Order 2689148: men and mental health in rural Australian farmers

Farmers’ contact with health care services prior to suicide: evidence for the role of general practitioners as an intervention point

Katerina KavalidouA, Samara McPhedranA,B and Diego De LeoA

AAustralian Institute for Suicide Research and Prevention, National Centre of Excellence in Suicide Prevention, WHO Collaborating Centre for Research and Training in Suicide Prevention, Level 1, Building M24 Psychology, 176 Messines Ridge Road, Mt Gravatt Campus, Griffith University, Qld 4122, Australia.

BCorresponding author. Email: [email protected]

Abstract. Suicide in Australian rural communities has received significant attention from researchers, health practitioners and policymakers. Farmers and agricultural workers have been a focus of particular interest, especially in relation to levels of help seeking for mental health concerns. A less explored area, however, is the level of contact that Australian farming and agriculture workers who die by suicide have had with health providers for physical, rather thanmental, health conditions. It is often assumed that farmers and agricultural workers have lower levels of contact with health care services than other rural residents, although this assumption has not been well tested. Using data from the Queensland Suicide Register, this paper describes levels of contact with health care providers in the 3 months before death by suicide among men in farming and agriculture occupations and other occupations in rural Queensland. No significant differences were found in farming and agricultural workers’ levels of contact with a general practitioner when compared with other rural men in Queensland. The current findings lend weight to the view that rural general practitioners represent an important intervention point for farming and agriculture workers at risk of suicide (whether or not those individuals exhibit accompanying psychiatric illness).

Received 2 April 2013, accepted 9 July 2013, published online 5 August 2013

Introduction

Suicide among Australian farmers and agricultural workers has received significant attention from researchers, health practitioners and policymakers. A higher suicide rate in farming- related occupations, compared with non-farming related occupations, has been demonstrated in several Australian states (Page and Fragar 2002; Miller and Burns 2008). In Queensland, for example, agricultural workers (including farmers) have been found to have markedly higher suicide rates (24.1 per 100 000) relative to the employed population as a whole (10.6 per 100 000) (Andersen et al. 2010).

Although reluctance by farmers to seek help for mental health concerns has been widely discussed, a less-explored area is the level of contact that Australian farming and agriculture workers who die by suicide have with health providers for physical, rather than mental, health conditions. It is often assumed that farmers’ patterns of help-seeking behaviour extends to low levels of seeking help for physical health conditions, as well as mental health conditions (e.g. Brumby et al. 2009, 2011; Hossain et al. 2009; Fragar et al. 2011), but this has not been closely examined. This is a notable gap in knowledge, for two reasons. First, there is considerable evidence that the role of physical health as a risk factor for suicide should not be overlooked (De Leo et al. 1999; Booth and Lloyd 2000; Booth et al. 2000; Waern et al. 2002;

Judd et al. 2006). Second, farm-related work is also associated with an elevated risk of physical injury and accident (Gerrard 1998; Franklin and Davies 2003). Also, due to the increasing mechanisation of farming, conditions such as obesity are becoming an increasing concern among farmers. Declining physical health (as well as injury-related physical disability) have, in turn, been linked with psychological distress, family and relationship stress and/or breakdown and increased risk of suicide (Inskip et al. 1996; Carruth and Logan 2002; Gregoire 2002; Solomon 2002; Melberg 2003; Fraser et al. 2005).

Given the health issues facing farmers, it is reasonable to expect that some individuals may seek assistance for physical conditions while also being at risk of suicide (with or without the presence of mental illness). For example, Booth et al. (2000) found that many British farmers who died by suicide had a prior health service contact in relation to physical symptoms. It is increasingly recognised that general practitioners (GPs) represent an important pathway by which people at risk of suicide may be identified and assisted, even if an individual presents to a GP for reasons that are not immediately or overtly related to suicide (Fuller et al. 2004).

Gaining a better understanding of the incidence of contact with GPs among farming and agriculture workers who die by suicide represents an important step toward informing suicide-

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prevention efforts and targeted-intervention strategies. This paper describes levels of contact with health care providers in the 3 months before death by suicide among men in farming and agriculture occupations and other occupations in rural Queensland.

Methods

Data source and sample selection

Male suicide data were extracted from the Queensland Suicide Register (QSR). The QSR is a comprehensive database maintained by the Australian Institute for Suicide Research and Prevention that details Queensland suicide cases from 1990 to the present (see De Leo and Sveticic 2012 for further description). Information is based on post-mortem, police and psychological autopsy report, and includes a wide range of demographic, medical and psychiatric information regarding the deceased.

Location

Geographic location was categorised using Accessibility/ Remoteness Index of Australia information within the QSR. The Accessibility/Remoteness Index of Australia defines remoteness as the distance people must travel along a road network to get to service centres (areas where they can access goods, services and opportunities for social interaction; Australian Bureau of Statistics 2001). A dichotomous location variable was created: ‘urban’ location was defined as including major cities, with inner and outer regional, and remote and very remote locations categorised as ‘rural’. For the purpose of analysis, only rural men were included.

Occupation

A dichotomous occupation variable, based on the 4-digit Australian Standard Classification of Occupation, was created: farming and agricultural occupation (farmers and farm managers, farm hands and assistants, agricultural labourers and related workers,sheepshearers, macropodharvesters, forestrylabourers, agriculturalplantoperatorsandloggingplantoperators)andother (encompassing all other types of work). Only those men who had been employed at the time of their death, and for whom occupation data were available, were selected.

Presence of physical conditions

The QSR contains information about whether the deceased had any physical disorders at the time of death. A dichotomous variable was created: physical disorder (the presence of any physical condition) or no physical disorder (no recorded physical condition). It should be noted that ‘no physical condition’ may also indicate that a condition was not diagnosed, or that information was not provided.

Presence of psychiatric conditions

Two variables were considered: whether the deceased had previously or currently been receiving treatment for a psychiatric disorder, and whether there was evidence that the deceased may have had an untreated psychiatric condition. Again, caveats on ‘no’ responses apply.

Contact with health care providers

The QSR contains information about whether the deceased had contact with health services before death. The two variables of particular interest were: whether the deceased had consulted with a doctor for a physical condition in the 3 months before death, and whether the deceased had consulted with a mental health care professional for a psychiatric condition in the 3 months before death. Caveats on ‘no’ responses again apply.

All ‘unknown’ cases were treated as missing data.

Results The sample consisted of 1375 rural men who were employed at the time of their death, and for whom occupation data were available. Of these men, 212 (15.4%) were in farming and agricultural occupations, and 1163 (84.6%) were in other occupations.

Men in farming and agricultural occupations at the time of death had a mean age of 43.0 years (�15.1), which was significantly older than rural men in other occupations whose mean age at the time of death was 37.5 years (�12.6) (t(1373) = –5.71, P < 0.01). There were few other demographic differences between the two groups (Table 1).

Table 2 contains descriptive data and Chi-square analyses comparing farming and agriculture occupations with other occupations. Although several cases had missing data on the contact with health care provider variables, there was not any evidence that missing data was non-randomly distributed (i.e. both groups of interest had comparable proportions of missing information).

In terms of overlap between contact with a GP for a physical condition and contact with a mental health professional for a psychiatric condition, and noting the small sample for whom information was available about each different type of contact, 102 men (20 farming and agriculture, 82 other) had seen only a GP, 56 men (13 farming and agriculture, 43 other) had seen only a mental health professional, and 69 men (15 farming and agriculture, 54 other) had seen both a GP and a mental health professional. Given the small farming and agriculture samples, thesedataare providedfordescriptivepurposesonlyandwerenot further analysed.

Discussion This is the first Australian study describing contact with health careservices,inthecontextofbothphysicalandmentalhealth,for male farming and agriculture workers who died by suicide. Regarding psychiatric history, there were no differences between occupation groups, which suggests that the higher proportion of farmers seeing a mental health professional, relative to men in other occupation types, is unlikely to be explained by higher levelsofmentalillnessinfarmers.Thisisconsistentwithprevious research (e.g. Judd et al. 2006; Andersen et al. 2010), but it is unclear what factors mayhave influenced farming and agriculture workers’higherlevels ofcontactwithmentalhealthprofessionals relative to other men.

Regarding physical health, where information was available, almost half of the farming and agriculture group (48.0%) had contact with a GP in regard to physical health issues in the 3 months before their death by suicide. This highlights the

Farmers’ contact with health care before suicide Australian Journal of Primary Health 103

possibility of GPs in rural areas being an important gateway to support for persons at risk of suicide (whether or not an individualhasaconcurrentpsychiatriccondition).Also,although the small sample should be taken into account, the observation that 102 men who later died by suicide had seen only a GP, rather than a mental health professional, emphasises the apparent need for GPs in rural areas to be cognisant of suicide indicators and risk factors.

A limitation of the study was its inability to determine whether farming and agriculture workers who had contact with GP before death by suicide may have sought advice on mental health and/or suicidal ideation during the course of a consultation for a physical condition. Also, given the low sample size, the study was unable to reliably assess whether controlling for demographic characteristics affected the observed results. However, it should be noted that there were very few

demographic differences between the two occupation groups. An additional limitation is that information about health care service contact was not recorded for all cases. To overcome this limitation, percentages for both the farming and non-farming groups were calculated on the basis of the number of cases where information was available, ensuring that missing data did not bias or otherwise influence the results.

Despite these limitations, the current findings lend weight to the view that rural GP may represent an important intervention point for farming and agriculture workers at risk of suicide (whether or not those individuals exhibit accompanying psychiatric illness), and suggest that farmers’ contact with the health care system before death by suicide may – in contrast to commonly made assumptions about farmers and helpseeking – not be lower than levels of contact with the health care system found among other rural men who die by suicide. This highlights

Table 2. Psychiatric history, physical conditions and contact with health services before death by suicide, by occupation type Percentages are calculated based on the exclusion of missing data

Farming/agriculture Other c2 P-value n % n %

Contact with a GP Yes 48 48 198 41.5 1.42 0.23 No 52 52.0 279 58.5

Presence of a physical condition Yes 57 26.9 238 20.5 4.39 0.04 No 155 73.1 925 79.5

Contact with a mental health professional Yes 50 42.7 178 32.0 4.96 0.03 No 67 57.3 378 68.0

Current or past treatment for psychiatric condition Yes 65 52.4 307 46.9 1.29 0.26 No 59 47.6 348 53.1

Psychiatric diagnosis Yes 63 29.7 296 25.5 1.69 0.19 No 149 70.3 867 74.5

Evidence for untreated psychiatric condition Yes 36 34.3 197 37.7 0.43 0.51 No 69 65.7 326 62.3

Depression mentioned in case Yes 85 40.1 442 38.0 0.33 0.57 No 127 59.9 721 62.0

Table 1. Demographics of rural males who died by suicide in Queensland, by occupation type Percentages are calculated based on the exclusion of missing data

Farming/agriculture Other c2 P-value n % n %

Marital status Married/defacto 88 48.4 440 44.5 0.90 0.32 Single/never married 48 26.4 274 27.7 0.14 0.71 Divorced/separated 46 25.3 265 26.8 0.19 0.66 Widowed 0 0.0 9 0.9 n/aA n/aA

Living arrangements With spouse 64 39.3 313 34.9 1.13 0.29 Friends/other shared 22 13.5 181 20.2 4.00 0.05 With parents 29 17.8 115 12.8 2.88 0.09 Alone 38 23.3 253 28.2 1.68 0.20 Temporarily away from home 8 4.9 32 3.6 n/aA n/aA

Ethnicity Caucasian 146 89.6 796 88.7 0.10 0.76 Aboriginal/Torres Strait Islander 14 8.6 86 9.6 0.16 0.69 Asian 1 0.6 7 0.8 n/aA n/aA

Other 2 1.2 8 0.9 n/aA n/aA

Non-English speaking background 3 6.0 15 4.9 n/aA n/aA

ADue to the small number of cases, statistical analyses were not conducted.

104 Australian Journal of Primary Health K. Kavalidou et al.

the need for primary care in rural areas to consider the knowledge and training of GP in suicide assessments, and their potential attitudes toward suicide (Rihmer et al. 1995; Neimeyer et al. 2001), which could influence their ability to recognise at-risk individuals and intervene appropriately.

Conflicts of interest

None declared.

Acknowledgements

The authors gratefully thank Queensland Health/Queensland Mental Health Commission for their continuing support of the Queensland Suicide Register.

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