Country Life May Be Quieter, But No Protection Against Mental Illness

Some people would argue that youngsters living in rural areas of America are better shielded against psychiatric illnesses than are youngsters living among the stresses and anxieties of cities. Some might also assume that if any youngsters living in rural areas succumbed to mental ill health, it would more likely be those living in poverty.

Both assumptions are wrong.

So, at least, implies a study reported in the September American Journal of Public Health. It was conducted by E. Jane Costello, Ph.D., an epidemiologist and professor of medical psychology at Duke University Medical Center in Durham, N.C.; Adrian Angold, M.D., a child psychiatrist and associate professor of psychiatry at Duke; and Gordon Keeler, M.S., also at Duke.

Costello and her colleagues focused on 920 children (541 black and 379 white), aged 9 to 17 from four rural North Carolina counties who constituted a representative sample of children in that age group in the four counties. They conducted structured interviews with the children and their parents to learn whether the children had various psychiatric disorders; whether the children’s lives involved risk factors known to set the stage for psychiatric disorders, such as mental illness in the family, lack of parental warmth, lack of supervision, harsh parental punishment, maternal depression, parental criminal arrest, lack of education, and so forth; and the family income for each child studied.

They then attempted to determine the prevalence of psychiatric disorders among their subjects, how the prevalence of psychiatric disorders among black subjects compared with the prevalence among white subjects, and how known risk factors for children’s mental illnesses and poverty contributed to mental ill health among their subjects.

First, the researchers found, the prevalence of psychiatric disorders among their subjects was about 20 percent—the same as that found for youth in most studies conducted in the United States during the past two decades. This finding suggests that compared with living in Boston, Pittsburgh, Los Angeles, or other cities throughout the United States, living in rural areas does not protect young people from psychiatric illnesses.

In addition, the investigators discovered that the prevalence of psychiatric disorders among their black subjects appeared to be about the same as among their white subjects (19 percent versus 21 percent). The only significant difference was that the prevalence of depression was higher in the white children.

This finding suggests that young people living in rural areas of the United States are about equally susceptible to mental illness, no matter what their race.

Furthermore, when the researchers examined how known risk factors for childhood psychiatric illnesses contributed to mental ill health among their subjects, they found that the risk of such illnesses increased proportionally to the number of risk factors that the subjects faced.

Finally, when the investigators took known risk factors for childhood psychiatric illnesses into consideration, poverty alone did not contribute substantially to mental health problems among the study’s black subjects, yet it did contribute substantially to the mental health problems of the white subjects. For instance, while the effects of poverty on the mental health of black subjects appeared to be small, with the exception of an excess of depression in the relatively poorer children, white subjects had a significantly higher risk for having any emotional disorder, especially depression, and of any behavioral disorder, especially oppositional and conduct disorder, when poverty alone was the criterion.

When Psychiatric News asked Costello why poor white children in rural areas appear to be more susceptible to mental illness than poor black children in these areas, she replied: “I think the question is rather, How come black children are so resilient, given the burden of poverty and other risk factors that they carry?”

Interestingly, the investigators came up with a similar finding in another study where they compared white children in North Carolina with native-American children in the state: Poverty predicted child psychiatric disorders only among the white children.

Psychiatric News asked Costello what the implications of this study are for psychiatrists and mental health professionals. “I think the most significant message for mental health professionals,” she said, “is the vulnerability to environmental risk shown by all children, but especially poor white children. . . . This implies that reducing child mental illness is a social as well as a medical problem. Another implication is that the high level of problems reported by researchers in inner-city black [populations] may well be linked to the pressures of inner-city life, since they do not occur in poor, rural black children.”

An abstract of the study, “Poverty, Race/Ethnicity, and Psychiatric Disorder: A Study of Rural Children,” is posted on the Web at www.ajph.org/cgi/content/abstract/91/9/1494?. ▪