Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697633826065.pdf (Australia)
Inquiry into the accessibility and quality of mental health services in rural and remote Australia On the Line welcomes the opportunity to make a submission on the inquiry into the accessibility and quality of mental health services in rural and remote Australia.

On the Line is a professional social health business that supports and counsels people anywhere and anytime.
We specialise in mental health; suicide prevention and trauma-informed practice for people affected by suicide; anger management; family violence; healthy relationships and integrated wellbeing; chronic health conditions; and problematic drug and alcohol abuse.

Our operational footprint includes: • Twenty-one tele-psychotherapy service, managed in partnership with commercial and government sectors, and the Primary Health Networks.
• Our telephone, web chat and video counselling services are supported by digital and offline marketing and promotions, interactive websites, and moderated social media channels and forums.

• From July 2016 to June 2017, we supported 80,216 calls and provided 100,000+ hours of professional counselling across telephone, web chat, live video and social media channels.
(a) the nature and underlying causes of rural and remote Australians accessing mental health services at a much lower rate; Australians in rural, regional and remote areas are inherently disadvantaged compared to people in major urban centres.

They consistently have access to fewer mental health services than people in major cities.

People in cities access on average 40 per cent more Medicare-funded mental health services than those in rural and remote areas.
Remote areas have one-third the number of psychologists compared to major cities 1 – and 15 rural and remote areas have no registered psychologists at all 2.

The more remote the community, the scarcer the general level of access.

For example, the number of GP services per person in very remote areas is around half that of major cities 3.

The general lack of services means that people in need of treatment must travel long distances.
This can be inconvenient, expensive and disheartening, especially when there is limited or no public transport.

Not having facilities nearby has been shown to be a barrier to seeking treatment and the problem can be exacerbated if illness or disability are a factor4.

The size of the community can also affect how likely a person is to obtain help.
People in a regional or remote community may be reluctant to seek help from a mental health professional out of concern that their ‘business’ may become publicly known 5.

The close-knit nature of small communities means a GP, psychologist or even an office staff member is more likely to interact or even have rapport with the help-seeking individual outside of a professional setting.

These factors add to a sense of social isolation and can compound existing mental health conditions.
Consequently, timely diagnoses and treatment are less likely to occur in smaller communities.

On the Line recommends the following to help address the nature and underlying causes of rural and remote Australians accessing mental health services at a much lower rate: • Increase access to mental health services in rural and remote Australia by increasing the availability of telehealth and digital mental health services.
This would improve accessibility by addressing known barriers to the uptake of mental health, like travel distance and concerns about discretion and anonymity.
1 National Rural Health Alliance 2 Department of Health/Royal Flying Doctor Service 3 Australian Institute of Health and Welfare 4 https://www.aihw.gov.au/reports/rural-remote-australians/survey-health-care-selected-findings-rural-remote/contents/summary 5 https://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-10-113#CR12 Accessibility and quality of mental health services in rural and remote AustraliaSubmission 58 • Apply new or alternative technology to further improve access and take-up rates of mental health services.
For example, telephone, SMS text6 and a wide range of internet-based services (e.g.

video counselling, web chat, mobile self-help apps) have been shown to be effective means of treatment for a range of conditions.

Implementing services on the back of these technologies can alleviate the burden on existing mental health infrastructure (for example, by providing effective counselling that doesn’t require face-to-face contact).
These technologies can also make a significant contribution to overcoming previously mentioned barriers to take-up.

(b) the higher rate of suicide in rural and remote Australia; The suicide rate in remote and regional areas is almost double that of major cities7.

Across a range of metrics, men and Indigenous Australians are consistently over-represented.

For example, men aged 15-29 years living outside of major cities were twice as high as those in major cities to die by suicide 8.
Very old men (aged 85 years and over) outside of major cities had an extremely high suicide rate: 40 per 100,000, significantly higher than the national average of 11.7.

The suicide rate among indigenous youth is also five times higher than in non-Indigenous people9.

– and just 14% of Indigenous people with a mental illness had previously sought treatment at the time of suicide 1011.
A range of risk factors contribute to the high suicide rate, including12: • Unemployment, often linked to economic and climate-based factors like drought 13.

• Greater exposure to and risk of natural disasters14.

• Loneliness and social isolation15.

• Lack of access to mental health services 16.

• Relatively easy access to lethal means of self-harm, such as firearms and pesticides.

Many suicide attempts by other means are not fatal whereas firearms generally have a high lethality rate17.
• Social stigma and perceived lack of confidentiality.

The tight-knit nature of small communities is not in itself a risk factor, however, the fact that a person in need of support may feel that ‘their business’ will become known to the community can be a disincentive to seeking treatment18.

On the Line operates three dedicated suicide prevention telephone and online counselling services.
Online counselling and psychotherapeutic support has been shown to have almost the same effectiveness as face-to-face services.

On the Line therefore recommends the following to help reduce the higher rate of suicide in rural and remote Australia: • Improve access to psychologists, case workers and other mental health professionals by increasing the availability of telehealth and digital services.
These services provide a dual benefit in that they not only overcome the often very significant distances that people must travel to seek treatment, but also allow individuals to access treatment in a way that is discrete and private, decreasing both real and perceived barriers to help-seeking behaviour.

• Promote mental health and suicide prevention programs through existing institutions like schools and local community centres.
6 https://onlinelibrary.wiley.com/doi/full/10.1111/j.1440-1584.2007.00859.x 7 http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4102.0Main+Features30Mar+2011 8 http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4102.0Main+Features30Mar+2011 9 http://ruralhealth.org.au/content/mental-health 10 https://trialsjournal.biomedcentral.com/articles/10.1186/1745-6215-14-396 11 https://trialsjournal.biomedcentral.com/articles/10.1186/1745-6215-14-396#CR3 12 http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4102.0Main+Features30Mar+2011 13 http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4102.0Main+Features30Mar+2011 14 http://ruralhealth.org.au/sites/default/files/publications/nrha-mental-health-factsheet-dec-2017.pdf 15 http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4102.0Main+Features30Mar+2011 16 http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4102.0Main+Features30Mar+2011 17 http://ruralhealth.org.au/sites/default/files/fact-sheets/fact-sheet-14-suicide%20in%20rural%20australia_0.pdf 18 http://ruralhealth.org.au/sites/default/files/fact-sheets/fact-sheet-14-suicide%20in%20rural%20australia_0.pdf Page 2 Accessibility and quality of mental health services in rural and remote AustraliaSubmission 58 (c) the nature of the mental health workforce; Australia’s mental health workforce is disproportionately under-represented in rural, regional and remote areas.
For example, the ratio of psychologists per 100,000 population is significantly higher in major cities (92.4 per 100,000) than in inner regional (55.5 per 100,000), outer regional (40.8 per 100,000) and remote or very remote regions (29.6 per 100,000) 19.

Where a psychologist is employed in a regional area, their work hours are longer than those of their urban counterparts 20.

Overall, Medicare expenditure in rural areas is lower than in major urban centres 21.
Limited access to mental health facilities correlates with negative mental health outcomes.

For example, the fewer the number of psychologists in an area, the greater its rate of mental health hospitalisation (856 mental health hospitalisations per 100,000 in major cities, increasing to 1096 per 100,000 in remote areas)22.
The high suicide rate in rural areas is exacerbated by increased risk factors, and limited access to mental health services, with fewer opportunities for diagnosis and treatment, as well as fewer opportunities for early intervention.

On the Line recommends the following to help reduce the burden on current rural mental health workforce: • Improve the availability of telehealth and digital services.
This would reduce the current burden on the workforce by providing effective alternatives to many traditional referral-based face-to-face services and treatments.

(d) the challenges of delivering mental health services in the regions; The overall incidence of mental health disorders is generally equal between major cities and rural areas – what is significantly skewed is the outcome of mental health disorders when left undiagnosed or untreated.
Ready access to effective mental health services does not reduce the overall incidence of disorders.

Instead, ready access to services directly affects the severity of those disorders.

Consequently, mental health conditions are likely to become more acute if left untreated or undiagnosed for long periods due to limited access to services.
This is evident in a raft of disparate negative mental health outcomes recorded in rural Australia, ranging from the higher than average volume of mental health hospitalisations in rural communities 23 to the well-documented high rate of suicide and self-harm in remote and Indigenous communities 24.
As per our responses to the terms of reference (a), (b) and (c), significant travel distances and reservations about obtaining treatment in closely-knit communities for fear of being ‘discovered’ add to the burden.

On the Line recommends the following will help address the challenges of delivering mental health services in the regions: • • • Improve and promote the volume and quality of research conducted specifically on rural health.
Rural health research attracts 1.1% of National Health and Medical Research Council funding25.

Improve and increase existing services to increase the likelihood of early intervention, diagnosis and treatment.

Improve access to telehealth and digital mental health services to reduce the burden on face-to- face services.

This would also help decrease the acuteness of mental health conditions among people who require support, as they are more likely to obtain preventative help.
19 http://ruralhealth.org.au/content/mental-health 20 https://www.aihw.gov.au/getmedia/ceeac63a-1670-4e75-85d2-61225ffb4ca9/15993.pdf.aspx?inline=true 21 http://ruralhealth.org.au/content/mental-health 22 http://ruralhealth.org.au/content/mental-health 23 http://ruralhealth.org.au/content/mental-health 24 http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0~2015~Main%20Features~Intentional%20self- harm%20in%20Aboriginal%20and%20Torres%20Strait%20Islander%20people~9 25 http://ruralhealth.org.au/media-release/rural-health-research-funding-critically-low-levels Page 3 Accessibility and quality of mental health services in rural and remote AustraliaSubmission 58 (e) attitudes towards mental health services; A number of factors contribute to people in regional areas feeling apprehensive about either seeking treatment or being publicly seen to seek treatment.
In farming communities, for example, ingrained attitudes (particularly among men) have been identified that are dismissive of the concept of depression.

People who talk about their mental health condition are perceived as being “whingers” and help is not sought from mental health services, but from friends and family26.

These communities have a tradition of self-reliance and view problems as being best solved via practical solutions.
People in these communities may also feel that there is a stigma associated with having a mental illness27.

The well-documented lower mean income and lower education level in regional areas, coupled with the previously mentioned challenges of distance and concerns about confidentiality, further contribute to lower uptake rates of mental health services 28.
Among Indigenous communities, research has consistently associated a link between feelings and experiences of discrimination and “mental health conditions such as psychological distress, depression and anxiety”29.

It also appears to be “consistently associated with health risk behaviours such as smoking, alcohol and substance misuse”30.
On the Line recommends the following to improve attitudes towards mental health services: • Improve access to telehealth and digital mental health services in order to increase uptake among people concerned about privacy and discretion.

• Promote mental health and suicide prevention programs through existing institutions like schools • and local community centres.
Improve access to specialist Indigenous mental health services that are culturally aware and which are capable of supporting the mental health needs of local communities.

(f) opportunities that technology presents for improved service delivery; and Many existing technologies can facilitate or improve the effective delivery of services to areas with limited access to mental health services.
Internet and telephone-based services in particular can fulfil a wide range of roles that were traditionally done via face-to-face referrals.

This is especially relevant to rural areas where non face- to-face services (i.e.

web and phone-based services) can provide suitable mental health expertise while negating the traditional barriers of travel distance and concerns about privacy and confidentiality.
The benefits of non face-to-face services have been shown to be at least equally effective at delivering support across a wide range of mental health applications, such as web-based psychotherapy31.

The widespread use of smartphones means it is also inherently easier to reach people directly, even if they are based in remote or rural locations.
For example, SMS text messaging between psychologists and patients in rural areas is thought to be an effective means of overcoming travel time and even inconsistent mobile network coverage32.

Internet and telephone-based services also have the potential to make the administration of services more efficient and faster as they generally do not require the establishment and maintenance of permanent local offices.
26 https://www.beyondblue.org.au/about-us/research-projects/research-projects/depression-in-farmers-and-farming-families 27 https://www.beyondblue.org.au/about-us/research-projects/research-projects/depression-in-farmers-and-farming-families 28 https://www.beyondblue.org.au/about-us/research-projects/research-projects/depression-in-farmers-and-farming-families 29 http://dro.deakin.edu.au/eserv/DU:30058493/paradies-impactofracism-2008.pdf (Paradies 2006a) 30 http://dro.deakin.edu.au/eserv/DU:30058493/paradies-impactofracism-2008.pdf (Paradies 2006a) 31 http://www.popsci.com.au/science/internetbased-psychotherapy-actually-works,380055 32 http://www.abc.net.au/news/rural/2018-02-07/text-messaging-helping-solve-mental-health-issues-in-bush/9404112 Page 4 Accessibility and quality of mental health services in rural and remote AustraliaSubmission 58 On the Line recommends considering the following technological opportunities with a view to improving service delivery: • Develop digital, telephone and hybrid forms of technology to improve access and take-up rates of mental health services, including web chat, live video counselling, SMS text and mobile apps.
These overcome the problem of travel distance and also allow people to seek treatment without fear of being ‘discovered’ in a small community.

• Develop mobile and web apps that allow users to self-manage and take ownership of their mental health treatment.

For example, On the Line operates a self-assessment app (mHealth platform) that allows users to track their mental wellbeing while simultaneously providing useful diagnostic data to a qualified telephone counsellor.
Investigate how digital social media can promote and deliver mental health services, especially among youth and Indigenous communities, where social media use is higher compared to the rest of the population 33.

• (g) any other related matters.

There are no further related matters that On the Line wishes to address in this response.

33 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4881203/ Page 5 Accessibility and quality of mental health services in rural and remote AustraliaSubmission 58