Does living in remote Australia lessen the impact of hardship on psychological distress?

AIMS: Rural and remote regions tend to be characterised by poorer socioeconomic conditions than urban areas, yet findings regarding differences in mental health between rural and urban areas have been inconsistent. This suggests that other features of these areas may reduce the impact of hardship on mental health. Little research has explored the relationship of financial hardship or deprivation with mental health across geographical areas. METHODS: Data were analysed from a large longitudinal Australian study of the mental health of individuals living in regional and remote communities. Financial hardship was measured using items from previous Australian national population research, along with measures of psychological distress (Kessler-10), social networks/support and community characteristics/locality, including rurality/remoteness (inner regional; outer regional; remote/very remote). Multilevel logistic regression modelling was used to examine the relationship between hardship, locality and distress. Supplementary analysis was undertaken using Australian Household, Income and Labour Dynamics in Australia (HILDA) Survey data. RESULTS: 2161 respondents from the Australian Rural Mental Health Study (1879 households) completed a baseline survey with 26% from remote or very remote regions. A significant association was detected between the number of hardship items and psychological distress in regional areas. Living in a remote location was associated with a lower number of hardships, lower risk of any hardship and lower risk of reporting three of the seven individual hardship items. Increasing hardship was associated with no change in distress for those living in remote areas. Respondents from remote areas were more likely to report seeking help from welfare organisations than regional residents. Findings were confirmed with sensitivity tests, including replication with HILDA data, the use of alternative measures of socioeconomic circumstances and the application of different analytic methods. CONCLUSIONS: Using a conventional and nationally used measure of financial hardship, people residing in the most remote regions reported fewer hardships than other rural residents. In contrast to other rural residents, and national population data, there was no association between such hardship and mental health among residents in remote areas. The findings suggest the need to reconsider the experience of financial hardship across localities and possible protective factors within remote regions that may mitigate the psychological impact of such hardship.

Short- and long-term outcomes for patients with variceal haemorrhage in a tertiary hospital.

BACKGROUND/AIM: To determine short- and long-term outcomes among a cohort of patients with variceal haemorrhage at a tertiary referral centre, and to determine the predictive value of the model for end-stage liver disease (MELD) score for mortality in these patients. METHODS: Prospective database hospital audit that captured patients who presented with or were transferred with variceal haemorrhage between 2004 and 2008, and a retrospective review of long-term outcomes. Patients who presented to or were transferred to John Hunter Hospital, a tertiary referral hospital, with confirmed variceal bleeding were included. The main outcome measures were in-hospital, 6 weeks and end-of-audit mortality. We also recorded cause, location and degree of planning surrounding the deaths in this patient group. We analysed the MELD score for patients with complete survival data. RESULTS: We recorded 93 episodes of variceal haemorrhage from 78 unique patients during the initial study period. The in-hospital mortality, 6 weeks mortality and end-of-audit mortality were 2.6, 9.0 and 59, respectively, and median survival time was 3.2 years (95% confidence interval 0.0, 6.1). The most frequent cause of death was related to complications of end-stage liver disease at 74%, followed by variceal bleeding (19%) and unknown (6%). A Cox proportional hazard model showed that the risk of mortality is increased by 1.06 (1.01-1.11) for each unit increase in MELD score. CONCLUSIONS: Short-term outcomes for patients with variceal bleeding continue to improve, but long-term prognosis remains guarded and should prompt further emphasis on advanced care planning to optimise patient care.