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Setup Instructions |
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Mental
Health and Rural America: 1994-2005 An Overview and Annotated Bibliography U.S. Department of Health and Human Services Health Resources and Services Administration Office of Rural Health Policy This document was prepared under HRSA contract #03H1163080D, U.S. Department of Health and Human Services, Health Resources and Services Administration, Office of Rural Health Policy. Contents Chapter 2-Epidemiological Overview of Mental Health in Rural America Chapter 3-Epidemiological Overview of Substance Abuse in Rural America Chapter 4-Mental Health Service Delivery in Rural Areas: Organizational and Clinical Issues Chapter 5-Workforce Development Chapter 6-Where to Go From Here: Rural Mental Health in the 21st Century A User's Guide to the Annotated Bibliography
Mental Health and Rural America:1994-2005 represents the third edition of a comprehensive overview and annotated bibliography focused on rural mental health. The previous editions (Flax, Wagenfeld, Ivens & Weiss, 1979; and Wagenfeld, Murray, Mohatt & DeBruyn, 1994) have been frequently cited in the rural mental health literature and have served as valuable sources of information relating to rural mental health in the United States. The previous editions, and the current, have reviewed the environment of rural mental health at points-in-time over the past three decades. Not surprising to those engaged daily in the delivery of mental healthcare in rural America, much has changed and much has remained the same across this span of time. This new edition will examine both what is new and what remains unchanged. Support for Mental Health and Rural America: 1994-2005 has been made available by the Federal Office of Rural Health Policy (ORHP) in the Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS). ORHP is the "focal-point" for coordination of rural health services for HHS. ORHP also supported the production of the second edition, in the early 1990s, and has provided strong leadership since its establishment in including mental health in its rural health vision. The Mental Health Program of the Western InterState Commission for Higher Education (WICHE) was selected to edit and coordinate its production. Since 1955, the WICHE mental health program has worked to support mental health system improvement and workforce development. It is fitting the publication of this Third edition coincides with the 50th anniversary of the WICHE mental health program. The production of this third edition also marks the departure of Morton O. Wagenfeld from the editorial team. Dr. Wagenfeld has happily and gainfully retired from a prestigious academic and research career at Western Michigan University. Mortie was a true mentor to generations of many of us with a passion for rural mental health and rural America. His lively mind, and eye for what makes a difference, resulted in a significant body of rural mental health research and analysis. His work is a gift to us all. In keeping with the style and content of the previous editions, the Third edition seeks to provide a single-source of current rural mental health information. The focus is upon the period of 1994-2005. The volume is divided into two sections: the narrative overview and annotated bibliography. These two sections are integrated, however not all annotated references have been cited in the narrative section or vice versa. The material utilized in this document was discovered through electronic library searches of mental health and health related archives and indexes. The editors reviewed the enormous amount of material and selected those that together seemed to provide a clear and comprehensive picture of the rural mental health environment today. The electronic search was augmented by numerous colleagues who offered their insights, knowledge, and assistance. In the midst of the "information age," when a simple Google™ search reveals 26,500+ hits for the term "rural mental health," the need for this work is even more important to provide a source of context, review, and analysis of the vast array of data and information that can sometimes be overwhelming and often more than a little confusing. The world of the personal computer and internet access is also one of the most significant differences between this edition and the previous volumes. The current edition will include citations of material published on websites, something not cited in past editions. The development of the Mental Health and Rural America: 1994-2005, coincided with the WICHE Mental Health Program's work with the Rural Issues Subcommittee of the President's New Freedom Commission on Mental Health and the development of the Rural Issues Background Paper released for public access in 2005. The work of the President's Commission has truly created new momentum across the nation to transform mental healthcare, and has brought serious attention to rural mental health. The Commission's Rural Issues Subcommittee Chairperson, Nancy Speck, Ph.D., provided extraordinary guidance to these parallel review efforts. Blanca Fuertes, from the staff of the Federal Office of Rural Health Policy, served as the project officer for the development of Mental Health and Rural America: 1994-2005 and provided both good counsel and technical advice. The support of ORHP was essential to making the notion of a third edition a reality. The leadership of ORHP Director, Marcia Brand, and Deputy Director, Tom Morris, was critical in making this project move from a good idea to a finished product. We also acknowledge the support and guidance of many colleagues from across the nation. Dr. Anthony Pollitt, from the National Institute of Mental Health (NIMH) Office of Rural Mental Health Research, was always prepared to field a research question and assist our efforts to identify key studies. Dr. David Lambert, past-President of the National Association for Rural Mental Health, and Steve Wilhide, former Executive Director of the National Rural Health Association, were always responsive to requests for information and policy analysis. Finally, Jenny Shaw, the WICHE mental health administrative and project coordinator provided the organizational focal point for putting it all together. Thank you for the hard work. Transforming mental health in America is the battle cry today, as a result of the work of the President's New Freedom Commission on Mental Health. Other reports such as the Institute of Medicine Report Quality through Collaboration: The Future of Rural Health (2005) also emphasize the need for better coordination of care and collaboration among providers of services and their communities. Rural mental health is on the agenda, and the leadership within HRSA and SAMHSA are taking rural seriously. From rural mental health workforce development to scientific discovery, rural America has often simply not been taken into account, it is our hope that Mental Health and Rural America: 1994-2005 helps support those many individuals from across our vast nation make rural count. Dennis F. Mohatt Western InterState Commission for Higher Education
1 There is not one rural America. The rural United States is a place of great diversity, which is perhaps a surprise to many in the majority metropolitan population. Rural is many small places scattered across the vast landscape of America. In the eastern half of the nation, rural is the green space between the large metropolitan areas from Maine to Florida, the little towns and villages off the InterState 95 corridor, the isolated places of Appalachia, the Deep South, the Ohio and Mississippi river valleys. This rural America is much more densely populated, with many small towns spread along the twisting two-lane highways and back roads that lace the region like a spider's web. The State with the largest rural population is Pennsylvania, with over 2.8 million rural residents, while in Vermont, over 60 percent of the population is rural.1 Crossing the Mississippi River marks the beginning of a different rural. The density begins to thin, the little towns and villages becoming increasingly spread apart. The twisting roads give way to a uniform grid of roads, which follow the checkerboard like section lines. Finally, out past the 100th meridian, precipitation becomes a welcome albeit infrequent event and the population becomes so lean and remote it is referred to by many as frontier. Large metropolitan areas exist like island fortresses, and rural dominates the landscape. While satellite pictures of the eastern U.S. at night emanate a glow, much of the west is darkness. The west coast again emulates the pattern of the east, with the population density high along the InterState 5 corridor, and thinning proportionate to distance from it. Rural America has always been a place of diversity. The picture many hold of a homogeneous agrarian hinterland is simply a myth. Even prior to European discovery, diversity was the norm with an indigenous population made up of hundreds of tribes speaking nearly as many different languages. Some farmed in settlements, while others were nomads. Small places may have been the norm, but even then these places were very different. This chapter will provide a picture of the demographics and socioeconomic landscape of the United States and attempt to share what is clear about rural America at the close of the 20th and beginning of the 21st century. It cannot be a complete picture, but it will be a complex illustration. What's Rural? A myriad of methods for determining what physically constitutes rural versus non-rural areas of the United States is employed by the Federal government. No consistent definition is used across agencies or programs (HHS, 2002). For the purposes of this book, the terms rural and nonmetro will be used interchangeably, as will the terms urban and metro. When programs are implemented to provide health services to rural areas, they immediately encounter the problem that there are no operational definitions of "rural areas" that precisely divide the population of the United States into "rural residents" and "urban residents." The two most commonly used definitions are by the Office of Management and Budget (OMB) and the Census Bureau. All information for the following section was cited from OMB, Census Bureau and Economic Research Service data. Over the past 10 years, many sources encouraged the OMB to classify the entire United States into population categories and to not leave any regions outside urban areas as unclassifiable. In June 2003, the OMB released a new classification system to define metropolitan (i.e., metro or urban) and nonmetropolitan (i.e., nonmetro, micropolitan, or rural) areas based on census data from 2000. The OMB previously defined metropolitan areas by central counties with one or more cities of at least 50,000 residents or with an urbanized area of 50,000 or more and total area population of at least 100,000. Counties surrounding these areas were included if they met two primary criteria: 1) they were both economically tied to the central county measured by daily commuting and 2) they showed a level of "metropolitan character" defined by population density, urbanization and population growth. However, a county with high "metropolitan character" would be included even though only 15 percent of it workers commute, but a county low in "metropolitan character" would be classified as nonmetro no matter how high the commuting percentage to the main county. In the new "core-based statistical area" system, OMB defined metro by the following two characteristics: 1) central counties with one or more urbanized areas and 2) outlying counties that are economically tied to the core counties as measured by the amount of people who commute for work. Outlying counties are included in the metro classification if 25 percent of workers living in the county commute to the metro counties, or if 25 percent of the employment in the county consists of workers coming out from the metro counties (i.e., reverse commuting). The OMB defines nonmetro as those counties outside
the boundaries of metro areas. These nonmetro counties are then
subdivided into two types: 1) micropolitan areas and 2) noncore
counties. The Census Bureau modified its measurement procedures for rural and urban areas in 2003 as well. An urbanized area is defined by a region with at least 50,000 people. The Census Bureau added the definition of urban cluster, measured by at least 2,500 people but no more than 50,000 people. Rural is still defined by small settlements of less than 2,500 people. However, the Bureau now identifies small towns and cities that have adjoining towns or suburbs. For example, if a town of 3,000 people has 300 residents living in thinly settled portions, the 300 are classified as rural and the 2,700 are classified as an urban cluster. Map 1
New classification parameters within the OMB and the Census Bureau have led to significant shifts in the description of rural geography and population data. These shifts highlight the diversity that exists in non-urban areas in America. New population measurement procedures will allow for better and more complete data collection in rural areas. Better data will ultimately lead to increased understanding of rural population trends and attention from policymakers and other interested parties. Extensive discussions of the implications of this array of definitions to health and human services programs have been published by Hewitt (1989), Wagenfeld, Murray, Mohatt & DeBruyn (1994) and Ciarlo, Wagenfeld & Mohatt (1996). Despite advances in making rural definitions more precise, the fact that the OMB and the Census Bureau categorize regions slightly differently leads to disparate population results. For example, according to the OMB definition, rural America comprises 17 percent (49 million) of the population, compared to 21 percent (59 million) by the Census definition. Researchers and policy makers need to be aware of which definition is used and that it is used consistently throughout a study or document. According to the Census Bureau definitions, in 2000, 68 percent of Americans lived in urbanized areas, 11 percent lived in urban clusters and 21 percent in rural areas. In the OMB's recent population data (also from 2000), 298 formerly nonmetro counties are now classified as metro and 45 metro counties were reclassified as nonmetro. These recent statistics reflect the pattern of urban growth over the past decade as well as highlight the new system for metro and nonmetro classification. Defining rural does make a difference in ensuring limited resources intended to address critical rural needs actually are transmitted to locations that have those needs. The President's New Freedom Commission on Mental Health, Subcommittee on Rural Issues (NFC-SRI, 2004) recommended DHHS adopt a single definition that was precise enough to capture the diversity of rural America as to enable focused targeting of Federal resources to address specific rural needs. Rural Demographics For rural America to be taken into account, it is essential that the reality of rural be understood instead of the myths. Many myths exist, and perhaps the most persistent is the notion of rural America being synonymous with agriculture and farms. There is a persistent image of rural areas being a patchwork of family farms surrounding tranquil communities. Today, less than 10 percent of the rural population live on farms and people in rural areas are engaged in a wide range of activities. In 1992, only 7.6 percent of rural employment was in farming (ERS/USDA 1995:5). Service employment, on the other hand, accounted for 50.6 percent and has experienced the greatest growth over the past two decades. Even in areas of the U.S. with the greatest percentage of farm employment, non-farm employment still accounts for nearly 80 percent of jobs. Simply Stated, most family farmers supplement their farm-based income with non-farm employment (ERS/USDA, 1995:12). The family farm is fading from the rural landscape, with a continued decline in the number of family farms during the past decade, which continues a trend established for over a half-century. Family farms are broadly defined here to include family-held corporations and partnerships, as well as sole proprietorships. Census of agriculture data confirms that family-owned farms are not losing their share of U.S. farm product sales in relation to non-family corporations. Non-family corporations comprised a relatively stable and minor share (0.3 to 0.4 percent) of total U.S. farm numbers between 1978 and 1997, while their share of total farm product sales actually fell, from 6.5 percent in 1978 and 1982 to 5.6 percent in 1997. Socio-economic factors play an important role in the accessibility of health and human services. Rural employment is dominated by low wages, and rural incomes are less than those in urban areas. In 1996, 23 percent of rural workers were employed in the service sector and were nearly twice as likely to earn the minimum wage as their urban peers (U.S. Congress, 2002). Compared to urban workers, rural citizens are more likely to be unemployed and less likely to move out of low wage jobs. Rural working families are more likely to be poor than working urban families. More than 25 percent of rural workers over age 25 earn less than the Federal poverty rate of $18,390, and 600 (23 percent) rural counties are classified as persistent poverty counties by the U.S. Government. According to the Economic Research Service (ERS) website (http://www.ers.usda.gov/), the rural low-wage employment was 24 percent versus 16.6 percent in urban areas. The higher incidence of nonmetro poverty compared with metro poverty has existed since the 1960s when poverty rates were first formally recorded. Rural economies benefited from the economic expansion during the 1990s. In addition, recent data on metro and nonmetro employment change shows substantial employment growth in nonmetro areas since mid-2002, based on the 2003 classification of metropolitan status. Micropolitan and noncore counties are now experiencing employment growth at a rate of more than 1 percent a year (ERS, 2005). Over the last decade, nonmetro employment growth has generally been fastest in the West even in times of economic slowing. The slowdown had the greatest effect on nonmetro employment growth in the South and the Midwest (ERS, 2005). Nonmetro unemployment rates were highest in mining counties during the 1990s, but this changed around the year 2001. After a relatively positive experience in the 1990s, manufacturing counties experienced a sharp increase in unemployment in 2001 and currently have the highest unemployment rate of any county economic type (ERS, 2005). Child poverty is higher in rural areas, with more than half of all rural children (3.2 million) in female-headed households living in poverty. Children of color are particularly at risk, with 46.2 percent of rural African American, 43 percent of rural Native American, and 41.2 percent of rural Hispanic children living in poverty (U.S. Congress, 2002). People of color constituted about 17 percent of the rural population in 1997, compared with about 25 percent of the overall U.S. population. A disproportionately large number of Native Americans-nearly half of the overall Native American population-live in rural areas. The rural white population is roughly proportional, with 23 percent of whites living in rural areas. The remaining major ethnic and racial groups are underrepresented in rural areas. Fifteen percent of African Americans, nine percent of Hispanics, and five percent of Asians and Pacific Islanders are rural. Poverty rates by race indicate that non-Hispanic Black people have the highest incidence of rural poverty at a rate of approximately 30 percent. One out of every four Hispanics living in rural areas lived in poverty in 2003. The above statistics exceed the rate of poverty for non-Hispanic White people in rural areas, which was 11 percent in 2003. The high poverty level for Hispanic people is remarkable as their share of the rural population has been increasing in the past 10 years (ERS, 2005).
As for rural population, some places are growing, while many are not. During the 1990s, 2.2 million more people moved from the city to the country than vice versa, reversing a trend of rural outmigration established during the early 20th century. During this same time period, 70 percent of rural counties grew in population, but the pace of growth slowed during the end of the decade of the 1990s (U.S. Congress, 2002). Since the mid-1990s, all rural counties (except rural commuter counties) have experienced reduced rates of population growth and the rural rate of growth is only half the rate of urban. The great plains has experienced the most significant population loss, and depopulation of some frontier counties (those counties with fewer than six persons per square mile). These population trends, especially population loss, strain the resources available to sustain comprehensive systems of health and human services (NFC-SRI, 2004). Rural educational levels continue to be less than those in urban environments. Fewer rural adults have a college education than do urban adults (15 percent versus 28 percent), and the number of rural adults without a high school diploma is greater than in urban areas (20 percent versus 15 percent). Fewer young adults in rural areas seek higher education. Since the high school graduation levels match or exceed urban levels, clearly these graduates are leaving rural America more often than are their non-graduating peers, making the "best and brightest" a chief rural export (U.S. Congress, 2002). This out-migration of capable young persons limits the pool of local persons available to train and staff health and human service systems. As a result many services are provided by persons who are not indigenous to the rural communities they serve, and often are only available on an itinerant basis (NFC-SRI, 2004). Immigration is changing rural America in some places. While most immigrants (about 95 percent) settle in large metro areas, those who move to rural areas concentrate in a few locations (Effland & Butler, 1997). For example, Texas is home to 17 percent of the total rural immigrant population of the United States. The West accounts for about seven percent of the nation's rural immigrants. Overall, immigrants to rural areas comprise only two percent of the total rural population. The single largest group of rural immigrants is Mexican, whose share in rural immigrants has increased from 48 percent in the 1980s to 57 percent in 1990s. Rural America is home to numerous social, cultural, religious and language differences. These differences are a part of the reason why it is difficult to capture a cultural understanding of rural America as a whole. While there are many similarities (e.g., small community), rural areas also differ from region to region. For example, a rural community in the Northeast is likely very different culturally from a small town in Alaska. These differences are distinguished by the ethnicities that reside there, the political climate of the State and other economic and social factors that are indigenous to the area. Data on homelessness in rural is limited and does not reflect the true number of homeless, as efforts to identify homeless persons often depend upon formal systems of support (e.g. shelters) and often miss rural homeless who may be outside of rural support systems. However, according to the National Coalition for the Homeless (1997), "studies comparing urban and rural homeless populations have shown that homeless people in rural areas are more likely to be white, female, married, currently working, homeless for the first time and homeless for a shorter period of time" (p. 1). Rural Mental Health Demographics, economics and cultural values have a dynamic impact upon mental health and mental health care. The prevalence and incidence of adults with severe mental illnesses and children with serious emotional disturbances are not significantly different in rural and urban areas. What differs in rural America is the experience of individuals with mental illnesses and their families (Wagenfeld et al., 1994). Too often, that experience seems to result in higher suicide rates for both rural adults with mental illnesses and children with serious emotional disturbances (George Mason University, 2000). The different experiences that rural persons with mental illnesses face are influenced by three factors (variables) that may prevent them from receiving the mental health care they need:
These variables lead rural residents with mental health needs to: enter care later in the course of their disease than do their urban peers; enter care with more serious, persistent and disabling symptoms and require more expensive and intensive treatment response (Wagenfeld et al., 1994). Accessibility: The New Freedom Commission on Mental Health, Subcommittee on Rural Issues (2004) identified three significant components of access to mental health services that put rural residents at a significant disadvantage: knowledge, transportation and financing. An essential element of access is knowing when one needs care and where and what care options are available to address needs. In both respects, the rural experience differs from the urban one. The frequently noted myth of an idyllic rural existence persists (HHS Rural Task Force, 2002). This myth, when widely held, becomes a barrier to creating an impetus for action to address rural mental health problems. The perception of need for care is the first step in seeking care, and rural residents enter care later than do their urban peers due to a lower perception of need-a problem that is then compounded by their perceiving less access to care. Empirical studies show that lower access to mental health services is directly related to lower availability or supply of mental health providers (Lambert & Agger, 1995). The barrier to care posed by provider availability in rural areas is discussed further in the next section. The ability to travel to services and to pay for those services if accessed is a significant barrier to rural persons. Physically and psychologically accessible and affordable transportation services may be unavailable, especially to rural children, people with disabilities and the elderly. Public transportation is often not an option to rural consumers of mental health services. As a result, many rural mental health providers operate some form of transportation service to bring consumers to care-an operational cost not often incurred by their urban counterparts. Rural consumers and families must often travel hundreds of miles weekly to access care available only in larger communities that serve as "regional centers of trade." Employment-based health insurance covers a wide variety of health services for Americans, and is the most common form of health insurance coverage in the United States, covering 64.9 percent of the non-elderly population and 34.4 percent of the elderly population in 1998. Size matters; often small employers do not offer a full range of benefits and employers with 50 or fewer workers were exempt from the Mental Health Parity Act of 1996. Retiree health benefits have steadily declined over the past decade, with only 30 percent of employers offering retiree health benefits in 1998, as compared to 40 percent in 1993 (McDonnell & Fronstin, 1999). A similar dramatic decline occurred for mental health benefits, where per employee expenditures for behavioral health benefits have gone from $151.54 in 1988 to $69.61 in 1997 (The Hay Group, 1998). For rural Americans, the cost of health services (only partially reimbursed by Medicare Part B; or at a discount by Medicaid) may be too expensive-especially prescription drugs. Small group and individual purchasers, who often cannot afford comprehensive policies, dominate the rural health insurance marketplace. As a result, these policies often have large deductibles, and limited or no behavioral health coverage (McDonnell & Fronstin, 1999). Rural residents also have longer periods of time without insurance than do their urban peers and, hence, a greater likelihood of pent-up demand. Also, they are more likely not to seek physician services when they cannot pay, both because of pride and limited opportunities for free or reduced-fee clinical care (Mueller, Kashinath & Ullrich, 1997). Parents who have children with mental health problems but limited or no ability to pay for treatment may have to face a disturbing option: relinquishing custody of the child in order to obtain needed services. Multiple groups have commented on this practice, including the National Alliance for the Mentally Ill (NAMI), the Bazelon Center for Mental Health Law, and the Federation of Families for Children's Mental Health (FFCMH). 2 It is beyond the scope of this document to present all the issues related to relinquishment of custody to receive services. However, a report by the FFCMH lists the consequences of relinquishment. They State: "These public practices:
The implications of these phenomena can have a significant bearing on rural mental health through limiting the:
Rural mental health systems can rarely
operate without direct or indirect governmental subsidy; this is
especially true for programs serving persons with serious mental
illness (SMI) or children with severe emotional disturbances (SED)
(Wagenfeld, 2000). It is often difficult to recruit and keep
professionals in rural areas. Although there have been government-subsidized
programs (e.g., student loan repayment), they have only had a minimal
effect in solving the mental health workforce shortage in rural
areas. Furthermore, it is often difficult for mental health providers
with spouses or partners to find work for both people. For those
brought up or currently living in urban or suburban areas, the transition
to life in a rural or frontier area can be difficult. Lower salaries
and a more limited range of social and other outlets may be disincentives
to move to such areas or motivators to return to urban centers.
Acceptability: Most Americans value self-reliance or utilizing family or other close relationships to solve problems. For this reason, many attach stigma to having or seeking help for mental health or substance abuse problems. However, this appears to be more of an issue in rural communities, as there is less anonymity in seeking help. That is, belief in self-reliance and limited anonymity combine to more significantly limit a rural person's likelihood of seeking services. On the provider side, Roberts, Battaglia and Epstein (1999) described how rural caregivers face serious clinical ethical dilemmas every day. Rural clinicians commonly provide care without optimal supports, services and safeguards for their patients. It is necessary at times to ration care; to provide care outside of their usual areas of expertise and competence; to deal with patients' "noncompliance" related to access problems; to respond to complaints about colleagues' impairments and to make complex clinical decisions about reproductive, end-of-life and quality-of-life issues without the benefit of specialists. Care requires addressing patients' potential for self-harm and violence; dealing with the heightened social stigma associated with mental disorders; protecting vulnerable patients from potential abuse or exploitation and grappling with care planning for individuals with impaired decision-making capacity. These ethical issues are often more acute in rural or isolated health care settings primarily because usual practices to ensure ethical conduct are narrowed by the scarcity of health care resources. References Bird, D.C., Dempsey, P. & Hartley, D. (2001). Addressing mental health workforce needs in underserved rural area: Accomplishments and challenges. Portland, ME: Maine Rural Health Research Center, Muskie Institute, University of Southern Maine. Ciarlo, J.A., Wackwitz, J.H., Wagenfeld, M.O. & Mohatt, D.F. (1996). Focusing on "frontier": Isolated rural America. Letter to the Field No. 2. Boulder, CO: Frontier Mental Health Resource Network, WICHE Mental Health Program, http://www.wiche.edu/mentalhealth/. Effland, A. B. W. & Butler, M. A. (1997). Fewer immigrants settle in nonmetro areas and most fare less well than metro immigrants. Rural Conditions and Trends, 8(2), 60-65. Economic Research Service; United States Department of Agriculture. (Information accessed in 2005) http://www.ers.usda.gov/ ERS/USDA (1995). Understanding Rural America. Agricultural Information Bulletin No. 710. Washington, D.C.: Economic Research Service, U.S. Department of Agriculture. Gamm, L., Tai-Seale, M. & Stone, S. (2002). Meeting the mental health needs of people living in rural areas. Rockville, MD: Center for Mental Health Services, SAMHSA, U.S. Department of Health and Human Services. Lambert, D. & Agger, M. (1995). Access of rural Medicaid beneficiaries to mental health services. Health Care Financing Review, 17(7), 133-145. McDonnell, K. & Fronstin, P. (1999). EBRI health benefits data book (1st ed.). Washington, D.C.: Employee Benefit Research Institute. Mueller, K., Patil, K. & Ullrich, F. (1997). Lengthening Spells of Uninsurance and their Consequences. The Journal of Rural Health, 13(1). National Advisory Committee on Rural Health (1993). Sixth annual report on rural health. Rockville, MD: Office of Rural Health Policy, Health Resources and Services Administration, HHS. National Coalition for the Homeless (1997). Rural homelessness (NCH Fact Sheet No. 13). Also available: http://www.nationalhomeless.org/publications/facts/Rural.pdf (1998, November 10). Office of Management and Budget (1990). OMB Circular A-11. Preparation and Submission of Budget Estimates. Office of Management and Budget (2003). OMB Bulletin No. 03-04. http://www.whitehouse.gov/omb/bulletins/b03-04.html Roberts, L. W., Battaglia, J., & Epstein, R. S. (1999). Frontier ethics: Mental health care needs and ethical dilemmas in rural communities. Psychiatric Services, 50(4), 497-503. The Hay Group. (1998). Health care plan design and trends. Arlington, VA: The Hay Group. The President's New Freedom Commission on Mental Health (2004). Achieving the Promise: Transforming Mental Health Care in America. A final report. DHHS Pub. No. SMA-03-3832. Rockville, MD. The President's New Freedom Commission on Mental Health (2004). Subcommittee of Rural Issues: Background Paper. DHHS Pub. No. SMA-04-3890. Rockville, MD. U.S. Census Bureau (2003). http://www.ers.usda.gov/Briefing/Rurality/NewDefinitions/. U.S. Congress (2002). Why rural matters. In Fast Facts [Electronic Version]. Washington, DC: Congressional Rural Caucus. U.S. House of Representatives. U.S. Health and Human Services Rural Task Force. (2002). One department serving rural America (Report to the Secretary). Washington, DC: U.S. Department of Health and Human Services. Wagenfeld, M.O. (2000). Organization and delivery of mental health services to adolescents and children with persistent and serious mental illness in frontier areas. Journal of the Washington Academy of Sciences, 86(3), 81-88. Wagenfeld, M.O., Murray, J.D., Mohatt, D.F., and DeBruyn, J.C. (1994). Mental Health and Rural America 1980-1993: An Overview and Annotated Bibliography. Rockville, Md. Office of Rural Health Policy, HRSA, and Office of Rural Mental Health Research, NIMH, NIH, 1994. NIH Publication No. 94-3500. Notes for Chapter 1 1. Source: Northeast-Midwest Institute calculations based on data from U.S. Department of Commerce, Census Bureau, 2000 Census, Summary File 3, Table P.5 Urban and Rural, data extracted via http://factfinder.census.gov. 2. For more information on these
organizations and the issue of relinquishing custody, please visit
the following websites: http://www.bazelon.org/issues/children/publications/index.htm;
2 Epidemiological Overview of Mental Health in Rural America This chapter will review the epidemiologic evidence for the prevalence of mental health disorders in rural areas of the United States since the last publication of this book. In addition, this section will address some of the clinical, social and policy implications for rural communities as a result of the epidemiologic data. Historically, rural America has lacked the necessary political influence to promote effective rural mental health policy agendas (Ahr & Halcomb, 1985; Danbom, 1995; Dyer, 1997; Kimmel, 1992). Recent survey results indicate that rural health centers and State organizations for rural health rated mental health as a top priority (Gamm, Tai-Seale & Stone, 2002). Several Federal projects including Rural Healthy People 2010, the President's New Freedom Commission, Subcommittee on Rural Issues and the 1990 Surgeon General's report on Mental Health indicate the existence of underserved mental health issues in rural communities. Recommendations from these various reports are described throughout this chapter. Prevalence The most comprehensive and recent data indicate that the prevalence and incidence of mental health problems are similar between rural and urban populations (Kessler et al., 1994). Current prevalence rates show that approximately 20 percent of the United States population is affected by mental health issues each year (Kessler et al., 1994). Additionally, although this book presents mental health and substance abuse disorders in separate chapters, it is important to keep in mind that these disorders often co-occur. A study by Gogek (1992), found that approximately 40 percent of mentally ill individuals in rural populations were using illegal substances. This illustrates the importance of integrating services through formal and informal collaboration and including substance abuse statistics when discussing mental health. The overall prevalence of substance abuse among adults has frequently been shown to be comparable between rural and urban areas. According to the Epidemiological Catchment Area (ECA) Study, which compared rural and urban prevalence rates for a large variety of psychiatric disorders, the rural lifetime prevalence rate of these combined disorders was 32 percent, only slightly lower than the 34 percent rate in urban areas (Robins & Reiger, 1991). In a review of studies investigating the prevalence of psychiatric disorders in rural primary care settings, Sears and colleagues (2003) found that 34 to 41 percent of patients had a mental health disorder. Additionally, results of studies of seriously mentally ill individuals indicate that rural residents have poorer outcomes (e.g., reliance on inpatient services, increased symptom severity) when compared to urban residents, especially if there are co-occurring substance abuse issues (Fisher, Owen & Cuffel, 1996; Rost et al., 1998). One striking difference between rural and urban
populations is the higher rate of suicide in rural communities,
which has been a consistent trend for more than a decade (New
Freedom Commission Subcommittee on Rural Issues; NFC-SRI, 2004;
Institute of Medicine, 2002; Stack, 1982; Wagenfeld et al., 1994).
Specifically, the suicide rate for older adult (elderly) males and
Native American youth in rural populations is significantly higher
than in urban populations (Eberhardt, Ingram & Makuc, 2001).
Adults suffering from depression, who live in rural areas, tend to make more suicide attempts than their urban counterparts (Rost et al., 1998). However, Rost and colleagues (2002) suggest that it is difficult to attribute these elevated suicide rates to rurality per se because suicide comparisons have not been adjusted for other variables such as income and education. Women & Families Rural families often experience stress because of the high poverty rates, high unemployment rates and low educational opportunities (Champion, 2002; Human & Wasem, 1991). Women living in rural areas are particularly affected by these barriers of rural culture and are at a higher risk for abuse (Boyd, 2000; Champion, 1999; Champion, 2002; Dimmitt, 1995). Because of the small size of rural communities and a lack of anonymity, it may be very difficult for women to leave abusive or dangerous relationships, which is compounded by a lack of mental health and other community services. Health providers, especially in rural communities, need to be aware of the complex emotional repercussions of abuse (emotional or physical), such as depression and other mood disturbances. Studies have found additional factors associated with depression in rural women, including isolation, declining farm economy (making income unpredictable) and the lack of social, educational and childcare resources (Bushy, 1993; Hauenstein & Boyd, 1994). Rural women are more likely to seek mental health treatment than rural men, but both are more likely to utilize mental health care services if they have previously sought mental health treatment in the past (Kenkel, 2003). Hauenstein and Boyd (1994) found that 41 percent of their sample of rural women reported depressive symptoms, which contrasts with the typical urban prevalence rates of 13 to 20 percent. Several factors including age, employment status (i.e., unemployed) and lack of education were associated with more depressive symptoms (Hauenstein & Boyd, 1994). Despite the fact that depression is common in rural areas (i.e., 40 percent of all patient visits to primary care physicians), rural doctors detect 50 percent less depression in their patients than their urban counterparts (Rost et al., 1995). The implication of this lower detection rate is the need for increased training for general medical professionals and improved collaborative relationships between medical and mental health professionals. Children Approximately one-third of American youths live in rural areas (Cutrona, Halvorson & Russell, 1996). Epidemiologic studies of rural youths are not common, but existing results have consistently found comparable rates of psychiatric disorder, controlling for income (Angold et al., 2002). Rural children have some different characteristics when compared to urban children. Nordal, Copans and Stamm (2003) report that although drug abuse rates are lower overall, rural teenagers tend to drink more alcohol and have higher rates of risky sexual behavior (i.e., two times as likely to be sexually active, have an earlier first sexual experience and report more alcohol-related sexual intercourse). Twenty percent of teen pregnancies occur in rural communities (Yawn & Yawn, 1993). It is not uncommon for adolescents who engage in risky sexual behavior or who have substance abuse problems to also be struggling with emotional issues that contribute to or increase the odds of engaging in such behaviors. Rural areas often have difficulty meeting the needs of children with serious mental health problems (Holzer, 1998). A study by Angold and colleagues (2002), which compared psychiatric disorder, impairment and service use among rural African American and White youth, found that despite equal access to mental health services (i.e., school-based mental health services), African American youth were only half as likely as White youth to use specialty mental health services. This study also reported that only one in three youth with a current psychiatric diagnosis had received any mental health care from any professional during the previous three months (Angold et al., 2002). Youths in the United States who are in need of mental health services are not receiving care traditionally offered by outpatient service agencies (Flaherty, Weist & Warner, 1996; Weist, 1997). Possible reasons for this trend include a lack of trained mental health providers, transportation issues, family disorganization, or stigma linked to mental health issues (Kelleher, Taylor & Rickert, 1992). However, there is a significant lack of providers specializing in providing treatment to children and adolescents (Nordal et al., 2003). Students with mental health issues are most commonly
seen in school-based clinics, which reduce some barriers to accessing
care (Welsh, Domitrovich & Bierman, 2003). These authors describe
a school program initiated in rural Pennsylvania in which several
mental health programs were integrated into their current services.
Specifically, the referral process for mental health services was
directly connected with the Student Assistance Program (SAP), a
State-regulated program that identified and provided interventions
to students with emotional or behavioral problems. School-based
mental health professionals participated on the SAP team and were
able to conduct assessments, provide case management when necessary
and act as a link to the community mental health care system, which
increased access and helped streamline care. Elderly Rural elders may perceive or interpret the need for mental health services differently than their urban counterparts. Rural elderly often encounter the same or increased health needs as urban elderly. However, they often face unique geographic and economic factors (e.g., transportation difficulties, inadequate housing and limited availability of health care services) that influence the environment in which they grow older (Chalifoux et al., 1996; Lubben, Weiler, Chi & De Jong, 1988). The literature indicates that rural elderly persons with mental health issues are often underserved (Dellasega, 1991; Gamm, Stone & Pittman, 2003). It is estimated that 15 to 25 percent of individuals 65 years or older have significant mental health problems. However, roughly 85 percent do not receive needed treatment (Dorwart, 1990). This is troubling, as rural areas typically have a higher number of older adults than urban areas, a ratio that continues to increase. This increase, which began in the 1950s, is partly attributable to the aging of the population in general, the immigration of older persons from urban areas and the outmigration of younger adults (Rogers, 1999; Rowland & Lyons, 1989). The rural elderly also have complex mental health needs (e.g., Alzheimer's and other dementias) that are compounded by fragmented and inaccessible services (Buckwalter, Smith & Caston, 1994), fears of institutionalization and geographic isolation. Although there are national data on the prevalence of dementia in the general population, there are no data on the specific prevalence of dementia in rural areas (Buckwalter, Smith & Caston, 1994). It has been noted that the misdiagnosis of Alzheimer's disease may have serious repercussions for the elderly in rural areas, who often have less access to diagnostic expertise (Rathbone-McCuan & Fabian, 1992). Only approximately five percent of patients at Community Mental Health Centers and less than two percent of private psychiatric patients in rural areas are elderly, which is most likely attributable to transportation issues and stigma regarding mental health in general. In rural areas, the criminal justice system and nursing homes are frequently responsible for the mentally ill rural elderly (Buckwalter et al., 1994). Despite some of the barriers encountered by rural elderly, there are some positive attributes as well, including a strong sense of community and social support. In addition, despite isolation and evidence of diminished health status for rural elders, they do not differ much in life satisfaction compared to urban elders. While there are some value differences between urban and rural areas, some authors (Buckwalter et al., 1994; Harbert & Ginsberg, 1990) caution against categorizing rural elders as a homogenous group, as cultural differences exist even in predominately white farmlands. Area Agencies on Aging (AAA) can be influential in mobilizing informal community resources to provide support during crises and prevent unnecessary institutionalization (Rathbone-McCuan, 1993). In addition, increased outreach efforts directly targeting the rural elderly, as well as increased home visitation programs may be helpful in increasing education and utilization of mental health services for this group. Psychiatric nurses and other mid-level providers with adequate training in geriatric mental health may be instrumental in providing services for the rural elderly. A higher percentage of rural elderly live below 200 percent of the Federal poverty level compared to their urban counterparts (52.3 percent vs. 41.2 percent) (Agency for Healthcare Research and Quality, 2000). Rural elderly comprise almost 25 percent of the Medicare population, but not all beneficiaries may be offered a plan that covers prescription drugs. In 2003, rural beneficiaries on average spent more out-of-pocket on prescription drugs compared to urban beneficiaries (Caplan & Brangan, 2004). In 2003, Medicare beneficiaries either obtained drug coverage from some other public or private source, or paid for their drugs out of pocket. Prescription drugs for all Medicaid beneficiaries in 2003 were the largest single out-of-pocket expense on health care, with the exception of the costs of health care premiums. Sixty percent of rural beneficiaries had some type of prescription drug coverage in 2003, compared to almost three quarters (72 percent) of urban beneficiaries. In addition, rural beneficiaries were more likely to have Medigap and were less likely to be in a private health plan, regardless of drug coverage status. Prescription drug coverage under Medigap generally provides a limited benefit, with higher coinsurance (50 percent) and annual benefit limits that are not commonly found in employer-provided plans. Consequently, the majority of beneficiaries with Medigap do not have any drug coverage (Caplan & Brangan, 2004). The drug benefit established by the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 will be effective in 2006. The goals of the new benefit are to change the spending characteristics of the Medicare population, increase utilization, decrease drug prices and lower out-of-pocket spending for Medicare beneficiaries (Stell & Rodgers, 2004). This new legislation (MMA) will add prescription drug coverage to Medicare beginning in 2006. The availability of new coverage may provide a critical source of drug coverage for individuals in rural areas (Caplan & Brangan, 2004). Veterans In the late 1980s, veterans in rural areas did not have access to specialized Post-Traumatic Stress Disorder (PTSD) treatment unless they traveled long distances to larger Veteran's Administration hospitals (Sandrick, 1990). Research indicated that veterans are more likely to access PTSD treatment through the Veteran's Health Administration (VHA) than through non-VA mental health services (Rosenheck & Fontana, 1995). By the late 1990s, the VHA opened 141 inpatient and outpatient PTSD treatment programs across the nation (Fontana et al., 1999). However, a commission that reviewed the methodology used to identify new clinic locations indicated that the selection process was disadvantageous to veterans living in rural areas. In response to these findings, the VHA revised its Community Based Outpatient Clinic (CBOC) planning criteria to include more emphasis on the importance of access to care for rural veterans. The purpose of these clinics was to improve access to primary care and mental health services for veterans in rural communities. Refugees Refugee communities from a variety of racial and ethnic backgrounds are increasing in rural areas (Marsella et al., 1994) in search of safety and job opportunities (Markstrom et al., 2003). Between five and 35 percent of refugees are survivors of torture (Baker, 1992) and often struggle with emotional difficulties (e.g., Post-Traumatic Stress Disorder, social adjustment problems) (U.S. Committee for Refugees, 1997). This is important for mental health professionals working in rural areas and implies the need for increased knowledge and training in working with refugee populations and survivors of trauma. The information regarding refugee mental health in rural communities is significantly inadequate. While there is some information regarding refugee mental health in general that may be useful and applicable to rural refugees, there is a significant need for further research in this area. Language and cultural barriers also sometimes prevent refugees from receiving mental health services. Barriers to Mental Health Treatment in Rural Communities There are numerous barriers that contribute to disparities in access to care, utilization of services and treatment of mental health disorders for rural residents. Fox, Merwin and Blank (1995) and the New Freedom Commission on Mental Health, Subcommittee on Rural Issues (2004) indicate that obstacles to service use generally fall into three categories: availability, accessibility and acceptability. Availability refers to the presence or absence of services and service providers. Accessibility refers to whether or not people can reach the services they need. Acceptability indicates a person's attitude to mental health issues, willingness to seek services and enter treatment. Whether individuals with mental health issues received treatment has been predicted by availability (Fortney, Rost & Zang, 1998) and accessibility (Fortney, Rost & Warren, 2000). Hoyt and colleagues (1997) indicated that perceived acceptability predicts the willingness to initiate an evidence-based treatment regimen. The mental health service system in rural areas is often described as de facto and is comprised of a loosely organized and fragmented array of services and providers (Fox, Merwin & Blank, 1995; Rost et al., 2002). Rural residents with mental health issues often do not seek treatment until the problem has worsened and is currently impeding functioning in multiple areas of life (e.g., relationships, work). Delays in seeking treatment are often due to financial barriers (Schur & Franco, 1999). In this way, rural mental health, generally speaking, is not preventive, but is often reactive to mental health issues that have been exacerbated by crises. Availability There is clear evidence that the availability of mental health services and the number of mental health providers in rural areas is severely inadequate. Rural America has been underserved by mental health professionals for the past 40 years. Over 85 percent of the 1,669 Federally designated mental health professional shortage areas (MHPSAs) are rural (Bird, Dempsey & Hartley, 2001). According to the National Advisory Committee on Rural Health (1993), of the 3,075 rural counties in the United States, 55 percent had no practicing psychologists, psychiatrists, or social workers, and all of these counties identified were rural (NFC-SRI, 2004). In the past 10 years, many rural hospitals have closed or been converted to Critical Access Hospitals due to financial and other economic reasons (NFC-SRI, 2004). Although Critical Access Hospitals provide a more limited array of services than full-service hospitals, they still serve an important function in the service system in rural areas. It is estimated that approximately two-thirds of individuals with symptoms of mental illness receive no care at all. Of those who do receive treatment in rural areas, approximately 40 percent receive care from a mental health specialist and 45 percent from a general medical practitioner (Regier et al., 1993). There are approximately 605 rural counties in the U.S. without a medical health care provider, and approximately 1,600 rural counties that do no have accredited mental health care providers (Rosmann & Van Hook, 1998). Primary care physicians and other general medical practitioners are often the first-line mental health providers for rural residents. However, primary care physicians may not be adequately trained to identify and treat mental illness and behavioral disorders (Ivey, Scheffler & Zazzali, 1998; Little et al., 1998; Susman, Crabtree & Essink, 1995). In addition to training concerns, primary care physicians may also lack the time and resources to diagnose mental health disorders adequately. The public mental health system is frequently the only provider in rural areas that serves individuals with serious mental health issues. In the absence of a formal safety net of providers (e.g., public hospital systems, Federal, State and locally supported Community Health Centers and local public health departments), the "informal" safety net (e.g., private professionals and organizations that provide free or low-cost care) is forced to bear the responsibility of treating the majority of mental health issues in rural communities (Taylor, et al., 2003; Hartley & Gale, 2003). Additionally, informal safety net providers utilize lay community health workers (also known as indigenous paraprofessionals) as providers of mental health care in rural communities (Hollister et al., 1985; Wagenfeld et al., 1994). As a result of the lack of mental health services in rural areas, law enforcement is often responsible for responding to mental health emergencies (Larson, Beeson & Mohatt, 1993). Other first responders include fellow community members who, as with law enforcement, generally do not have the training or experience recognizing mental illness and/or providing triage or stabilization assistance to individuals in immediate crisis. Identifying mental illness, especially if substance abuse issues are also present, is often complicated and requires specialized knowledge and experience to handle these situations effectively. There are significant differences in the distribution of rural Community Health Centers (CHCs). Many Eastern and Southern States have approximately 30 to 40 rural CHC sites, but many Midwestern and Mountain States (e.g., Iowa, Minnesota, Nebraska, Kansas) have few or none (e.g., North Dakota) (National Advisory Committee on Rural Health, 2000; Hartley & Gale, 2003). The Farm Bill of 1987 included the Rural Crisis Recovery Act which helped support direct funding of rural mental health services. However, community efforts are often limited by the lack of long-term funding to ensure sustainability. The recruitment and retention of certified mental health professionals is of major concern in rural communities (Kimmel, 1992). In addition, Medicare reimbursement rates are often lower in rural areas, which affect the earning potential for rural mental health professionals (Meyer, 1990). The shortage of mental health professionals prompted the National Health Service Corps (NHSC) to offer loan repayment in exchange for service in MHPSAs. From 1995 to 1999, the NHSC placed 244 mental health professionals in rural areas (Bird et al., 2001). The availability of specialty mental health services (e.g., neuropsychology, geriatric) is even lower than that of general mental health services. Most specialty mental health services are available through larger trade centers or locally by periodic visits made by providers (Wagenfeld et al., 1994). Rural areas also contain fewer hospital-based inpatient and outpatient services for both psychiatric and substance abuse (Hartley et al., 1999). Often when individuals are released from inpatient care to the community, there are few social services and rehabilitation agencies to provide follow-up care. Although there has been increased National attention and support for evidence-based practices, there have been only minor efforts to increase workforce development activities to enable rural mental health providers and systems to initiate such practices. In fact, there has been a steady decline in the number of training programs that specifically target rural mental health professionals (NFC-SRI, 2004; Wagenfeld et al., 1994). Accessibility Despite comparable prevalence rates for mental disorders among rural and urban residents, rural residents are much less likely to have access to services or providers (Lambert & Agger, 1995). As discussed in Chapter 1, there are three significant components of access to mental health services for rural residents: knowledge, transportation and financing. These issues will be briefly expanded upon here. Mohatt and Kirwan (1995) found that rural residents lacked an awareness of the need for mental health care, which leads to seeking care later in the course of their disorders. Perceived need for treatment is often hindered by acute symptoms that obscure an individual's understanding of the need for immediate treatment (Rost et al., 2002). Current research suggests that perceived need for care is so low that even minimal barriers in other areas can prevent a person from seeking assistance (Rost et al., 2002). One response to overcoming these barriers is a marketing effort to enhance rural knowledge of mental illnesses, treatment options/best practices and local resources. However, administrators and providers of rural mental health services have expressed their apprehension about creating an increased demand when current resources are often over-utilized. Nevertheless, consumers, noting "they couldn't go because they didn't know," believe public education/marketing efforts should be among the top priorities for enhancing the rural mental health care system (Ralph & Lambert, 1999). Many outreach interventions in rural areas have failed to convince mentally ill individuals that they need to seek care (Fox et al., 1999). The ability to travel to mental health services is a significant barrier for rural Americans (NFC-SRI, 2004). Transportation barriers for people living in rural communities include the lack of personal transportation to travel to service providers, limited, inefficient, or inconvenient public transportation (Schauer & Weaver, 1993; U.S. Senate, 1992) and the use of catchment areas, which can complicate access to services for rural residents. The catchment area system may require individuals to seek services in an area that they do not usually frequent due to the allocation of funding streams (Mulder et al., 2002). Inability to pay further hinders accessibility to mental health services, either because of insufficient insurance coverage or high co-payments for appointments (Zevenbergen & Buckwalter, 1991). Of the people living in rural areas who do have health insurance, many do not have comprehensive benefits and do not have coverage for psychotherapy (NIMH, 2000). Many rural residents are self-employed or are employed by a small business and, thus, may not have employer-based health insurance. In response to increased insurance premiums (by an average of 16.4 percent in 2001), many small businesses are either discontinuing insurance coverage for their employees, dropping coverage for dependents, increasing the employee's contribution to the premium and deductibles, or not providing health insurance at all (Levitt, Holve & Wang, 2001; Hartley & Gale, 2003). As a result, more rural residents are paying out-of-pocket for basic primary care services (Hartley & Gale, 2003). Two-thirds of those uninsured living in rural areas are poor or near-poor, meaning their family income is less than 200 percent of the poverty level (Kaiser Commission, 2003). Low-income adults, who comprise almost half of the rural uninsured, only qualify for Medicaid if they are disabled, pregnant, elderly, or have dependent children (Kaiser Commission, 2003). Approximately one-fourth of the rural poor qualify for Medicaid, compared to 43 percent of low-income urban residents. The cost of health services that are only partially reimbursed by Medicare and Medicaid may be too expensive for some rural residents. Further complicating the cost issue is the lack of Federal strategies for sustainable mental health services (NFC-SRI, 2004). In addition, rural programs often operate in areas with limited sources of financial resources to leverage as matching funds for other grant support (NFC-SRI, 2004). Finally, although the actual numbers of individuals with serious mental illness in rural areas may be relatively small (Gale & Deprez, 2003), the geographic limitations and fragmented delivery of mental health services make it difficult for this population to access appropriate services. Lack of insurance can be especially tragic for families with children with severe emotional disturbances (SED). Too often, parents face the unthinkable choice of relinquishing custody of their child to obtain mental health treatment because they cannot pay for care. It has been estimated that more than 25 percent of families in the nation face this crisis each year (Bazelon Center, 2000; NAMI, 1999). While the data are not extensive in this area, the available data would suggest that rural families with lower rates of insurance coverage and lack of provider availability may be at greater risks of facing this horrible dilemma. The emergence of telehealth strategies over the past decade has opened a new access point for many rural consumers, families and systems. The use of telecommunication in the delivery of health services, consultation and training in mental health is expanding rapidly. The field is very broad, spanning audio-only telephone or radio consultation and crisis intervention to very sophisticated interactive audio-video linkages between distant clinical and training sites. A recent review and survey of current grantees
under the Federal Office for the Advancement of Telehealth (LaMendola,
Mohatt & McGee, 2002) found mental health was listed as the
most often service being delivered. However, closer examination
found that telehealth mental health care was a major component of
less than a dozen projects, and few noted any formal link to the
systems of care for adults with SMI or children with SED. Frequently,
these projects are organized around hospital and primary care networks
that may lack strong collaborative traditions with the systems of
care for adults with SMI and children with SED. Acceptability The acceptability of mental health services in rural areas is hindered by stigma, cultural beliefs and values (Intermill & Rathbone-McCuan, 1991). Rural residents tend to value self-reliance and view help-seeking behavior in a more negative light than urban residents (Rost et al., 2002). Other cultural attitudes often observed in rural communities include the fear that fellow rural community members will discover they are in treatment for emotional issues (Berkowitz & Helund, 1979; Bushy, 1993; Wagenfeld et al., 1994). Many rural individuals may be fearful of being labeled "insane," of being shunned by friends and other community members, or of being institutionalized (Buckwalter et al., 1994). According to Rost, Smith and Taylor (1993), the more negative the labeling of a rural individual struggling with depression, the less likely they are to seek treatment. A survey of rural mental health outreach programs by the National Association for Rural Mental Health (NARMH) found that even the best programs felt unprepared to meet the cultural and clinical needs of recent immigrants to rural areas (NFC-SRI, 2004; Lambert et al., 2001). Many ethnic minority individuals are unable to access providers who are of similar ethnic or cultural background, speak their native language, or are knowledgeable about their particular culture (Martin, 1997; NFC-SRI, 2004; U.S. Public Health Services Office of the Surgeon General, 2001). Because of this barrier, ethnic minority individuals may be more hesitant to enter treatment based on fear that the provider may not understand their culture and traditions. It is common for public mental health programs and services to be based on urban models and experiences, and are merely applied to fit rural communities (Beeson et al., 1998; Bergland & Dixon, 1988; Gamm et al., 2002; Larson et al., 1993; Mohatt, 2000; NFC-SRI, 2004). Mental health professionals are generally trained with urban-centered standards that often do not directly apply to rural communities (Wagenfeld & Buffum, 1983). Mental health providers in rural areas need an understanding of and appreciation for cultural similarities and differences within, among and between groups (NRHA, Issue Paper, 1999). The American Psychological Association (1995) identified five important goals of cultural competence: 1) identifying social, economic, political and religious influences affecting rural communities 2) understanding the importance of ethnic and cultural influences in rural communities and the importance of the oral tradition 3) understanding the impact of the interaction between social institutions and ethnicity on the delivery of mental health services 4) recognizing the impact of the provider's own culture, sensitivity and awareness as it affects his or her ability to deliver mental health care and 5) understanding alternative treatment sources in the ethnic minority culture. Reducing the stigma against mental disorders and encouraging individuals to seek treatment when needed may be accomplished by increasing educational campaigns and enhancing social and professional network referrals (Kenkel, 2003). Understanding and utilizing the work of indigenous healers or other natural supports could be particularly helpful in this regard (Neese, Abraham & Buckwalter; 1999; Buckwalter, 1992). Summary As Roberts, Battaglia and Epstein (1999) wrote, "The mental health needs of rural America are immense, and it is increasingly recognized that implementation of adequate psychiatric services in nonmetropolitan areas is a critical national health imperative." Rural mental health has emerged as a priority area for policy makers, mental health professionals and rural community-based service providers. The literature on mental health in rural communities clearly defines areas of unmet need for individuals with mental health issues including a lack of availability of services, a lack of access to these services and a lack of acceptability by rural residents due to the ever-present stigma around mental illness. Suggestions for improvement include increasing the number of training programs focused on rural issues while simultaneously promoting recruitment and retention efforts for students interested in working in rural areas. Other recommendations include increasing training for primary medical providers about mental health issues and increasing collaborative relationships between medical providers and mental health professionals. The most recent Institute of Medicine report Quality through Collaboration: The Future of Rural Health (2005) also emphasizes the need for better coordination of care and collaboration. This report offers many suggestions on increasing partnerships and is a guide for service agencies and policymakers on the benefits of such collaboration in rural America. Policy reform at the legislative level is also critical to increasing public attention to rural mental health issues and to increasing funding streams for providers and agencies working in rural communities. 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