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Rural mental health challenges and hope for the future

Ty Borders

Kate Downes


In a 2017 survey, the National Institute of Mental Health reported that about 20 percent of American adults live with some form of mental, behavioral, or emotional disorder — and that’s excluding developmental and substance abuse disorders. Fewer than half of those affected received any mental health services during the year studied.*

A dearth of mental health practitioners, social isolation — perhaps now exacerbated by the COVID-19 crisis — and perceived stigma can combine to make identifying, quantifying, and treating mental health issues complicated everywhere, but particularly in rural areas. Researchers are taking action to pinpoint rural mental health needs and solutions.

Focus on suicide awareness and prevention

“There is a higher suicide mortality rate among residents of rural and nonmetropolitan areas than those living in metropolitan areas,” says Ty Borders, PhD, University of Kentucky Rural and Underserved Health Research Center director and Foundation for a Healthy Kentucky endowed chair in rural health policy.

“The discrepancy has existed for decades, and the gap has widened in recent years,” he says. “The reasons are a bit unclear, but one possible explanation is rural residents on average are more likely to have engaged in types of work that have been disappearing in the past decade or so. We see that especially in the eastern Kentucky, West Virginia, and Appalachian region underground coal mining industry, which has been decimated. Many of those out of work lack education beyond high school, and there aren’t many other employment opportunities.”

A number of national and international studies point to a link between long-term unemployment, depression, and other mental health issues. But unemployment isn’t the only issue causing strain in rural communities.

“We see a lot of stress, anxiety, and depression in our rural New York farming communities,” says Kate Downes, NY FarmNet outreach director. NY FarmNet is a program created by Cornell University and supported by Cornell and New York State as a resource for farmers in need.

“Farming is rewarding, but also challenging,” Downes says. “Farmers must deal with so many issues beyond their control, like weather, worldwide economic conditions, and government policies. Add to that the stress of working closely with family members; the inability to take time off; the physical hazards and demands; equipment breakdowns; and the emotional weight of expectations to carry on a tradition that may have been in the family for generations.

“There have been many studies showing that suicide rates are higher in rural communities,” she adds. “Anecdotally, we had one county in New York recently that saw five farmer suicides within six months. Those instances have a ripple effect. The people who support the farmers, the cooperative extension office, the local business owners, the kids’ friends at school — everyone gets to know the farmers really well, and the losses reverberate throughout the community.”

At NY FarmNet, farmers and family members needing assistance can call a toll-free line, staffed 24/7. Financial consultants and social workers deal directly with the family, and the service is confidential.

“Sometimes it’s easier for a caller to say, ‘I need someone to look at my books,’ than admit they are struggling with anxiety or depression,” Downes says. “Our trained counselors often find underlying issues to address. We may work with families for years, but in an emergency, of course, we do our best to get help to them immediately.”

A nationwide shortage of mental health professionals

Encouraging those suffering in rural areas to reach out is the beginning of a process that will put them in touch with care. Rural physicians, nurse practitioners, and physician assistants frequently provide mental health services for conditions like depression and anxiety. But hurdles remain in treating mental health disorders that require more specialized services.

According to the Kaiser Family Foundation, there is a shortage of mental health care professionals throughout the country. Nationally, on average, only 27 percent of the need for mental health care professionals is met, with 15 states plus the District of Columbia meeting less than 20 percent of the need. (New Jersey and Rhode Island have the highest percentage of mental health care needs met with more than 69 percent each, still leaving a significant portion of the population underserved.)**

Rural areas fare worse than average. According to the American Journal of Preventive Medicine, the per capita supply of psychiatrists, psychologists, and psychiatric nurse practitioners in nonmetropolitan counties is substantially lower than in metropolitan counties.***

“Despite lower levels of health care availability overall, rural residents may be able to travel to metropolitan areas for, say, cancer care that may be unavailable in their communities,” Borders says. “But for mental health care, that may not be an option, since there’s a shortage in metropolitan areas as well.”

There is also a shortage of treatment centers for alcoholism and substance abuse, which in the worst cases can lead to suicide or unintentional death by overdose.

Current research and outreach efforts

Borders is currently involved in research to document changes in the availability of community mental health centers and federally qualified health centers in nonmetropolitan and metropolitan counties across the U.S.

“There is greater investment in federally qualified health centers, but the degree to which they are expected to provide additional mental health care is unclear and needs to be identified,” Borders says. “That said, some of the more innovative work is being conducted by researchers affiliated with the Department of Veterans Affairs (VA), which has really invested in providing mental health services through community-based outpatient clinics. Additionally, the VA has been at the forefront of offering telehealth services, including telepsychiatry.”

Telemedicine may be particularly helpful in supporting mental health in rural areas by linking residents to providers elsewhere.

“Because of the push toward reducing provider-patient contact due to COVID-19, some regulations around providing telehealth services are being relaxed,” Borders says. “The changes being made may end up reducing the hurdles to telepsychiatry and benefit us long-term.”

“Telemedicine is certainly an area that may grow,” Downes adds. “But in many of our rural areas, broadband access is sketchy or nonexistent. For the time being, our constituency relies on phone and, once current shelter-in-place orders are relaxed, in-person contact.”

As for specific programs and techniques to help rural communities manage stress, many university extension services are at the forefront.

“Michigan State University, for example, offers a farm stress management program, and it is collecting data to determine the types of stresses farmers face in order to develop more effective solutions,” Downes says. “The University of Maryland Extension and University of Delaware Cooperative Extension have jointly developed a farm and family risk and resilience guide to help provide guidance and tools for professionals. The University of Maine Cooperative Extension provides resources of the Maine agricultural community to cope with stress.”

Make your voice heard

The absence of mental health treatment is a serious problem in rural communities. NRHA members can help increase the availability of rural mental health care services by advocating for government policies to widen access to mental health care, expand insurance coverage for mental health services, and create incentives to encourage individuals to enter the behavioral health field. In addition to bringing issues like lack of broadband access, telehealth reimbursement restrictions, and stigma surrounding mental health to the forefront, advocating for and talking about mental health allows progress to be made.

* Source: National Institute of Mental Health, www.nimh.gov.
** Source: Kaiser Family Foundation, www.kff.org.
*** Source: American Journal of Preventive Medicine, www.ajpmonline.org.
Image © Getty Images / john shepherd

Mental health resources

Rural residents should contact their family physician or primary care provider if they are having mental health concerns. In a mental health emergency, call 911.

National Suicide Prevention Lifeline

En Español 1-888-628-9454

NY FarmNet (for New York farm families)


National Institute of Mental Health – Help for Mental Illnesses resource page


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