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Urban-Rural Differences in the Nature and Prevalence of Mental Ill-Health in Adults with Intellectual Disabilities

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Title: Urban-Rural Differences in the Nature and Prevalence of Mental Ill-Health in Adults with Intellectual Disabilities
Language: English
Authors: Kiani, R., Tyrer, F., Hodgson, A., Berkin, N., Bhaumik, S.
Source: Journal of Intellectual Disability Research. Feb 2013 57(2):119-127.
Availability: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA/
Peer Reviewed: Y
Page Count: 9
Publication Date: 2013
Document Type: Journal Articles
Reports - Research
Descriptors: Rural Urban Differences, Mental Retardation, Incidence, Mental Disorders, Statistical Analysis, Classification, Clinical Diagnosis, Autism, Pervasive Developmental Disorders, Behavior Disorders, Health Services, Foreign Countries, Urbanization, Correlation
Geographic Terms: United Kingdom (England)
DOI: 10.1111/j.1365-2788.2011.01523.x
ISSN: 0964-2633
Abstract: Background: In the general population there are statistically significant urban-rural differences in the rate of common mental disorders. In people with intellectual disability (ID) no study has attempted to address this issue. Aims: To compare the prevalence of mental illness, autism spectrum disorder (ASD) and behaviour disorder in people with ID living in urban areas with those living in rural areas. Methods: Cross-sectional study of 2713 individuals registered with an ID service. Participants were assigned to urban or rural groups using the Department for Environment Food and Rural Affairs rural/urban local authority classification for their district. The main outcome variable was a clinical diagnosis of mental illness, ASD and behaviour disorder. Differences between diagnoses of mental illness in urban and rural areas were evaluated using the chi-squared test for the difference in two independent proportions. Results: No differences were observed between gender, age and level of ID of service users based on their place of residence. But more people from an ethnic minority background were living in urban areas than rural areas. No differences were observed in the overall prevalence of mental illness by place of residence. However, the results showed that ASD was more common in people living in rural areas. Conclusions: We found these results surprising and at odds with the majority of studies carried out in the general population and propose several reasons for the differences found. We believe that the results and further studies in this area will help inform health service provision for those with ID who live in different geographical areas. (Contains 2 tables.)
Abstractor: As Provided
Number of References: 43
Entry Date: 2014
Accession Number: EJ1012859
Database: ERIC
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  Value: <anid>AN0084622603;eul01feb.13;2018Jul09.14:14;v2.2.500</anid> <title id="AN0084622603-1">Urban-rural differences in the nature and prevalence of mental ill-health in adults with intellectual disabilities. </title> <p>Background  In the general population there are statistically significant urban–rural differences in the rate of common mental disorders. In people with intellectual disability (ID) no study has attempted to address this issue. Aims  To compare the prevalence of mental illness, autism spectrum disorder (ASD) and behaviour disorder in people with ID living in urban areas with those living in rural areas. Methods  Cross‐sectional study of 2713 individuals registered with an ID service. Participants were assigned to urban or rural groups using the Department for Environment Food and Rural Affairs rural/urban local authority classification for their district. The main outcome variable was a clinical diagnosis of mental illness, ASD and behaviour disorder. Differences between diagnoses of mental illness in urban and rural areas were evaluated using the chi‐squared test for the difference in two independent proportions. Results  No differences were observed between gender, age and level of ID of service users based on their place of residence. But more people from an ethnic minority background were living in urban areas than rural areas. No differences were observed in the overall prevalence of mental illness by place of residence. However, the results showed that ASD was more common in people living in rural areas. Conclusions  We found these results surprising and at odds with the majority of studies carried out in the general population and propose several reasons for the differences found. We believe that the results and further studies in this area will help inform health service provision for those with ID who live in different geographical areas.</p> <p>intellectual disability; mental ill‐health; psychiatric disorders; urbanisation; urban–rural differences; city–county differences</p> <p>The relationship between living in urban areas and increasing prevalence of mental ill‐health has been studied extensively over the past decade (Paykel et al. 2000; Van Os et al. 2001; Dekker et al. 2008). Findings suggest that this correlation is statistically significant across a wide range of psychiatric morbidities (Boardman et al. 1997) including neurotic disorders, mood disorders (e.g. depression) (Paykel et al. 2003; Weich et al. 2006) and personality disorder (Lee et al. 1990); this is in addition to the long‐established link between psychosis (specifically schizophrenia) and urbanicity (Faris & Dunham 1939; Lewis et al. 1992; Pedersen & Mortensen 2001).</p> <p>Adding weight to this association has been the aim of recent large‐scale studies across the EU, including research by Sundquist et al. (2004) who documented a relationship between the incidence of psychosis and depression and urbanised areas, in a longitudinal study involving the entire adult Swedish population.</p> <p>There are several proposed hypotheses to explain the relationship between mental ill‐health and urbanisation. These include (<reflink idref="bib1" id="ref1">1</reflink>) breeder hypothesis i.e. a greater number of stressful life events and environmental exposures such as pollution and noise (Verheij 1996); and (<reflink idref="bib2" id="ref2">2</reflink>) drift hypothesis i.e. selective migration, leading to concentration of those with psychiatric disorders in urban areas (Lewis et al. 1992). However, the latter is difficult to substantiate, as it would require longitudinal data including past illness behaviour and migration for a large population (Blazer et al. 1986).</p> <p>A number of confounding variables may also play a role in the relationship between place of residence and mental ill‐health. Some of these include alcohol consumption (Neff & Husaini 1985), age (Crowell et al. 1986), marital status (Romans‐Clarkson et al. 1990), unemployment (Harding & Sewel 1992) and ethnicity (Neff & Husaini 1987). However, even after controlling for such variables, the correlation between living in urban areas and higher rates of psychiatric morbidity is statistically significant (Paykel et al. 2000; Van Os et al. 2001).</p> <p>Although the majority of literature found an association with urbanicity and higher rate of mental health problem as described above, Peters & Jackson (2005) reported several studies in which no conclusive evidence of an association with urban/rural residence could be found for psychiatric morbidity (Romans‐Clarkson et al. 1990; Blazer et al. 1994; Parikh et al. 1996; Eckert et al. 2004).</p> <p>Urbanisation as an independent variable is very difficult to define and categorise, and several inconsistencies in the literature may be a reflection of this (Weich et al. 2003). Varied methodologies have been used in an attempt to address this, including categorising urban areas in terms of population density (Sundquist et al. 2004) numbers of addresses per unit area (Van Os et al. 2001) or interviewers' subjective interpretation of the area (Paykel et al. 2000). Alternatively research has looked at the relationship between socio‐economic aspects of an area and psychiatric morbidity, using both individual census variables and composite indexes such as the Jarman score to reflect socio‐economic deprivation (Boardman et al. 1997). Similarly, there is no standardised and accepted definition of rurality (Nicholson 2008). Previous definitions have included everything that is ‘not urban’ to definitions specific to a certain county. As ‘rural’ environments are so diverse, it is difficult to both define it and to compare international research into this area.</p> <p>Traditionally, living in rural areas has been considered advantageous because of a stronger sense of community (Gething 1997), supportive social networks (Romans‐Clarkson et al. 1990) and economic restructuring (Judd et al. 2002). Physical health has also been found to be better in urban areas (Australian Institute of Health and Welfare 1998) which is often closely linked to mental health (Goldberg & Posner 1993). However, living in a rural area does not guarantee these benefits and it may have its own drawbacks including social exclusion, stigma and loss of independence. Rural residents have been found to be disadvantaged in relation to admission to psychiatric hospitals, use of other psychiatric teams and access to outpatient appointments (Seivewright et al. 1991). A BMA report (British Medical Association, Board of Science 2005) also highlighted that rural areas were being neglected in terms of both access and service.</p> <p>In terms of need within populations, mental illness is known to be highly prevalent in those with intellectual disabilities (IDs), with a point prevalence within this population of 40.9% (Cooper et al. 2007). Smiley et al. (2007) suggest that some of the factors leading to mental ill‐health in those with IDs differ from those in the general population. In their study they showed that factors related to the incidence of mental ill‐health in an ID population included not living with a family carer, urinary incontinence, a positive past psychiatric history and moderate rather than mild ID. Therefore, as a result of these underlying differences in factors leading to the development of psychiatric morbidities and also because the literature described above plays an important role in allocation of health services as higher rates of need in urban areas have been found compared with the needs of service users in a semi‐rural setting (Najim & McCrone 2005), this study was conducted to discover whether urbanisation would still have an impact in people with ID. The study was granted ethical approval by Derbyshire Research Ethics Committee.</p> <hd id="AN0084622603-2">Method</hd> <hd id="AN0084622603-3">Study population</hd> <p>The overall population of Leicestershire and Rutland health districts is one million. Approximately four hundred thousand of these people reside in the city of Leicester, and six hundred thousand live in the counties of Leicestershire or Rutland. The study included all adults (including and above 19 years of age) with ID, registered with the ID service in Leicestershire between 1 January 2001 and 31 December 2006. The exclusion criteria for the study were those with borderline intellectual functioning and those with a missing postcode or address. A diagnosis of borderline intellectual functioning was determined by performing above the threshold of a mild ID based on assessment using the Leicestershire Intellectual Disability Scale (Tyrer et al. 2008), which combines questions on intelligence, adaptive behaviour and dependency and has been validated against the original Vineland Adaptive Behaviour Scales (Sparrow & Cicchetti 1985).</p> <hd id="AN0084622603-4">Classifying urban and rural areas</hd> <p>Participants were assigned a local authority district according to their postcode (ONS Geography 2004). Each district was defined as urban or rural, based on the Department for Environment Food and Rural Affairs (2005) rural/urban local authority classification. Participants were defined as living in urban areas if their district was predominantly urban (major urban, large urban or other urban) and rural if their district was either predominantly rural (more than 50% of the population in rural settlements) or significantly rural.</p> <hd id="AN0084622603-5">Outcome variable</hd> <p>The main outcome variable was a clinical diagnosis of mental illness, autism spectrum disorder (ASD) (F84), or behaviour disorder (F7x.1). A clinical diagnosis of mental illness, ASD and behaviour disorder was recorded in the medical case files of those participants who received a psychiatric assessment from the specialist ID service using the World Health Organisation's International Classification of Disease (ICD)‐10 criteria.</p> <p>Updating the service users' computerised database according to ICD‐10 diagnostic criteria has been one of the objectives of the Leicestershire Partnership NHS Trust in recent years. As a result, every service user within the organisation has a clinical diagnosis based on ICD‐10 coding system. ICD‐10 criteria for a formal diagnosis have been used independently in each case by a consultant psychiatrist after one or more clinical assessments and discussion among the multidisciplinary team consisting of psychiatric trainees, clinical psychologists and other allied healthcare professionals, e.g. Community Nurses and Speech and Language Therapists.</p> <p>Although there are other assessment tools available such as diagnostic criteria for psychiatric disorders for use with adults with learning disabilities (OP48) (DC‐LD) by the Royal College of Psychiatrists (2001), the authors only used the ICD‐10 diagnostic data already confirmed and recorded in the medical case files. This included those with a diagnosis of ASD and behaviour disorders.</p> <hd id="AN0084622603-6">Demographic data</hd> <p>The demographic data collected, using the Leicestershire ID Register (LIDR) database, included gender, age at psychiatric assessment or home interview (divided into <30, 30–39, 40–49 and 50+ years of age), ethnic group (white, South Asian or other/unknown), level of ID (mild, moderate, severe or profound). The LIDR is a case register of adults with ID using specialist services in Leicestershire, UK. The register holds information on all adults aged 19 years or over living in the unitary authorities of Leicester city, Leicestershire and Rutland (McGrother et al. 1993) who are using specialist services and/or need a high level of support in this geographical location. The register supports a rolling programme of home interviews, which are carried out every 5–7 years. Because information on IQ score or Vineland Adaptive Behaviour Scale was not available for all service users, level of ID was estimated uniformly for all service users using the Leicestershire Intellectual Disability Scale (Tyrer et al. 2008), which combines questions on intelligence, adaptive behaviour and dependency and has already been validated against the original Vineland Adaptive Behaviour Scale (Sparrow & Cicchetti 1985).</p> <hd id="AN0084622603-7">Statistical analysis</hd> <p>Differences in demographic variables between urban and rural areas were evaluated using the chi‐squared test. The proportion of participants with specific mental health diagnoses was also reported and any differences were evaluated using the chi‐squared test for the difference in two independent proportions and 95% confidence intervals (Table 2).</p> <p>2 Prevalence of various forms of mental illness by urban/rural status ( N  = 2713)</p> <p> <ephtml> <table><tr><th>Mental illness*</th><th>[ICD code(s)]</th><th>Urban (N = 1507)</th><th>Rural (N = 1206)</th><th>Per cent difference (95% CI)</th><th>Chi<sup>2</sup>P‐value</th></tr><tr><th>%</th></tr><tr><td>Any mental illness</td><td /><td>32.8</td><td>35.2</td><td>−2.5 (−6.0–1.1)</td><td>0.18</td></tr><tr><td>Any mental illness excluding ASD and organic disorders</td><td /><td>29.5</td><td>31.3</td><td>−1.9 (−5.4–1.6)</td><td>0.29</td></tr><tr><td>Dementia and other organic disorders</td><td>[F00, F01, F02, F03, F04, F05, F06, F07, F09]</td><td>1.3</td><td>1.4</td><td>−0.1 (−1.0–0.8)</td><td>0.85</td></tr><tr><td>Mental and behavioural disorders as a result of psychoactive substance use</td><td>[F10, F11, F12, F13, F14, F15, F16, F17, F18, F19]</td><td>0.1</td><td>0.1</td><td>–</td><td>–</td></tr><tr><td>Schizophrenia</td><td>[F20]</td><td>2.5</td><td>2.1</td><td>0.4 (−0.7–1.6)</td><td>0.44</td></tr><tr><td>Other psychotic disorders</td><td>[F21, F22, F23, F24, F25, F28, F29]</td><td>2.1</td><td>1.4</td><td>0.6 (−0.3–1.6)</td><td>0.20</td></tr><tr><td>Bipolar affective disorder</td><td>[F30, F31]</td><td>3.4</td><td>2.6</td><td>0.8 (−0.5–2.1)</td><td>0.22</td></tr><tr><td>Depression</td><td>[F32, F33]</td><td>3.7</td><td>5.0</td><td>−1.3 (−2.8–0.3)</td><td>0.11</td></tr><tr><td>Other/unspecified affective disorder</td><td>[F34, F38, F39]</td><td>0.9</td><td>1.3</td><td>−0.4 (−1.2–0.4)</td><td>0.33</td></tr><tr><td>Anxiety disorders</td><td>[F41]</td><td>1.5</td><td>1.5</td><td>0.0 (−0.9–1.0)</td><td>0.94</td></tr><tr><td>Obsessive compulsive disorders</td><td>[F42]</td><td>0.2</td><td>0.6</td><td>–</td><td>–</td></tr><tr><td>Other neurotic, stress‐related and somatoform disorders</td><td>[F43, F44, F45, F48]</td><td>0.1</td><td>0.3</td><td>–</td><td>–</td></tr><tr><td>Eating disorders</td><td>[F50]</td><td>0.0</td><td>0.3</td><td>–</td><td>–</td></tr><tr><td>Sleep disorders</td><td>[F51]</td><td>0.1</td><td>0.2</td><td>–</td><td>–</td></tr><tr><td>Other behavioural syndromes associated with physiological disturbances and physical factors</td><td>[F52, F53, F54, F55, F59]</td><td>0.3</td><td>0.0</td><td>–</td><td>–</td></tr><tr><td>Personality disorders</td><td>[F60, F61, F62, F63, F64, F65, F66, F67, F68, F69]</td><td>2.0</td><td>1.1</td><td>0.9 (0.0–1.8)</td><td>0.06</td></tr><tr><td>Problem behaviour</td><td>[F7x.1]</td><td>18.8</td><td>21.2</td><td>−2.4 (−5.4–0.6)</td><td>0.11</td></tr><tr><td>ASD</td><td>[F84]</td><td>7.8</td><td>10.1</td><td>−2.4 (−4.5–0.2)</td><td>0.03</td></tr></table> </ephtml> </p> <p>1 * Some service users had more than one diagnosis.</p> <p>2 ASD, autistic spectrum disorder; CI, confidence interval; N: number of participants in the study.</p> <hd id="AN0084622603-8">Results</hd> <p>Sixty‐five people had a diagnosis of borderline ID. For nine individuals no postcode or address could be found. After excluding the above individuals from the project, the study population comprised 2713 individuals, 1507 (55.5%) of whom were living in urban areas and 1206 (44.5%) were living in rural areas within Leicester city, Leicestershire and Rutland.</p> <p>In terms of demographic variables, there were no significant differences observed between gender, age and level of ID, based on participants' place of residence (Table 1). However, a significantly greater proportion of ethnic minorities were residing in the urban areas and the prevalence of mental illness was lower in the ethnic minority population than in the white population (21.4% vs. 35.4%) and this was a statistically significant result. After analysis to include only the white population, the prevalence of mental illness among adults in urban areas showed a slightly higher figure (n = 1134; 35.9%), but this was still not significantly different from the prevalence of mental illness in adults in rural areas (n = 1146; 34.9%) (P‐value = 0.62).</p> <p>1 Demographic characteristics by urban/rural status ( N  = 2713)</p> <p> <ephtml> <table><tr><th>Demographic characteristics</th><th>Urban (N = 1507)</th><th>Rural (N = 1206)</th><th>Chi<sup>2</sup>P‐value</th></tr><tr><th>%</th></tr><tr><td>Sex</td><td /><td /><td /></tr><tr><td> Male</td><td>57.5</td><td>54.8</td><td>0.17</td></tr><tr><td> Female</td><td>42.5</td><td>45.2</td></tr><tr><td>Age group</td><td /><td /><td /></tr><tr><td> <30</td><td>28.9</td><td>27.9</td><td>0.88</td></tr><tr><td> 530–39</td><td>23.6</td><td>23.6</td></tr><tr><td> 40–49</td><td>20.8</td><td>22.0</td></tr><tr><td> 50+</td><td>26.7</td><td>26.5</td></tr><tr><td>Ethnic group</td><td /><td /><td /></tr><tr><td> White</td><td>75.3</td><td>95.0</td><td><0.001</td></tr><tr><td> South Asian</td><td>21.0</td><td>2.7</td></tr><tr><td> Other/unknown</td><td>3.7</td><td>2.3</td></tr><tr><td>Level of ID</td><td /><td /><td /></tr><tr><td> Mild</td><td>18.5</td><td>21.6</td><td>0.07</td></tr><tr><td> Moderate</td><td>22.0</td><td>18.7</td></tr><tr><td> Severe</td><td>32.2</td><td>32.7</td></tr><tr><td> Profound</td><td>27.4</td><td>27.0</td></tr></table> </ephtml> </p> <p>3 ID, intellectual disability; N, number of participants in the study.</p> <p>For specific psychiatric disorders, no differences were observed in the prevalence of overall mental illness by place of residence. There were no significant differences in the prevalence of psychotic or mood disorders, dementia and organic disorders, disorders because of use of psychoactive substances, anxiety or eating disorders and personality disorders when comparing urban with rural areas. The results, however, showed that ASD was more common in people living in rural areas than those living in urban areas (Table 2).</p> <hd id="AN0084622603-9">Discussion</hd> <p>Results from this study do not support the hypothesis that urbanicity is associated with a higher rate of psychiatric disorders in people with ID. However, we found that ASD was significantly more common in people living in rural than urban areas. We also found no differences in level of ID, sex and age between urban and rural settings. However, ethnicity remained a potential confounder.</p> <p>Our finding that ASD was more common in people living in rural than urban areas was surprising. We propose the following possible explanations. First, it is possible that there has been a development of higher numbers of specialist residential placements in the county to accommodate people with ASD. Second, almost all the literature found by the authors in this area focused on other mental health disorders; i.e. ASD has not traditionally been used as outcome measures for studies within the general population, so it is possible that a different trend is seen within the ID population with ASD specifically.</p> <p>Yet even with psychiatric morbidities that have a well‐established link with urban living, such as schizophrenia or personality disorders, no significant difference was found in our study population, suggesting that for people with IDs, other factors may be contributing to those that cause the differences seen in the general population.</p> <p>As Cooper et al. (2007) and Smiley et al. (2007) suggest there may be different factors underlying psychiatric morbidities in those with ID. In the general population environmental stressors such as lack of social cohesion, overstimulation and restricted living space are thought to play a significant role (the breeder hypothesis). We propose that although people with IDs experience similar stressors found in the general population, they usually receive a package of care and support within a protected environment regardless of whether they are living in urban or rural areas. Additionally, it is possible that early developmental problems leading to brain damage have a bigger impact on the pathogenesis of mental illness in this population than urbanicity. This may particularly apply to those individuals who, because of severity of their ID and brain damage, spent their childhood in residential accommodations and moved from one area to another (because of lack of an appropriate placement), or those who have little interaction with mainstream society (including stressful situations imbedded in an urban environment which are less pertinent to people with ID, e.g. divorce, substance misuse, lack of employment).</p> <p>Generally, there are problems in accessing health services in a rural environment (Nicholson 2008). These problems may not only be because of physical access to services but other barriers may play a role. A culture of stoicism common in rural and remote areas may prevent residents from seeking help, as may the lack of confidentiality perceived to be present in a ‘small town’ environment. Therefore, another possible explanation for the findings is that difficulty accessing services and underreporting by families because of cultural issues or stigma may have distorted the results in this particular study population.</p> <p>Finally, there may also be an element of under‐diagnosis in this group because of problems in communication, diagnostic overshadowing and limitations in eliciting psychopathology from both individual and collateral histories, leading to inaccuracies in making a diagnosis.</p> <hd id="AN0084622603-10">Limitations</hd> <p>The authors did not do any face‐to‐face interviews with the participants to diagnose mental illness and ASD but rather used the data already available in each psychiatric case file based on just one classification system (ICD‐10). Research (Cooper et al. 2007) shows that using other diagnostic tools in people with ID such as DC‐LD, gives a better diagnostic yield as some of the patients might be missed by using ICD‐10 criteria. However, in our study ICD‐10 criteria had been uniformly used by different teams in categories of both urban and rural areas.</p> <p>As a cross‐sectional study, the results provide only a snapshot of the long‐term burden of mental health disorders in people with IDs. Research suggests that socio‐economic factors have more wide‐reaching consequences, for example a greater impact on the length of an episode of mental ill‐health, rather than simply its onset (Weich & Lewis 1998; Lorant et al. 2003). Thereby without follow‐up, the results may have concealed any association between risk factors and the long‐term outcome of the mental illnesses studied.</p> <p>The participants were known to the LIDR and consequently adults with ID who did not have specialist support needs were unable to participate in our study. This group of people with mild ID (e.g. majority of people with a mild intellectual impairments who are not in need of a specialist social or healthcare service) are more likely to experience the same kind of stressors commonly associated with depression and anxiety disorders in the general population (substance misuse, lack of employment and divorce). Additionally, the results of our study might be a reflection of housing development patterns in Leicestershire.</p> <hd id="AN0084622603-11">Strengths</hd> <p>This study is the first to address the issue of an urban–rural divide in psychiatric morbidity which has been studied extensively within the general population, yet never in people with ID. Though not a population‐based study, this research project had a very large sample size and included all people with an ID known to both the LIDR and specialist ID psychiatric service. A post hoc power calculation revealed that the current sample size had 77% power to detect a 5% difference and more than 99% power to detect a 10% difference in overall mental illness between people in urban and people in rural areas [given an expected prevalence of 34% (Bhaumik et al. 2008)]; thus we think it unlikely that our findings can be explained by type 2 error. There were approximately 700 000 adults living in Leicester city, Leicestershire and Rutland during the study period (National Statistics 2001) and the 2713 adults observed for this study make up approximately 3.9 per 1000 of this population. The register holds a representative sample of people with moderate to profound ID because of their need for specialist service support. People with mild intellectual impairments are less well represented as the majority do not need specialist support. That said, our experience suggests that most adults with suspected ID and mental illness are referred to ID psychiatric services, and we are confident that people with mental illness are fairly well represented in the study population.</p> <hd id="AN0084622603-12">Conclusion</hd> <p>In conclusion, further longitudinal research projects are needed to support the theory that psychiatric morbidity is higher in urban areas. This relationship should reflect the reality by exploring the association of a variety of risk factors with psychiatric disorders, including presence of ID, which interplay to determine mental ill‐health. This may then inform us of which risk factors for psychiatric morbidity in people with ID are specific to either urban or rural areas which in turn will lead to a better mental health service provision to people with ID who live in diverse geographical areas.</p> <hd id="AN0084622603-13">Acknowledgements</hd> <p>The authors would like to thank all clients registered on the LIDR and their families/carers who made this study possible. Authors are also grateful to staff from the Leicestershire Learning Disability Register and the Community Learning Disability Teams for their help with this project.</p> <ref id="AN0084622603-14"> <title>Footnotes</title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext>Declaration of interest: None. </bibtext> </blist> </ref> <ref id="AN0084622603-15"> <title>References</title> <blist> <bibtext>Australian Institute of Health and Welfare ( 1998 ) Health in Rural and Remote Australia. [AIHW Cat, no. PHE 6]. Australian Institute of Health and Welfare, Canberra. </bibtext> </blist> <blist> <bibl id="bib2" idref="ref2" type="bt">2</bibl> <bibtext>Bhaumik S., Tyrer F., McGrother C. & Ganghararan S. K. ( 2008 ) Psychiatric service user and psychiatric disorders in adults with intellectual disability. Journal of Intellectual Disability Research 52, 986 – 95. </bibtext> </blist> <blist> <bibl id="bib3" type="bt">3</bibl> <bibtext>Blazer D., George L. K., Landerman R., Pennybacker M., Melville M. L., Woodbury M. et al. ( 1986 ) Psychiatric disorders, a rural/urban comparison. Archives of General Psychiatry 42, 651 – 6. </bibtext> </blist> <blist> <bibl id="bib4" type="bt">4</bibl> <bibtext>Blazer D. G., Kessler R. C., McGonagle K. A. & Swartz M. S. ( 1994 ) The prevalence and distribution of major depression in a national community sample: the National Co‐morbidity Survey. 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  Data: Urban-Rural Differences in the Nature and Prevalence of Mental Ill-Health in Adults with Intellectual Disabilities
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Intellectual+Disability+Research%22"><i>Journal of Intellectual Disability Research</i></searchLink>. Feb 2013 57(2):119-127.
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  Data: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA/
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  Data: <searchLink fieldCode="DE" term="%22Rural+Urban+Differences%22">Rural Urban Differences</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Retardation%22">Mental Retardation</searchLink><br /><searchLink fieldCode="DE" term="%22Incidence%22">Incidence</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Disorders%22">Mental Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Statistical+Analysis%22">Statistical Analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Classification%22">Classification</searchLink><br /><searchLink fieldCode="DE" term="%22Clinical+Diagnosis%22">Clinical Diagnosis</searchLink><br /><searchLink fieldCode="DE" term="%22Autism%22">Autism</searchLink><br /><searchLink fieldCode="DE" term="%22Pervasive+Developmental+Disorders%22">Pervasive Developmental Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Disorders%22">Behavior Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Services%22">Health Services</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Urbanization%22">Urbanization</searchLink><br /><searchLink fieldCode="DE" term="%22Correlation%22">Correlation</searchLink>
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  Data: <searchLink fieldCode="DE" term="%22United+Kingdom+%28England%29%22">United Kingdom (England)</searchLink>
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  Data: 10.1111/j.1365-2788.2011.01523.x
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  Data: 0964-2633
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  Data: Background: In the general population there are statistically significant urban-rural differences in the rate of common mental disorders. In people with intellectual disability (ID) no study has attempted to address this issue. Aims: To compare the prevalence of mental illness, autism spectrum disorder (ASD) and behaviour disorder in people with ID living in urban areas with those living in rural areas. Methods: Cross-sectional study of 2713 individuals registered with an ID service. Participants were assigned to urban or rural groups using the Department for Environment Food and Rural Affairs rural/urban local authority classification for their district. The main outcome variable was a clinical diagnosis of mental illness, ASD and behaviour disorder. Differences between diagnoses of mental illness in urban and rural areas were evaluated using the chi-squared test for the difference in two independent proportions. Results: No differences were observed between gender, age and level of ID of service users based on their place of residence. But more people from an ethnic minority background were living in urban areas than rural areas. No differences were observed in the overall prevalence of mental illness by place of residence. However, the results showed that ASD was more common in people living in rural areas. Conclusions: We found these results surprising and at odds with the majority of studies carried out in the general population and propose several reasons for the differences found. We believe that the results and further studies in this area will help inform health service provision for those with ID who live in different geographical areas. (Contains 2 tables.)
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  Data: 2014
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      – TitleFull: Urban-Rural Differences in the Nature and Prevalence of Mental Ill-Health in Adults with Intellectual Disabilities
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