Research projects

xTEND: eXtending Treatments, Education and Networks for Depression

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Principal researchers

Professor Brian Kelly 1,2
Professor John Attia 2,3
Dr Frances Kay-Lambkin2
Terry Lewin4
Professor Amanda Baker2
Trevor Hazell5
HMRI Xstrata Coal Post-Doctoral Fellow1


1 Hunter Medical Research Institute
2 University of Newcastle
3 John Hunter Hospital
4 Hunter New England Area Mental Health Service
5 Hunter Institute of Mental Health



Co-funded with

Xstrata Coal $300,000
NSW Centre for Rural and Remote Mental Health $100,000
NHMRC funding $270,000
NDARC University of NSW $120,000 (to support a post-doctoral fellowship)
NSW Health $250,000
University of Newcastle $40,000

Total supporting funds from other sources is approximately $1,080,000

Award type

Beyond Blue grant

Project completion year


Executive Summary

The xTEND project enabled the establishment of a unique set of mental health-related data from two large community samples across rural and urban regions of New South Wales in which to explore the role of community and interpersonal networks, adversity and depression as potential risk factors for suicide and poor physical and psychological outcomes. Given the critical need for effective and accessible interventions to address rural suicide risk and mental health needs, including depression and alcohol use problems, this program of research was designed to build upon existing data sets to quickly inform strategies to assist in addressing mental health problems among people in rural communities. It incorporated the development of a pilot intervention combining existing effective interventions for depression and risk factors for suicide, including substance use and family breakdown.

The existing data sets used by xTEND were from the Australian Rural Mental Health Study (ARMHS) incorporating regional and remote communities of NSW, and the Hunter Community Study (HCS), incorporating urban and inner regional areas from NSW. To support this work data from the 2007 National Survey of Mental and Well-being (under-representative of remote and very remote regions) were also utilised as well as environmental data from the Australian Bureau of Statistics (community remoteness, socio-economic advantage/disadvantage, drought severity, population change), NSW Adult Population Health Survey (area-level social capital and health service accessibility) and Australian Bureau of Meteorology (i.e. drought severity); geocoded to survey participants.

The project consisted of three phases. The first allowed cross sectional analyses on baseline data from ARMHS in key areas including suicidal thoughts and behaviours, unintentional injury, alcohol misuse, help-seeking and service use, and wellbeing in older residents to be undertaken. Baseline data across rural (ARMHS) and urban (HCS) communities were combined to assess the impact of geographical differences on the demographic and social risk factors for psychological distress and the impact of chronic illnesses on quality of life. ARMHS data was linked to the 2007 national survey to identify the differences in determinants of suicidal behaviours across urban and rural communities. The second phase allowed follow-up of both the ARMHS and HCS cohorts using common measures, allowing comparison across geographical regions to further identify risk and protective factors for mental health problems over time. The third phase allowed the pilot of two evidenced based interventions to establish their acceptability and feasibility in rural communities: (1) an online treatment for co-existing depression and alcohol misuse; and (2) a program that provides support for the partners of someone with depression. 

This research has highlighted the key roles that social support and adversity play for people with mental health problems, including depression or suicidal thoughts, in rural communities. Adversity, including chronic illness or injury, impacts significantly on our mental health. A significant relationship between at-risk alcohol use and the number of recent adverse life events highlights the importance of individualised care, particularly for young males. 

The study allowed the exploration of the consequences of poor mental or physical health and detected a significant link between a history of depression and unintentional injury in rural populations, highlighting the importance of attending to mental health factors in injury prevention. Heart disease and depression were also shown to have a significant adverse impact on quality of life among older community residents in urban and rural areas, emphasises the importance of addressing both physical and psychological problems in older people.

Multiple recent adverse life events including relationship strain, especially for younger men was associated with higher risk of alcohol misuse. This was higher for those who had been living in a rural area for a shorter time. Among rural residents who sought professional help for mental health problems the overall perception of the adequacy of the service they received was low, especially among those with the highest levels of distress and greatest adversity (recent adverse life events). Promising findings suggested acceptability of internet based services for mental health problems to young men in rural areas. Nevertheless, a number of attitudinal barriers to internet treatments were identified.

In terms of frameworks for investigating mental health and methods of combining data sets we found that pooling data from multiple studies can be worthwhile where the effects of interest are small though important, where events are of relatively low frequency or rarely observed, and where the issues are of immediate regional or national interest – such is the case for suicidal behaviours. xTEND researchers were able to investigate the course of suicidal thoughts, to assess factors that lead to both the development and amelioration of suicidal thoughts, in order to inform early interventions for rural populations. Linking existing health-related national and urban-based cohort data sets with rural data sets can be used to better understand geographic variation in risk and protective factors for mental health, contributing to knowledge about how the determinants of mental disorders affect outcomes over time.

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