Mental Health Care in Rural Communities

Lack of Mental Health Care in Rural Communities

Genevieve Young California State University Monterey Bay Collaborative Health and Human Services Professor Gayle Yamauchi-Gleason May 17, 2012

Mental Health Care in Rural Communities

ii

Table of Contents

Table of Contents.................................................................................................. ii Lack of Services in Rural Areas ............................................................................ 3 Challenges in Providing Mental Health Care to Rural Americans ......................... 3 Consequences of Inadequate service ................................................................... 6 Implementing Telemental Health in Rural America ............................................... 7 Providing Assistance and Support ........................................................................ 9 References ......................................................................................................... 10 Appendix ............................................................................................................. 12

Mental Health Care in Rural Communities Lack of Services in Rural Areas

Rural Americans are at a significant disadvantage when it comes to mental health services; they have substantial set of health care needs yet they often experience difficulties in obtaining appropriate services (Roberts, Battaglia, Epstein, 1999). Because of their disadvantage, many rural residents go without health care services, which can worsen their mental health conditions. According to Gamm and Hutchinson (2003), mental health ranks fourth among the leading health concerns that rural communities face. Individuals that reside in rural communities are more prone to suicide, stress, depression, and anxiety disorders (apa.org). Although rural areas are in desperate need of mental health services, our country still struggles to provide adequate care. Rural Americans should have the same level of access to mental health services as their urban counterparts, and in order to do so, we must implement telehealth technology to connect patients with clinicians. Challenges in Providing Mental Health Care To Rural Americans It is important to note that the term rural has not been defined as a single term. However, Fenell and Hovestadt (2005), state that, Common characteristics that distinguish [rural] from urban areas include lower population density; less access to goods and services; great familiarity among members of the community; less affluence; less access to education; and more health and mental health problems (p. 246). In essence, rural areas can be defined as small communities that are distant from large cities. The main issue of providing mental health care to rural Americans lies in availability, accessibility and acceptability of mental health services. Although lack of mental health care is a problem throughout our nation, rural areas are more significantly impacted. Fenell (2005), reported that two thirds of rural counties do not have basic mental health programs or access to qualified practitioners. This can lead individuals with mental health issues no other option than to forgo treatment. Specifically, rural counties have less than 2 mental health organizations, while non-rural counties have an average of 13 organizations (Gamm, Stone & Pittman, 2010). Indeed, the disparity in rural mental health services is drastic when compared to its non-rural counterparts. Deleon, Wakefield, & Hagglund (2003) note that, it is challenging to find practitioners that are willing to relocate to rural areas. They may find it difficult to adapt to rural life, which may include a lower salary and reduced social interaction. Availability, however, is not the sole problem when it comes to providing care to rural Americans. We also have to assess the accessibility and acceptability related to receiving mental health care Accessibility may also contribute greatly when it comes to providing mental health care in rural areas.

Mental Health Care in Rural Communities The following figure illustrates the shortages of clinicians in the United States. Scores range from 1-25. The higher the score, the greater the need for mental health services.

Figure 1. Health Professional Shortage Areas (HPDS) Mental Health HPSA Clinician Priority Scores. Health Resources and Services Administration, Bureau of Health Professions, October 2011. Retrieved March 27, 2012, from http://www.raconline.org/maps/topic_details.php?topic=46 Gamm (2003) reports that due to lack of mental health services, patients must travel long distances to receive care. They also may decide that it is too far to travel and therefore many patients may never visit a mental health professional due to this fact alone. Travelling distance is not the only factor of accessibility, however; lack of health insurance can also prevent rural Americans from receiving services. Many rural Americans struggle to afford regular health

Mental Health Care in Rural Communities

insurance coverage, let alone a policy that includes mental health services. Ziller, Anderson and Coburn (2008) report that rural residents have a greater chance of being uninsured than urban residents. Due to their lack of insurance, they may have a higher chance of sacrificing mental health care because they simply cannot afford the costs. Gustafson, Preston and Hudson (2009) p.2 agree when they say: With many families already struggling to pay their health insurance premium or existing medical debt, accessing uncovered mental health treatment is not a choice they can make. In other words, mental health coverage is just not an option for most rural Americans. Besides availability and accessibility, rural Americans also face the issue of acceptability. When mental health care is available and accessible, the issue of how mental health care is perceived by the community still exists. Gustafson, Preston and Hudson (2009) report that those who live in remote areas are less likely to pursue treatment because of the cultural stigmas related to mental illness. They say that this may stem from lack of awareness and fear of being judged or shamed upon. This cultural obstacle can prevent people in rural areas from obtaining mental health care that they greatly need. Hoyt, Conger, Valde & Weihs (1997) found that the level of stigma is related to the population size of the community. Smaller towns with a tighter knit community may face a greater cultural stigma than a larger town. We also must consider that many rural towns often have a tight knit community and are familiar with one another. This can result in a reduction of anonymity for a patient who is receiving mental health care (Helbok, 2003). For example, they may personally know the health professional they are receiving services from, which may be the only place of treatment in the area. Roberts, Battaglia & Epstein (1999) offer an example of the hurdles that rural residents face when seeking mental health care in the following vignette: A 35 year old mansaid for the past two weeks he could not rid himself of the idea of killing himself. He reported nightmares, intrusive thoughts, irritability, avoidance and anxiety. He had not sought care because he didnt want to be identified going to the rural mental clinic and had little money to go elsewhere. Everyone watches who goes in there, he said. My mom works down the street. If you go in, they think you are crazy. I didnt want them to know I was weak. I didnt want to lose my job. I didnt want the whole town to know I was nuts. (p.4) This vignette demonstrates how difficult overcoming stigmas can be in rural communities. Many individuals do not want to be labeled as having a mental disorder and therefore they may opt out of treatment. Consequently, this may worsen their mental health. As been noted, there is an increased stigma and decreased anonymity in rural areas, however, there is also a relation between these two barriers. Smalley et al. (2010) suggests, The increased stigma and decreased anonymity likely combine to leave rural residents less likely to seek

Mental Health Care in Rural Communities care than their urban counterparts. Essentially, ones culture has a large influence on how they may proceed in seeking mental health treatment. Consequences of Inadequate Services

It should be noted that living in a rural area does not produce mental disorders. Not receiving sufficient treatment, however, can be a contributing factor in the development of mental disorders. There is a discrepancy in the literature regarding the prevalence of mental disorders in urban vs. rural areas. The consensus, though, states that rates of prevalence are generally the same and their differences are not significant. Gamm et al. (2003) insists that, mental disorders affect nearly 20% of the American population, regardless of their residence. Although the prevalence rate is nearly equal when comparing urban and rural areas, the effects that rural Americans experience can vastly differ from their urban counterparts. For example, consider these harmful consequences that are attributed to lack of mental health services. The National Alliance on Mental Illness (2003) states that, rural residents with mental health needs: Enter care later in the course of their disease than their urban peers, Enter care with more serious, persistent, and disabling symptoms, and Require more expensive and intensive treatment response.

These are important factors to consider because they distinguish how rural Americans are affected when they do not receive mental health services. Additionally, it demonstrates the desperate need for mental health services so that mental health patients can receive care at more appropriate times, are not disabled by their symptoms and are not forced to pay for intensive treatment. Although the previously stated effects are significant to understanding rural mental health, further examination of specific mental health issues in rural areas is needed to reach a comprehensive awareness of this issue. Gamm et al. (2003) found a higher rate of suicide in rural communities, which is an indicator of mental illness, especially among men and children. Although this may not be credited to lack of mental health services, it is still an issue and certainly alarming. Furthermore, there is evidence that depression rates in some rural areas are higher than urban areas (Gamm et al., 2003). In fact, The U.S Department of Health and Human Services (2005) found that, depression is common in rural areas, as much as 40 percent of patients visit their primary care doctor for treatment of depression.

Mental Health Care in Rural Communities Kermode (2009) presents the following vignette of what it may feel like to experience depression while living in a rural area:

Meena is 30 years old and was fine until six months ago when she began to feel tired all the time. She says that she is sad and has lost interest in life. Even her children and family dont make her feel happy. She cannot sleep and she has lost the taste for food, which she used to love. She has also lost interest in cooking because she cant concentrate. Sometimes she feels like jumping in the well to end her life. (p.1089) This vignette demonstrates how debilitating depression can be to an individual. Not sleeping and losing interests in activities that were once enjoyed can be devastating to anyone, but particularly to individuals that cannot access treatment to return to a healthy state of mind. Largely, the issue here is that rural residents are at a higher risk for mental health morbidity and mortality. Whether this can be attributed to lack of mental health services is not known, however, it is clear that rural communities need more services in order to effectively treat mental health patients needs. Implementing Telemental Health in Rural America Rural mental health is a unique situation because of how difficult it is to provide adequate care for rural areas. The combination of health professionals unwilling to relocate to rural areas, patients unable to travel long distances, stigmas and lack of health insurance all contribute to the challenge of providing care to this population. Fortunately, there is a solution that could be beneficial for both patients and health professionals alike: telemental health. This new model of mental health care uses technology to remotely deliver services including psychological assessment and intervention services. Patients interact with health professionals via videoconferencing (Yuen & Forman, 2012). Yuen et al., (2011) reports that, videoconferencing therapy involves realtime video and audio transmission between individuals in different physical locations. Individuals canconverse while viewing the other party on their [computer] screen (p.2). Meaning, patients have more anonymity because they can videoconference in the comfort of their own home, versus walking into the local mental health clinic. Yuen et al., 2011) continues, videoconferencing has been successfully used to treat PTSD, panic disorder with agoraphobia, obsessive-compulsive disorder, anxiety in cancer patients, and depression in adolescents and children (p.2). Because rural communities have a higher risk of cultural stigma and lack of anonymity, telemental health via videoconferencing can be a beneficial alternative for many rural Americans who are suffering from mental health issues. Telemental health can change how mental health care is delivered to rural areas and is shown to be as effective when compared to in person mental health

Mental Health Care in Rural Communities

services (Saeed, Diamond, & Bloch, 2011). It is important that it has shown to be as effective as in person visits, as that is an essential factor when considering telemental health. Saeed et al., (2011) found significant benefits of telemental health such as, high patient satisfaction, improved patient convenience, higher attendance rates for telehealth visits and improved continuity of care (p.220). In other words, telemental health has shown positive outcomes and was a pleasant experience for the patient. Although telemental services are needed in all areas of the country, San Joaquin Valley in California is especially in need of this service. All eight counties in San Joaquin Valley are HPSA shortage areas. Essentially, this means that there is a population to practitioner ratio of 10,000:1. In fact, when San Joaquin Valley is compared to California, there are 85% fewer psychiatrists, 70% fewer psychologists, 50% fewer Licensed Clinical Social Workers, and 65% fewer Marriage and Family Therapists. Executing a telemental health program in these eight counties would allow residents to get the mental health services they need so that they can lead a healthier and happier life. The following is a list of recommendations that would move telemental health in the right direction in rural San Joaquin Valley: Create a resource website to inform and train practitioners interested in working in the telemental health field. This website would also demonstrate current telemental health programs that have been successful so new ones can follow in their lead. Use incentives to get new practitioners in the rural mental health field. Loan forgiveness programs would attract new graduates to work in this field. Join existing programs with new ones. This would allow the programs that have been successful to help build upon a new program. This would also advance the curriculum and instruction for health professionals. Create programs to help reduce the stigma of mental health issues. Using television commercials and radio ads could be used to broadcast anti-stigma campaigns, which could help to change peoples attitudes towards receiving mental health care. Notify stakeholders of the grant funding that would be required to implement and sustain a telemental health program. Grant funding necessities would be computers and videoconferencing software needed for teleconferencing. The previous recommendations for implementation could alleviate the critical need for mental health professionals in San Joaquin Valley. Although, as with any treatment option, there are a few limitations to telemental health. The main issues are security, privacy and competence issues. (Yuen, et al., 2011). By exploring these issues, we can gain a better understanding of telemental health and decide if it is a feasible option.

Mental Health Care in Rural Communities

Firstly; security, confidentiality and privacy related issues are important when it comes to telemental health. Patients are often asked to send written forms to their therapist via Internet. Although there has not been any major issues with this, when communicating via the Internet, privacy breeches are a real concern and must be addressed to the patient. Secondly, the therapists competence in telemental health is vital to the success of the program. When working in mental health, therapists must be able to handle a wide range of patients whose psychopathology may vary widely. For example, a therapist providing videoconferencing services may not be able to fully observe a patients behaviors such as eye contact, posture, and some facial expressions. Therapists must be prepared to handle a wide range of patients and expect complications. Providing Assistance and Support Rural Americans in California and across the nation are not getting equal access to mental health services that they deserve. Many may not choose to live in rural towns, but rather, have grown up there and perhaps cannot afford to leave. Access to mental health care is a basic need that every citizen should have the right to, yet hundreds of thousands of rural Americans do not receive treatment for their mental health problems. Luckily, the future of telemental health could drastically change this situation for rural communities. Additionally, providing these populations with mental health services would bridge the gap that exists between rural and urban areas. We should not ignore rural populations but rather provide assistance and support so that they can have the same level of access to services as other populations and in return, live a happier and healthier life.

Mental Health Care in Rural Communities

10

References American Psychological Association (n.d.). The Critical Need for Psychologists in Rural America. http://www.apa.org/about/gr/education/rural-need.aspx

DeLeon, P.H., Wakefield, M., & Hagglund, K.J. (2003). The behavioral health care needs of rural communities in the 21st century. Rural behavioral healthcare: An interdisciplinary. 13(4), 367-384. Fenell, D. L., & Hovestadt, A. J. (2005). Rural mental health services. In Handbook of mental health services for children, adolescents and families Gamm LD, Hutchison L. Rural Healthy People 2010evolving interactive practice. Am J Public Health. 2004;94:17111712. Gustafson, DT., Preston, K. & Hudson, J. (2009). Mental Health: Overlooked and Disregarded in Rural America. Center for Rural Affairs Helbok, C.M. (2003). The practice of psychology in rural communities: potential needs and ethical dilemmas in rural communities. Psychiatric Services

Hoyt, R. D., Conger, R. D., Valde, J. G., & Weihs, K. (1997). Psychological distress and help seeking in rural America. American Journal of Community Psychology Roberts, L. W., Battaglia, J., & Epstein, R. S., (1999). Frontier ethics: Mental health care Saeed SA, Diamond J, Bloch RM. Use of telepsychiatry to improve care for people with mental illness in rural North Carolina. NC Med J Smalley, K. B., Yancey, C. T., Warren, J. C., Naufel, K., Ryan, R., & Pugh, J. L. (2010). Rural mental health and psychological treatment: A review for praciioners. Journal of Clinical Psychology, 66(5), 479-489. Yuen, E. K., Goetter, E. M., Herbert, J. D., & Forman, E. M. (2012). Challenges and opportunities in internet-mediated telemental health. Professional Psychology: Research And Practice, 43(1), 1-8. Ziller, E. C., Anderson, N. J., & Coburn, A. F. (2010). Access to rural mental

Mental Health Care in Rural Communities

11

health services: Service use and out-of-pocket costs. The Journal Of Rural Health, 26(3), 214-224.

Appendix

Figure 2. Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services. http://www.raconline.org/racmaps/ As shown in Figure 2, red areas are those who are uninsured. Rural states such as Alaska and Oklahoma make up a large percentage of uninsured.

Mental Health Care in Rural Communities

12

Mental Health Care in Rural Communities

13

Mental Health Care in Rural Communities