Mental health outcomes are worse in the bush, partly because

A mother in rural NSW once told me about a devastating conversation she’d had with her 18-year-old son, Callum*. Callum was scared his depression would never be bad enough for him to commit suicide.

Things wouldn’t get better, he was sure, but what if they also didn’t get worse? He’d be trapped in purgatory, condemned to suffer without the acuity required to follow through on his plans. Suicide was practically feasible but would never be inevitable, no matter how much he wanted it.

Despite his mother’s desperate attempts, Callum could not be persuaded that this storm might eventually pass. Weeks after this conversation, he walked deep into the bush on his family’s property and killed himself using a firearm stolen from a neighbouring farm.

There are many confronting details to unpack from this story, but one has always struck me as particularly distressing: when he died, Callum was utterly alone and had access to a gun. Exactly as he’d implied to his mother, self-destruction was a task rendered so easy it almost lost meaning.

Worse still, he knew suicide was not the answer but did it anyway. This is a tragedy with profound implications for the discussion about suicide and mental health care in rural Australia.

I wrote my novel Denizen partly in response to stories like this. I knew when it was released in July that I’d be asked questions about mental health in the bush. I was prepared to discuss why I was drawn to writing about the topic and my own struggles with mental illness as a teenager.

What I hadn’t expected was to find myself fielding broader questions better suited to academics and policymakers. Why are mental health outcomes worse in the bush? What’s broken and how do we fix it?

I’m still not sure I’m the best person to be answering these questions, but I understand why I’m asked. They’re things I’ve considered at length, both in the context of my own adolescence caught up (and often falling through gaps) in the system and as an adult working in emergency health care in regional NSW.

That question – why are mental health outcomes worse in the bush? – is highly euphemistic. It refers in a whisper to the dramatically higher rates of suicide, violence and drug abuse in remote and regional Australia.

The data bears out this hushed, almost urban legend-esque perception: men in regional areas are at least 50% more likely to commit suicide than those in major cities. In remote settings, this likelihood jumps to double.

On the one hand, the answer seems so simple that the question hardly needs asking: research shows again and again that rates of chronic illness, unemployment, socioeconomic disadvantage and exposure to natural disasters are higher in the bush than in cities. Doesn’t it follow that mental ill health would be worse too?

But these cherrypicked statistics don’t tell the whole story. As well as the fact that rural Australians routinely report higher life satisfaction than people in the cities, there’s another number crucial to this conversation: rates of self-harm and suicide might be higher in the bush, but the prevalence of mental illness itself is the same. People in the bush don’t experience higher rates of mental illness than their metropolitan counterparts. It’s just more likely to end in tragedy when they do.

Callum completed suicide, at least partly, because he had access to means and no access to intervention.

This reality is borne out in evidence: 92% of all firearm suicides in Australia in the past 20 years were in the bush. For every three psychologists available in the city, there’s one in outer regional or remote Australia. When regional and remote Australians face mental illness, it’s easier for them to get their hands on a high-lethality mode of self-harm than a counsellor.

This twofold problem of access to means and lack of access to services is deeply entrenched, but not impossible to solve. Perhaps a good starting point would be to accept that one side of this coin is more easily addressed than the other.

Guns, poisons and farm equipment may contribute disproportionality to suicides in rural Australia, but they’re also integral to the way of life for these communities. Removing them altogether is impossible.

So, attention is better turned to the other factor, where the most change can be achieved. It’s not complicated: more psychologists, more psychiatrists, better-staffed emergency departments and, if all else fails, better utilisation of telehealth. You don’t have to look far to see that better access to mental health care improves outcomes and reduces suicides. Just as far as your nearest capital city.

Callum’s mother maintains that suicide was not inevitable for her son. It’s by no means a given that he, nor the hundreds of regional and remote Australians who die by suicide every year, would have had a different outcome in a different setting. But the data suggests they would have had a better chance.