Rural America and Mental Health

When I was in sixth grade, my parents and I traveled through the Midwest for vacation. We visited major cities such as Chicago, Nashville, and Kansas City. It was a great bonding experience for my family and me. Traveling between states, I was able to see a huge chunk of rural America, which consisted of corn fields and flat lands. 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?

Since I’m a mental health blogger, I wondered about their mental healthcare. Research has shown me that mental healthcare 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 is also assumed that rural families of children with mental health problems experience a greater 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. Also, since many rural areas are lower income, the limited economic opportunities mean a decrease in the ability for the rural families to care for children with severe mental health problems.

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. According to a study operated by the South Carolina Rural Health Research Center, an estimated 2.6 million rural residents suffer from depression. In a 2002 report by the American Journal of Public Health, in the 1970s, the suicide rate for urban and rural men

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.

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 healthcare in the countryside and there are few trained professionals that work in those areas.

What’s worse is that the most marginalized and under-resourced communities are those with the most severe need for mental healthcare 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).

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. Also, that high no-show rates among mental health clients and large numbers of uninsured patients further intensify the issue of low reimbursement rates paid by Medicaid and others.

There are consequences resulting from the lack of accessible healthcare services for rural people. One consequence is that law enforcement is the de facto response to mental illness issues in the countryside. Take Chicago’s Cook County, for example; estimates run as high as 30 percent of jail mates suffering from mental illness, the majority of them undiagnosed and untreated. Furthermore, a lack of accessible care could mean that people with mental health issues end up in emergency rooms if the closest mental health provider is far from where they live.

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.

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

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.

Rural areas such as Codington County, South Dakota, have established 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 contracts with a community mental health center to go to the jail and identify people who might have a mental health problem. From there, troubled inmates are placed in case management programs.

Other approaches that rural areas can take to minimize the challenges of providing mental health services and expanding the mental health workforce are:

  • Offering loan repayment programs and state tax waivers
  • Providing clinical rotations in a rural setting to grow-your-own workforce
  • Allowing education and awareness efforts targeted toward 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).

Mental health affects everyone, even the stoic, hardy, self-reliant individuals in the countryside. Hopefully, with potential solutions and people who are open to fighting the stigma of mental illness and spreading awareness about mental health, mental health care will improve in rural America.