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Urban-rural differences in psychiatric rehabilitation outcomes

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Aust. J. Rural Health (2010) 18, 66–71
Original Article
Urban–rural differences in psychiatric
rehabilitation outcomes ajr_1127
Srinivasan Tirupati,1,2 Agatha Conrad,2 Barry Frost1 and Suzanne Johnston1
1
Psychiatric Rehabilitation Service, Hunter New England Area Health Service, Hamilton, and
2
Centre for Brain and Mental Health Research, University of Newcastle, Callaghan,
New South Wales, Australia
Abstract
Objective: Employing rural and urban patient popula-
tions, the aim of the study was to examine the differences
in rehabilitation intervention outcomes, particularly in
regard to the social and clinical determinants.
Design: The study employed a retrospective, cross-
sectional analysis of patient outcome and characteristics.
Setting: Community-based psychiatric rehabilitation
service in regional and rural Australia.
Participants: A total of 260 patients were included in
the service evaluation phase of the study and 86 in the
second part of the study. Participants were community-
based and suffered from a chronic mental illness.
Main outcome measure(s): Clinical and functional
outcomes were measured using the Health of Nations
Outcome Scale and the 16-item Life Skills Profile.
The outcome score employed was the difference bet-
ween scores at intake and at the last complete assess-
ment. Clinical and sociodemographic characters were
recorded using a proforma developed for the study.
Results: Patients from rural Maitland had a signifi-
cantly larger mean reduction in total scores and classi-
fied more often as ‘Improved’ on both the Health of
Nations Outcome Scale and Life Skills Profile than
patients from either of the urban areas (P < 0.01). Study
of randomly selected patients showed that those from an
urban area had a more complex illness with multiple
needs and less often received family support than their
rural counterparts.
Conclusions: For rural communities the improvement
in rehabilitation outcomes might be attributable to a
more benign form of the illness and the availability of
higher levels of social capital.
Correspondence: Srinivasan Tirupati, Psychiatric Rehabilita-
tion Service, Hunter New England Area Health Service, 20
Stewart Avenue, Hamilton, New South Wales, 2303, Australia.
Email: srinivasan.tirupati@hnehealth.nsw.gov.au
Accepted for publication 1 February 2010.
© 2010 The Authors
Journal compilation © 2010 National Rural Health Alliance Inc.
66..71
KEY WORDS: family, rural mental health, severe
mental disorder.
Introduction
Urban–rural differences are reported in the inci-
dence and outcome of severe mental disorders like
schizophrenia.1–3 One of the reasons attributed for this
difference was the ‘drift’ of severely ill patients in their
socioeconomic status towards the poor central urban
districts of a city. Thornicroft et al. wrote about the
effect of cities in clustering seriously disabled psychiatric
patients in areas of low-cost housing where they lived in
relative social isolation.4
Social migration theories alone are not sufficient to
explain the urban–rural differences.5 Rural communities
have socioeconomic and cultural characteristics that are
distinct from non-rural communities.6 Social capital is
described as a key asset for rural communities in com-
parison with urban societies. Social capital is fundamen-
tally an ecological characteristic that incorporates a host
of overlapping constructs, including social trust/
reciprocity, cohesion and participation and a sense of
community.7 It is proposed as potentially relevant in the
aetiology and mental health-related outcomes including
quality of life, social function and coping capacities of
person with severe mental disorders.5,8–11 A higher level
of social capital is found in rural areas compared with
urban areas.12
While the majority of studies urban–rural differences
in severe mental disorders focussed on their epidemiol-
ogy and aetiological factors, it is of interest to study
such differences in outcome of rehabilitative interven-
tions and explore factors related to such differences.
This study was conducted with an aim to examine
urban–rural differences in outcome of patients in a
community-based rehabilitation program and explore
factors that could possibly underlie any differences
observed.
doi: 10.1111/j.1440-1584.2010.01127.x
REHABILITATION AND RURAL MENTAL HEALTH
What is already known on this subject:
• Outcome of severe mental disorders like
schizophrenia is worse in urban areas.
• Urban-rural differences in outcome of re-
habilitation interventions for people with
chronic severe disorders living in the commu-
nity is not well studied.
• Social capital is an important compo-
nent in understanding differences in mental
health outcomes between urban and rural
populations.
Method
Study population
This study was conducted at the three community psy-
chiatric rehabilitation centres of Hunter New England
Area Health Service (HNEAHS) in New South Wales,
Australia. The centres provide rehabilitative services to
patients residing in their respective local government
areas, namely Maitland (MT), Lake Macquarie (LM)
and Newcastle (NT). MT is predominantly rural
whereas NT and LM are urban in nature although some
of the suburbs in LM local government areas are rural in
nature. The Maitland District Hospital is classified as a
rural hospital by the New South Wales Area Health
Service attachment classification.13The geographical
locations of MT and other areas served by the hospital
are classified as Rural areas (Large, Small or Other) by
the Rural, Remote and Metropolitan Areas (RRMA)
Classification.14 Defined by intake criteria, the patient
population at the three centres was composed of adults
with long duration (usually five years or more) psy-
chotic, mood and anxiety disorders. These patients had
recovered adequately from acute stage of the illness with
stable symptoms and were at low to moderate risk for
self harm or aggression.
The data for this presentation was gathered in two
stages. The first one was a service evaluation study of
outcome of subjects receiving rehabilitation care from
the three centres. The second part of the study compared
clinical and sociodemographic characteristics of a dif-
ferent cohort attending the three centres.
Data collection
The data for the evaluative part of the study was
gathered from electronic medical records of patients
accepted into the rehabilitation program between the
years 2005 and 2007. Two standardised instruments,
the Health of Nations Outcome Scale – HoNOS15 and
© 2010 The Authors
Journal compilation © 2010 National Rural Health Alliance Inc.
67
What this study adds:
• Outcome of rehabilitation intervention for
chronic severe mental disorders is better in a
rural community.
• The better outcome in rural communities is
attributable to a less severe form of illness
and access to better family support.
• Need to consider the role of family support
and other forms of social capital in long-term
care of severe mental disorders.
16-item Life Skills Profile – LSP-1616 were used to
measure clinical and functional state of subjects rou-
tinely at intake and every 13 weeks of follow up. These
were taken to measure outcome for the purpose of
this study. These two scales were part of the suite of
assessments (Mental Health Outcome Assessment Tool
– MHOAT) used by the whole of mental health service.
HoNOS and LSP were both designed for use in clinical
settings with good interrater reliability, validity and
sensitivity to change.17
The three centres were compared on the change in
mean total scores on HoNOS and LSP-16 from intake to
the last completed assessment using paired t-test. Out-
comes were further categorised as Improved, Worsened
or Unchanged based on the direction of change of total
scores on each scale – a reduction as Improved, an
increase as Worsened, and no change as Unchanged.
The group-wise divisions at the three centres were
compared using c2-test.
For the second part of the study, we selected a random
sample of subjects (every fifth person from a list with
last names arranged in an alphabetical order, starting
with the first name) attending the three centres compiled
on 28 of January 2008. A semistructured proforma was
developed for the study to record demographic, social
and clinical information. The data included age, gender,
current marital and accommodation status, involvement
of Non-Governmental Organisations and current social
supports. The current social support measure consid-
ered three domains, family, friends and other social
groups. Each domain was measured on three facets –
Frequency, Involvement and Quality. Frequency was
assessed as None, Occasional (less than monthly) and
Frequent (at least monthly). Involvement of the social
network in patient life was classified as Little, Some,
Significant and Quality as Supportive, Not supportive or
Not assessable. Support from a domain was considered
‘significant’ when the frequency was ‘Frequent’, involve-
ment was ‘Significant’ and quality as ‘Supportive’. Clini-
cal details recorded included psychiatric diagnosis,
68 S. TIRUPATI ET AL.

TABLE 1: Comparison of outcomes at three rehabilitation centres

Scale Outcome Maitland Lake Macquarie Newcastle c2

HoNOS (246) Same 4 (7%) 6 (7%) 9 (8%) 13.22, P < 0.01

Better 37 (73%) 46 (52%) 45 (42%)
Worse 10 (20%) 36 (41%) 53 (50%)
LSP (226) Same 5 (11%) 10 (13%) 5 (5%) 9.29, P < 0.01
Better 24 (51%) 40 (49%) 35 (36%)
Worse 18 (38%) 31 (38%) 58 (59%)
Change – HoNOS total score, mean (SD) -3.51 (4.81) -0.86 (6.12) 0.71 (5.28) F = 10.172, P < 0.001
Change – LSP total score, mean (SD) -0.94 (5.03) -0.43 (6.37) 2.57 (6.26) 7.762, P < 0.01
Interval between assessments in weeks, mean (SD) 62.4 (39.8) 58.0 (35.3) 68.3 (43.1) F = 1.710, not significant
(NS)
Intake total HoNOS score, mean (SD) 9.5 (5.0) 8.3 (5.6) 8.4 (4.9) F = 1.019, NS
Intake total LSP score, mean (SD) 10.7 (6.0) 10.0 (7.0) 10.1 (5.6) F = 0.201, NS

HoNOS, Health of Nations Outcome Scale; LSP, Life Skills Profile.

substance use, legal orders in place (like forensic
Conditional release orders and Community Treatment
Orders), number of clinical issues for management
(positive symptoms, negative symptoms, cognitive diffi-
culties, depression, anxiety and medication side-effects),
frequent alcohol and substance use, hospitalisation
during the three years prior to the study (years 2005–
2008), current medications and engagement with
rehabilitation activities. The current state of risk for
violence, suicide, harm to reputation and exploitation
was taken from the standard risk assessment form in the
electronic medical record of the subjects. The data was
gathered from interviewing the care coordinator of each
patient and review of individual case file. The three
service centres were compared using univariate statistics
(c2-, anova and t-test). The level of significance was set
at <0.05 for all analyses.
The Hunter New England Research Ethics Unit
advised that the project was a service evaluation project
and did not require formal ethics approval.
Results
Outcome study
Data records were available for 260 subjects (54 from
MT, 90 from LM and 116 from NT). There were more
men (152, 59%) than women (108, 41%) with a mean
age of 36.5 years (standard deviation, (SD) 11.8). The
mean interval between first and last assessment was
63.5 weeks (SD 39.9). Complete data on HoNOS
were available for 246 subjects (95%) and LSP for
226 subjects (87%).
Table 1 compares HoNOS and LSP scores and out-
comes at the three rehabilitation centres. There was no
significant difference between the centres in the total
HoNOS and LSP scores at intake and mean interval
between intake and last assessment. Significantly more
patients of MT were classified as ‘Improved’ than NT
or LM on both HoNOS and LSP (P < 0.01). The MT
group had the highest mean reduction in total scores on
both scales than the LM or NT (P < 0.01). Post-hoc
test showed that LM had greater reduction in mean
scores than NT on both HoNOS (P < 0.05) and LSP
(P < 0.01).
Patient characteristics study
A total of 86 subjects (27 from MT, 29 from LM and 30
from NT) were selected from a total of 419 patients.
Diagnosis of a chronic psychotic disorder (schizophrenia,
bipolar or schizoaffective disorder) was made in 73
(91%) patients. Table 2 compares subjects from the three
centres. Patients at NT centre were significantly older
(post-hoc test: NT older than LM patients, t = 2.054,
P < 0.05). Patients at NT lived less often with their
families than both MT and LM patients. More patients at
NT and LM centres were frequent users of substances
and alcohol than those from MT. Patients at both NT and
LM centres presented with a risk factor of medium level
more often than those at MT centre. The NT group were
considered at risk more often than the patients of LM
(c2 = 4.91, P < 0.05). Furthermore, patients at NT pre-
sented more often with multiple risk factors than at the
other two services. Patients of both NT and LM experi-
enced multiple (3 or more) clinical problems more often
than the MT group. Less number of patients in NT
received a significant level of support from their families.
While the family support was not different between MT
and LM (c2 = 1.82), the maximum difference was

© 2010 The Authors

Journal compilation © 2010 National Rural Health Alliance Inc.
REHABILITATION AND RURAL MENTAL HEALTH 69

TABLE 2: Comparison of subjects at the three rehabilitation centres

Statistic and
Variable MT (n = 27) LM (n = 29) NT (n = 30) P-values

Male : female 16:11 18:11 18:12 c2 = 0.05, 0.98

Mean age (SD) 36.4 (12.4) 39.2 (9.3) 44.9 (11.7) F = 4.304, <0.05
Living with family 14 (51.8%) 12 (41.3%) 2 (6.6%) c2 = 14.76, <0.001
In any kind of employment 8 (29.6%) 11 (37.9%) 12 (40%) c2 = 0.73, 0.69
Diagnosis of chronic schizophrenia 16 (59.2%) 18 (62.1%) 19 (63.3%) c2 = 0.10, 0.95
History of developmental disorder/brain damage 3 (11.1%) 1 (3.4%) 7 (23.3%) c2 = 5.33, 0.07
Current substance and alcohol issues 2 (7.4%) 13 (44.8%) 12 (40%) c2 = 10.67, <0.01
Under legal treatment orders 4 (14.8%) 6 (20.7%) 9 (30%) c2 = 1.95, 0.38
Hospitalisation during last 3 years 10 (37%) 16 (55.1%) 9 (30%) c2 = 4.09, 0.13
On >1 antipsychotic medication 18 (66.6%) 20 (68.9%) 26 (86.7%) c2 = 3.67, 0.16
Any risk factor of medium level 3 (11.1%) 10 (34.5%) 20 (66.7%) c2 = 18.83, <0.001
More than one risk factor of medium level 1 (3.7%) 1 (3.4%) 11 (36.7%) c2 = 16.68, <0.001
3 or more current clinical issues 3 (11.1%) 17 (58.6%) 16 (53.3%) c2 = 15.46, <0.001
NGO support 9 (33.3%) 5 (17.2%) 11 (37.9%) c2 = 3.05, 0.22
Significant support from family 22 (81.5%) 19 (65.5%) 14 (46.7%) c2 = 7.52, <0.05
Significant support from friends 10 (37%) 6 (20.7%) 6 (20%) c2 = 2.72, 0.26
Significant support from other social groups 3 (11.1%) 4 (13.8%) 3 (10%) c2 = 0.22, 0.90
Problems in adherence to rehabilitation programs 10 (37%) 12 (41.4%) 7 (23.3%) c2 = 2.34, 0.31

LM, Lake Macquarie; MT, Maitland; NGO, Non-Governmental Organisations; NT, Newcastle.

between MT and NT (c2 = 7.40, P < 0.01). A greater
percentage of patients at NT, although not statistically
significant, had a history of developmental disorder or
brain damage than the other two centres.
The three centres did not differ significantly regar-
ding gender, employment status, diagnosis of chronic
schizophrenia, application of legal treatment orders,
recent hospitalisation, use of multiple antipsychotic
drugs, degree of support from other social networks and
involvement of Non-Governmental Organisations in
care and treatment adherence issues.
Discussion
The study made three observations on urban–rural dif-
ferences in populations with chronic severe mental dis-
orders in a community rehabilitation program. First, the
outcome was better for those living in a rural commu-
nity compared with the urban cohort. Although patients
had comparable scores at intake, those patients from the
rural MT improved most while those from urban NT
did the least. Second, patients from rural MT had a
comparatively more benign form of illness being
younger, with lower rates of substance use, multiple risk
factors and clinical issues compared with those at the
urban centre. Third, patients from rural MT more often
lived with families and received significant support from
them compared with the urban group. We found a rural
to urban gradient with an intermediate outcome and
level of social support in LM area with a mix of urban
and rural communities
The retrospective nature, use of two different cohorts
of patients, small sample size for the second part of the
study and limited range of outcome assessments limits
the scope in application of multivariate statistics and
interpretation of results. However the two sets of patients
were in the same standard rehabilitation program of the
service around the same period of time and deemed
comparable. We feel that, despite the limitations, the
study throws light on issues of significance that merit
discussion and further exploration. Another limitation of
the study was in the assessment of social support by the
care coordinators and not the patient, although the care
managers were deemed to have taken into account their
knowledge of individual patient’s appraisal of their social
network. Professionals should be aware that personal,
clinical and social factors could substantially influence
the way patients perceive social support and be sensitive
to discrepancies patients might experience between avail-
ability and adequacy of social support.18
We add here a comment on the direction of outcomes
observed in this study. The negative outcome as mea-
sured by the instruments in a substantial proportion of
patients was not reflected in gross outcomes like rehos-
pitalisation or discontinuity from the rehabilitation
program. Many patients in the program with long-term

© 2010 The Authors

Journal compilation © 2010 National Rural Health Alliance Inc.
70
and stable clinical condition might not have shown gross
improvement in their clinical and functional status. For
them, maintenance of stability or sometimes marginal
improvement would be the main target of rehabilitation
intervention. Burgess et al. noted that expectation of
change would differ from setting to setting.19 They com-
mented that a reasonable degree of improvement would
be anticipated during an average acute inpatient admis-
sion whereas maintenance of current levels of symptoma-
tology and functioning might be a more reasonable goal,
at least for some, in ambulatory settings like the one
where this study was conducted.
Based on the three main observations mentioned, we
interpret that while the urban–rural difference in sever-
ity of the illness and associated factors could be related
to the difference in outcome, the availability and access
to ‘social capital’ in form of family support might also
have played a significant role in better outcomes for the
rural cohort.
Family is noted to be a significant part of the social
capital that provides the structure for the manifestation
of affective, behavioural and cognitive components of
the sense of community described by Pretty et al.20
Family support is shown to be associated with better
outcomes for schizophrenia and other severe mental
disorders.21–23 The collective family structure and ‘close
knit’ nature of rural communities were discussed as
some of the features of the social capital that repre-
sented a considerable asset for rural communities to deal
with mental health issues.7,24
Several studies presented a negative impression on the
state of mentally ill in rural communities25 while some
found evidence to the contrary.26 Despite the health
inequalities relative to metropolitan Australia, many
rural and remote residents feel a sense of well-being and
strong connection to where they live.27 These factors are
critical to understanding the complexity of health out-
comes and perceptions of well-being and to design
appropriate prevention and health promotion interven-
tions.27 Fragar et al. in their New South Wales Farmers
Blueprint for Mental Health and well-being identified
building local social networks/opportunity as one of the
22 key areas of action leading to pathways to health.28
Our study lends strength to this position and under-
scores the important role of support provided by the
family network in the long-term care of patients with
severe mental illness living in the community. We should
end however on a note of caution on this point. Higher
level of social capital is not an invariable characteristic
of rural life with a section of the population shown to
experiencing poor participation, social cohesion and
psychological distress.29 Henderson and Whiteford30
indicated that there was inadequate evidence either
to support or refute its association with mental health
and therefore a need for stronger evidence before it
S. TIRUPATI ET AL.
can be embraced for the promotion of mental health
in populations.
Author contributions
S.T., A.C., B.F. and S.J. were responsible for conceptu-
alisation and design. S.T. and A.C. were responsible for
compilation of data and analysis. S.T., B.F. and S.J. were
responsible for interpretation of data. S.T. was respon-
sible for drafting the article. S.T., A.C., B.F. and S.J.
were responsible for revision and final approval.
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