Rural America and Mental Health

Vacation in the Midwest

When I was in sixth grade, my parents and I traveled through the Midwest for vacation. We visited essential cities such as Chicago, Nashville, and Kansas City. It was a great bonding experience for my family and me. Traveling between states, I saw rural areas that consisted of corn fields and flatlands. It was beautiful and peaceful.

Now with the current political situation in the U.S., my interest has peaked in the culture of rural America. What are their lifestyle and culture like? Why do they make the decisions that they do?

Mental Health Conditions in Rural America

Since I’m a mental health blogger, I wondered about their mental health care. I have learned that in rural America, mental health care is virtually non-existent and that mental illness is stigmatized. Mental health conditions in rural America usually come from stress with cyclical farm crisis, social isolation, and natural disasters. It also assumed that children of rural families with mental health problems experience a more significant financial and emotional impact compared to urban households. These assumptions come from the lower availability of mental health specialty care and support services in rural areas. The limited economic opportunities in agricultural regions mean a decrease in the ability of families to care for children with severe mental health problems.

Mental Illness May Be More Serious in Rural Areas

Mental illness is a problem throughout the United States, but the condition may be more serious in rural areas. Major depression is significantly higher in the countryside compared to urban areas. The South Carolina Rural Health Research Center estimated that 2.6 million rural residents suffer from depression.

Statistics

In a 2002 report by the American Journal of Public Health, in the 1970s, the suicide rate for urban and rural men was about the same, but by the next quarter century, the rural rate was more than 50 percent higher. The suicide rate is considerably higher among elderly males and Native American youth. Researchers Garth Kruger and Jacque Gray found evidence for this rural trend in North Dakota in a 2005 study. During a ten-year period in the state, at least 797 people (the equivalent of the population of a small town) took their own lives, and hundreds more attempted to do so.

Challenges to Accessing Mental Health Care

There are many challenges to accessing mental health care in rural America. According to the Western Interstate Commission for Higher Education (WICHE) Center for Rural Mental Health, the following challenges to providing mental health services in agrarian communities are:

  • Accessibility- Residents living in the countryside often travel long distances to receive services, they are less likely to be insured for mental health services, and less likely to recognize mental illness.
  • Availability- There are chronic shortages of mental health professionals in rural areas, and mental health providers are more likely to practice in urban centers.
  • Acceptability- There is a stigma of needing or receiving mental health care in the countryside, and there are few trained professionals that work in those areas.

It’s the Most Marginalized That Need It The Most

What’s worse is that the most marginalized and under-resourced communities are those with the highest need for mental health care providers. County-Level Estimates of Mental Health Professional Shortage of the United States notes that the higher levels of unmet need for mental health professionals happened in counties that were in the countryside and had low socioeconomic status (SES).

Reimbursement

A significant obstacle that affects the accessibility of mental health care in rural areas is reimbursement. The publication, Encouraging Rural Health Clinics to Provide Mental Health Services: What Are Options? mention that rural health clinics may be cautious to start offering mental health services when reimbursement is low. It is also not helpful that many mental health clients and uninsured patients in agricultural areas often do not show up for appointments.

Consequences

Consequences are resulting from the lack of accessible health care services for rural people. One outcome is that law enforcement is the de facto response to mental illness issues in the countryside. In Chicago’s Cook County, the majority of its jail mates that have mental illness are undiagnosed and untreated. A lack of accessible care could mean that people with mental health issues end up in emergency rooms if there are no nearby mental health clinics.

Rural Focused Healthcare Providers

Despite the lack of mental health care in the countryside, there has been an uptick of rural-focused healthcare providers. From 1999 to 2010, a behavioral health program, called Sowing the Seeds of Hope served uninsured and underinsured farmers in the Midwest, and from 2002 and 2004, the Iowa Rural Mental Health Initiative provided families with one-on-one mental health care that was culturally competent-meaning that clinicians providing the care were sensitive to rural needs.

Mental Health Training

Other rural areas tackle the lack of mental health care by training primary care providers and community health clinics with mental health training. One example of this approach is The Billings Clinic, the largest healthcare organization in Montana. The organization has been arming nurse practitioners with additional mental health training for the primary care setting. Nurse practitioners treat mild to moderate anxiety or depression, and the psychiatrists treat the more complicated cases.

Telemedicine

Telemedicine is another approach that helps rural people if the nearest mental health center is far from where they live. Clinicians and clients can establish care via phone or the internet instead of in person. Another great case of this approach is with The Billings Clinic of Montana. They teamed up with Eastern Montana Telemedicine Network to expand care to the most far-flung areas of the state. It is not perfect because internet access in the countryside can be sparse and some states have strict telehealth restrictions.

Stepping Up

In Codington County, South Dakota, it has programs to reduce the number of people with mental illness in jails. Codington County has implemented a program called Stepping Up, an initiative that the National Association of Counties introduced in 2015. In this program, Codington County and a community mental health center work together. They go to the jail and identify people who may have a mental illness. From there, troubled inmates then go into case management programs.

Other Positive Approaches

Here are other approaches rural areas can take to minimize the challenges of providing mental health care and expand the mental health workforce:

  • Offering loan repayment programs and state tax waivers
  • Providing clinical rotations in a rural setting up a grow-your-own workforce
  • Allowing education and awareness efforts targeted at rural residents that create familiarity and comfort with mental health issues. For instance, Mental Health First Aid, a program that let’s lay people identify, understand (therefore reduce the stigma), and respond to signs of mental illness and substance abuse disorders.
  • Rural schools can implement school-based prevention program which can include an expansive set of interventions, such as :
          1. Gatekeeper training programs that seek to develop individuals’ knowledge, attitudes, and skills to identify people at risk for suicide, determine levels of risk, and make referrals when needed.
          2. Mental Health Screenings
          3. Health education curriculum that includes suicide prevention/and or mental health.
          4. Peer mentoring
          5. School-based mental health services
          6. Crisis response
          7. Postvention- an intervention conducted after a suicide, taking the form of support for the bereaved (family, friends, professionals and peers).

Conclusions

Mental health affects everyone, even the stoic, hardy, self-reliant individuals in the countryside. I have hope that mental health care will improve in rural America due to people spreading awareness about mental illness stigma and mental health.