As a large country with a relatively small population that is concentrated in a small number of major urban areas, issues related to distance and isolation mean that rural and remote communities in Australia have an additional set of challenges in terms of relapse prevention. Rural communities are not homogeneous and each has a unique set of factors contributing to the social and emotional wellbeing of its members. Importantly, many rural and remote communities are home to significant populations of people from Aboriginal and Torres Strait Islander backgrounds, and some have a large proportion of people aged over 65 years (ABS 2002). While facing complex challenges in terms of mental health care, rural and remote communities have less access to services than urban centres.

A common barrier to relapse prevention in rural and remote communities is fear of stigma, which reduces awareness and acceptance of mental illness, partly because it is difficult to maintain privacy in small and more insular communities. Along with 'rural stoicism', stigma makes it more likely that rural people will withdraw rather than seek help from appropriate mental health and support services (Hoolahan 2002). Improving community attitudes toward mental illness and encouraging appropriate help-seeking behaviour are, therefore, priorities in smaller and more remote communities.

Everybody here knows everybody else's business. If I get to the doctor, it will be all about town before I get out the door. —Consumer
Access to mental health and community services is a serious concern in many rural and remote communities (AIHW 2002, 2004), and has a substantial impact on planning for, and providing the support services that are required for preventing relapse.

There is no such thing as discharge planning here. You get shoved out the door, often before you are well enough and ready, and then there is nothing ... no contact, no follow-up, no services, nothing. They just wait for you to come back in again. Then it is the same thing all over again. —Consumer
Frequently, mental health care in rural and remote communities is provided through community health centres, hospitals in major regional centres, and a small number of GPs. Many communities have no resident mental health services and must rely on visiting services or travelling to communities where services are available. Lack of accommodation is, therefore, a highly related issue, including accommodation for visiting service providers as well as for consumers and their families and carers. People requiring services often have to travel away from their families and communities, which becomes an additional stressor and denies people an important source of social support. Transport and accommodation are major barriers to providing early intervention and continuing care.

One of the main reasons we can't get services to come out here is lack of accommodation. The few places there are to stay are booked up, and they are also expensive. It costs more to stay out here than it does to stay in town. Who is going to pay accommodation prices like that for this sort of place. If we had more accommodation at decent rates, we might be able to attract some more services to come out here. —Remote area service provider
Top of pageFamilies and carers are at increased risk in rural and remote communities because, like consumers, they also lack services and support. They often have to provide ongoing support to their family member in the absence of any community support services and with no access to crisis services. This can be a very heavy burden, and there is a great deal that needs to be done to support families and carers in their continuing care role in rural and remote communities.

Special attention needs to be given to general practice within rural and remote communities. The GP is often the only source of continuing care for people who have experienced a mental illness in rural and remote locations (AIHW 2002, AIHW 2004). However, waiting lists are long, there are often low rates of bulk billing, and there is a focus on crisis rather than continuing care and relapse prevention. Initiatives to support GPs working in rural and remote communities to provide relapse prevention through continuing care are essential.

Although they are important in all communities, the role of non-health services and community agencies is paramount for supporting relapse prevention in rural and remote communities. Schools, the police, businesses, publicans, the local newspaper—all the members of the community—need to work in close partnership to provide a positive attitude toward and an integrated network of support for those members of the community who are particularly vulnerable because they have been seriously affected by mental illness.

The coppers here are great. If they see [blank] wandering around, they pick him up and bring him home. It helps keep him out of trouble. They keep an eye on him and bring him home to Mum. —Family member
The development and implementation of new technologies that overcome issues of distance and isolation are essential to providing continuing mental health care within rural and remote communities. Initiatives such as the Commonwealth telepsychiatry initiative, whereby Medicare rebates were introduced to enable people with mental illness living in rural and remote areas to participate in telepsychiatry consultations with their psychiatrist, need to be sustained and expanded. Internet technologies also enable opportunities to provide information about mental health and mental illness and to connect people living in rural and remote communities with support groups (Christensen, Griffiths & Evans 2002).

In terms of planning interventions around the risk and protective factors that affect relapse, it must be noted that rural and remote communities are often more exposed to risk factors for mental health. For example, rural communities have more economic problems, higher unemployment rates, higher suicide rates, more domestic violence (Sheil 1997), and poorer physical health than urban areas (Mathers, Vox & Stevenson 1999). There are environmental and occupational hazards, sparse infrastructure and risk-taking attitudes to health, illness and behaviour (Wainer & Chesters 2000). Social polarisation has occurred in some areas as a consequence of the closure of services and changes to agricultural and industrial practices (HREOC 1998).

There is a general lack of opportunities and alternatives to support mental health and wellbeing and thereby reduce the risk of relapse in many rural and remote areas. This can be particularly pronounced for younger people who lack social, employment and educational opportunities. Consequently, people who are more vulnerable to the stressors of life by having previously experienced a mental illness may be at greater risk of relapse in rural and remote communities because they are more exposed to stressors, and the services and opportunities that support rehabilitation and recovery are not available.

Alternatively, there are protective factors available in many rural and remote communities that are lacking in more urban settings. Rural people are less likely to report unhappiness than their urban counterparts, and women from rural and remote areas report lower levels of stress than women from metropolitan areas (AIHW 2002). Rural communities can be more socially connected; specifically, health professionals and community service providers can work more closely together as they often know each other well and have an investment in the health of their community (Hoolahan 2002). Paradoxically, lack of traditional services and resources can be an asset, as services have a capacity to change and adapt more quickly; something that is difficult to achieve within more established service systems (Curtis & McCabe 1990). Finally, the open spaces and slower pace of rural communities provide an environment that can be very supportive of mental health and wellbeing compared with overstimulating and hectic urban environments. It is important for rural and remote communities to identify their strengths and work together to enhance the ability of these protective factors to support the people within their communities who have experienced mental illness.