The current study examined whether individual level characteristics influence psychological distress outcomes differentially across urban-remote regions of Australia in a community sample of persons aged 55 and over. We hypothesised that the association of individual level characteristics with high psychological distress would be moderated by indices of area remoteness. Results provide support for our hypothesis and suggest that remoteness may have a moderating effect on the association of both social support and age with high psychological distress. Persons with low levels of social support were less likely to be highly distressed as remoteness increased; an effect particularly evident in remote, compared to urban and regional, participants. Further, older persons were less likely to be highly distressed as remoteness increased, with urban participants showing little change in psychological distress with increasing age. This study is the first to examine how determinants of psychological distress vary across to urban very remote regions of Australia.
The current results confirm often observed findings that increased likelihood of high psychological distress is associated with lower levels of education and with not being in a married or defacto relationship. Results also indicate that when controlling for age, education, marital status, social support and remoteness, there was no influence of gender on high distress in either the combined urban-remote baseline sample or the three year follow-up data from the urban-regional HCS. Recent Australian population data found women to have higher K10 scores across all age groups compared to men , though these effects are not always observed . Additionally, a Canadian population study noted that when using a criterion cut-off for major depression, differences in the rate of major depression between men and women decreased with increasing age . Given the older age of the current sample such an effect may have contributed to current results. While it is unclear why some studies of psychological distress do not show gender effects, we also observed no differential effect of gender by remoteness, suggesting that community remoteness was not a factor in the lack of gender effect, as previously proposed .
Interpretations of the lack of main effects of age and remoteness and the main effect of social support on the likelihood of high psychological distress are more difficult in the presence of their significant interactions. However, while the lack of association between high psychological distress and remoteness confirms observations in American  and Australian  community samples, the current research suggests that it may moderate the effects of other potential demographic and social risk factors. Previous literature has observed a positive relationship between age and psychological distress, however it is likely that the restricted age range of the current sample may explain the lack of association observed here. Indeed research suggests there is a spike in psychological distress in the adult life for persons aged in their 50s  and, as our study was a cohort of persons 55 and over, this restriction may explain the absence of a positive association of age and distress. The exploration of the observed interaction of age and remoteness suggested that increased age was associated with a decreased likelihood of distress in our regional and remote participants, although this had little or no impact on distress in urban areas. These results suggest that there may be some benefits associated with aging in non-metropolitan communities; however, this may also represent an urban-drift phenomenon wherein persons experiencing high levels of distress move to urban or regional areas in their older age. Indeed a Western Australian study of migration patterns of remote, regional, and urban populations found that persons in remote areas were more likely to move to urban areas following onset of disease relative to background rates of urban migration in the healthy population . While the mechanisms underlying the current observation that older persons were less likely to be highly distressed as remoteness increased are unclear, the current research highlights the importance of examining contextual variations, such as remoteness, when assessing the influence of demographic factors such as age on psychological outcomes.
The current study confirmed findings that decreased levels of social support were associated with an increased likelihood of psychological distress. Exploration of the significant interaction of social support and remoteness demonstrates that the direction of this association was consistent across urban, regional and remote areas, though the strength varied. Stress and coping theories addressing the protective effects of social support on psychological wellbeing suggest that these effects may be due to ‘stress buffering’ processes wherein social support decreases the stress associated with challenging or stressful situations by increasing the individual’s coping resources thus moderating the impact of stressful life events on mental health outcomes . Such theories have received limited support as literature examining an association between life stressors and levels of social support have rarely observed this buffering effect (see  for review). More recent 'social cognitive’ theories such as Relational Regulation Theory  have proposed that the protective influence of social support may actually reflect a general heightening of wellbeing and self-esteem resulting from social interactions and support and that the level of support needed to maintain this wellbeing benefit varies depending on the individual’s desire for social interaction (i.e. as shaped by social norms and individual’s personality characteristics etc.). Both researchers and theorists [2, 3, 46, 47] have proposed that high levels of social support and social capital in rural samples underlie observations of lower rates of psychiatric morbidity compared to urban samples, however this proposal has rarely been formally tested. The current findings indeed suggest that the characteristics of the place in which we live may moderate the protective effect of social support on psychological wellbeing. However, they indicate that low levels of social support have a greater effect on wellbeing in urban and regional centres than in remote areas and, as discussed below, there are a number of scenarios which may contribute to this finding.
Firstly, this result may reflect a real difference in the association between social support and psychological distress that is borne of the values and environmental context associated with remote, in contrast to urban or regional, living. The isolation and associated social norms that come with living in remote communities may mean that the self-esteem of persons living in these environments may be less influenced by their level of social support. Alternatively, there may be more salient stressors that underlie psychological wellbeing in these communities (i.e. drought, access to resources, physical wellbeing), the effects of which are not moderated by social support.
Secondly, Relational Regulation Theory  suggests that different persons need different levels of social support to maintain wellbeing. As such, results may reflect a self-selection process wherein individuals who have a lesser reliance on social support for maintenance of their psychological wellbeing will move to or remain in remote areas, whereas individuals who require high levels of social support for maintenance of wellbeing will move to regional or urban areas where there is a greater opportunity to have these needs met.
Thirdly, researchers assessing the potentially negative consequences of ‘social support’ have noted that too much social interaction and participation may be detrimental to wellbeing when these interactions exceed the coping resources of the individual. In a community sample of persons aged 50 years and over, Beard et al.  observed that everyday contact with family and friends was related to increased depressive symptoms over time, potentially reflecting increased involvement of social networks with persons who have greater need, or increased social demand on individuals which may be beyond their coping resources. It is feasible that increased levels of social interaction in remote areas may be associated with additional burdens (i.e. stress associated with leaving farm or work commitments, longer distances to travel etc.) which may not be as keenly felt in regional or urban environments and thus the protective effect of social interactions is reduced in remote populations.
Finally, these results may indicate that social relationships described here, such as access to close confiding relationships and group participation do not describe the types of social support that are important for the maintenance of wellbeing in remote communities. There is some evidence that the influence of all facets of social support on psychological wellbeing are not uniform between urban and rural environments [18, 21], perhaps reflecting the increased salience of some aspects of social support in determining psychological wellbeing in these environments. Such findings may indicate that the influence of different aspects of a person’s social sphere may differently influence, or be influenced by, psychological wellbeing depending on the environmental and social context in which that individual lives. Recent research from a South Australian study conducted as part of a broader survey by the South Australia Department of Health  examined a range of social capital indices, with confirmatory factor analyses producing factors representing three aspects of social capital: cognitive (‘Trust’ in the wider community; belief in the ‘Reciprocity’ of helping, and; perceived community ‘Cohesion’ in terms of character and values); bonding (the availability of ‘Help’ from close connections if needed); and bridging (‘Networks’ participation in community groups, and; individual’s participation in ‘Civic activities’ such as marches, voting, and local action groups). Structural equation models of demographic and social capital influences on mental health urban and non-urban populations revealed that ‘Trust’, ‘Help’ and ‘Cohesion’ were associated with good mental health in both the urban and rural models, while ‘Networks’ were only associated with mental health in the urban model, perhaps suggesting social networks are either less important for mental health in rural areas, or are less prone to the effects of mental health. Current evidence highlights the necessity of examining the relative influence of different aspects of social capital on psychological wellbeing outcomes in different environments.
Strengths and limitations
A strength of the current research is its capacity to compare determinants of psychological distress across a broad spectrum of urban-remote populations, which was achieved by combining studies sampling urban and non-urban environments. By uniting cohorts in this way, the Extending Treatments, Education and Networks in Depression project (xTEND)  is not only able to examine these baseline associations but to ensure overlap in measures for their respective three year follow-up surveys. There are a growing range of approaches for integrating and comparing data across different cohorts (e.g. [49, 50]). The current study used a process of calibrating different though conceptually similar measures of social support to provide comparable assessment of their association with psychological distress outcomes across both cohorts. The availability of a common follow-up phase allowed us to employ methods to directly compare the association of these measures of social support both with each other and a common measure of psychological distress to create a single index of social support. However, while we have combined data from studies designed for different purposes, and with differing response rates, they were conducted within similar time frames, drew samples from electoral rolls using a similar methodology and had comparable socio-demographic profiles. Nevertheless, questions remain as to whether the differences in measures used influenced our current findings. In the HCS three year follow-up dataset, the correlation between the social support measures was only moderate. However, the overlapping confidence intervals for the adjusted odds ratios of our composite measures of social support in the prediction of high distress suggest that the association between social support and high distress did not differ between the two indices. These findings will need to be verified using common measures of social support (when three year follow up data are available for both the HCS and ARMHS cohorts), as well as replicated in other samples using common measures of social support both to confirm current findings and ensure generalizability to other areas of Australia. Researchers interested in examining effects of remoteness should consider collaborations with similar cohorts to improve their representativeness.
A limitation of the current research is that younger people were not represented and so current findings may not be generalizable to this section of the population. Further, traditional measures of social support, as used in the current research, do not take into account modern forms of socialisation such as instant video, chat and text messaging and social networking services, nor do they consider the importance of persons outside the community for sustaining mental health. With the increasing accessibility and use of these services, it is likely that these modes of social communication will become increasingly important for the maintenance of psychological wellbeing, perhaps particularly in isolated communities. Future research is needed to develop tools to assess the use of and support derived from these sources.
Finally, future research should consider the influence of previous environmental exposure on relationships between remoteness and psychological wellbeing. Kim et al  found that the influence of remoteness on the association between social support and depression outcomes was moderated by the individual’s migration history. While the ARMHS collected information on how many years the individuals had lived in their current district, no information on previous area of residence or residential history was collected from HCS participants. As such, the current research is unable to determine what effect, if any, previous environmental exposure had on the current associations. Future research is needed to examine what effects such migration patterns have on the current findings.