One in five residents of nonmetropolitan counties in the United States had some sort of mental illness in 2015.
That’s according to the Substance Abuse and Mental Health Administration. More than 6 million people in the United States—our friends, neighbors and family members in our own communities—needed some form of mental help last year. The same data showed in non-metro areas, 1.4 million people experienced serious thoughts of suicide in 2015.
And that was when the farm economy wasn’t so bad.
Today rural America faces economic and sociological challenges on a great scale. Mental healthcare is a crisis that can no longer be ignored by good neighbors who don’t want to interfere in other people’s business.
Ric Dalke is the executive director of both the Compass Behavioral Health in Garden City, and the Iroquois Center for Human Development in Greensburg, Kansas. Tabitha Marksi is the clinical director of the Iroquois Center, which has a management agreement with Compass. Compass serves 13 counties in southwest Kansas, while the Iroquois Center serves another four counties.
Dalke and Marski said mental health care in rural America is a complex issue with three core challenges: accessibility, availability and acceptability of treatment.
More than 60 percent of rural Americans live in mental health professional shortage areas, with about 65 percent getting their mental health care from their primary care physician, according to the Western Interstate Commission for Higher Education’s Mental Health Program.
Dalke said Compass works to build relationships with physicians in their service area. He said it’s understandable people go to their trusted physicians with their problems. But, when patients are in need of further help, they work with their partners in clinics and offices around their service area to offer it.
One challenge to serving patients’ needs where they are most comfortable is insurance companies, Dalke said. For example, if a patient comes into Compass for care, staff can use a specific insurance billing code. But, if a Compass therapist were to go to a doctor’s clinic and help a patient in that setting, then that would be an entirely different billing code and might not even be covered by some insurance companies. Worse, some rural patients’ health insurance might not even cover mental health services.
“We need more providers,” Marski said. “We have a limited amount of providers and most don’t want to move here.” While Iroquois has satellite offices in each of the counties it services, there remains a need for more psychiatrists and therapists to staff them.
Compass and the Iroquois Center both work with their contacts in local communities to match residents with mental health care providers. Often the first agencies to identify a need are the local law enforcement—who respond to the harmful aspects of mental health concerns—or the local school counselors—who see families and students struggling with mental health disorders. Pastors and even Extension agents are also referral contacts, often having weekly or monthly access to individuals and can see changes in behavior that others might miss, or are trusted neighbors who people feel comfortable confiding in.
Still, beyond access is the struggle of availability of specialized care, Dalke said.
“If someone needs a child psychiatrist, for example, they’re pretty prevalent in urban areas, but not here,” he said. The WICHE reports that more than 90 percent of all psychologists and psychiatrists work exclusively in metropolitan areas.
“We have a great need for autism specialist in our rural areas,” Marski said. “Especially a need for individuals who are trained to evaluate and diagnose and then treat those with autism.” Other specialties needed include child psychiatrists, eating disorder specialists and drug and alcohol abuse counselors.
It’s tough to recruit psychiatric prescribing staff to live in rural areas, so Compass has gone to more telepsychiatry—or using computers and tablets to connect therapists in cities with rural patients over the internet. Fortunately, technology has advanced enough that telepsychiatry isn’t challenged so much by access, but rather the comfort levels of patients speaking to a therapist on a screen rather than in person, he added. Yet even though that’s the only way many in rural America can receive specialized mental health care, some insurance companies won’t cover that service today, Dalke said.
“We have a child psychiatrist who works out of Olathe that we can use for a half of a day each week, so it’s still a limited supply,” Dalke said. But, for some clients, even a little bit of online help, whether or not it’s covered by their insurance, is better than traveling long distances to in person appointments each week. Or worse, no help at all.
The mental health challenges in rural America today can run the gamut, from trauma to depression, and from eating disorders to drug and alcohol addiction. Dalke said he’s seen a rise in recent years of opioid addiction in southwest Kansas.
Opiod addiction, including heroin and prescription drug misuse, was identified by the U.S. Department of Agriculture last fall as a growing epidemic in rural America. According to the USDA, opioid addiction played a role in more than 28,000 deaths in 2014. Rural communities are hit harder by this epidemic because of the lack of treatment resources available in remote communities.
“We have a Suboxone treatment program that we run out of our Greensburg and Garden City offices,” Dalke said. “We have doctors that are trained in using Suboxone as an alternative to opioid addictions.” Even though Suboxone doesn’t require a patient to attend the clinic every day for a dose, unlike methadone, it still requires a prescription from a doctor. That means patients in one of the 13 counties that Compass covers needs to first accept they need treatment. Then, they need to make arrangements to travel to one of the two clinics that may be up to an hour away from their home, just to get a prescription to help them recover from their addiction. And they may need to repeat the process several times over the course of months to fully recover.
Dalke said Compass also uses traveling therapists and counselors to serve patients’ needs closer to their homes when possible. Because rural communities have fewer resources available than urban communities, Dalke said it’s critical that organizations like Compass use community partnerships with physicians, school counselors, law enforcement agencies and others. Together they can help neighbors find mental health care that fits their needs.
If there’s one thing that rural America has, it’s an independent spirit, Dalke said.
“One of the biggest challenges we face is that there is still a stigma, especially in our country,” Dalke said. “Producers are independent, the type who say ‘we’ll do it ourselves and we’ll manage.’” While that attitude helps in running a farm or ranch, it doesn’t transfer to decisions about mental health care.
A farmer could plant and harvest crops without a crop consultant, but many use these specialists to help them manage their crops. It’s widely accepted agribusinesses use consultants and experts to help in managing large and small operations. And yet, when it comes to mental health, perhaps the biggest challenge to an agribusiness’s success and a family’s well-being, is that many will try to go it alone, Dalke said.
“We also see a lot of depression, and in fact I’d say the rates of depression have risen over the last 10 to 20 years,” he added. Depression can come on from a trauma, like a natural disaster or a workplace accident. It can also be tied to a decline in physical health or problems with family or businesses. The rural population is aging and facing its own mental health issues that range from family concerns about who will take over the farm to declining commodity prices and rising debt.
And even if a rural neighbor were to come to terms with their need to reach out for help, they would then face the obstacles of availability and accessibility of that help.
It can be a cycle that causes people to give up on ever finding care. It can also be daunting if you’re a neighbor or loved one who sees a friend or family member struggling and in need of help.
“It’s the $64,000 question,” Marski said. “How do we get people to use our services? The services are out there and we can make them available. But we can’t force them on people. Unfortunately, the stigma is still there.
“Sometimes people don’t want to seek help because they are afraid someone will find out,” she added. “They fear that they’ll look like they can’t take care of things on their own, or that they’ll appear unstable. And it doesn’t always mean any of that. Sometimes it just means they’re tired of figuring out things on their own.”
Marski said the signs of someone struggling take many forms. Some people may lose interest in taking care of livestock and farm chores to the degree that they used to. Others may avoid public situations like church services, social outings, coffee at the café or others. Some neighbors may act out with destructive behaviors like drug and alcohol abuse or violence.
“Any time we see a change in how someone typically functions is when people could benefit from assistance,” she said.
How it could be
Dalke, Marski and their staffs continue to overcome the obstacles of helping their rural neighbors with mental healthcare needs. Ideally, they could see a rural America where services are available in every local community, with even more partnerships among providers to ensure specialty mental health needs are met. It would be ideal in the future if mental health services were covered by more insurance policies, with more logical coverage for rural providers able to meet with patients over internet access or in their primary physician’s office. Another need would be for more providers to provide bilingual services for the immigrant populations in our rural communities. And, for the Veterans Administration to work more with community mental health centers to cover closer service providers to veterans so they don’t have to travel so far for help.
But, above all, the best thing that could happen for improved mental health care in rural America is for neighbors to speak up and reduce the stigma of seeking help when it’s needed.
“One-quarter of us in any part of this state will experience significant emotional health issues,” Dalke said. “That’s 25 percent of us who are struggling at any point. And in our lifetimes, 90 percent of us will have a mental health challenge, whether that’s in our senior years with the loss of faculties and major depression to other issues at other ages. We all struggle with stresses all the time.
“So we need to beat down the stigma that keeps us from seeking help,” he said.
Jennifer M. Latzke can be reached at 620-227-1807 or firstname.lastname@example.org.