There is a growing body of research about the use of formal and informal support services for mental health problems. For example, recent national surveys from Australia , USA , England  and Canada  have documented prevalence rates for mental disorders, professional and non-professional service usage patterns [5–9], perceived need profiles [10–12], and associated linkages to sources of mental health information . However, evidence about the prevalence of mental disorders, symptoms, and patterns of service use in rural and remote communities is in short supply for a variety of reasons. Surveying residents of these regions is expensive and difficult. Indeed, the 2007 Australian National Survey of Mental Health and Wellbeing (NSMHWB) acknowledged that it was ‘… limited in its representation of people from remote and very remote areas’ (, p. 597) while in some Canadian provinces oversampling has been used in the national survey to provide reliable sub-provincial prevalence estimates .
The meaning of rurality varies and there are difficulties in assessing evidence from countries with substantial rural populations such as Scotland, Australia, Canada or the United States. Some authors  have concluded that the definition and official classifications of rurality are not helpful in making meaningful distinctions between communities and that we should either change the classifications  or stop using them; for example Rost et al. proposed ‘… that investigators no longer employ any of the multiple definitions of rurality proposed in the literature  (p. 232).
There are a number of reports that conclude that the prevalence of mental health symptoms is similar between rural and urban areas [16–18]. Likewise, Smith  reports that ‘there is little evidence linking prevalence of mental health disorders with rurality’ (p. 58). Some authors, such as Ziller , found that self reported need for mental health services was slightly (but statistically significantly) higher in rural US. However, there are a number of reasons to believe that the use of services for mental health problems may differ between rural/remote residents and their urban peers including: specialist workforce shortages in rural areas ; generalist workforce shortages in remote and very remote areas [21, 22]; costs, travel and waiting times for rural and remote patients ; culture and attitudinal factors including “rural stoicism”, concerns about privacy and confidentiality in small communities ; and, lower rates of engagement in and continuation with treatment for mental illness in rural areas .
In a study of 78,000 employees in Australia, Hilton et al.  found, perhaps unsurprisingly, that those in very remote regions were less likely to access mental health treatments. Parslow et al.  compared service use in Australia using the 1997 and 2007 NSMHWB and concluded that use of any mental health service had risen significantly but that the proportion seeing General Practitioners (GPs) for mental health services had not increased (p. 206). This increase in mental health service use has been influenced by Federal programs to improve access to mental health practitioners, including the Access to Allied Psychological Services and the Better Access to Psychiatrists, Psychologists and General Practitioners initiatives introduced in 2001 and 2006 respectively . GPs are key providers in rural areas with specialist shortages and they are the first choice for many people seeking help for a mental health problem .
While Mechanic  argues that we cannot use prevalence of mental disorders as a proxy for service need, the aggregate pattern of service use in Australia and elsewhere by those with mental health disorders would appear to be one of underuse . The 2007 Australian NSMHWB concluded that ‘rates of service use for people with a mental health condition are less than optimal  (p. 615). About one-third (34.9%) of those meeting the Composite International Diagnostic Interview (CIDI) criteria for a mental disorder reported that they received services in the previous 12 months. There was evidence that those with severe disorders made more use of community based mental health services (63.5%) than those with mild disorders (17.7%). The extent of this “underuse” is not clear, since no-one is suggesting that all those with a mental health disorder identified in a research interview would benefit from treatment from a generalist or a mental health specialist. In another Australian study, Short et al.  concluded that public mental health services care for people with psychotic disorders while ‘those with high prevalence disorders … seek psychiatric treatment elsewhere’ (p. 475).
It is important to acknowledge that the Australian health care system differs from unitary health care systems, such as those in the UK and New Zealand, having a state-federal separation of specialist and primary mental health care funding and responsibilities. Unitary systems are better able to integrate specialist and primary care based services since they have population based planning and funding arrangements. In Australia, access to services can be compromised since there is no effective process for joint or shared planning .
There is some international evidence about non-specialist sources of care such as religious advisors  or self care . Verhaak et al.  note that patients may not recognise that their problems have a mental health origin or may question the effectiveness of their providers. In a cross-European survey of adults from six nations, ten Have et al.  reported a low perceived effectiveness of professional care and about a third of respondents believed it was worse than no care for those with serious emotional problems. In the Australian context, Olesen et al.  concluded that there is widespread use of non-professional services and self-management strategies (e.g., 33.5% of adults with an affective or anxiety disorder in the last 12 months sought help from family or friends). These findings are consistent with those from studies investigating community attitudes to mental illness in general, with low rates of confidence in professional treatment, as a component of the prevailing stigma of mental disorders .
Some American studies have examined whether rural residents have access to an appropriate range and “dose” of services. Fortney reported that about 60% of a rural sample with self-reported depression received some formal treatment, with more than 50% receiving pharmacotherapy and 25% receiving psychotherapy [36, 37]. The rates of minimally adequate treatment were measured as the number of scripts filled and the number of psychotherapy sessions attended . He noted that if these rural residents do not respond to medication they may not have access to psychotherapy as an alternative treatment. In a study of American veterans with depression, anxiety or post traumatic stress disorder, Cully et al.  found that rural veterans were less likely to receive psychotherapy than their urban peers and that the “dose” was less likely to be adequate. While shortages of specialist mental health staff characterise rural and remote communities in Australia, it is not clear if these findings hold true.
In a study of depression and remoteness in South Australia, Goldney  found that rates of treatment of depression with antidepressants were similar in less accessible and more accessible areas and that a higher proportion of the rural depressed had contact with a health service, social worker or counsellor than their more accessible peers. Diagnostic interviews were not used in this study; hence, a limitation was the reliance on self-identification of past “depression”. Jackson et al.  have identified factors contributing to mental health usage in a rural setting, including gender, age, marital status, mental disorder, co-morbidity and psychological distress. Similarly, in the 2007 Australian NSMHWB, service usage among adults with a mental health problem was lowest among males and the youngest and oldest age groups [5, 6].
In summary, the use of services for mental health disorders presents a complex picture. A focus on rural and remote settings complicates matters and international evidence is hard to compare. Given that access to services for mental health problems is limited in rural and remote regions, questions remain about from whom rural residents in Australia seek help, how frequently this occurs and what characteristics are associated with this help-seeking behaviour. This paper examines the impact of remoteness on the patterns of service use for mental health problems in a rural community sample, how they compare with national data for urban residents from the 2007 Australian NSMHWB, and the relationship between self-reported service use and estimates of the potential need for services.
Heath service context
Australia is a federation of 6 states and 2 territories, where public hospitals are funded by state departments of health and admission to public hospitals is free. The majority of GPs and medical specialists, including psychiatrists, are self-employed and their fees are subsidised or paid in full by the Federal Medical Insurance system. GPs act as gatekeepers for accessing specialist services, and patients can be referred to psychiatrists, psychologists and other allied health professionals, including social workers, mental health nurses and occupational therapists .
While the number of full-time equivalent GPs per 100,000 members of the population is reasonably similar across all categories of remoteness in Australia, the number of medical specialists decreases with increasing remoteness. For example, there are approximately 18 full-time equivalent psychiatrists per 100,000 people comprising 23 (per 100,000) in major cities, compared to 7 for inner regional, 5 for outer regional, and 3 for remote and very remote areas . In rural and remote areas, access to GPs is also complicated by distance and sometimes by cost, through the use of co-payments.