Approximately one-fifth of our country’s population lives in a rural area, and approximately one-fifth of them (about 6.5 million) have a mental illness. Sadly, though the prevalence of mental illness is similar in rural and metropolitan areas, those living in rural locations experience significant disparities in treatment. The reasons underlying this disparity are well documented and include limited availability of specialty mental health care, lack of trained mental health providers, and underutilization of available services. Here are some cold hard facts: more than 60% of rural Americans live in mental health professional shortage areas, and more than 90% of mental health professionals work exclusively in metropolitan areas. That means that most rural Americans receive mental health care from their primary healthcare provider or none at all. Statistics also show that rural Americans are less likely to recognize the symptoms of a mental illness and understand where to turn for help.
Addressing rural mental health response in the United States is challenging. The National Rural Health Association has created a toolkit that contains evidence-based models and resources to assist organizations in addressing these challenges. The toolkit’s modules focus on developing, implementing, evaluating, and sustaining rural mental health programs. The Association identified four areas that can present challenges: accessibility, availability, affordability, and acceptability. We will examine these areas and discuss viable solutions to help rural communities develop a plan.
Accessibility to Mental Health Services
When we examine accessibility to mental health services, most people would agree that rural Americans travel long distances for even basic needs, and that is true. They travel further for groceries, and to send kids to school. However, it should be noted that driving 150 miles or more to access mental health care is not uncommon. In fact, many rural areas still have mental health professional “circuit” care where providers travel a circuit, visiting one area perhaps only once or twice per month. Obviously, this also spills over into affordability when travel costs become prohibitive. To counter this disparity, many rural communities are introducing technologies to deliver mental health care remotely. Due to the recent pandemic, telehealth expansion is showing great promise in the mental health world. Even older adults are adapting to technology as it is easily available through computers, smartphones, and tablets. The use of telehealth solutions expands access to services and promotes the integration of primary and mental health services. Communication between providers is enhanced as well as more effective patient monitoring.
Availability of Services – Integration of Primary Care and Mental Health Services
Rural communities are gaining a better understanding of the need for mental health services and have begun integrating them into primary care. An editorial written by the World Health Organization contains recommendations for integration that include:
- That policy, plans, and laws be developed to strengthen integration to ensure that physical and mental health needs are equally available and affordable to patients,
- That primary care providers receive training to enable them to effectively screen and treat mental health conditions, and
- That mental health specialists be available to primary care providers to answer questions or provide guidance.
Integrated (or collaborative) care has been defined by the American Psychiatric Association as care for mental health that includes a Primary Care Provider (PCP) and a mental health professional. General medical care is provided by the PCP, while a mental health professional screens and monitors the patient for mental health disorders. In rural areas, the two professionals are often located in two separate locations and provide services through telehealth.
Choosing the right technology solution is vital to the integration of services. Julota’s cloud-based platform provides easy access to sensitive patient information over disparate healthcare systems. The information is held securely and safely and is HIPAA-compliant. The software provides a way to coordinate efforts between the primary care provider and the mental health professional in real-time. Because it is hosted in the cloud, providers will not require multiple permissions or credentials to access the system.
Affordability of Mental Health Services
The affordability of mental health services is one of the primary barriers to receiving treatment in rural areas. According to the U.S. Census Bureau, the poverty rate in urban areas in 2020 was 11% while the poverty rate in rural areas was 14.1%. Because of this disparity, patients in rural areas are more likely to receive public insurance, which doesn’t always cover mental health services. To aid in this area, some rural communities are seeking expansion of Medicare/Medicaid reimbursement from the U.S. government to provide full costs for mental health professionals located in rural and other underserved areas. Even if individuals can afford it, many insurance companies do not cover mental health services at all or require higher co-pays and out-of-pocket payments. Additionally, in rural settings, public transportation is rare, and residents must provide their own transportation to appointments, which can present insurmountable challenges.
Acceptability of the Need for Mental Health Services
While there are many factors that impact rural mental health response, public and personal stigma is one of the most reported barriers. Anonymity and privacy are particularly challenging in rural areas. Fewer choices of trained professionals or the fact that a provider may be a friend or associate often result in a lack of faith in confidentiality. Individuals may even fear being seen going into a mental health facility. The need for greater reliance on family members or friends may be embarrassing and traumatizing. There also frequently exists a lack of knowledge and understanding of mental illness, even among health care staff.
An essential component of breaking the stigma associated with mental illness is education. For example, teaching people that the brain is an organ, just like the heart or lungs, can bring a greater understanding of mental health. This education can occur in schools, workplaces, families, or even in religious organizations. Health care organizations can take an active part in reducing stigma by partnering with organizations like the National Alliance on Mental Illness. NAMI’s Stigma Free program encourages the use of respectful language that doesn’t define a person by their illness and avoids labeling people. For example, rather than saying a person “is bipolar,” one should say something like “they are living with bipolar disorder.”
Spreading awareness is another valuable tool in reducing the stigma of mental illness. According to the American Psychiatric Association, about three out of four teens experiencing depression search online for personal stories shared by other teens who deal with the same illness. In rural areas where contact with outside sources is often limited, social media can be a powerful platform for connecting people with support. One positive impact of the recent pandemic is the increased availability of online support groups as well as therapy.
Improving Rural Mental Health Response Through Community Partnerships
Community partnerships are an essential component of a plan for improving mental health response in rural communities. Community members and organizations working together can help ensure that residents have access not only to mental health care but also to social support networks. Partners can include law enforcement, mental health professionals, primary care providers, advocacy organizations, employment services, social services, and peer support, to name a few. Effective partnerships can maximize resources by sharing expertise, funds, training, and staff time. The National Rural Health’s toolkit includes a resource created by the National Association of County and City Health Officials (NACCHO) that outlines strategies and techniques for rural communities to develop and maintain organizational and community partnerships effectively.
In the United States, law enforcement plays a key role in mental health response, and this is especially true in rural areas. The Police Mental Health Collaboration Toolkit, developed by the Bureau of Justice Assistance, provides a framework for the development of partnerships with mental health professionals. Built on the success of response models like CIT (Crisis Intervention Team), co-responders, and mobile crisis teams, Police Mental Health Collaborations feature formal partnerships with mental health providers, advocacy groups, and community-based services. Included in the framework are guidelines for data collection and the sharing of information between partners. Officers are fully trained to collect and capture data when they respond to a mental health call and that data is used to inform mental health providers of the situation in real-time. Using Julota’s robust software solution on a smartphone, laptop, or computer, information is quickly and securely shared among the agencies for an efficient, effective resolution. Individuals experiencing a crisis can be connected directly to the mental health provider, transported to a location, the problem can be resolved at the scene, or the person connected to social services.
Conclusion: Rural Mental Health Response
According to data collected by the Census Bureau, an estimated 122 million Americans lived in 5,833 mental health professional shortage areas in 2021. Two-thirds of those areas are in rural parts of the country. In this article, we have identified areas that can be improved in addressing rural mental health response. A few of these areas are showing improvement though we still have a long way to go as a country. However, the horizon is becoming much brighter through better telehealth solutions, the integration of mental health care and primary care, and the reduction of stigma through greater mental health education and awareness.