OPINION | Rural mental health in crisis

We who live in more urban areas too often subscribe to the stereotype of rural life as peaceful and idyllic. We assume that, far away from the pollution and stress of city life, people live easily and free from worry. Open air, no traffic, a simple life—great for mental health, right?

Wrong. In reality, people living in rural areas often face a higher burden of mental health problems than their urban counterparts. Agricultural communities can see an accumulation of stressors that result in distress, depression, anxiety, and substance abuse. The Minnesota Department of Health reported in 2005 that rates of depression among rural women were as high as 40 percent, while only 13 to 20 percent of urban women were depressed. In one study, rural patients in treatment for depression were three times as likely to be hospitalized for physical or mental health problems than urban patients. Another found that rural patients with bipolar disorder were four times as likely to have a manic episode during the year after diagnosis and were 17 percent more likely to attempt suicide.

Many factors influence mental health, but today we’re going to focus on just one of them: Access to care. Rural Minnesota is facing a critical shortage of mental health providers. The Health Resources and Services Administration (HRSA) reports a shortage equal to 52 full-time equivalent practitioners in Minnesota. The shortage means that patients have to drive longer distances to reach mental health practitioners. Social stigma makes it even more difficult for people to access care, and beyond this, a lack of health insurance among rural residents means that even those able to access care often can’t afford it. HRSA estimates that 1,456,036 Minnesotans do not receive an appropriate amount of mental health services. These patients cannot receive the medication, treatment, or support that would help them.

Emergency medical services and police are too often the ones who must deal with patients facing mental health crises. They must transfer patients to hospitals. Often patients are admitted across the state in order to find an open psychiatric hospital bed. The fractured system can mean that people with serious mental illness end up in county jails.

Let’s take the example of Nobles County. Because there’s no psychiatric unit in Nobles County, any persons deemed to be potentially harmful and put on a 72-hour commitment must be driven by a squad car to Marshall or to Sioux Falls. These patients are interviewed, sometimes multiple times, by social workers who must drive to the place the patient is being held. Each time the person is called back to Nobles for a hearing, he must be transported back. And in the case that the person is deemed able to leave the unit, she must find her own transportation home.

It is essential that we address the shortage of rural mental health services. Attracting practitioners and funding to rural areas is crucial, but we also need innovative solutions that can help mental health patients now.

One such solution is telemental health – long-distance counseling with the help of technology like teleconferencing or video conferencing. Telemental health makes it easier for people to access mental health services because it removes the barrier of transportation. Better access leads to better diagnoses and better treatment for mental health patients. It saves money because people can stay in the community while receiving health care. And it means that psychiatrists can communicate among themselves in order to improve care.

The Itasca County Crisis Response Team coordinates its emergency medical services and its local mental health professionals through telemental health services in order to combat problems with emergency mental health situations. A team of mental health professionals is available to the county’s emergency medical services workers in order to provide face-to-face or telephone intervention, helping patients find care that is nearby and assisting with care from initial contact. Normalizing mental health emergency care to reduce stigma has resulted in better and more efficient care. Itasca county has seen both clinical benefits and savings from this program.

Even for such an innovative solution there are barriers. The Department of Health reports that Minnesota lacks a central telemental health resource to guide organizations on the development of telemental health programs. There is no consistency of reimbursement for telemental health care. The shortage of mental health practitioners means that even with telemental health services there are still few doctors available. Finally, inconsistencies in internet access across rural Minnesota and difficulties with technical support can impede telemental health.

Rural mental health care is in danger. Between the shortage of practitioners, the culture of stigma, and the fractured emergency mental health system that lands patients in jails instead of care facilities, it is clear that we are failing to appropriately address this issue. We can no longer afford to ignore our neighbors. Says Deb Hogenson, social worker in southwest Minnesota, “It’s a crisis – no question about it.”

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Meg Reid


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What a wonderfully insightful article! This really made me think about the assumptions I make about rural life (as the hip city dweller that I am). Great job Meg Reid, and great job Daily Planet! There is much to be proud of here. 

Improving Living Options

As someone who has bipolar disorder and who is living in the city, I am very thankful for the services that I have here.  I do think that if I was to leave the city, I would be able to make it work, but I know there would be more challenges.  The idea of telemental health is really quite interesting, and I hope as technology improves, proper care will be increasingly accessible.  Now, I just need to get past the strangeness factor with doing therapy over Skype :).

I covered this article on my blog, Bipolar Today, since I thought it could really help generate an interesting discussion.  If anyone is interested, the page can be found here.