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Mental Health Care for Rural and Remote Australians During the Coronavirus Disease 2019 Pandemic

Published:September 08, 2020DOI:https://doi.org/10.1016/j.amj.2020.08.008

      Abstract

      The aims of this article are to comment on pre–coronavirus disease 2019 (COVID-19) mental health activity in rural and remote Australia, including related air medical retrievals; to discuss how the current pandemic is likely to impact on this vulnerable population's mental health; and to provide potential solutions. The COVID-19 pandemic has resulted in significant air medical activity from rural and remote Australia. COVID-19 and the necessary public health and socioeconomic interventions are likely to significantly compound mental health problems for both the general public and the mental health workforce servicing rural and remote communities. However, the COVID-19 crisis provides a window of opportunity to develop, support, and build novel and sustainable solutions to the chronic mental health service vulnerabilities in rural and remote areas in Australia and other countries.
      As a result of the current coronavirus disease 2019 (COVID-19) pandemic, rural and remote populations throughout the world are likely to suffer worse mental health outcomes than metropolitan populations because of a higher burden of underlying physical and mental health risk factors, poorer access to health services, and lower levels of psychological support.
      Australian Institute of Health and Welfare
      Australia's Health 2018.
      This is especially true of countries that have populations dispersed over wide areas, such as Australia, Canada, and China,
      • Cui X
      • Zhou X
      • L-l Ma
      • Sun T-W
      • Gardiner FW
      • Wang L-X
      A nurse-lead structured education program improves self-management skills and reduces hospital readmissions in patients with chronic heart failure: a randomized and controlled trial.
      • Zhang P
      • Tao G
      • Anderson LA
      Differences in access to health care services among adults in rural America by rural classification categories and age.

      Gardiner FW, Bishop L, Gale L, et al. Poor access to kidney disease management services in susceptible patient populations in rural Australia is associated with increased aeromedical retrievals for acute renal care [e-pub ahead of print]. Intern Med J. 2020;50:951–959.

      with limited provision of generalist and specialist health care in rural and remote areas. Many rural populations are also socioeconomically disadvantaged, such as Australian and Canadian Aboriginal people.
      Australian Institute of Health and Welfare
      Australia's Health 2018.
      ,
      • Cass A.
      Health outcomes in Aboriginal populations.
      It is vitally important that the mental health needs of these vulnerable population groups are not forgotten during, and at the conclusion of, the COVID-19 pandemic.
      There is a critical need to collect quality data on the mental health effects of the COVID-19 pandemic across vulnerable groups.
      • Holmes EA
      • O'Connor RC
      • Perry VH
      • et al.
      Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science.
      As such, the aims of this article are to comment on pre–COVID-19 mental health activity in rural and remote Australia, including related air medical retrievals; to discuss how the current pandemic is likely to impact on this vulnerable population's mental health; and to provide potential solutions.

      COVID-19 Pathophysiology

      The COVID-19 pandemic was first identified in Hubei Province in China. There is evidence of community transmission throughout the world. Currently, a diagnosis is made via nasopharyngeal specimens or lower respiratory samples (sputum or bronchoscopy samples) sent for molecular detection of severe acute respiratory syndrome coronavirus 2.
      • Thevarajan I
      • Buising KL
      • Cowie BC
      Clinical presentation and management of COVID-19.
      It is currently unknown how many people have asymptomatic infection; however, there appears to be different rates in children compared with adults.
      • Thevarajan I
      • Buising KL
      • Cowie BC
      Clinical presentation and management of COVID-19.
      COVID-19 has an estimated incubation period of 5.1 days (95% confidence interval, 45-5.8 days) with the majority (97.5%) of people with the disease developing symptoms within 11 days of exposure (95% confidence interval, 8.2-15.6 days).
      • Thevarajan I
      • Buising KL
      • Cowie BC
      Clinical presentation and management of COVID-19.
      This is a prime reason for the isolation/quarantine of exposed and potentially exposed individuals for at least 14 days from the initial exposure.
      Infection can cause severe acute respiratory illness commonly with fever and cough, but there is a spectrum of disease ranging from mild to severe symptoms.
      • Lai C-C
      • Shih T-P
      • Ko W-C
      • Tang H-J
      • Hsueh P-R
      Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): the epidemic and the challenges.
      Approximately 80.0% (generally the mild cases) of patients can be managed within their community; however, patients with moderate to severe disease are admitted to the hospital. These moderate patients are often dyspneic, tachypneic at rest, hypoxemic, hypotensive, have an altered mental state, or have been found to have extensive pulmonary infiltrates evident on chest imaging. Severe patients with a respiratory rate greater than 30 breaths/min, oxygen saturation less than 92%, or prolonged hypotension require urgent hospital care.
      • Thevarajan I
      • Buising KL
      • Cowie BC
      Clinical presentation and management of COVID-19.

      Royal Flying Doctor Service in Rural and Remote Australia

      The Royal Flying Doctor Service (RFDS) is 1 of the largest air medical services in the world
      • Margolis SA
      • Ypinazar VA.
      Aeromedical retrieval for critical clinical conditions: 12 years of experience with the Royal Flying Doctor Service, Queensland, Australia.
      and provides air medical retrievals, primary health care, mental health services, oral health services, and ground transport services. It delivers essential health services for rural and remote Australians who do not have access to health care provided through Australia's Medical Benefits Schedule.
      • Gardiner FW
      • Coleman M
      • Teoh N
      • et al.
      Aeromedical retrievals of people for mental health care and the low level of clinical support in rural and remote Australia.
      The RFDS services the majority of Australia's landmass (7.69 million square kilometers),
      Geoscience Australia
      Area of Australia - states and territories.
      with rural and remote populations (N = 2,543,960, 10.2%) comprising the majority of people accessing RFDS services.
      Australian Bureau of Statistics
      Population estimates by age and sex, regions of Australia (ASGS 2016), 2018.
      From July 2014 to June 2018, the RFDS conducted 105,147 air medical retrievals,
      • Gardiner FW
      • Bishop L
      • Santos AD
      • et al.
      Aeromedical retrieval for stroke in Australia.
      with respiratory system and mental and behavioral disorders comprising 7,697 (7.3%) and 3,230 (3.1%) of the retrievals, respectively.
      The RFDS provides a lifeline to rural and remote areas that have significantly lower levels of primary health care and mental health service provision than major city areas.
      • Gardiner F
      • Gale L
      • Ransom A
      • Laverty M
      Looking ahead: responding to the health needs of country Australians in 2028- the centenary year of the RFDS.
      This includes transporting patients to key health services such as inpatient mental health units. Often, rural and remote patients experiencing mental health problems that require inpatient care need to be flown long distances to major cities or inner regional areas, placing considerable strain on RFDS daily resources. In a recent article, the median distance traveled by the RFDS for a mental health retrieval was 324 km (interquartile range, 298 km).
      • Gardiner FW
      • Coleman M
      • Teoh N
      • et al.
      Aeromedical retrievals of people for mental health care and the low level of clinical support in rural and remote Australia.
      In 2017, the total medical costs for air medical retrieval and hospitalization of 1,048 mental health patients was estimated to be AUD $20,070,527.
      • Gardiner FW
      • de Graaff B
      • Bishop L
      • Campbell JA
      • Mealing S
      • Coleman M
      Mental health crises in rural and remote Australia: an assessment of direct medical costs of air medical retrievals and the implications for the societal burden [e-pub ahead of print].

      Changes to the Air Medical Landscape due to COVID-19

      The RFDS conducted the first COVID-19 air medical retrieval within Australia, if not the world. Between February 2, 2020, and August 13, 2020, the RFDS has conducted 1,118 patient episodes of care for confirmed or suspected COVID-19 by air and road. This included 1,107 separate patients, including 331 males and 317 females (459 sexes to be confirmed), with a median age of 65.0 years (interquartile range, 45.0-79.0 years). Episodes included 1,055 interhospital transfers (also known as secondary retrievals), 55 primary evacuations, and 8 repatriations. All patients were either confirmed with COVID-19 (n = 132) or strongly suspected of having it (n = 975).
      The majority of patient episodes have been conducted by road within the Australian state of Victoria (n = 865, 78.0%). Many of these transports have been conducted for older patients with confirmed COVID-19 (n = 126), a high-risk population group for severe symptoms and outcomes. Patients retrieved are transported to metropolitan areas, usually hundreds of kilometers from their community.
      • Gardiner FW
      • Coleman M
      • Teoh N
      • et al.
      Aeromedical retrievals of people for mental health care and the low level of clinical support in rural and remote Australia.
      During this time period, the RFDS has had 81 staff members who were required to self-isolate while they awaited COVID-19 pathology test results before being able to restart work, with some clinical staff testing positive.
      In this demand context, it is unlikely that non–COVID-19 patients with mental health problems will assume priority for urgent transfers.
      The RFDS deals with respiratory and mental health patients routinely. However, COVID-19 presents challenges in terms of potential volumes of patients needing care and the impacts it has on organizational capacity. In response to growing COVID-19 activity (Fig. 1), the RFDS conducted surge planning and modeling.

      Gardiner FW, Johns H, Bishop L, Churilov L. Royal Flying Doctor Service COVID-19 activity and surge modelling in Australia [e-pub ahead of print]. Air Med J. doi:10.1016/j.amj.2020.05.011, Accessed June 6, 2020.

      This article showed that the RFDS is able to meet current COVID-19 demand; however, if activity increases, they will be required to use more aircraft, which in turn will require additional workforce and funding. Furthermore, if aircraft provision (and workforce to service and operate the aircraft) are not increased, many lower acuity patients, including mental health patients, would likely be left within their community.

      Gardiner FW, Johns H, Bishop L, Churilov L. Royal Flying Doctor Service COVID-19 activity and surge modelling in Australia [e-pub ahead of print]. Air Med J. doi:10.1016/j.amj.2020.05.011, Accessed June 6, 2020.

      The nonheterogeneous nature of rural and remote populations and their regions presents another challenge in coordinating a COVID-19 response, which is sensitive to each community's needs.
      Figure 1
      Figure 1Confirmed and suspected COVID-19 weekly retrieval trends.

      COVID-19–Related Challenges to Mental Health Care Delivery in Rural and Remote Population

      Recent evidence from before the onset of the COVID-19 pandemic showed that retrievals for mental health disorders were a significant issue in rural and remote Australia.
      • Gardiner FW
      • Coleman M
      • Teoh N
      • et al.
      Aeromedical retrievals of people for mental health care and the low level of clinical support in rural and remote Australia.
      The RFDS transported 2,257 patients from 2014 to 2017 for mental and behavioral disorders, increasing from 309 (2.7% of retrievals) in 2014 to 2015 to 1,038 (3.6%) in 2016 to 2017. What is of greatest concern is that the COVID-19 pandemic is expected to increase mental health cases
      • Wang C
      • Pan R
      • Wan X
      • et al.
      Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China.
      because of stress from social isolation, economic stressors, increased drug and alcohol use, medication supply disruption,

      Cadogan CA, Hughes CM.On the frontline against COVID-19: community pharmacists’ contribution during a public health crisis [e-pub ahead of print]. Res Social Adm Pharm. doi:10.1016/j.sapharm.2020.03.015, Accessed June 5, 2020.

      and a lack of capacity within regional health care workforce and resourcing.
      • Zhou X
      • Snoswell CL
      • Harding LE
      • et al.
      The role of telehealth in reducing the mental health burden from COVID-19.
      Rural area health care is being further compromised during the COVID-19 pandemic because of the smaller available pool of health care workforce, travel restrictions, and increasing demand on the health care workforce in nonmetropolitan areas. Travel restrictions not only meant that individuals could not travel out of their communities but also resulted in many fly-in fly-out clinicians not being able to access patients. Furthermore, many were required to isolate before and after traveling, taking them out of the workforce for 2 weeks. These issues have since been addressed with essential services, such as RFDS clinicians, being exempt from the travel restrictions.
      Reduced or no access to higher-level or intensive care beds and supports increases the vulnerability of these communities. The North West health system in the state of Tasmania, Australia, has recently experienced an outbreak of COVID-19 cases among health professionals. Despite the relatively low number of infections among health care workers,
      • MacDonald L.
      More coronavirus cases found in Tasmania's north-west as 'testing blitz' announced.
      the 2 regional hospitals were closed, and the state required Commonwealth government intervention with Military and Australian Medical Assistance Teams support. Regional health care resource vulnerability, in particular specialist mental health care, was recognized as a problem pre–COVID-19, with air medical retrieval being an important and integral part of the rural and remote landscape with RFDS clinical teams doing the majority of patient retrievals.
      • Gardiner FW
      • Coleman M
      • Teoh N
      • et al.
      Aeromedical retrievals of people for mental health care and the low level of clinical support in rural and remote Australia.
      Clinical and nonclinical staff are also at risk of psychological distress through longer working hours and increased high risk of exposure to the virus.
      • Zhou X
      • Snoswell CL
      • Harding LE
      • et al.
      The role of telehealth in reducing the mental health burden from COVID-19.
      Between February 2, 2020, and August 13, 2020, the RFDS has had 81 members impacted by COVID-19, with some clinical staff testing positive. Additional, and unprecedented, stresses caused by the COVID-19 pandemic will lead to anxiety, burnout, depression, and increased sick and personal leave within our clinical workforce.
      • Maunder RG.
      Was SARS a mental health catastrophe.
      These health care providers are already in short supply in rural and remote Australia
      • Gardiner F
      • Gale L
      • Ransom A
      • Laverty M
      Looking ahead: responding to the health needs of country Australians in 2028- the centenary year of the RFDS.
      ; as such, we need clinical and general population policy and practice interventions aimed at supporting these clinicians and the public they service. However, the best way to support mental health during pandemics such as COVID-19 remains unclear.
      • Chen Q
      • Liang M
      • Li Y
      • et al.
      Mental health care for medical staff in China during the COVID-19 outbreak.
      Impacts on the local and retrieval workforce will inevitably add to the disadvantage and pressures this pandemic places on rural and remote communities.
      Many rural and remote communities have closed their borders to outsiders (with the exception of essential services in some cases).
      • Chan G.
      Rural Australia is used to isolation, but Covid-19 gives it a whole new meaning.
      In the absence of a vaccine for COVID-19, individuals have been mandated to reduce social contact and to maintain hand hygiene to reduce the risk of infection.
      • Zhou X
      • Snoswell CL
      • Harding LE
      • et al.
      The role of telehealth in reducing the mental health burden from COVID-19.
      Travel restrictions, quarantining, and social distancing are likely to exacerbate the inherent isolation experienced in rural and remote communities, resulting in increased loneliness and disrupting social connectedness and social network supports.
      • Zhou X
      • Snoswell CL
      • Harding LE
      • et al.
      The role of telehealth in reducing the mental health burden from COVID-19.
      In Australia, delays and problems in accessing mental health care in rural and remote communities
      • Morley B
      • Pirkis J
      • Naccarella L
      • Kohn F
      • Blashki G
      • Burgess P
      Improving access to and outcomes from mental health care in rural Australia.
      lead to increased crisis presentations, increasing both the health care costs and the complexity of care required.
      • Gardiner F
      • Gale L
      • Ransom A
      • Laverty M
      Looking ahead: responding to the health needs of country Australians in 2028- the centenary year of the RFDS.
      Completed suicide, particularly among younger remote Aboriginal Australians, is 1 of the serious consequences of poorer access to earlier specialist care.
      • Hunter E
      Disadvantage and discontent: a review of issues relevant to the mental health of rural and remote Indigenous Australians.
      It is currently unclear whether social isolation restrictions have impacted the rates of road and air retrieval for mental health disorders. It is our belief that periods of social isolation and travel restrictions coupled with limited access to normal health care provision will result in more mental health cases once social isolation measures are lifted. Although anecdotally it appears there are more severe mental health retrievals during social isolation, this remains untested and will be a subject of future analysis.

      Potential Solutions

      Understandably, technological and Internet-based platform use has been endorsed and rapidly expanded during the COVID-19 pandemic as an alternative to shortfalls in access to face-to-face care. The Australian government has responded with additional funded services through the Medical Benefits Schedule, enabling a greater range of telehealth services, including videoconferencing, to be used to connect patients with general practitioners and mental health practitioners, such as psychologists and psychiatrists. Although this is a welcome initiative, there are some limitations. Specifically, it assumes patients have access to a mental health clinician or had been previously been receiving face-to-face treatment with a clinician. However, many rural and remote areas already experience significant shortages of psychologists and psychiatrists.
      • Margolis SA
      • Ypinazar VA.
      Aeromedical retrieval for critical clinical conditions: 12 years of experience with the Royal Flying Doctor Service, Queensland, Australia.
      Web-based mental health treatment and support sites have also been promoted widely before the crisis, and within Australia there has been significant investment in expanding these services. However, rural and remote communities have lower levels of digital literacy, Internet use, and access,
      • Moffatt J
      • Eley DS.
      Barriers to the up-take of telemedicine in Australia-a view from providers.
      ,
      • Park S.
      Digital inequalities in rural Australia: a double jeopardy of remoteness and social exclusion.
      with poorer connectivity and broadband width.
      • Islam AR
      • Selvadurai N
      • Town G
      Wireless Broadband technologies for regional and rural Australia: a last-mile perspective.
      Pre-COVID telehealth models of care often used point-to-point care from within health care facilities (eg, metropolitan hospital to remote clinic); however, these models have largely been made redundant by the COVID-19 pandemic due to hospitals and clinics canceling many nonacute services. Telehealth platforms that provide care into the home have rapidly expanded during the pandemic, but rural and remote connectivity issues may preclude their uptake into these vulnerable communities,
      • Park S.
      Digital inequalities in rural Australia: a double jeopardy of remoteness and social exclusion.
      further disproportionately disadvantaging people who live in these locations.
      To provide adequate telehealth capability, policy makers need to ensure rural and remote residents and communities have sufficient Internet access.
      • Holmes EA
      • O'Connor RC
      • Perry VH
      • et al.
      Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science.
      Many rural and remote communities do not have the connectivity of a standard that would allow “visual” teleconferencing.
      • Jang-Jaccard J
      • Nepal S
      • Alem L
      • Li J
      Barriers for delivering telehealth in rural Australia: a review based on Australian trials and studies.
      Although asking clinicians to provide telehealth services to rural and remote areas makes sense during a pandemic, we still need to address the infrastructure limitations many of these communities experience.
      Immediate action is required to assist in the psychology and individual factors as a result of COVID-19 on mental health.
      • Holmes EA
      • O'Connor RC
      • Perry VH
      • et al.
      Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science.
      This should include improving the monitoring and reporting of anxiety, depression, self-harm, and suicide in rural and remote Australia. Furthermore, there is an opportunity to use social media to determine trends in rural and remote populations. For example, a recent report indicated that social media posts related to mental health appeared to reflect air medical retrievals for mental health and behavioral disorders.
      • Holmes EA
      • O'Connor RC
      • Perry VH
      • et al.
      Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science.
      Rural and remote communities are notorious for not asking for help until it is too late. If we could understand social media posts and the role of repeated media consumption in rural and remote Australia related to the amplification of distress and anxiety, we would be able to develop targeted interventions to help reduce acute mental health cases.
      • Farmer J
      • McCosker A
      • Kamstra P
      • et al.
      Mapping the Hidden Voices in Rural Mental Health: A Pilot Study of Online Community Data.
      A key short-term intervention that must be completed is determining what psychological supports there are for the rural and remote workforce.
      • Holmes EA
      • O'Connor RC
      • Perry VH
      • et al.
      Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science.
      We cannot expect our already overworked rural workforce to shoulder additional stress without support. Additional COVID-19 support should include psychological support for clinicians and their families, providing coping resources, assisting them maintain sleep and nutrition, and maintaining work-life balance.
      • Holmes EA
      • O'Connor RC
      • Perry VH
      • et al.
      Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science.
      Providing more support to mental health staff working in more remote sites through regular specialist telephone and videoconferencing (telehealth) consultations may be 1 way to improve local service provision and reduce the demand for RFDS transfer.
      Policies and interventions for rural and remote people and communities with COVID-19 need to address both the physical, psychological, and social aspects of the pandemic. Remote mental health service teams will require tailored COVID-19 training, peer support, supervisory leadership, and debriefing strategies to manage additional demands on services.
      • Greenberg N.
      Nightingale Mental Health Team Standard Operating Procedure.
      Before the COVID pandemic, many services were already overstretched, and there had been relative underspending in the workforce of mental health services in rural communities. Despite the current economic constraints, rural health service investment should be prioritized as part of broader strategic social and economic recovery programs for communities using innovative training and workforce development programs to improve local workforce viability and sustainability. This may future proof future natural disasters and adversities such as fires, floods, and drought. COVID-19 economic stimulus packages may provide an opportunity to strategically invest in local community health infrastructure in addition to improving supply, retrieval, and communication network capabilities. COVID-19 now adds additional unprecedented strain on the mental health of communities and presents as a new emerging challenge for governments, health care providers, and communities.

      Conclusion

      Very few countries have not been affected by the COVID-19 pandemic, and its impacts are likely to be felt for years to come. Rural and remote adversity and health care vulnerabilities have been a problem in Australia and other countries for many decades. These communities often have significantly lower health services per population compared with metropolitan areas. This is coupled with these areas having worse mental health outcomes, such as suicide completion rates. COVID-19 and the necessary public health and socioeconomic interventions are likely to significantly compound mental health problems for both the general public and the mental health workforce servicing rural and remote communities. However, the COVID-19 crisis provides a window of opportunity to develop, support, and build novel and sustainable solutions to the chronic mental health service vulnerabilities in rural and remote areas in Australia and other countries.

      Acknowledgment

      We would like to acknowledge supporters of the Royal Flying Doctor Service who made this research possible. We would also like to acknowledge Professor John Gleeson for reviewing the article before journal submission.

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