMedSci*, Jana Gerlach BSpPath*, Hanaho Imamura BSci*, Danielle Medek PhD*, Damon O’Leary Counahan BArts(Hons)*, Emily Sansoni BPsyc(Hons)* |

*Medical Student, The Australian National University

Abstract

Objective: To compare the type and proportion of mental health disorders encountered by general practitioners (GPs) in urban and rural settings.

Design, Setting and Participants: Cross-sectional clinical audit collected over the period of 2005-2012 from patients within the Australian Capital Territory and Greater Southern NSW Health Network. Three thousand five hundred and eighty one patients from this database were selected on the criteria of presenting to a GP and being over the age of 18 at the time of the appointment.

Main Outcome Measure: Percentage of mental health diagnoses in urban and rural general practice.

Results: Of 3581 patients, 1934 (54%) were seen in rural general practice. It was identified that there was no statistically significant difference in the proportion of presentations that were for mental health issues between rural and urban general practice (6.2% vs 6.4%, p = 0.728). Additionally, there was no statistically significant difference between the proportions of presentations for the top three mental health diagnoses in urban and rural areas. Substance use disorders were identified as more commonly diagnosed in urban general practice. There was no statistical significance in the difference between rural and urban settings in the difference of the proportion of mental health diagnoses when adjusted for age and sex, however a larger population sample may be required to identify any discrepancies.

Conclusions: While our results are consistent with previous studies, they raise questions as to the true nature and impact of health-seeking behaviours in both rural and urban populations. Similar studies with larger sample sizes are needed in order to

Introduction

M

ental health disorders are a common presentation managed by general practitioners (GPs) across Australia and there is sometimes an assumption that mental illness is more prevalent amongst rural populations when compared to urban. However, this assumption is not supported by current epidemiological studies which demonstrated that there is no significant difference in the proportion of those affected by mental illness between rural and urban populations (4, 6,7). Studies have examined the prevalence of associated risk factors (1-3) and suicide(4) and a limited positive effect of rural community ties has been linked with mental health outcomes. This study aimed to investigate mental health diagnoses extracted from GP records rather than self-reported symptoms and to identify any differences in the proportions of individual mental health disorders diagnosed by GPs.

There are interacting risk factors for poorer mental health status in rural locations; specifically, limited availability of medical services, cultural beliefs regarding treatment, stigmatisation of mental illness, and socioeconomic constraints (8). Additionally, smaller isolated populations experience a decrease in services, employment prospects, social opportunities, and wellbeing (7). Despite these risk factors, no differences have been found in overall self-reported prevalence of mental illness between rural and urban locations (4, 6-7, 9). However, as Caldwell et al. reported in 2004 (4), this may reflect the reduced tendency of rural and remote residents to visit a GP, particularly when this involved encounters for psychological problems (10). Their study also documented slightly higher rates of depression management (4.8% vs 3.6% encounters) and lower rates of anxiety management (1.4% vs 1.8%) by rural GPs when compared to GPs in capital cities.

In 2004, Caldwell et al identified no significant differences between the proportion of rural and metropolitan females and males with any ICD-10 defined mental health disorders receiving professional help, with approximately 4% more males and 1% more females in the metropolitan region seeking treatment. However, they did show that rural females were more likely than rural males to receive professional help, with 44.3% and 26.2% of each population treated respectively. Young rural men, with the highest suicide rates (4, 11), were found to have less contact with health professionals than both metropolitan men and rural women (12). This may be due to the strong culture of self-reliance (13-14), perception that mental illness equates to insanity (15) or the stigma associated with a mental health diagnosis (16-17).

This study therefore aimed to explore the use of clinical data to describe trends in general practice, specifically mental health diagnoses in rural and urban settings of ACT and rural NSW and to compare the impact of mental illness between rural and urban settings. It aimed to compare the proportions of common mental health diagnoses among rural and urban populations, accounting for age and gender.

Methods

This study was based on successive cross-sectional clinical audits of GP consultations. Over the period 2005-2012 data were collected by The Australian National University medical students from patients within the Australian Capital Territory (ACT) and rural New South Wales who presented to a health practitioner. For the purposes of the study, rural patients were classified only as those seen within the former Greater Southern New South Wales Local Health District and urban patients were classified as those seen within the ACT. Ethics approval was obtained for this study from the ethics committees of the ANU, NSW Health and ACT Health.

In this study there were 3581 patients who presented to a GP and were over the age of 18 at the time of the appointment. Mental health diagnoses were formally defined using ICPC-2+ data codes (23). If multiple mental health diagnoses existed for one patient only the first was accepted for analysis in order to measure the proportions of the most common diagnoses.

Data was analysed using SPSS version 18 software (SPSS Inc, Chicago). Chi-square tests were performed to test for statistical significance in the differences in the proportions between urban and rural patients, and difference by sex and age. A p value of < 0.05 was considered statistically significant, except where adjustments for multiple comparisons were deemed appropriate. In these cases, the Bonferroni method was used to reduce the risk of Type 1 error. An independent samples T test was used to compare the mean age between rural and urban patients. The age groups were defined as: young adults (18 to 35 years old), middle aged (36 to 64 years old), and elderly (65 years or over).

Results

There were a total of 3581 GP consults in the dataset. Of these, 1934 (54.0%) consults occurred rurally. Rural patients were significantly older than urban patients (mean ≤ 58 and 53 years respectively: p <0.001), and there was also a higher proportion of female patients in the rural GP setting (1155/1934, 60%) compared with the urban setting (898/1647,55%) (Table 1). Out of 3581 GP consults, 225 mental health diagnoses were made at the end of the encounter (mean 6.3 diagnoses per 100 consults) for 207 patients. There was no difference in the rate of mental health diagnoses between rural (6.2%) and urban (6.4%) areas (Table 1).

Stroke death rates by sex, 1987-2007. Sourced from AIHW (6, p. 81.)
Table 1. Demographic characteristics and proportion of rural and urban patients with mental health diagnoses among GP consults

Out of the 225 mental health diagnoses, the three most common were depression that accounted for 39% of diagnoses (88/225), anxiety at 17% (39/225)  and substance use disorders at 16% (35/225).  The next most common diagnoses were acute stress (8%), psychotic disorders (4%), dementias (4%) and manias (3%). If a patient had one of the top three diagnoses, any subsequent diagnoses were then removed from the remainder of the analysis. This left only one primary diagnosis for each of 154 patients with depression, anxiety or substance abuse (Table 2). The overall prevalence of these primary diagnoses were 2% for depression (87/3581), 1% for anxiety (35/3581) and 1% (32/3581) for substance use disorders. Depression was the most common in both urban and rural samples but substance use disorders was more common in the urban group and anxiety was more common in the rural group as shown in Table 2 (P>0.05).

Stroke death rates by sex, 1987-2007. Sourced from AIHW (6, p. 81.)
Table 2. Comparison of the three most common mental health diagnoses in rural and urban GP consults

This analysis was repeated, stratifying the sample by sex (Table 3). In the 63 male patients with one of the “top three” diagnoses, substance abuse was the most common diagnosis (35 patients; 56%), followed by anxiety (16 patients; 25%) and depression (12 patients; 19%). There was no statistically significant difference between rural and urban patients (p=0.27). In the 91 female patients with one of the “top three” diagnoses, depression was the most common diagnosis (52 patients; 57%) followed by anxiety (23 patients; 25%) and substance abuse (16 patients; 18%). The differences between urban and rural were not statistically significant (p=0.08).

Stroke death rates by sex, 1987-2007. Sourced from AIHW (6, p. 81.)
Table 3. Comparison of the three most common mental health diagnoses between rural and urban GP consults in males and females

Discussion

Our results showed no significant overall difference in the overall proportion of mental health diagnoses in GP consultations in rural and urban populations and depression was the most common diagnosis in both rural and urban areas. However, our study did find a significant difference in the proportion of diagnoses for substance use disorders and anxiety disorders, with substance use in urban areas more than double that of rural areas, and anxiety more common in rural areas.

There was a difference in age distribution of GP patients by location. The proportion of those above the age of sixty was greater in rural compared to urban populations (p <0.05), while the opposite was true of those between the age of eighteen and sixty-five. Andrews and colleagues (10) found a lower prevalence of mental health disorders in those aged over sixty-five and the Australian Bureau of Statistics (ABS) reported that young people were much more likely to report a mental health disorder than those in older age categories (18). We might therefore have expected a higher prevalence in the urban group due to confounding by age.

Our study documented a significantly larger proportion of patients visiting a GP who were female in rural compared to urban areas (p = 0.002). It is difficult to ascertain whether this difference may impact upon our mental health diagnostic analysis. Andrews and colleagues (10) and later Komiti and colleagues (14) identified disparities in the type of mental illnesses experienced between genders. Caldwell et al (4) found that males who have mental health disorders are less likely to access help in rural areas than those in the city, and that overall, young women were much more likely to access help than young men.

Depression, anxiety and substance use disorders were identified as the most common three mental health diagnoses within each population.  Our top three diagnoses are equivalent to those identified in the National Survey of Mental Health and Wellbeing as the most common mental health problems experienced by Australians (18). This suggests that similar mental health issues are common within both populations. However, while the study found no differences in the top three mental health diagnoses between rural and urban populations, it did document variations in the proportions of diagnoses. Depression was the most frequent mental health diagnosis in both rural and urban populations (60% urban, 53% rural; p > 0.05), correlating to the BEACH study, where depression was reported as the most frequently managed mental health problem by Australian GPs (19). The percentage of anxiety disorders was found to be higher in the rural than urban population (27% vs 19%; p>0.05). This is analogous to national data collected by Andrews et al. who also found a slight increase in anxiety disorders in the rural population (10). However, women are more likely than men to report the symptoms of anxiety to their GP (18). In Australia’s Health 2010 (20) it is noted that anxiety disorders are the most prevalent across all age groups. Anxiety is a common mental health comorbidity particularly with depressive and substance use disorders (21).The proportion of substance use disorders also varied between settings, with more than 50% greater prevalence of substance use disorders in the urban population. This also reflects national data which has found a reduction in substance use disorders associated with increasing remoteness (4). As men are two times more likely than women to report substance use disorders particularly in younger age groups, the lower rates reported in this study could be partly attributed to the higher proportion of women and elderly amongst our study population. More research may provide further insights into the nature and cause of this finding.

Our study was limited by an inability to investigate the homogeneity of our rural population. This was due to the questionnaire not specifying a precise location, instead distinguishing only between rural or urban. It has been demonstrated that this ‘catch-all’ rural category can be misleading due to distinct differences between towns which can impact on mental health. For example, while some rural towns are experiencing population growth, others are seeing population decline, and there is also a wide discrepancy in infrastructure such as housing, health services, education and recreation, all of which can impact on mental health (22). Therefore, using ‘rural’ as an overall category without being able to analyse each town separately means we may be missing nuances related to various differences between the areas.

It also needs to noted that the data are collected only from areas ANU medical students attend and our data may not be representative of the wider population. A medical student was present during each presentation and due to the reluctance of some patients to discuss mental health issues with a GP, having a student present may have dissuaded them further. This may have resulted in missing those who had intended to present with such issues, but decided against it due to the student presence. 

Conclusion

Our study found a significant difference in the age and gender demographics of rural and urban patients attending for GP consults, and 10% of consults had a mental health diagnosis. Depression was the most common mental health diagnosis. The overall rates of mental health diagnoses managed by GPs in rural and urban populations were found to be similar but varied in the proportions of the three most common mental health diagnoses between rural and urban groups. A statistically significantly greater rate of diagnosis of substance use disorder was identified in the urban setting while a greater rate of anxiety was found in the rural population.

 

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