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.

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.

Western InterState Commission for Higher Education
Boulder, Colorado
January 2005

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.

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.
Micropolitan areas are defined by clusters of 10,000 or more persons. All remaining areas are classified as "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.

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.

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).

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:

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).

Availability: The availability of rural mental health services and providers is seriously limited in rural communities. 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.

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.
Unlike the situation in general rural healthcare, specific Federal strategies for sustaining a rural mental health infrastructure do not exist (e.g., Community and Migrant Health Clinic Programs, Critical Access Hospitals). Finally, rural programs often operate in areas with disproportionately limited sources of financial resources to leverage as matching funds in seeking to compete for Federal and private foundations grant support.

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.

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.

Office of Management and Budget (1990). OMB Circular A-11. Preparation and Submission of Budget Estimates.

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. 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.

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.

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.

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.

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.

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.

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).

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.

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.

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.

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).

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.

The study also found little data on telehealth mental health care performance beyond consumer satisfaction surveys and process measures. Telehealth mental health care has been held forth as a significant tool in improving the chronic lack of access to mental health services among rural populations. However, there simply are not enough data available to measure the ability of such telehealth strategies to enhance access for adults with SMI or children with SED.

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).

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. New technology, such as telemedicine, can also help to fill some of the service gaps in rural communities. Lastly, continued research is necessary to further define rural mental health issues and the service needs that result from those issues.

Ahr, P.R. & Halcomb, W.R. (1985). State mental health directors' priorities for mental health care. Hospital and Community Psychology, 36, 39-45.

Agency for Healthcare Research and Quality (2000). Medical Expenditure Panel Survey: MEPS HC-011, 1996 Preliminary Person Level Expenditure File. [Electronic data file].

American Psychological Association (1995). Caring for the rural community: An interdisciplinary curriculum. Washington, DC: Office of Rural Health.

Angold, A., Erkanli, A., Farmer, E., Fairbank, J., Burns, B., Keeler, G., Costello, J. (2002). Psychiatric disorder, impairment, and service use in rural African American and White youth. Archives of Genereal Psychiatry, 59, 893-901.

Anthony, W., Rogers, E.S. & Farkas, M. (2003). Research on evidence-based practices: Future Directions in an Era of Recovery. Community Mental Health Journal, 39(2), 101-114.

Baker R. (1992). Psychosocial consequences for tortured refugees seeking asylum and refugee status in Europe. In M. Basoglu (Ed.), Torture and its consequences: Current treatment approaches (pp. 83-101). Cambridge: Cambridge University Press.

Bazelon Ceneter (2000). Relinquishing Custody: The Tragic Result of Failure to Meet Children's Mental Health Needs. http://www.bazelon.org

Beeson, P.G., Britain, C., Howell, M.L., Kirwan, D. & Sawyer, D.A. (1998). Rural mental health at the millennium. In R.W. Manderscheid & M.J. Henderson (Eds.), Mental Health United States 1998 (pp. 82-97). Rockville, MD: Center for Mental Health Services, SAMHSA, U.S. Department of Health and Human Services.

Bergland, B. (1988). Rural mental health : Report of the National Action Commission on the Mental Health of Rural America. Journal of Rural Community Psychology, 9, 2, 29.

Berkowitz, A. & Hedlund, D. (1979). Psychological stress and role congruence in farm families. Cornell Journal of Social Relations, 14, 47-58.

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.

Boyd, M.R. & Mackey, M.C. (2000). Running away to nowhere: Rural women's experiences of becoming alcohol dependent. Archives of Psychiatric Nursing,14(3), 142-149.

Buckwalter, K. (1992). Mental and social health of the rural elderly. Paper presented at the Health and Aging in Rural America: A National Symposium, San Diego, CA.

Buckwalter, K., Smith, M. & Caston, C. (1994). Mental and social health of the rural elderly. In R. Coward, N. Bull, G. Kulkulka, and J. Gallager (Eds.), Health services for rural elders (pp. 203-232). New York: Springer Publishing Co.

Bushy, A. (1993). Rural women: Lifestyles and health status. Nursing clinics of North America, 28(1), 187-197.

Caplan, C. & Brangan, N. (November, 2004). Prescription Drug Spending and Coverage Among Rural Medicare Beneficiaries in 2003. AARP Public Policy Institute: Washington, D.C., Available online: http://www.aarp.org/ppi

Chalifoux, Z., Neese, J., Buckwalter, K., Litwak, E., Abraham, I. (1996). Mental health services for rural elderly: Innovative Service Strategies. Community Mental Health Journal, 32, 5, 463-480.

Cutrona, C.E., Halvorson, M.B.J & Russell, D.W. (1996). Mental health services for rural children, youth, and their families. In: Heflinger, C.A., Nixon, C.T. (Eds). Families and the mental health system for children and adolescents: Policy, services, and research. Children's mental health services, Vol. 2. (pp. 217-237).

Danbom, D. (1995). Born in the country: A history of rural America. Baltimore: Johns Hopkins University Press.

Dekraai, M. (2004). Web-cast/Powerpoint Presentation. Welcome to Building Child and Family Systems of Care in Rural Areas. WICHE.

Dellasega, C. (1991). Meeting the mental health needs of elderly clients. Journal of Psychosocial Nursing, 29(2): 10-14.

Dimmitt, J. & Davila, Y. (1995). Group psychotherapy for abused women: A survivor group prototype. Applied Nursing Research, 8, 3-8.

Doniger, M, Tempier, R., Lalinec-Michaud, M. & Meunier, D. (1986). Telepsychiatry: Psychiatric consultation through two-way television. A controlled study. Canadian Journal of Psychiatry, 31(1) 32-34.

Dorwart, R.A. (1990). "Managed Mental Health Care: Myths and Realities in the 1990s." Hospital & Community Psychiatry 41: 1087-1091.

Dyer, J. (1997). Harvest of rage: Why Oklahoma City is on the beginning. Boulder, CO: Westview Press.

Eberhardt, M.S., Ingram, D.D & Makuc, D.M. (2001). Urban and rural health chartbook: Health United States 2001. Hyattsville, MD: National Center for Health Statistics.

Fischer, E.P., Owen, Jr., R.R. & Cuffel, B.J. (1996). Substance abuse, community services use, and symptoms severity of urban and rural residents with schizophrenia. Psychiatric Services, 47(9), 980-984.

Flaherty, L.T., Weist, M.D. & Warner, B.S. (1996). School-based mental health services in the United States: History, current models and needs. Community Mental Health Journal, 32, 341-352.

Fontana, A., Ronsenheck, R., Spencer, H., Gray, S. & DiLella, D. (1999). The long journey home VII: Treatment of posttraumatic stress disorder in the Department of Veterans Affairs: Fiscal year 1998 service delivery and performance. West Haven, CT: U.S. Department of Veterans Affairs Northeast Program Evaluation Center.

Fortney, J., Rost, K. & Warren, J. (2000). Comparing alternative methods of measuring geographic access to health services. Health Services and Outcomes Research Methodology, 1(2), 173-184.

Fortney, J., Rost, K. & Zhang, M. (1998). A joint choice model of the decision to seek depression treatment and choice of provider sector. Medical Care, 36(3), 307-320.

Fox, J., Merwin, E. & Blank, M. (1995). Defacto mental health services in the rural south. Journal of Health Care for the Poor and Underserved, 6(4), 434-468.

Fox, J., Blank, M., Berman, J. & Rovnyak, V.G. (1999). Mental disorders and help seeking in a rural impoverished population. International Journal of Psychiatry in Medicine, 29(2), 181-195.

Gale, J.A. & Deprez, R.D. (2003) A public health approach to the challenges of rural mental health service integration. Rural behavioral health care: An interdisciplinary guide. B.H. Stamm. Washington, DC, American Psychological Association: 95-108.

Gamm, L.G., Stone, S. & Pittman, S. (2003). Mental Health and Mental Disorders - A Rural Challenge. Rural Health People 2010: A companion document to Health People 2010. Volume 1. College Station, TX: The Texas A&M University System Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center.

Gogek, L.B. (1992). Letters to the editor. American Journal of Psychiatry 149: 1286.

Hartley, D., Bird, D. & Dempsey, P. (1999). Mental health and substance abuse. In Ricketts, T. (Eds). Rural Health in the United States. New York: Oxford University Press.

Hartley, D. & Gale, J. (2003). Rural Health Care Safety Nets. In Weinick, Robin M. and John Billings, Eds. Monitoring the Health Care Safety Net. Book III: Tools for Monitoring the Health Care Safety Net. (AHRQ Pub. No. 03-0027). Rockville, MD: Agency for Healthcare Research and Quality.

Hauenstein, E.J. & Boyd, M.R. (1994). Depressive symptoms in young women of the Piedmont: Prevalence in rural women. Women and Health, 21(2/3), 105-123.

Hollister, W., Edgerton, J., and Hunter, R. (1985). Alternative services in community mental health: programs and processes. Chapel Hill, North Carolina. University of North Carolina.

Hoyt, D.R., Conger, R.D., Valde, J.G. & Weihs, K. (1997). Psychological distress and help seeking in rural America. American Journal of Community Psychology, 25(4), 449-470.

Human, J. & Wasem, C. (1991). Rural mental health in America. American Psychologist, 46, 3, 232-239.

Institute of Medicine (2005). Quality Through Collaboration: The Future of Rural Health. The Committee on the Future of Rural Health Care; Board on Health Care Services. The National Academies Press: Washington, D.C.

Institute of Medicine (2002). Reducing Suicide: A National Imperative. Goldsmith, S.K., Pellmar, T.C., Kleinman, A.M. & Bunney, W.E. (Eds). Washington, D.C.: National Alchemy Press.

Intermill, N.L. & Rathobone-McCuan, E. (1991). Mental health services for elders in rural America. Kansas City, MO: National Resource Center for Rural Elderly.

Ivey, S.L., Scheffler, R. & Zazzali, J.L. (1998). Supply dynamics of the mental health workforce: Implications for health policy. Milbank Quarterly, 76, 25-58.

Kelleher, K.J., Taylor, J.L. & Rickert, V.I. (1992). Mental health services for rural children and adolescents. Clinical Psychology Review, 12, 841-852.

Kenkel, M.B. Rural women: Strategies and resources for meting their behavioral health needs. Stamm, B. Hudnall (Ed). (2003). Rural behavioral health care: An interdisciplinary guide. (pp. 181-192). Washington, DC, US: American Psychological Association. Xiv, 250pp.

Kessler, R.C., McGonagle, K.A., Zhao, S., et al. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the national comorbidity survey. Archives of General Psychiatry, 51(1), 8-19.

Kimmel, W.A. (1992). Rural mental health policy issues for research: A pilot exploration. Rockville, MD: National Institute of Mental Health, Office of Rural Mental Health Research.

Lambert, D. & Agger, M. (1995). Access of rural Medicaid beneficiaries to mental health services. Health Care Financing Review, 17(1), 133-145.

Lambert, D., Donahue, A., Mitchell, M. & Strauss, R. (2001). Mental Health Outreach in Rural Areas: Promising Practices. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services.

LaMendola, W. F., Mohatt, D. F. & McGee, C. (2002). Telemental health: Delivery models and performance measurement. Boulder, CO: WICHE Mental Health Program Administration.

Larson, M.L., Beeson, P.G. & Mohatt, D.F. (1993). Taking rural into account: A report of the National Public Hearing on Rural Mental Health. St. Cloud, MN: National Association for Rural Mental Health and the Federal Center for Mental Health Services.

Levitt, L., Holve, E., Wang, J. (2001). Employer Health Benefits 2001 Annual Survey. Menlo Park: Henry J. Kaiser Family Foundation.

Lewis, S.H. (2003). Unspoken crimes: Sexual assault in rural America. National Sexual Violence Resource Center.

Little, D.N., Hammond, C., Kollisch, D., Stern, B. & Dietrich, A.J. (1998). Referrals for depression by primary care physicians. A pilot study. Journal of Family Practice, 47, 375-377.

Lubben, J.E., Weiler, P.G., Chi, L. & De Jong, F. (1988). Health promotion for the rural elderly. Journal of Rural Health, 4(3), 85-96.

Markstrom, C.A., Stamm, B.H., Stamm, H.E., Berthold, S.M. & Running Wolf, P. (2003). Ethnicity and rural status in behavioral health care. In: Stamm, B.H. (Ed). Rural behavioral health care: An interdisciplinary guide. Washington, DC, US: American Psychological Association.

Marsella, A.J., Bornemann, T., Ekblad, S. & Orley, J. (Eds.) (1994). Amidst peril and pain: The mental health and well-being of the world's refugees. Washington, D.C.: American Psychological Association.

Martin, P. (1997). Immigration and the changing face of rural America. In Increasing understanding of public problems and policies (pp. 201-212). Oak Brook, IL: Farm Foundation.

Medicare Payment Advisory Committee. (2001). Report to the Congress: Medicare in rural America. Washington, DC: Medicare Payment Advisory Committee. Accessed May 7, 2003.

Meyer, H. (1990). Rural American: Surmounting the obstacles to mental health care. Minnesota Medicine, 73, 24-31.

Mohatt, D.F. (2000). Access to mental health services in frontier areas. Journal of the Washington Academy of Sciences, 86(3), 35-48.

Mohatt, D.F. & Kirwan, D. (1995). Meeting the challenge: Model programs in rural mental health. Rockville, MD: Office of Rural Health Policy.

Mulder, P.L., Shellenberger, S., Kenkel, M., Constantine, M. G., Jumper-Thurman, P., et al., (2000). The behavioral health care needs of rural women. Washington, D.C.: American Psychological Association, Committee on Rural Health. Available online: http://www.apa.org/rural/ruralwomen.pdf.

NAMI (July 1999). Families on the brink: The impact of ignoring children with serious mental illness. Washington, DC: National Alliance for the Mentally Ill.

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 Economic Council/Domestic Policy Council. (2000). Prescription drug coverage & rural Medicare beneficiaries: A critical unmet need. June 13, 2000. Available online: clinton4.nara.gov/WH/New/html/20000613.html

Neese, J.B., Abraham, I.L., Buckwalter, K.C. (1999). Utilization of mental health services among rural elderly. Archives of Psychiatric Nursing, (13)1, 30-40.

Nordal, K.C., Copans, S.A. & Stamm, B.H. (2003). Children and adolescents in rural and frontier areas. In: Stamm, B.H. (Ed). Rural behavioral health care: An interdisciplinary guide. Washington, D.C., US: American Psychological Association.

Ralph, R.O. & Lambert, D. (1999). Best practices in rural Medicaid Managed Behavioral Health: Consumer Issues. In Working Papers Series. Portland, ME: Muskie Institute, University of Southern Maine.

Rathbone-McCuan, E. Rural geriatric mental health care: A continuing service dilemma. Bull, C. Neil (Ed). (1993). Aging in rural America. Sage focus editions, 162, 146-160.

Regier, D.A., Narrow, W.E, et al. (1993). The de facto United States mental and addictive disorders services system. Archives of General Psychiatry, 50, 85-94.

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.

Robins, L.N. & Reiger, D.A. (Eds). (1991). Psychiatric disorders in America: The Epidemiologic Catchment Area Study. New York: The Free Press.

Rogers, C.C. (1999). Growth of the oldest old population and future implications for rural areas. Rural Development Perspectives, 14, 3, 22-26.

Rosenheck, R. & Fontana, A. (1995). Do Vietnam era veterans who suffer from posttraumatic stress disorder avoid VA mental health services? Military Medicine, 160, 136-142.

Rosmann, M. & Van Hook, M..P. (1998). Changes in rural communities in the past twenty-five years: Policy implications for rural mental health. Available online: http://www.narmh.org/pages/refone.html.

Rost, K., Smith, R. & Taylor, J. (1993). Rural-urban differences in stigma and the use of care for depressive disorders. Journal of Rural Health, 9, 57-62.

Rost, K., Williams, C., Wherry, J. & Smith, Jr., G.R. (1995). The process and outcomes of care for major depression in rural family practice settings. The Journal of Rural Health, 11(2), 114-121.

Rost, K.M., Owen, R.R., Smith, J. & Smith, Jr., G.R. (1998). Rural-urban differences in service use and course of illness in bipolar disorder. Journal of Rural Health, 14(1), 36-43.

Rost, K., Fortney, J., Fischer, E., Smith, J. (2002). Use, quality and outcomes of care for mental health: The rural perspective. Medical Care Research and Review, 59(3), 231-265.

Rowland, D, & Lyons, B. 1989. Triple Jeopardy: Rural, Poor, and Uninsured. Health Services Research, 23, (6): 975-1004.

Sandrick, K. (1990). Expanded delivery system needed for post-traumatic stress. Hospitals, 64(11), 44-45.

Schauer, P.M. & Weaver, P. (1993). Rural elder transportation. In J.A. Krout (Ed.), Providing Community-Based Services to the Rural Elderly (pp. 42-64). Thousand Oaks, CA: Sage.

Schur, L, Franco, S. Access to health care. In: Ricketts T, editor, Rural health in the United States. New York: Oxford University Press; 1999. p 25-37.

Sears, S.F. & Evans, G.D. et al. (2003). Rural social services systems as behavioral health delivery systems. Rural behavioral health care: An interdisciplinary guide. B.H. Stamm. Washington, D.C., American Psychological Association: 109-120.

Stack, S. (1982). Suicide: A decade of review of the sociological literature. Deviant Behavior: An Interdisciplinary Journal, 4, 41-66.

Susman, J.L., Crabtree, B.F. & Essink, G. (1995). Depression in rural family practice. Easy to recognize, difficult to diagnose. Archives of Family Medicine, 4, 427-431.

Taylor, P, Blewett, L, Brasure, M, et al. (2003). Small town health care safety nets: report on a pilot study. J Rural Health, 19(2):125-34.

Wagenfeld, M.O. & Buffum, W.E. (1983). Problems in, and prospects for, rural mental health services in the United States. International Journal of Mental Health, 12(1-2), 89-107.

Wagenfeld, M.O., Murray, J.D., Mohatt, D.F. & DeBruyn, J.C. (Eds.). (1994). Mental health and rural America: 1980 - 1993 (NIH Publication No. 94-3500). Washington, D.C.: US Government Printing Office.

United States Committee for Refugees (1997). A cry for help: Refugee mental health in the United States. Refugee Reports, 19, 9.

United States Public Health Service Office of the Surgeon General (2001). Mental health: Culture, race, and ethnicity. Rockville, MD: Department of Health and Human Services

United States Senate, Special Committee on Aging. (1992). Common beliefs about the rural elderly: Myth or fact? Serial No. 102-N. Washington, D.C.: U.S. Government Printing Office.

Weist, M.D. (1997). Expanded school mental health services: A national movement in progress. Advances in Clinical Child Psychology, 19, 319-352.

Welsh, J., Domitrovich, C.E. & Bierman, K. (2003). Promoting Safe schools and health students in rural Pennsylvania. Psychology in the Schools, 40(5), 457-472.

Yawn, B.P. & Yawn, R.A. (1993). Adolescent pregnancies in rural America: A review of the literature and strategies for primary prevention. Family and Community Health, 16(1), 36-45.

Zevenbergen, P. & Buckwalter, K.C. (1991). The mental health of rural elderly outreach project: Then and now. Paper presented at the Gerontological Society of American Annual Conference, San Francisco, CA.

Since the last publication of this book, research regarding substance abuse in rural America has grown significantly. A wide variety of publications have addressed issues such as substance abuse in a rural context from a developmental perspective; specific populations that include youth, elderly, women, inmates and ethnic minority groups; prevention and service delivery.

Findings described in previous chapters regarding the similarity in prevalence rates for both mental health and substance use disorders, as well as the widely documented spread of such drugs as methamphetamine, have undoubtedly contributed to the increased attention paid to substance abuse in rural areas. Additionally, the recent release of the President's New Freedom Commission on Mental Health, Subcommittee on Rural Issues report will continue to propel rural America to the forefront of research foci.

As discussed in Chapter 2, an increasingly important issue is the co-occurrence of mental and substance abuse disorders for both adults and children (Regier et al., 1990). The interrelationship of mental health and substance abuse problems has been well-documented, and efforts have occurred to address this fact. For instance, the Substance Abuse and Mental Health Services Administration (SAMHSA) has released grants that promote integrated mental health and substance abuse services through State or tribal agencies. Furthermore, some States (e.g., Alaska) have integrated their substance abuse and mental health service divisions into single entities, usually called a "Division of Behavioral Health."

Evidence-based practices have been established for treating co-occurring disorders (Drake et al., 2001; SAMHSA, 2004), but there is little research on the incidence, prevalence, and etiology of co-occurring disorders in rural populations. Thus, the field lacks an understanding of current needs, as well as ways to tailor evidence-based practices to treat persons with co-occurring disorders in rural areas. Furthermore, because there is not one rural America, research findings are still very difficult to generalize across the manifold places and variety of people that live in these areas.

This chapter will discuss each of the topic areas indicated above, but it should be viewed as only a snapshot of a process that is in continual motion.

The National Institute on Drug Abuse (USDHHS, 1997) published a monograph series titled "Rural Substance Abuse: State of Knowledge Issues." In that publication, Conger (1997) reviewed the literature on substance abuse in rural America and provided a context in which to understand the process that underlies the development of substance use disorders. Synthesizing work from a number of authors and researchers, he described five major themes that characterize the relationships among social context, individual dispositions and syndromes of problem behaviors that include substance use and abuse. The five themes are:

In other words, substance abuse problems do not "just happen"; they develop over time and are foreshadowed by early childhood behavioral problems, which are often the result of particular interactions between parents and their children, as well as individual family member interactions with other social contexts (e.g., jobs, school, friends, law).

Aspects of individuals who develop substance abuse disorders include genetic, biological and/or neuropsychological factors, emotional responses, and cognitive factors that interact with social-contextual issues.

For instance, Moffitt (1993) discussed how genetically or environmentally-induced biological deficits may reduce overall competence or exacerbate behavioral problems. Estimates of heritability for substance use and abuse are consistent with the degree to which delinquency is heritable (Hawkins et al., 1992; Plomin et al., 1994). Furthermore, based on adoption studies, Conger (1997) concludes "the genetic component of a biological predisposition to substance abuse and related conduct problems appears to become manifest largely in disrupted social environments; and social-contextual variables (poverty) affect biological development, which… affects antisocial substance use behaviors" (p. 16).

Chassin and colleagues (1993) reported that negative emotional responses can include antisocial behavior and predict involvement with alcohol and other drugs. Environmental issues can exacerbate a child or adolescent's emotional characteristics and make him or her more vulnerable to substance abuse, as can biologically-based emotional dispositions. Several dimensions of delinquency, such as behavior under-control, poor emotional regulation and impulsive, risky behaviors, both predict and are predicted by substance use (Elliott et al., 1989; Hawkins et al., 1992; Sher et al., 1991).

Additionally, in terms of cognitive issues, when models (e.g., family members, family friends) for substance use are plentiful, consumption is defined as acceptable and enjoyable, and use is encouraged in social settings, youths will likely adopt these beliefs and practices, which increases risk for later substance use problems (Akers, 1994; Conger & Rueter, 1995). Thus, the conclusion is that the social-contextual approach to understanding substance use and abuse provides a framework for identifying the dynamic through which social settings combine with the individual attributes that impact "developmental trajectories of risk or resilience to substance abuse and related conduct problems" (Conger, 1997, p. 17).

In 1999, Mental Health: A Report of the Surgeon General was released and addressed youth and adolescent substance use and abuse. According to the report, the early 1990s was the beginning of a "sharp resurgence" in the misuse of alcohol and other drugs by adolescents (Johnston et al., 1996). Kessler and colleagues (1996) reported results from the National Comorbidity Study, indicating that about 51 percent of those with one or more lifetime mental disorders also had a lifetime history of at least one substance use disorder, with the rates being highest in the 15 to 24 year-old age group (Kessler et al., 1994).

The National Center on Addiction and Substance Abuse (CASA; 2000) analyzed national data and reported that the prevalence of tobacco, alcohol, marijuana, amphetamine and cocaine use among eighth-graders to be higher in rural areas (defined as counties with no city over 50,000 inhabitants) than in urban areas. Rural eighth-graders were reported to be more than twice as likely to smoke cigarettes, 70 percent more likely to have been drunk, 34 percent more likely to smoke marijuana, 104 percent more likely to use amphetamines, and 50 percent more likely to have used cocaine than their urban counterparts. Johnston, Bachman and O'Malley (2000) found the alcohol use prevalence rate among rural eighth-graders to be 57 percent, compared with 50 percent among their urban peers.

Substance abuse rates in rural areas were reported to exceed those in urban areas for every drug except ecstasy and marijuana among 10th graders (CASA; 2000). In addition, the monthly prevalence rate of alcohol use among youth (6th, 8th, and 11th graders) in a rural Midwestern State was 26 percent (Iowa Consortium on Substance Abuse and Research Evaluation, 1999), compared with 21 percent in a national sample of adolescents (USDHHS, SAMHSA, Office of Applied Studies, 1999).

Despite these data, Edwards (1997) warned against using national level data to characterize rural drug use, as rural community variability is significant. For instance, communities similar in size and geographic location can have very different youth drug use profiles. Also, consistent with the need for research based on a continuum of rurality, data illustrate that there is a lower aggregate level of drug use among youth in very small, rural communities (population <2,500) than among those in larger rural and metropolitan communities. Edwards (1997) reported that problems related to drug use are much higher for metro than nonmetro and rural youth. For example, the percent of metropolitan youth who have tried marijuana is reportedly almost twice that of small rural community youth and significantly higher than that of other nonmetropolitan youth. Thus, the differences in data represent the ongoing problems of researching certain rural populations and then generalizing these findings across diverse rural areas.

Underlying the prevalence of substance abuse by rural youth are risk and protective factors. Although studies of specific individual and family risk factors in the 1980s and beginning of the 1990s indicated that there were higher levels of risk in urban areas (especially risk associated with peer influence), more recent research has found some risk factors to be more prevalent among adolescents in rural areas (e.g., family history of drug involvement, early initiation of problem behavior and low school achievement) (Becker et al., 1999a, 1999b).

Oetting and colleagues (1997) surveyed a total of 2,861 students in the 7th, 8th, 11th and 12th grades in nine rural communities (population range 451 to 18,400) in nine States. The surveys included a drug use questionnaire, The American Drug and Alcohol Survey, and the Prevention Planning Survey. Youth were classified into high, moderate, or no drug involvement groups. The results indicated that risk factors for rural and urban youth are similar; adolescent drug use is chiefly a social behavior rather than a response to the addictive properties of drugs. Additionally, families can have either a direct or indirect influence on substance use, particularly alcohol and tobacco. For instance, a direct influence identified was that a smoking parent doubles the risk of a child's smoking, and quadruples the risk if the parent's attitude is conducive toward the child's smoking. Indirect influence on increasing drug use was seen when young people believe their families are unconcerned about it and when there is family conflict (Oetting et al., 1997).

Children with relational problems at home are more likely to select friends who also have problems, and their peers are more likely to get involved with drugs and reinforce drug use. Nonusers typically have friends who would try to stop them (Oetting et al., 1997). Young women who are depressed and/or have low self-esteem may find that drug use relieves negative feelings, which increases their susceptibility to drug-using peers. Angry youth and adolescents with high need for excitement or risk-taking interact with similar youth, which drug use may satisfy.

Studies of the accumulation of risk factors show that there is an almost linear relationship; the greater the number of risk factors, the greater the chances of drug use (Swaim, 1991). Although personal and social risk factors are generally the same for urban and rural youth, there is likely to be more variability in risk factors across rural towns. This is supported by the work of Spoth and colleagues (2001), who evaluated rural-urban differences in cumulative risk for youth substance abuse using a cumulative risk index. The index included family-related (e.g., parent-child bonding or conflict, family financial stress, parental marital status, parental education, etc.) and individual-related (items from the Child Behavior Checklist that ask about youth problem behaviors) risk and protective variables.

The results of the study indicated that parent-reported cumulative risk for young adolescence substance use was significantly higher for rural youth than urban youth, although differences were small to medium in magnitude (Spoth et al., 2001). However, comparing these findings to others in the literature is difficult due to differences in cohorts, rural-urban classification schemes and measures. The studies also differ in sampling methods and related sample characteristics across studies. Nevertheless, consistent with the CASA (2000) report, there is evidence to indicate that risk factors for youth substance use may be changing for rural and urban populations. Also, factors that have protected rural youth against developing substance abuse problems may be eroding, and the literature generally suggests a higher level of cumulative risk for rural youth (Spoth et al., 2001).

One aspect of protective factors that has gained attention in the literature is the role of spirituality and/or religious participation in youths' lives. For instance, Hodge, Cardenas and Montoya (2001) examined the relationship between spirituality and religious participation and substance use in a multicultural (Hispanic, Native American, non-Hispanic white and African-American) sample of rural youths. The authors viewed spirituality and religion as distinct but overlapping concepts-spirituality was defined as "an experiential relationship with God," and religion was defined as "a formal set of rituals, beliefs, and practices that expresses an internal, commonly held, spiritual reality in a community context" (p. 154).

The results indicated that the higher the level of religious participation, the higher the probability that an adolescent never used alcohol. Also, the higher an adolescent's level of spirituality, the higher the probability the youth had not used marijuana. Finally, the higher the level of spirituality, the greater the likelihood of abstaining from hard drugs. Spirituality was not significantly related to alcohol use, while participation in religious activities was not significantly related to marijuana use or to hard drug use. More research in this area is needed to corroborate, clarify, or generalize these findings.

The use of prevention programs to curb rising rates of substance abuse has proliferated since the last edition of this book. Although there is no distinctively rural prevention program, D'Onofrio (1997) described two general categories: 1) school-based and 2) community-based.

Prevention programs conducted by rural school districts and communities without outside sponsorship are often not theoretically-based, but reflect reasoned assumptions about what is needed, using available resources creatively, and are more limited in scope (D'Onofrio, 1997). Programs sponsored by local service organizations usually try to coordinate referrals and treatment resources. Those organized by civic groups seek to develop youth leadership or provide youth with new options for recreation and employment.

Reviews of existent school-based programs indicated that most rural districts provide at least three types of drug education for students, which may include classroom instruction, extracurricular activities and drug-free social events, student intervention services, peer-managed self-monitoring, as well as parent and/or community involvement (D'Onofrio, 1997). Classroom instruction was a program component in nearly all districts, augmented by extracurricular activities, drug-free social events and intervention services. There were also training programs for teachers and staff, parent programs, and educational programs in the community.

Having multiple components in school-based prevention programs apparently increases their effectiveness (NIAAA, 1994). It has been recommended that such programs provide factual information about the harmful effects of drugs; support and strengthen students' resistance to using drugs; carry out collaborative drug abuse prevention efforts with parents and other community members; be supported by strong school policies and provide services for confidential identifications, assessment, and referral to treatment and support groups for users.

Community-based prevention programs are typically organized in rural areas by professionals in schools and agencies, local business leaders, service clubs, local activists, and external sponsors (D'Onofrio, 1997). Different types include community programs for youth; media campaigns; community coalitions; community team-building and networking; community development; grassroots movements and participation in statewide coalitions. Many include young people and other members of the community in assessing issues of alcohol use and generating possible solutions. Most complement or substitute for school-based programs.

D'Onofrio (1997) also described characteristics of the various programs that existed at the time of that writing, but pointed out that very few rural programs focus solely on the prevention of youthful drinking; goals and objectives tend to be general rather than specific and vary with program sponsorship. For instance, at SAMHSA, the Center for Substance Abuse Prevention (CSAP) programs are required to endorse a philosophy of youth abstinence from substance use. Almost all of these projects are based on a risk factor model and try to reduce at least two risk factors from different domains (as of 1993: individual = 70 percent, family = 50 percent, school = 50 percent, peer = 40 percent, neighborhood/community = 40 percent).

The few rural prevention programs organized by university researchers are based on social normative theory, with most being implemented in school classrooms using diverse instructional and skill-building techniques. These programs seek to delay the onset of smoking and drinking and to reduce the prevalence of tobacco, alcohol, and sometimes marijuana use among youth in particular grades (usually seventh).

Two of the most popular and researched prevention programs are Preparing for the Drug Free Years (PDFY) and Drug Abuse Resistance Education (DARE). The PDFY program is theoretically based on the social development model, which is an integration of social control theory (Hirschi, 1969) and social learning theory (Akers, 1977). The former views prosocial bonding as a protective factor against adolescent substance use and delinquency, while the latter specifies processes by which bonding develops. The social development model hypothesizes that bonding is determined by the levels of 1) opportunities provided to the child for proactive involvement in the family, 2) the child's skills for participating, problem-solving, and positive interaction with other family members and 3) the rewards and punishments received from parents for appropriate and inappropriate behaviors. Thus, the quantity and quality of parent-child communication or family discipline style are hypothesized to affect family bonds, which in turn affect children's behavior.

The core objectives of PDFY include conveying information about the risks and dangers of childhood substance use, increasing opportunities for family involvement and teaching the necessary skills to ensure that such involvement is rewarding and enhances parent-child bonds.

DARE is an early prevention program that promotes youths' resiliency to later problem behaviors, including drug use, by co-training parents and children to enhance self-efficacy, effective child rearing, and problem-solving. It has historically focused on youth 5 to 18 years old, their parents, and/or community professionals who work with this age group. The community team component includes a curriculum that is delivered through 15-18 hours of training for multi-agency teams who provide services to youth. This training, from which the parent workshops evolved, emphasizes four areas: 1) decision-making and problem-solving skills, 2) assertiveness in communication and conflict management, 3) responsibility for one's behavior, and 4) esteem for oneself (e.g., self-efficacy) and others.

It was noted that the PDFY and DARE programs have been fairly well researched. However, among these studies, a relatively limited number have been concerned specifically with rural areas. Thus, this section will present findings from the available literature, but will primarily focus on research conducted on these programs in rural areas.

PDFY Program: The PDFY program has been found to have a significant, positive impact on parenting skills (e.g., proactive communication, child-management, protective behaviors,) and/or the parent-child relationship (e.g., reducing negative interactions) (Kosterman et al., 1997, 2001; Rueter, Conger & Ramisetty-Mikler, 1999; Spoth et al., 1995; Spoth, Redmond & Shin, 1998); protective factors (e.g., parent-child attachment, peers with prosocial norms) (Park et al., 2000; Spoth et al., 1996a, 1996b); initiation of substance use (Guyll et al., 2004; Mason et al., 2003; Park et al., 2000; Spoth et al., 1999, 2004; Spoth, Redmond & Shin, 2001); and delinquency (Ellickson, 1996; Mason et al., 2003). However, one study did not find significant effects of PDFY regarding the ability of parents to proactively manage their families, reduce family conflict, or help their children learn skills to resist antisocial peer influences (Park et al., 2000).

DARE Program: Burke (2002) notes that although DARE is the most widely implemented youth drug prevention program in the United States, research studies indicate poor results of this program. Multiple studies could not find any significant effects of the program on use of a number of substances (e.g., alcohol, cigarettes, marijuana, inhalants) (Becker, Agopian & Yeh, 1992; Britt & Jachym, 1996; Harmon, 1993; Thombs, 2000; Wysong, Aniskiewicz & Wright, 1994) for students ranging from fifth-grade to undergraduate college students or on such things as attitudes about police, coping strategies, attachment and commitment to school, resistance to peer pressure, delay of experimentation with drugs, rebellious behavior, or self-esteem (Dukes, Ullman & Stein 1996; Harmon, 1993). Seventh-graders in an "All Stars" program, developed to address four mediators of high-risk behaviors, had significantly better outcomes on each mediator compared to seventh-graders who received the DARE program (Hansen, 1996). Hansen and McNeal (1997) found that the primary effect of DARE on eighth- then ninth-graders was a change in commitment not to use substances, but the magnitude of the effect was relatively small.

On the positive side, Miller-Heyl, MacPhee and Fritz (1998) found DARE to have result in significant, persistent increases in parental self-appraisals and democratic child-rearing practices, parent satisfaction with social support, enhanced children's developmental levels, with a corresponding decrease in harsh discipline and oppositional behavior. Furthermore, Donnermeyer and Wurschmidt (1997) found that 286 fifth- and sixth-grade educators highly rated overall DARE program quality and the impact it had on students. Rural, suburban and urban parents' views of DARE indicated that parent involvement and knowledge of the program was high, and generally, parents were very positive about it, especially when they viewed the DARE officer as an effective educator (Donnermeyer, 2000). Finally, in comparing 341 fifth-grade DARE students to 367 non-DARE students, Harmon (1993) found significant differences for alcohol use in the last year, belief in prosocial norms, association with drug-using peers, positive peer association, attitudes against substance use, and assertiveness. Thus, it appears that individuals' views of the DARE program, as well as some results, are in conflict with significant data indicating that the actual effectiveness of the program is limited or non-existent, depending on what is being measured.

The current literature contains information on a number of other prevention programs that typically share similar goals to PDFY or DARE. These will be briefly summarized here. Pilgrim and colleagues (1998) evaluated a program called "Families in Action - Meeting the Challenge of Junior High and Middle School" (FIA) that was designed to increase positive attachment to family, schools and peers; use of counseling services as necessary and appropriate attitudes toward substance use by minors. The results indicated that girl- and boy-program graduates were more willing to seek counseling services at the follow-up, as were their parents. Program participation was more beneficial for boys than for girls, and increased parent activities at their child's school compared to non-participants. Short-term program effects found for parent graduates only included greater curriculum knowledge, higher family cohesion, and an increase in the age considered appropriate for alcohol consumption. The FIA program goals were slightly altered for students and parents, with results indicating that student participants, as compared to nonparticipants, had higher family cohesion, less family fighting, greater school attachment, higher self-esteem and believed that alcohol should be consumed at an older age at the one year follow-up (Abbey et al., 2000).

Miano, Forest and Gumaer (1997) evaluated a university and school collaborative project that provided individual counseling, group counseling, couples counseling and family counseling, as well as a day and evening program to a secondary school population and the larger community of a rural locality in Southwest Virginia. The purpose was to reduce the dropout rate and improve at-risk students' attendance and school achievement. Over approximately six years, the dropout rate went from 7.09 percent to 3.32 percent.

Johnson and colleagues (1996) evaluated the Creating Lasting Connections, a five-year demonstration project, designed to delay onset and reduce frequency of alcohol and other drug use among high-risk 12 to 14 year old youth by positively impacting resiliency factors in church community, family and individual (youth). Results showed that the program successfully engaged church communities in substance abuse prevention activities and produced positive direct effects on family and youth resiliency, as well as moderating effects on onset and frequency of alcohol and other drug use.

Results from the Community Health Demonstration Project (CHDP), which was organized to develop, implement, and evaluate substance abuse prevention programming in a resource-poor rural Appalachian area, included increased awareness and knowledge of problems associated with alcohol, tobacco and other drug (ATOD) use during pregnancy and postpartum; new services adopted by local agencies and organizations; more cooperative efforts to provide presentation programs for all ages throughout the community; a range of new or expanded programs to enhance development and a reduction in ATOD use during and after pregnancy by women in this rural area (Vicary et al., 1996).

Stevens, Mott and Youells (1996) tested two approaches to substance prevention in The New Hampshire Substance Abuse Prevention Study, which included a cohort of 4,406 rural public school children in elementary school, junior high school, or in the 10th grade. It included a comprehensive school curriculum implemented in grades 1 through 12, a parent communication course, a community task force, and delayed intervention control. Some positive prevention results were achieved for cigarettes, marijuana, other illicit drugs and spitting tobacco, but no effects were found for any of the three levels of alcohol use (initiation, drinking, drunkenness) at 36 months follow-up.

Karim (1997) offers an interdisciplinary approach to prevention in rural areas. First, the local context should drive the design and development of prevention programs. Specifically, there must be an investigation into the nature of substance abuse in a particular place, including a needs assessment and development of a prevention curriculum that is based (in part) on an evaluation of how community members view substance use and abuse issues. This information will help make the prevention message meaningful. Second, prevention practitioners must disseminate materials that are significant, relevant, and interesting to youth. This includes using the most effective instruction methods and ways in which young people learn best.

Karim (1997) argues that the traditional prevention paradigm needs to abandon program-driven approaches (i.e., those based on risk/resiliency, risk and protective factors, self-esteem and health models) in favor of a broad, unified, research-based understanding of substance abuse issues that is woven into an overall school- reform or school-improvement plan. Stand-alone programs will be unsuccessful if the bulk of the prevention responsibility is based on their successful implementation. For further information on substance abuse prevention strategies, see Biglan and colleagues (1997).

Treating substance abuse in rural America involves many of the same complications noted for mental health treatment generally, especially regarding co-occurring disorders. These include 1) rural substance abuse programs seem to be based on urban models, 2) a fragmented system of services, 3) centralized services in a large geographic area, 4) overly restrictive regulations, 5) conceptual differences in treatment approaches, 6) different value-orientations between providers and clients 7) confidentiality and stigma in a rural culture and 8) academic and professional isolation of mental health workers, leading to high turnover and a shortage of staff having appropriate training and experience to work with persons with dual diagnoses (Howland, 1995; Wagenfeld et al., 1997).

This last point is buttressed by results from a survey of licensed psychologists in Idaho about their training and provision of substance abuse services. Of 144 respondents, nearly all (89 percent) had contact with substance abusers, yet most rated their graduate training as inadequate preparation for practice. Rural psychologists reported seeing a high percentage of substance abusers, but many limited their treatment to self-help group referral (Celluci & Vik, 2001).
Using 1994-1996 indicator data, McAuliffe and colleagues (2003) estimated State substance abuse treatment needs and service gaps. There were large inter-state variations in the rates of drug and alcohol deaths, arrests and treatment services, which appeared to reflect real and substantial differences among State populations in their alcohol and drug treatment needs. Maps of the indexes showed that drug treatment needs were greatest in the urban Northeast, on the West Coast and in States bordering Mexico. Moderately high levels of drug treatment needs were also found in southern States (Mississippi, South Carolina, Georgia and Louisiana). The lowest levels of relative drug treatment needs were clustered in rural States of the northern plains and in New England. Alcohol treatment needs were greatest in the West; North Carolina had the highest alcohol needs in the East. The lowest alcohol treatment needs were in Hawaii, selected southern and Midwestern States and urban East Coast States.

Comparison of Substance Abuse Treatment index scores with the Substance Abuse Need index scores revealed that States varied substantially in the extent to which current treatment needs are being met. The States with the greatest relative treatment gaps were clustered in the South (Mississippi, Georgia, Arkansas, Tennessee, North Carolina and West Virginia), Southwest (Arizona, Nevada, Texas and New Mexico), and the most northern tier of plains and mountain States (Idaho, Montana, North Dakota, Minnesota and Wisconsin). The States with the most favorable combined service rates relative to substance abuse need were also mostly in two clusters: 1) New York, Massachusetts, Rhode Island, Connecticut, Maryland, Maine and Delaware and 2) Colorado, Utah, Nebraska, Kansas, and Iowa.

Anderson and Huffine (2003) studied treatment needs and service use of 177 rural adolescents with mental and substance use disorders who were served in community-based settings. The results indicated that two-thirds of adolescents with co-occurring disorders did not receive the recommended treatment based on widely supported guidelines, leaving this group's service needs unmet.
Regarding the location of services, Vaughan-Sarrazin, Hall and Rick (2000) evaluated effects of the Iowa Case Management Project (ICMP) for Rural Drug Abuse on the utilization of substance abuse, medical and mental health services by rural substance abuse treatment clients subsequent to initiating residential treatment. Clients who volunteered for the program were randomly assigned to one of four case management conditions: 1) an ICMP case manager located at the substance abuse treatment facility, 2) an ICMP case manager located at a facility independent of the substance abuse agency, 3) an ICMP case manager who provided case management through a computer-based telecommunication system, or 4) standard substance abuse treatment.

Results indicated that ICMP participants assigned to case managers housed in the treatment facility used more aftercare, outpatient services and medical services upon completion of the residential program than clients with no case manager, suggesting that key components to the success of a case management program are integration of case managers into the treatment organization and accessibility to clients (Vaughan-Sarrazin, Hall and Rick, 2000). However, the authors note that these results should be interpreted with caution, as the study relied on self-report data, difficulty defining specific types of services (e.g., physician contact, surgical procedure), missing data and attrition. Furthermore, they did not have data regarding the treatment styles of case managers.

Farrell and associates (1999) report the results of a comprehensive study of predictors influencing continuity of care for individuals discharged from State hospitals to communities. The results indicate that although someone discharged from a State hospital to a rural CMHC is twice as likely to have continuity of care compared to those discharged to an urban CMHC, a primary diagnosis of substance abuse strongly predicts low continuity of care.

In terms of particular kinds of treatment and their effectiveness, a meta-analysis and literature review concluded that family-oriented therapies were superior to other treatments and enhanced the effectiveness of other treatments (Stanton & Shadish, 1997). Multisystemic family therapy in particular was found to be effective in reducing alcohol, substance use and other severe behavioral problems among adolescents (Pickrel & Henggeler, 1996).

Killeen and Brady (2000) report outcome data from a study of a residential substance abuse treatment program for women and young children in rural South Carolina. Data were collected regarding addiction severity, parenting and child emotional and behavioral development at six and twelve months following discharge from the program. Results showed that women who completed treatment had better scores on addiction severity and parental stress, and their children had improved behavioral and emotional functioning at the six- and twelve-month follow-ups. Additionally, program completion and longer length of stay may be associated with improvement in the women's ability to function as parents.

Leukefeld and colleagues (2002) developed a therapy for rural drug and alcohol users that incorporated social skills training, motivational interviewing, case management and thought mapping. A primary basis for this type of therapy was that, in rural areas, there is a strong emphasis on independence and self-sufficiency, which makes it difficult to talk about substance abuse problems, especially with strangers. Additionally, fatalism (the belief that one must cope with unsolvable problems) persists. Thus, social skills training was taught in the context of cognitive-behavioral therapy via structured stories. The stories provided context, highlighted difficulties, and served as a starting point for describing negative thinking patterns and substituting positive for negative self-talk as described by cognitive-behavioral therapy.

Clark, Leukefeld, and Godlaski (1999) presented a model of case management with rural clients entering drug and alcohol treatment. As part of a larger treatment protocol called Structured Behavioral Outpatient Rural Therapy, behavioral contracting was combined with strengths perspective case management to help rural clients motivate themselves to engage and complete drug and alcohol treatment. This approach was designed to continually communicate and teach an "A-B-C" cognitive-behavioral approach to problems-solving and change. The Strengths Perspective of Case Management was developed to help clients identify resources despite the view that few exist, and to help clients overcome attitudes that feed denial as well as avoid change (Rapp et al., 1996).

Monti and colleagues (1997) adapted coping skills training (CST), a promising treatment approach for alcoholics, for use with cocaine abusers and evaluated the effects on outcomes. The cocaine-specific CST intervention was conducted in individual sessions and involved CST based on functional analysis of high risk situations. Clients who received CST had significantly fewer cocaine-use days, and the length of their longest binge was significantly shorter at the three-month follow-up period compared to clients in the control condition. CST did not affect relapse rates or use of other substances.

Starting in the 1990s, methamphetamine abuse and dependence has risen to near-epidemic levels in some parts of the country (Cunningham & Thielemier, 1995); therefore, it requires special attention in this chapter. A startling statistic indicates that emergency room admissions due to methamphetamine increased 261 percent from 1991 to 1994 (Drug Abuse Warning Network, 1997). While State substance abuse or behavioral health divisions have increased efforts to identify the prevalence of methamphetamine use, the task is difficult for several reasons, especially in rural areas.

For instance, Montana and Hawaii exemplify the difficulties found in large isolated or geographically separated areas, which have limited health care services, privacy issues related to disclosure of illicit drug use, lack of drug testing capability and failure of patients to report the problem (Freese et al., 2000). However, available data in Hawaii indicated that treatment agencies were reporting methamphetamine as the primary drug of abuse at entry for 38 percent of clients (ONDCP, 1997). An average of 55 percent of clients at treatment entry used the drug, and a significant number are single women with dependent children, half of whom were receiving public assistance (Joe, 1995).

Freese and colleagues (2000) note that determining key elements for effective treatment of methamphetamine abuse and dependence is complex, as use patterns are variable, the drug can be taken in multiple ways, and triggers for cravings and use vary widely. While specific populations affected by abuse of this substance can be identified according to a continuum of geography, culture, sexual orientation, and other circumstances leading to treatment, treatment programs must be accessible and understanding of these particular clients. The authors suggest that the Matrix Model Treatment Program (Rawson et al., 1991), a standardized relapse prevention treatment format that provides a comprehensive framework to learn recovery skills and facilitates participation in recovery activities, may be the means through which providers can identify key elements for successful treatment.

Despite the growth in literature regarding specific populations, such as ethnic minority groups, women and the elderly, an ongoing problem is the limited research regarding these populations in rural areas. Nevertheless, this section will cover literature produced since the last publication of this book regarding the populations noted, as well as jail inmates and prisoners.

Dawkins and Williams (1997) review literature on substance abuse in rural African American populations and note that most of the research has focused on alcohol problems. Among the small proportion of studies regarding rural black populations, three areas covered are 1) ethnographic studies describing the integration of alcohol in rural black culture, 2) community surveys of blacks and whites to determine racial differences in drinking behavior, attitudes and problems and 3) regional and national survey findings for areas of the country where rural blacks are concentrated. In general, existing literature suggests that patterns of use for substances such as alcohol and cigarettes are either similar between rural blacks and whites or somewhat lower for blacks, but health and social consequences are worse for rural blacks. Also, problems associated with use of illicit drugs, such as heroin, marijuana, and cocaine persist (Dawkins & Williams, 1997).

Albrecht, Amey and Miller (1996) used data from the most recently available Monitoring the Future survey to examine the role of race and residence in affecting substance abuse patterns among 12,168 high school seniors self-described as black or white. Between the two groups, blacks had substantially lower reported use of all types of drugs compared to whites in both urban and rural settings. Indeed, rural versus urban residence differences were modest, but access and opportunity were important for facilitating drug use. Also, family factors, self-esteem and involvement in activities such as church attendance play important protective roles.

Dawkins (1996) examined the extent to which substance use perceptions and behavior of African American youth and adolescents are influenced by social environmental contexts. The findings indicated that there are both similarities and differences in perceptions and patterns of substance use, as well as the prediction of alcohol and marijuana use in metropolitan (urban and suburban) and nonmetropolitan (rural) social contexts.

The major similarities were that 1) alcohol or illegal drugs were rated among the top three problems at school by youth in early adolescence (eighth-grade) in both metropolitan and nonmetropolitan settings; 2) by the time these youth reached 12th grade, patterns of marijuana use were similar across social contexts; and 3) there was a relatively strong influence of peers and early substance use on later substance use within each of the three settings.

The major differences were that 1) rural eighth-graders were more likely than metropolitan youth to perceive alcohol use as a problem at school and, as 12th-graders, were more likely to exhibit patterns of heavy alcohol involvement and more frequent current use; 2) in the rural setting, the strong direct effect of being male on alcohol use is consistent with previous research on drinking patterns of black men. However, being recognized for receiving good grades operated as a protective factor which decreased alcohol use in the rural setting only; 3) the urban context may provide a setting where substance use is more likely to be linked to violation of conventional norms and family, school and community values; 4) prior cigarette use was the most powerful predictor of marijuana use among rural youth.

Castro & Gutierres (1997) provide an overview of the literature regarding Mexican American substance use and abuse. They note that little research exists, but that studies of alcohol use in rural Mexico found that men were most likely to be heavy alcohol consumers, whereas women were most likely to be abstinent. Rural Mexican men who move to cities tend to reduce their alcohol consumption, which is the opposite pattern from that of the United States. The authors indicate that research regarding substance use for rural Mexican American youth is mixed, as some has shown similar use rates between these and white youth, whereas others have shown higher drug use rates for Mexican-American females. Issues of traditionalism and acculturation are thought to potentially influence different use rates.

Vega and colleagues (1998) report data from the Mexican American Prevalence and Services Survey, which presents lifetime prevalence rates for 12 DSM-III-R psychiatric disorders in a sample of 3,012 adults (non-institutionalized persons aged 18 to 59 years of age) of Mexican origin. Comparing these results with those of population surveys conducted in the United States and Mexico, Mexican immigrants had lifetime rates similar to those of Mexican citizens, while rates for Mexican-Americans were similar to those of the national population of the United States. A higher prevalence for any disorder was reported in urban (35.7 percent) compared with town (32.1 percent) or rural (29.8 percent) areas. Despite very low education and income levels, Mexican Americans had lower rates of lifetime psychiatric disorders compared with rates reported for the U.S. population by the National Comorbidity Survey.

Rural Native Americans do not differ from urban Native American populations in rates of alcohol abuse, which are higher than the population at large. However, rural Native Americans tend to have more episodes of binge drinking (National Rural Health Association, 1999).

Based on interviews with 212 children (115 boys and 97 girls) from three American Indian reservations located in the upper Midwest, Whitbeck and colleagues (2002) identified a profile among the fifth- to eighth-grade American Indian adolescents who report gang involvement. The profile is that of a male or female who engages in delinquent behaviors and/or substance abuse and lives in a single-mother household where the mother has a history of antisocial behavior. The adolescent is probably not doing well academically and has experienced multiple life transitions or losses in the past year.

Rowe (1997) reported results from a five-year CSAP-funded community substance abuse prevention program that was launched in a small (550 member), rural Native American communities in Washington State that had a history of serious alcohol and drug problems. The Chi-e-thee ("workers") grass-roots program sought to address substance abuse by using community collaboration between tribal agencies, community empowerment and education, cultural enhancement and development of support networks and services for people engaged in healing and recovery.

This program was successful in sponsoring over 215 cultural and educational events, and resulted in 96 community members making a commitment to sobriety, a community-wide change in norms about wellness and substance abuse, the creation of new networks of communication and collaboration and new tribal policies and enforcement practices to curtail drug and alcohol abuse. The number of clean and sober individuals was determined to have increased from 25 percent of the adult population in 1992 to 40 percent of the adult population in 1996.

Despite growing literature addressing mental health and substance use issues among the many populations that have Asian origin, the authors could find no research regarding substance use issues for Asians in mainland rural areas. This is likely due, at least in part, to very limited numbers of Asians in most rural areas of America. However, Waitzfelder, Engel and Gilbert (1998) studied substance abuse in Hawaii, including 1) the magnitude of the statewide substance abuse problem, 2) the unmet needs of the State's substance abuse treatment system and 3) the features of the problem unique to Hawaii's many ethnic and other subgroups.

The study targeted 55 human service organizations most burdened by the substance abuse problem. Respondents perceived the magnitude of the Hawaii substance abuse problem to be at least comparable to that of the mainland United States. Although most respondents viewed the problem using a medical model, the problem was generally thought to be exacerbated by a community context in which substance abuse is accepted, excused or denied. Increasing use of crystal methamphetamine and heroin were cited as the most worrisome trends.

Systems issues identified were similar to those of rural areas (e.g., unstable funding, lack of services, transportation, outreach). Cultural alienation, exacerbated by the State's prevailing multiculturalism, was thought to contribute to the substance abuse problem among all ethnic groups, but especially among Native Hawaiians. Cultural factors were thought to have a major impact on seeking care and subsequent acceptance of such care.

Boyd and Hauenstein (1997) describe efforts to diagnose co-occurring disorders in rural women. They used the Michigan Alcoholism Screening Test (MAST; Selzer, 1971), Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977) and the National Institute of Mental Health (NIMH) Diagnostic Interview Schedule, Version III (DIS; Robins, Helzer, Croughan & Ratcliff, 1981). The results indicate that the MAST and CES-D are effective screening tools for alcoholism and depression among rural women, and because these instruments are relatively short, they can be easily incorporated into regular health screening.

Warner and Leukefeld (2001) examined differences between urban and rural drug use patterns and treatment utilization among chronic drug abusers to determine whether, and in what ways, rurality may affect substance abuse and treatment seeking. Findings showed that chronic drug abusers from rural and very rural areas have significantly higher rates of lifetime drug use, as well as higher rates of drug use in the 30 days prior to their current incarceration than chronic drug abusers from urban areas. However, being from a very rural area decreased the likelihood of having ever been in treatment.

Using interview data collected at seven county jails in both urban and rural areas of Ohio, Lo and Stephens (2002) examined factors associated with arrestees' subjective perception of substance treatment needs and evaluated whether relationships between these factors and perceived needs for treatment were identical in urban and rural areas.

Results indicated that motivation for substance-specific treatment differed among urban and rural arrestees only regarding perceived treatment needs for cocaine, with urban arrestees more likely to see a need for treatment. However, respondents identified as currently dependent on alcohol, cocaine, opiates or marijuana were more likely than nondependent respondents-across the urban-rural spectrum-to show motivation for substance-specific treatment. The results show that having a romantic partner was linked to perceived needs for marijuana treatment. In addition, being employed full time increased perceived needs for cocaine treatment among urban arrestees. In contrast, full-time employment decreased this perception among rural arrestees.

Stohr and colleagues (2002) evaluated residential substance abuse and treatment (RSAT) programs developed to address the drug and alcohol treatment needs of inmates in prisons. Typically, such programs range from six to twelve months, have an Alcoholics Anonymous and/or Narcotics Anonymous component, occur in a therapeutic community environment and some programs include a cognitive self-change component. Inmate participation in their programming is crucial to the success of a therapeutic community treatment environment. Participants in two RSAT programs were generally positive in their perceptions of most of the program components. However, those who were in the program longest were less positive about several aspects of it, whereas those who were heavy alcohol users were more positive about other aspects.

Godley and colleagues (2000) described a case management model for individuals involved with the criminal justice system who had significant, co-occurring mental illness and substance abuse disorders. During the three-year project, 54 out of 115 screened were accepted into the project. Of the clients accepted into the program, 44 (81 percent) were terminated from the program (61 percent successfully, 39 percent unsuccessfully) and 10 (19 percent) remained active at the end of the pilot period.

Program evaluation data indicated that six months after entering the program, clients had fewer legal problems and appeared to have symptom relief. However, measures did not reveal significant improvements in drug or alcohol composite scores. Clients perceived themselves as better off in most areas than the previous year, were generally satisfied with the case-management program, but had some dissatisfaction in the area of employment. Qualitative reviews from two probation officers and a judge who referred to the project were positive.

The Surgeon General's Report on Mental Health (1999) included a section on alcohol and substance use disorders in older adults. The report Stated that older people are not immune to the problems associated with improper use of alcohol and drugs, but misuse of alcohol and prescription medications appears to be more common than abuse of substances. However, few studies have focused on incidence and prevalence of substance abuse for older adults, and these studies had methodological problems, suggesting that this popular perception may be misleading.

A persistent research problem has been that diagnostic criteria for substance abuse were developed and validated on young and middle-aged adults. For example, DSM-IV criteria include increased tolerance to the effects of the substance, which results in increased consumption over time. However, changes in pharmacokinetics and physiology may alter drug tolerance in older adults-decreased tolerance to alcohol for older individuals may lead to decreased consumption of alcohol with no apparent reduction in intoxication. Criteria that relate to the impact of drug use on typical tasks of young and middle adulthood (e.g., school and work performance) may be largely irrelevant to older adults. Thus, abuse and dependence among older adults may be underestimated (Ellor & Kurz, 1982; Miller et al., 1991; King et al., 1994).

In a cross-sectional study of 1,551 clients receiving care in 10 community-based rural mental health care systems, Barry and colleagues (1996) assessed problem behaviors and psychiatric symptoms among three groups of SMI clients: those with a current substance abuse problem, those with a history of substance abuse but no current problem and those with no history of substance abuse problems. Results indicated that clients with a current substance abuse problem were younger, had more 1) symptoms of anger, 2) trouble with the law and 3) suicidal threats than clients in the other two groups.

Mueser and colleagues (2001) evaluated the differences between two cohorts of patients with SMI (schizophrenia-spectrum or bipolar disorder) and co-occurring substance-use disorders, living in either predominantly rural (New Hampshire) or urban areas (two cities in Connecticut). The two study groups were compared on demographic characteristics, housing, legal problems, psychiatric and substance use diagnoses, substance use and abuse, psychiatric symptoms and quality of life. The urban group had higher rates of cocaine-use disorder, more involvement in the criminal justice system, more homelessness and was more likely to have a minority background. This group also had a higher proportion of patients with schizophrenia, more severe symptoms, as well as lower rates of marriage, educational attainment and work. Alcohol-use disorder was higher in the rural group.

The growing literature on substance abuse in rural America reflects data indicating increases in substance use disorders in these areas. Co-occurring mental health and substance abuse disorders for both children and adults has become a major focus of providers, administrators and policy makers in the 21st Century. We now have a better understanding of the developmental pathways toward substance abuse, but are still limited in our knowledge of the larger social context in which such disorders are cultivated. Part of the difficulty is the wide variability from one rural area to the next across the country and outlying States (i.e., Alaska and Hawaii). There are many different kinds of people, living in vastly different geographical and geological places, each with unique cultures.

Attempts to prevent the development of substance abuse disorders have had mixed results, but some programs, such as Preparing for the Drug Free Years, have been shown to have positive effects for parents and children. Other programs that adopt similar principles and objectives have also demonstrated success, but the long-term effects of all such programs still require more research.

Treating substance abuse in rural America involves the same problems noted for mental health, such as rural programs based on urban models, fragmented service systems, large geographic areas, confidentiality and stigma in a rural culture, to name just a few. Research regarding specific populations in rural areas, such as ethnic minorities, women and the elderly are still lacking. However, initiatives such as the President's New Freedom Commission on Mental Health have rural America as a primary area of focus, and will undoubtedly impel our knowledge and effectiveness forward.

Abbey, A., Pilgrim, C., Hendrickson, P. & Buresh, S. (2000). Evaluation of a family-based substance abuse prevention program targeted for the middle school years. Journal of Drug Education, 30(2), 213-228.

Akers, R. L., (1977). Deviant behavior: A social learning approach (2nd ed.). Belmont, CA: Wadsworth Press.

Akers, R. L. , (1994). Criminological Theories: Introduction and Evaluation. Los Angeles: Roxbury Publishing.

Albrecht, S.L., Amey, C. & Miller, M.K. (1996). Patterns of substance abuse among rural black adolescents. Journal of Drug Issues, 26, 751-781.

Anderson, R.L., & Huffine, C. (2003). Child & adolescent psychiatry: Use of community-based services by rural adolescents with mental health and substance use disorders. Psychiatric Services, 54, 1339-1341.

Barry, K.L., Fleming, M.F., Greenley, J.R., Kropp, S.; et al. (1996). Characteristics of persons with severe mental illness and substance abuse in rural areas. Psychiatric Services, 47, 88-90.

Becker, H.K., Agopian, M.W. & Yeh, S. (1992). Impact evaluation of Drug Abuse Resistance Education (DARE). Journal of Drug Education, 22, 283-291.

Becker, L., Barga, V., Sandberg, M., Stanley, M. & Clegg, D. (1999a). 1999 county profile on risk and protection for substance abuse prevention planning in Ferry County. Olympia, WA: Division of Alcohol and Substance Abuse, Research and Data Analysis, Department of Social and Health Services.

Becker, L., Barga, V., Sandberg, M., Stanley, M. & Clegg, D. (1999b). 1999 county profile on risk and protection for substance abuse prevention planning in King County. Olympia, WA: Division of Alcohol and Substance Abuse, Research and Data Analysis, Department of Social and Health Services.

Biglan, A., Duncan, T., Irvine, A.B., Ary, D., Smolkowski, K. & James, L. (1997). A drug abuse prevention strategy for rural America. In: Roberson, E.B., Sloboda, Z., Boyd, G.M., Beatty, L, and Kozel, N.J., eds. Rural Substance Abuse: State of Knowledge and Issues. National Institute on Drug Abuse; U.S. Department of Health and Human Services; National Institutes of Health: NIH Publication No. 97-4177. Rockville, MD.

Boyd, M.R. (2000). Predicting substance abuse and comorbidity in rural women. Archives of Psychiatric Nursing, 14, 64-72.

Boyd, M.R. & Hauenstein, E.J. (1997). Psychiatric assessment and confirmation of dual disorders in rural substance abusing women. Archives of Psychiatric Nursing, 11, 74-81.

Boyd, M.R. & Mackey, M.C. (2000). Alienation from self and others: The psychosocial problem of rural alcoholic women. Archives of Psychiatric Nursing, 14, 134-141.

Britt, M.A. & Jachym, N.K. (1996). Cigarette and alcohol use among 4th and 5th graders: Results of a new survey. Journal of Alcohol & Drug Education, 43, 44-54.

Burke, M.R. (2002). School-based substance abuse prevention: Political finger-pointing does not work. Federal Probation, 66, 66-71.

Castro, F.G. & Gutierres, S. (1997). Drug and alcohol use among rural Mexican Americans. In: Roberson, E.B., Sloboda, Z., Boyd, G.M., Beatty, L, and Kozel, N.J., eds. Rural Substance Abuse: State of Knowledge and Issues. National Institute on Drug Abuse; U.S. Department of Health and Human Services; National Institutes of Health: NIH Publication No. 97-4177. Rockville, MD.

Cellucci, T. & Vik, P. (2001). Training for substance abuse treatment among psychologists in a rural State. Professional Psychology - Research & Practice, 32, 248-252.

Chassin, L., Pillow, D.R., Curran, P.J., Molina, B.S.G & Barrera, M., Jr. (1993). Relations of parental alcoholism to early adolescent substance use: A test of three mediation mechanisms. Journal of Abnormal Psychology, 102, 3-19.

Clark, J.J., Leukefeld, C. & Godlaski, T. (1999). Case management and behavioral contracting: Components of rural substance abuse treatment. Journal of Substance Abuse Treatment, 17(4), 293-304.

Conger, R.D. (1997). The social context of substance abuse: A developmental perspective. In: Roberson, E.B., Sloboda, Z., Boyd, G.M., Beatty, L, and Kozel, N.J., eds. Rural Substance Abuse: State of Knowledge and Issues. National Institute on Drug Abuse; U.S. Department of Health and Human Services; National Institutes of Health: NIH Publication No. 97-4177. Rockville, MD.

Conger, R.D., Conger, K.J., Elder, Jr., G.H., Lorenz, F., Simons, R. & Whitbeck, L. (1992). A family process model of economic hardship and adjustment of early adolescent boys. Child Development, 63, 526-541.

Conger, R.D., Conger, K.J., Elder, Jr., G.H., Lorenz, F., Simons, R. & Whitbeck, L. (1993). Family economic stress and adjustment of early adolescent girls. Developmental Psychology, 29, 209-219.

Conger, R.D., Ge, X., Elder, Jr., G.H., Lorenz, F.O. & Simons, R.L. (1994). Economic stress, coercive family process, and developmental problems of adolescents. Child Development, 65, 541-561.

Conger, R.D. & Rueter, M.A. (1995). Siblings, parents, and peers: A longitudinal study of social influences in adolescent risk for alcohol use and abuse. In: Brody, G., ed. Sibling Relationships: Their Causes and Consequences. Norwood, NJ: Ablex Publishing.

Cunningham, J.K. & Thielemier, M.A. (1995). 24 Trends and Regional Variations in Amphetamine-Related Emergency Admissions: California, 1984-1993. Irvine, CA: Public Statistics Institute.

Dawkins, M.P. (1996). The social context of substance use among African American youth: Rural, urban and suburban comparisons. Journal of Alcohol & Drug Education, 41, 68-85.

Dawkins, M.P. & Williams, M.M. (1997). Substance abuse in rural African-American populations. In: Roberson, E.B., Sloboda, Z., Boyd, G.M., Beatty, L, and Kozel, N.J., eds. Rural Substance Abuse: State of Knowledge and Issues. National Institute on Drug Abuse; U.S. Department of Health and Human Services; National Institutes of Health: NIH Publication No. 97-4177. Rockville, MD.

Donnermeyer, J.F. (2000). Parents' perceptions of a school-based prevention education program. Journal of Drug Education, 30, 325-342.

Donnermeyer, J.F. & Wurschmidt, T.N. (1997). Educators' perceptions of the D.A.R.E. program. Journal of Drug Education, 27, 259-276.

D'Onofrio, C.N. (1997). The prevention of alcohol use by rural youth. In: Roberson, E.B., Sloboda, Z., Boyd, G.M., Beatty, L, and Kozel, N.J., eds. Rural Substance Abuse: State of Knowledge and Issues. National Institute on Drug Abuse; U.S. Department of Health and Human Services; National Institutes of Health: NIH Publication No. 97-4177. Rockville, MD.

Drake, R. E., Essock, S. M., Shaner, A., Carey, K. B., Minkoff, K., Kola, L., Lynde, D., Osher, F. C., Clark, R. E., & Rickards, L. (2001). Implementing dual diagnosis services for clients with severe mental illness. Psychiatric Services, 52, 469-476.

Drug Abuse Warning Network (1997). Number of Methamphetamine and Amphetamine-Related Episodes: 1988-1995. Substance Abuse and Mental Health Services Administration, http://www.samhsa.gov/oas/dawn/ar17_013.htm.

Dukes, R.L., Ullman, J.B & Stein, J.A. (1996). Three-year follow-up of drug abuse resistance education (D.A.R.E.). Evaluation Review, 20, 49-66.

Edwards, R.W. (1997). Drug and alcohol use among youth in rural communities. In: Roberson, E.B., Sloboda, Z., Boyd, G.M., Beatty, L, and Kozel, N.J., eds. Rural Substance Abuse: State of Knowledge and Issues. National Institute on Drug Abuse; U.S. Department of Health and Human Services; National Institutes of Health: NIH Publication No. 97-4177. Rockville, MD.

Elliot, D.S., Huizinga, D. & Menard, S. (1989). Multiple Problem Youth: Delinquency, Substance Use, and Mental Health Problems. New York: Springer-Verlag.

Ellor, J. R. & Kurz, D. J. (1982). Misuse and abuse of prescription and nonprescription drugs by the elderly. Nursing Clinics of North America, 17, 319-330.

Farrell, S.P., Blank, M., Koch, J.R., Munjas, B. & Clement, D.G. (1999). Predicting whether patients receive continuity of care after discharge from State hospitals: Policy implications. Archives of Psychiatric Nursing, 13, 279-285.

Freese, T.E., Obert, J., Dickow, A., Cohen, J. & Lord, R.H. (2000). Methamphetamine abuse: Issues for special populations. Journal of Psychoactive Drugs, 32, 177-182.

Godley, S.H., Finch, M., Dougan, L., McDonnell, M., McDermeit, & M., Carey, A. (2000). Case management for dually diagnosed individuals involved in the criminal justice system. Journal of Substance Abuse Treatment, 18, 137-148.

Gottfredson, M.R. & Hirschi, T. (1990). A General Theory of Crime. Stanford, CA: Stanford University Press.

Guyll, M., Spoth, R.L., Chao, W., Wickrama, K. & Russell, D. (2004). Family-focused preventive interventions: Evaluating parental risk moderation of substance use trajectories. Journal of Family Psychology, 18, 293-301.

Hansen, W.B. (1996). Pilot test results comparing the All Star program with seventh grade D.A.R.E.: Program integrity and mediating variable analysis. Substance Use & Misuse, 31, 1359-1377.

Hansen, W.B. & McNeal Jr., R.B. (1997). How D.A.R.E. works: An examination of program effects on mediating variables. Health Education & Behavior, 24, 165-176.

Harmon, M.A. (1993). Reducing the risk of drug involvement among early adolescents: An evaluation of Drug Abuse Resistance Education (DARE). Evaluation Review, 17, 221-239.

Hawkins, J.D., Catalano, R.F. & Miller, J.Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin, 112, 64-105.

Hays, R. D. & Ellickson, P. L. (1996). Associations between drug use and deviant behavior in teenagers. Addictive Behaviors, 21, 291-302.

Hirschi, T. (1969). Causes of Delinquency. Berkeley, CA: University of California Press.

Hodge, D.R., Cardenas, P. & Montoya, H. (2001). Substance use: Spirituality and religious participation as protective factors among rural youths. Social Work Research, 25, 153-162.

Howland, R.H. (1995). The treatment of persons with dual diagnoses in a rural community. Psychiatric Quarterly, 66, 33-49.

Joe, K.A. (1995). Ice is strong enough for a man but made for a woman: A social cultural analysis of crystal methamphetamine use among Asian Pacific Americans. Crime, Law, and Social Change, 22, 269-289.

Johnson, K., Bryant, D., Strader, T., Bucholtz, G., et al. (1996). Reducing alcohol and other drug use by strengthening community, family, and youth resiliency: An evaluation of the Creating Lasting Connections Program. Journal of Adolescent Research, 11, 36-67.

Johnston, L. D., O'Malley, P. M. & Backman, J. G. (1996). National survey results on drug use from the Monitoring the Future study, 1975-1995. Vol. I: Secondary school students. (NIH Pub. No. 97-4139). Rockville, MD: National Institute on Drug Abuse.

Johnston, L., O'Malley, P. & Bachman, J. (2000). Monitoring the future: National survey results on drug use, 1975-1999: Vol. 1. Secondary school students (NIH Publication No. 00-4802). Washington, D.C.: U.S. Department of Health and Human Services.

Karim, G. (1997). In living context: An interdisciplinary approach to rethinking rural prevention. In: Roberson, E.B., Sloboda, Z., Boyd, G.M., Beatty, L, and Kozel, N.J., eds. Rural Substance Abuse: State of Knowledge and Issues. National Institute on Drug Abuse; U.S. Department of Health and Human Services; National Institutes of Health: NIH Publication No. 97-4177. Rockville, MD.

Kessler, R. C., Berglund, P. A., Zhao, S., Leaf, P. J., Kouzis, A. C., Bruce, M. L., Friedman, R. M., Grosser, R. C., Kennedy, C., Narrow, W. E., Kuehnel, T. G., Laska, E. M., Manderscheid, R. W., Rosenheck, R. A., Santoni, T. W. & Schneier, M. (1996). The 12-month prevalence and correlates of serious mental illness (SMI). In R. W. Manderscheid & M. A. Sonnenschein (Eds.), Mental health United States, 1996 (DHHS Publication No. SMA 96-3098, pp. 59-70). Washington, D.C.: Superintendent of Documents, U.S. Government Printing Office.

Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen, H., and Kendler, K.S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the national comorbidity study. Archives of General Psychiatry, 51, 81-89.

Killeen, T. & Brady, K.T. (2000). Parental stress and child behavioral outcomes following substance abuse residential treatment: Follow-up at 6 and 12 months. Journal of Substance Abuse Treatment, 19, 23-29.

King, C. J., Van Hasselt, V. B., Segal, D. L. & Hersen, M. (1994). Diagnosis and assessment of substance abuse in older adults: Current strategies and issues. Addictive Behaviors, 19, 41-55.

Kosterman, R., Hawkins, J.D., Haggerty, K.P., Spoth, R. & Redmond, C. (2001). Preparing for the drug free years: Session-specific effects of a universal parent-training intervention with rural families. Journal of Drug Education, 31, 47-68.

Kosterman, R., Hawkins, J.D., Spoth, R., Haggerty, K.P., et al. (1997). Effects of a preventive parent-training intervention on observed family interactions: Proximal outcomes from preparing for the drug free years. Journal of Community Psychology, 25, 337-352.

Leukefeld, C.G., Godlaski, T., Clark, J., Brown, C. & Hays, L. (2002). Structured stories: Reinforcing social skills in rural substance abuse treatment. Health & Social Work, 27, 213-217.

Lo, C.C. & Stephens, R.C. (2002). Arrestees' perceived needs for substance-specific treatment: Exploring urban-rural differences. American Journal of Drug & Alcohol Abuse, 28, 623-642.

Loeber, R. & LeBlanc, M. (1990). Toward a developmental criminology. In: Tonry, J. and Morris, N., eds. Crime and Justice. Vol. 12. Chicago: University of Chicago Press.

Loeber, R. & Stouthhamer-Loeber, M. (1986). Family factors as correlates and predictors of juvenile conduct problems and delinquency. In: Tonry, J. and Morris, N., eds. Crime and Justice. Vol. 7. Chicago: University of Chicago Press.

Lytton, H. (1990). Child and parent effects in boys' conduct disorder: A reinterpretation. Developmental Psychology, 26, 683-697.

Mason, W.A., Kosterman, R., Hawkins, J.D., Haggerty, K.P., Spoth, R.L. (2003). Reducing adolescents' growth in substance use and delinquency: Randomized trial effects of a parent-training prevention intervention. Prevention Science, 4, 203-212.

McAuliffe, W.E., LaBrie, R., Woodworth, R., Zhang, C. & Dunn, R.P. (2003). State substance abuse treatment gaps. American Journal on Addictions, 12(2), 101-121.

Melby, J.N., Conger, R.D., Conger, K.J. & Lorenz, F.O. (1993). Effects of parental behavior on tobacco use by young adolescent males. Journal of Marriage and Family, 55, 439-454.

Miano, G., Forest, A. & Gumaer, J. (1997). A collaborative program to assist at-risk youth. Professional School Counseling, 1, 16-20.

Miller, N. S., Belkin, B. M. & Gold, M. S. (1991). Alcohol and drug dependence among the elderly: Epidemiology, diagnosis, and treatment. Comprehensive Psychiatry, 32, 153-165.

Miller-Heyl, J., MacPhee, D. & Fritz, J.J. (1998). DARE to be you: A family-support, early prevention program. Journal of Primary Prevention, 18, 257-285.

Moffitt, T.E. (1993). Adolescence-limited and life-course-persistent antisocial behavior: A developmental taxonomy. Psychology Review, 100, 674-701.

Monti, P.M., Rohsenow, D.J., Michalec, E., Martin, R.A. & Abrams, D.B. (1997). Brief coping skills treatment for cocaine abuse: Substance use outcomes at three months. Addiction, 92, 1717-1728.

Mueser, K.T., Essock, S.M., Drake, R.E., Wolfe, R.S. & Frisman, L. (2001). Rural and urban differences in patients with a dual diagnosis. Schizophrenia Research, 48, 93-107.

National Center on Addiction and Substance Abuse (CASA) at Columbia University (2000). No place to hide: substance abuse in mid-size cities and rural America. New York: Author.

National Institute on Alcohol Abuse and Alcoholism (1994). Alcohol and Health. Eighth Special Report to the U.S. Congress, September. NIH Publication No. 94-3699. Rockville, MD: U.S. Department of Health and Human Services.

Oetting, E.R., Edwards, R.W., Kelly, K. & Beauvais, F. (1997). Risk and protective factors for drug use among rural American youth. In: Roberson, E.B., Sloboda, Z., Boyd, G.M., Beatty, L, and Kozel, N.J., eds. Rural Substance Abuse: State of Knowledge and Issues. National Institute on Drug Abuse; U.S. Department of Health and Human Services; National Institutes of Health: NIH Publication No. 97-4177. Rockville, MD.

Office on National Drug Control Policy, Executive Office of The President (ONDCP) (1997). Pulse Checdk, Summer 1997: Special Report-Methamphetamine Trends in Five Western States and Hawaii, 1997. (Order # NCJ-164261). Available at: www.whitehousedrugpolicy.gov/drugfact/pulsechk/pcappa.htm.

Park, J., Kosterman, R., Hawkins, J.D., Haggerty, K.P., Duncan, T.E., Duncan, S.C. & Spoth, R. (2000). Effects of the "Preparing for the Drug Free Years" curriculum on growth in alcohol use and risk for alcohol use in early adolescence. Prevention Science, 1, 125-138.

Patterson, G.R. (1993). Orderly change in a stable world: The antisocial trait as a chimera. Journal of Consulting and Clinical Psychology, 61, 911-919.

Patterson, G.R., Reid, J.B. & Dishion, T.J. (1992). Antisocial Boys. Eugene, OR: Castalia Publishing.

Pickrel, Susan G; Henggeler, Scott W. (1996). Multisystemic therapy for adolescent substance abuse and dependence. Child & Adolescent Psychiatric Clinics of North America, 5, 201-211.

Pilgrim, C., Abbey, A., Hendrickson, P. & Lorenz, S. (1998). Implementation and impact of a family-based substance abuse prevention program in rural communities. Journal of Primary Prevention, 18, 341-361.

Plomin, R., Chipuer, H.M. & Neiderhiser, J.M. (1994). Behavioral genetic evidence for the importance of nonshared environment. In: Heatherington, E.M., Reiss, D, and Plomin, R., eds. Separate Social Worlds of Siblings: The Impact of Nonshared Environment on Development. Hillsdale, NJ: Erlbaum, pp. 1-31.

Rapp, R.C., Kelliher, C.S., Fisher, J.H. & Hall, J.F. (1996) Strengths-based case management: A role in addressing denial in substance abuse treatment. In H.A. Siegal & R.C. Rapp (Eds.), Case management and substance abuse treatment: Practice and experience (pp. 21-36). New York: Springer Publishing Co.

Rawson, R.A., Obert, J.L., McCann, M.J. & Ling, W. (1991). The Matrix Model for Outpatient Treatment for Alcohol Abuse and Dependency. Beverly Hills, CA: Matrix.

Regier, D.A., Farmer, M.E., Rae, D.S., Locke, B.Z., Keith, S.J., Judd, L.L., & Goodwin, F.K. (1990). Comorbidity of mental disorders with alcohol and other drug abuse: Results from the Epidemiologic Catchment Area Study. Journal of the American Medical Association, 264, 2511-2518.

Richters, J.E. & Martinez, P.E. (1993). Violent communities, family choices, and children's chances: An algorithm for improving the odds. Developmental Psychopathology, 5, 609-627.

Roberts, L.W., Battaglia, J. & Epstein, R.S. (1999). Frontier ethics: Mental health care needs and ethical dilemmas in rural communities. Psychiatric Services, 50, 497-503.

Rowe, W.E. (1997). Changing ATOD norms and behaviors: A Native American community commitment to wellness. Evaluation & Program Planning, 20, 323-333.

Rueter, M.A., Conger, R.D. & Ramisetty-Mikler, S. (1999). Assessing the benefits of a parenting skills training program: A theoretical approach to predicting direct and moderating effects. Family Relations: Interdisciplinary Journal of Applied Family Studies, 48, 67-77.

Sampson, R.J. & Groves, W.B. (1989). Community structure and crime: Testing social-disorganization theory. American Journal of Sociology, 94, 774-802.

Sher, K.J., Walitzer, K.S., Wood, P.K. & Brent, E.E. (1991). Characteristics of children of alcoholics: Putative risk factors, substance use and abuse, and psychopathology. Journal of Abnormal Psychology, 100, 427-488.

Simons, R.L., Whitbeck, L.B., Beaman, W.J. & Conger, R.D. (1994b). The impact of mother's parenting, involvement by nonresidential fathers, and parental conflict on the adjustment of adolescent children. Journal of Marriage and Family, 56, 356-374.

Simons, R.L., Wu, C., Conger, R.D. & Lorenz, F.O. (1994a). Two routes to delinquency: Differences between early and late starters in the impact of parenting and deviant peers. Criminology, 32, 247-276.

Spoth, R., Goldberg, C., Neppl, T., Trudeau, L. & Ramisetty-Mikler, S. (2001). Rural-urban differences in the distribution of parent-reported risk factors for substance abuse among young adolescents. Journal of Substance Abuse, 13, 609-623.

Spoth, R., Redmond, C., Haggerty, K. & Ward, T. (1995). A controlled parenting skills outcome study examining individual difference and attendance effects. Journal of Marriage & the Family, 57, 449-464.

Spoth, R., Redmond, C., Hockaday, C. & Yoo, S. (1996). Protective factors and young adolescent tendency to abstain from alcohol use: A model using two waves of intervention study data. American Journal of Community Psychology, 24, 749-770.

Spoth, R., Redmond, C. & Shin, C. (1998). Direct and indirect latent-variable parenting outcomes of two universal family-focused preventive interventions: Extending a public health-oriented research base. Journal of Consulting & Clinical Psychology, 66, 385-399.

Spoth, R.L., Redmond, C. & Shin, C. (2001). Randomized trial of brief family interventions for general populations: Adolescent substance use outcomes 4 years following baseline. Journal of Consulting & Clinical Psychology, 69, 627-642.

Spoth, R., Redmond, C., Shin, C. & Azevedo, K. (2004). Brief Family Intervention Effects on Adolescent Substance Initiation: School-Level Growth Curve Analyses 6 Years Following Baseline. Journal of Consulting & Clinical Psychology, 72, 535-542.

Spoth, R., Reyes, M.L., Redmond, C. & Shin, C. (1999). Assessing a public health approach to delay onset and progression of adolescent substance use: Latent transition and log-linear analyses of longitudinal family preventive intervention outcomes. Journal of Consulting & Clinical Psychology, 67, 619-630.

Spoth, R., Yoo, S., Kahn, J.H. & Redmond, C. (1996). A model of the effects of protective parent and peer factors on young adolescent alcohol refusal skills. Journal of Primary Prevention, 16, 373-394.

Stanton, M.D. & Shadish, W.R. (1997). Outcome, attrition, and family-couples treatment for drug abuse: A meta-analysis and review of the controlled, comparative studies. Psychological Bulletin, 122, 170-191.

Stevens, M.M., Mott, L.A. & Youells, F. (1996). Rural adolescent drinking behavior: Three year follow-up in the New Hampshire Substance Abuse Prevention Study. Adolescence, 31, 159-166.

Stohr, M.K., Hemmens, C., Shapiro, B., Chambers, B. & Kelley, L. (2002). Comparing inmate perceptions of two residential substance abuse treatment programs. International Journal of Offender Therapy & Comparative Criminology, 46, 699-714.

Swaim, R.C. (1991). Childhood risk factors and adolescent drug and alcohol abuse. Educational Psychology Review, 3(4), 363-398.

Thombs, D.L. (2000). A retrospective study of DARE: Substantive effects not detected in undergraduates. Journal of Alcohol & Drug Education, 46, 27-40.

Thornberry, T.P. (1987). Toward an interactional theory of delinquency. Criminology, 25, 863-891.

Thornberry, T.P., Lizotte, A.J., Krohn, M.D., Farnworth, M. & Jang, S.J. (1991). Testing interactional theory: An examination of reciprocal causal relationships among family, school, and delinquency. Journal of Criminal Law and Criminology, 82, 3-35.

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies (1999). National household survey on drug abuse, 1997 [Computer file; ICPSR version]. Ann Arbor, MI: Inter-university Consortium for Political and Social Research (Distributor).

U.S. Department of Health and Human Services (DHHS), Mental Health: A Report of the Surgeon General, (Rockville, MD: National Institute of Mental Health, 1999) chap. 3; accessed on February 10, 2004 at www.surgeongeneral.gov/library/mentalhealth/pdfs/c3.pdf.

Vaughan-Sarrazin, M.S., Hall, J.A. & Rick, G.S. (2000). Impact of case management on use of health services by rural clients in substance abuse treatment. Journal of Drug Issues, 30, 435-464.

Vega, W.A., Kolody, B., Aguilar-Gaxiola, S., Alderete, E., Catalano, R. & Caraveo-Anduaga, J. (1998). Lifetime prevalence of DSM-III-R psychiatric disorders among urban and rural Mexican Americans in California. Archives of General Psychiatry, 55, 771-778.

Vicary, J.R., Swisher, J.D., Doebler, M.K., Yuan, J., Bridger, J.C., Gurgevich, E.A. & Deike, R.C. (1996). Rural community substance abuse prevention and intervention. Family & Community Health, 19, 59-72.

Vuchinich, S., Bank, L. & Patterson, G.R. (1992). Parenting, peers, and the stability of antisocial behavior in preadolescent boys. Developmental Psychology, 28, 510-521.

Wagenfeld, M.O., Murray, J.D., Mohatt, D.F. & DeBruyn, J.C. (1997). Mental health service delivery in rural areas: Organizational and clinical issues. In: Roberson, E.B., Sloboda, Z., Boyd, G.M., Beatty, L, and Kozel, N.J., eds. Rural Substance Abuse: State of Knowledge and Issues. National Institute on Drug Abuse; U.S. Department of Health and Human Services; National Institutes of Health: NIH Publication No. 97-4177. Rockville, MD.

Waitzfelder, B.E., Engel Jr., C.C. & Gilbert Jr., F.I. (1998). Substance abuse in Hawaii: Perspectives of key local human service organizations. Substance Abuse, 19, 7-22.

Warner, B.D. & Leukefeld, C.G. (2001). Rural-urban differences in substance use and treatment utilization among prisoners. American Journal of Drug & Alcohol Abuse, 27, 265-280.

Whitbeck, L.B., Hoyt, D.R., Chen, X. & Stubben, J.D. (2002). Predictors of gang involvement among American Indian Adolescents. Journal of Gang Research, 10, 11-26.

Wysong, E., Aniskiewicz, R. & Wright, D. (1994). Truth and DARE: Tracking drug education to graduation and as symbolic politics. Social Problems, 41, 448-472.

Mental Health Service Delivery in Rural America: Organizational and Clinical Issues

Earlier chapters have provided a context for a discussion of mental health service delivery issues in rural America. "Rural America comprises 2,305 counties, contains 83 percent of the nation's land, and is home to just over 60 million Americans, 25 percent of this country's total population" (McCabe & Macnee, 2002). Rural communities must address an equivalent prevalence of serious mental illnesses and clinical complexities in comparison to urban areas. The overall numbers of individuals with serious mental illnesses may be small (Gale & Deprez, 2003), but these individuals often live across vast areas, making coordinated service delivery challenging.

At the same time, rural communities generally have fewer services and mental health professionals than their urban counterparts. In many areas the number of mental health professionals is actually decreasing (Kane & Ennis, 1996), further exacerbating the issue of limited core services, such as case management, inpatient service, crisis response and continuity of care (Kane & Ennis, 1996; Rohland et al., 1998; Shelton & Frank, 1995). Limited resources are usually directed toward acute care needs, as opposed to prevention and health promotion (Gale & Deprez, 2003). In fact, Shelton and Frank (1995) found that rural community general hospitals provide more emergency psychiatric services than do their urban counterparts. Clearly, barriers to workforce development, as well as funding shortages are ever-present challenges.

To not only survive but also provide quality care, rural mental health systems are required to become increasingly creative in the assessment and provision of services. There has been little research done on what organizational structures and partnerships are most effective in meeting rural need (Amundson, 2001). Local decision-makers are struggling with how to transform fragmented care into coordinated service delivery systems (Gale & Deprez, 2003). Specialty practices are often not feasible, pushing communities to explore cross-system partnerships to meet consumers' individualized needs.

Mental health consumers generally seek services through the path of least resistance, which is often emergency rooms, primary care physicians, schools, the criminal justice system and natural support systems (e.g., faith-based organizations). These various service sectors may become components of a community's integrated mental health system. More specifically, many communities are establishing partnerships with primary care and schools, establishing multidisciplinary teams using assertive community treatment (ACT) or ACT-like models and utilizing paraprofessionals on treatment teams (Gale & Deprez, 2003; Kane & Ennis, 1996).

As indicated in previous chapters, rural areas are often perceived as homogeneous. However, there is actually a rich diversity among rural communities in terms of geography and culture. In this sense, service delivery systems need to match the unique history and qualities of different communities (Mulder et al., 2003). Some rural communities are able to optimize the natural strengths and supports they possess (Kane & Ennis, 1996).

Culturally, rural communities may rely much more on institutions outside of the traditional mental health system for mental health issues (Sears et al., 2003). Funding levels are typically anemic for mental health care, but dollars are not the only driver of services in many communities. Talents, infrastructure and even geographical features can be community assets over and above general funding levels (Mulder et al., 2003). However, there has been little work done on how rural communities may most effectively scan and then optimize these local assets.

Calls for the integration of service sectors and community assets are frequent, but a number of potential hurdles exist. Different professional groups may have conflicting philosophies and practices, communication may be ineffective, there may be disagreement regarding roles and regulations may discourage service flexibility (Van Hook & Ford, 1998). Rural successes and barriers are presented below as information for communities exploring service delivery alternatives for mental health.

The Community Mental Health Centers Act of 1963 and amendments in 1975 created CMHCs in many rural areas. These CMHCs were required to provide a range of services, including outpatient, inpatient, consultation and education, partial hospitalization and emergency/crisis intervention. Federal regulations also required linkages to the community and other community agencies.

For many, this brought a mental health service presence to areas that had previously been lacking. In some cases, this service presence appears stronger in rural areas than it does in urban localities. For example, Farrell and colleagues (1999) found that persons discharged from State hospitals to rural CMHCs were twice as likely to have continuity of care compared to urban areas. In this study, continuity of care was operationalized as demonstrating sufficient communication and planning between CMHCs and hospitals and services offered within two weeks of discharge.

Although rural communities have benefited from the CMHC system, traditional centers are unable to sufficiently address the level of current need. CMHCs are considering ways to form relationships with other health services to leverage resources to adequately meet this need (Hargrove & Keller, 1997).

Mental health service teams require the participation of existing community provider organizations and agencies. This model has had initial positive results, but full utilization and systems outcome evaluations are in early stages of development. Early findings suggested that these multidisciplinary teams can be established by utilizing the existing range of mental health professionals within fairly simple community organizational structures, while optimizing community predispositions to integrated services (Amundson, 2001).

Assertive Community Treatment (ACT), an evidence-based practice (EBP) for persons with serious mental illness, is one example of using multidisciplinary treatment teams. While communities have been importing models of multidisciplinary care that have varying levels of fidelity to ACT, historically, ACT and other EBPs have been created and tested in urban, predominantly White treatment environments, and the availability of these service models have varied greatly.

EBP programs and policy are routinely based upon urban models and experiences, and scaled-down to fit rural settings (Gamm, 2002; Mohatt, 2000). Although ACT has been in existence for many years, there are only a small number of studies that have explored whether or not ACT can be effectively integrated into rural settings and across race/ethnicity. Accordingly, the challenges and pitfalls of adapting this EBP have been well documented (Lachance, 1996; McDonel, 1997; Santos, 1993).

Several studies provide emerging data regarding ACT models in rural America. Lachance and Santos (1995) discuss how to modify ACT models for use in rural areas and suggest the need to keep six basic elements: 1) multi-service teams, 2) 24-hour service availability, 3) small caseloads that do not vary in composition, 4) ongoing and continuous services, 5) assertive outreach and 6) in-vivo rehabilitation.

McGrew, Pescosolido & Wright (2003) evaluated 73 ACT teams' ratings on the benefit of 16 activities and importance of 27 possible critical ingredients of the ideal team. Having a full-time nurse on the team was rated as the most important ingredient, and medication management was rated as the most beneficial clinical activity. The ratings of teams from urban and rural settings were highly correlated. The most under-implemented critical elements included the presence of a full-time substance abuse specialist, a psychiatrist's involvement on the team, team involvement with hospital discharge and working with a client support system.

Santos and colleagues (1993) evaluated the effect of an ACT program on rates of hospital utilization and cost of care and found a 79 percent decrease in hospital days per year, a 64 percent decrease in the number of admissions per year, a 75 percent decrease in the average length of stay per admission, and a 52 percent reduction in estimated direct cost of care.

Fekete and colleagues (1998) assessed the effectiveness of ACT compared to traditional mental health services in four rural communities regarding hospitalization use, quality of life, level of functioning, attitudes toward medication and residential, vocational and legal involvement. Experimental differences on staff rating of quality of life, level of functioning and symptoms favored ACT clients. There were no experimental differences in hospital use, but ACT clients exhibited less residential stability than control clients.

In a three-year controlled comparison between urban and rural integrated service agencies in California, communities utilized interdisciplinary teams similar to those in ACT programs within a capitated service delivery system (Chandler et al., 1996). The study found that those receiving the intervention had less hospital care, greater workforce participation, fewer group and institutional housing arrangements, less use of conservatorship, greater social support, more leisure activity, less family burden and greater client and family satisfaction. It is noteworthy that urban participants also faired better than rural participants in financial stability, personal well-being and friendship.

For example, more than 20 pilot schools in largely rural areas in South Carolina created integrated school-based mental health services models (Motes et al., 1999). One study surveyed 62 school administrators from rural, suburban and urban and found that suburban and rural schools provided more health and mental health services than urban schools. Even so, across all sites, physical health services still far outnumbered mental health services (Weist et al., 2000).

Partnerships between higher education and rural mental health systems have been successfully implemented in several States through Cooperative Extension Programs (Sears et al., 2003). The Institute for Social and Behavioral Research at Iowa State University has collaborated with Iowa State University Extension Services since the early 1990s in the creation and delivery of the Strengthening Families Program, a parenting skills and substance use prevention program that has shown promising results. This collaborative effort has supplied training and dissemination of the Strengthening Families Program to 30 counties.

A second collaborative model of mental health service delivery is found in Florida. In response to the psychological effects of Hurricane Andrew in 1992, the University of Florida Rural Psychology Program collaborated with the Department of Clinical and Health Psychology and the North Florida Area Health Education Center to improve access of mental health education and services for rural residents. The collaborative also sought to train health practitioners who in turn might foster local sustainability. There is growing evidence in support of these collaborative models of mental health service delivery (Sears et al., 2003).

Primary care physicians (PCPs) provide most mental health treatment in rural areas (Badger et al., 1999), as they are usually the first medical professionals to encounter patients' mental health problems (Bray et al., 1997). Sears and colleagues (2003) reviewed studies investigating prevalence of psychiatric disorders in rural primary care settings and found that 34 to 41 percent of patients had a mental health disorder. Other authors have suggested that more than half of all people suffering from mental disorders seek help through primary care, yet the majority of their conditions remain inappropriately diagnosed (Badger et al., 1999).

Integration of behavioral and physical health matches many patients' preferences for the environment in which they wish to receive mental health services. From a resource management perspective, integrated models also reduce or eliminate duplicated assessment and treatment efforts (Badger et al., 1999). Integrated services allow a multidisciplinary team to efficiently treat the comorbid conditions that the majority of mental health consumers present.

Because most PCPs do not have the training to adequately diagnose mental health issues, a large number of individuals are not receiving appropriate or adequate treatment. Rural areas need to determine what proportion of mental health consumers are served through primary care and what particular integrated care models might be efficiently incorporated into local community health infrastructures. There is a wide spectrum of integrated models ranging from full onsite integration (almost always housed in a primary care setting) to more formalized linkage and referral systems (Badger et al., 1999; Bird et al., 1998).

McCabe and Macnee (2002) found that communities implementing integration plans moved through a series of stages, from parallel behavioral and physical health systems, to overlapping services, and finally to a synthesized system. Bird and colleagues (1998) studied 53 primary care organizations in 22 States and found that four integration models were identified: 1) diversification, 2) linkage, 3) referral and 4) enhancement, with communities typically using a combination of these strategies.

Although a number of viable alternatives exist, linking primary care and mental health care in rural areas remains difficult. A persistent problem is that primary care and mental health providers differ in terms of their patients, reimbursement and treatment philosophies (Lambert & Hartley, 1998). Additionally, primary care and mental health professionals may have long-standing modes of communication that are not advantageous to integrated care models. For instance, PCPs may be accustomed to consults at a distance (e.g., telephone), and they may receive little information back when referring out to mental health specialists. In part, this ineffective feedback loop is due to historical concerns regarding the balance between confidentiality and treatment partnerships (Little et al., 1998). In theory, integrated models are applauded by both the behavioral and physical health sectors, while in practice there are a multitude of details that must be worked through as communities forge innovative treatment partnerships.

Among the 53 successfully linked (i.e., integrated) programs Lambert and Hartley (1998) identified nationally, efforts ranged from small, local projects to sophisticated multi-county networks. The authors found that organizations cooperate with each other when it is in their self-interest and that motivation to integrate cannot be mandated. To overcome natural avoidance of change, community champions will need to identify and market the value-add that integrated models hold for all involved service sectors.

An essential element of outreach and marketing will be the clear message that integrated services are either cost neutral or, in the best case scenarios, lead to cost savings. At the same time, cost benefits will not be sufficient (Lambert & Hartley, 1998). There are inherent disadvantages to integrated care that must be addressed. For example, benefits to mental health consumers and cost savings may lead to individual organizations losing some autonomy. Also, sites may no longer enjoy the same levels of independence regarding budgets and accountability.

The Linkages Project is an example of a demonstration project that addresses many integration issues. The project trained psychologists and family physicians for collaborative practice and also focused on cultural differences between professional practices; differences between medical specialties and strategies for success, such as practice styles and issues, confidentiality and sharing patient records between the professions, stereotypes and emotional factors that impede collaborative practice, linkage and referrals, financial arrangements, methods for developing collaborative practice and nontraditional mental health practice (Bray et al., 1997).

Another study looked at the results of placing 28 mental health staff in general rural health care settings (Van Hook & Ford, 1998). The study found that benefits of the model included increased access and coordination and promotion of an integrated vision of health care. Barriers were also apparent. The partnering organizations needed to surmount space limitations, differences among health disciplines and administrative logistical problems. These and other studies of integrated care models will be instructive as communities tackle rural service delivery concerns such as healthcare professional shortages and the prevalence of mental health issues seen in primary care settings.

Various provider types (i.e., public hospitals and Community Health Centers) are often mentioned when discussing safety net providers. These two providers are responsible for a large portion of the safety net care in underserved communities (Hartley & Gale, 2003). The Community Mental Health Centers Act of 1963 provided Federal funding to develop satellite clinics in rural or remote areas (Geller et al., 1997). The number of these clinics has declined since 1981 due to shifts in government funding and with the growth of managed care systems (Geller et al., 1997).

Rural hospitals are more likely to be government-owned than urban hospitals (Mohr et al., 1999). Other differences exist between rural and urban hospitals. According to the Medicare Payment Advisory Committee (2001), rural hospitals, in general, have a lower Medicare inpatient margin (4.1 percent in 1999) when compared to urban hospitals (13.5 percent). Rural hospitals tend to be more dependent on Medicare and have a smaller percentage of patients who pay with private insurance (Medicare Payment Advisory Committee, 2001). Although urban hospitals have a large, publicly-funded patient base, they have a larger tax-base and have more clinicians to deliver the care (Hartley & Gale, 2003).

Federally Qualified Health Centers (FQHCs) are another type of safety net provider. According to Farley and colleagues (2002), as of 1998, 42 percent of the 1,890 FQHCs were located in rural counties.

A third type of safety net provider is public mental health departments. However, certain specialty services (e.g., prenatal care and HIV/AIDS treatment) are often not available in rural areas (Hartley & Gale, 2003; Ricketts, Slifkin & Silberman, 1998).

The Federal Government has established providers designed specifically for rural areas, including Rural Health Clinics (RHC) and Critical Access Hospitals (CAH) (Hartley & Gale, 2003). RHCs were created in 1977 to help recruit medical practitioners to rural communities (Gale & Coburn, 2003). RHCs are mandated to serve Medicaid patients but are not obligated to serve all uninsured patients (Hartley & Gale, 2003). CAHs were created by the Medicare Rural Hospital Flexibility Act (1997), which allows hospitals in rural areas to offer more acute inpatient services. A CAH facility must meet the following criteria: 1) be located in a State that has an approved rural health plan; 2) be located in a rural area more than a 35-mile drive from any other hospital or CAH (15 miles in mountainous terrain or in areas with only secondary roads) and 3) maintain an average acute care length of stay of 96 hours or less; limit their bed size to 25 acute care beds (Hagopian & Hart, 2001).

Hartley and Gale (2003) delineate several Federal programs that support the delivery of health care services in rural areas.

Models of mental health care have predominantly been designed in urban locales in coordination with academic centers. The dissemination of these models to rural communities may be a mismatch in terms of resource allocation and culture. It is critical that rural mental health administrators and decision makers not only explore workforce development but the structure in which mental health services are embedded. Some mental health systems are successfully leveraging their resources by coordinating care with other service sectors, such as the schools and primary care, as well as natural systems of supports (e.g., faith-based and philanthropic organizations). The thoughtful linkage of service systems may increase service access to rural residents, while also acknowledging cultural norms leading persons to seek services outside of a traditional CMHC structure. Rural service delivery advances are challenging, but the available literature suggests that communities do have pragmatic options.

Amundson, B. (2001). "America's rural communities as crucibles for clinical reform: Establishing collaborative care teams in rural communities." Families, Systems & Health 19(1): 13-23.

Badger, L., Robinson, H. et al. (1999). "Management of mental disorders in rural primary care: A proposal for integrated psychosocial services." Journal of Family Practice 48(10): 813-818.

Bird, D. Lambert, D., et al. (1998). "Rural models for integrating primary care and mental health services." Administration & Policy in Mental Health 25(3): 287-308.

Bray, J. H., Enright, M.F., et al. (1997). Collaboration with primary care physicians. Practicing psychology in rural settings: Hospital privileges and collaborative care. J. A. Morris. Washington, DC, American Psychological Association: 55-65.

Chandler, D., Meisel, J., et al. (1996). "Client outcomes in a three-year controlled study of an integrated service agency model." Psychiatric Services 47(12): 1337-1343.

Farrell, S. P., Blank, M., et al. (1999). "Predicting whether patients receive continuity of care after discharge from State hospitals: Policy implications." Archives of Psychiatric Nursing 13(6): 279-285.

Fekete, D.M., Bond, G.R., McDonel, E.C., Salyers, M., Chen, A.,

Miller, L. (1998). Rural assertive community treatment: A field experiment. Psychiatric Rehabilitation Journal, 21, 371-379.

Gale, J. A. and Deprez, R.D., (2003). A public health approach to the challenges of rural mental health service integration. Rural behavioral health care: An interdisciplinary guide. B. H. Stamm. Washington, D.C., American Psychological Association: 95-108.

Gale J & Coburn A. The characteristics and roles of Rural Health Clinics in the United State s: A chartbook. Portland: University of Southern Maine, Edmund S. Muskie School of Public Service, Institute for Health Policy, Maine Rural Health Research Center; 2003. Available at: http://muskie.usm.maine.edu/Publications/rural/RHChartbook03.pdf.

Gamm, L., Tai-Seale, M. & Stone, S. (2002). White paper: Meeting the mental health needs of people living in rural areas. College Station, TX, Department of Health Policy and Management, School of Rural Public Health, Texas A&M University System Health Science Center.

Geller, J., Beeson, P., and Rodenhiser, R. , (1997). Frontier mental health strategies: Integrating, reaching out, building up and connecting. Letter to the Field No. 6. Frontier Mental Health Services Resource Network.

Hagopian A, Hart G. Rural Hospital Flexibility Program Tracking Project. Seattle: WWAMI Rural Health Research Center, University of Washington; 2002. Chapter 1: Introduction to the Rural Hospital Flexibility Program Year 1 Report. Available at: http://www.rupri.org/rhfp-track/year1/chapter1.html. Accessed May 7, 2003.

Hargrove, D. S. and Keller, P. A. (1997). Collaboration with community mental health centers. Practicing psychology in rural settings: Hospital privileges and collaborative care. J. A. Morris. Washington, D.C., American Psychological Association: 67-80.

Kane, C. F. and Ennis, J. M., (1996). "Health care reform and rural mental health: Severe mental illness." Community Mental Health Journal 32(5): 445-462.

Lachance, K. R., Deci, P. A., Santos, A. B. & Halewood, N. (1996). Rural assertive community treatment: Taking mental health services on the road. Innovative services for difficult to treat populations. Washington, D.C., American Psychiatric Press: 279-294.

Lachance, K.R., Santos, A.B. (1995). Modifying the PACT model: Preserving critical elements. Psychiatric Services, 46, 601-604.

Lambert, D. and Hartley, D., (1998). "Linking primary care and rural psychiatry: Where have we been and where are we going?" Psychiatric Services 49(7): 965-966.

Little, D. N., Hammond, C., et al. (1998). "Referrals for depression by primary care physicians: A pilot study." Journal of Family Practice 47(5): 375-377.

McCabe, S. and Macnee, C. L., (2002). "Weaving a new safety net of mental health care in rural America: a model of integrated practice." Issues in Mental Health Nursing. 23(3): 263-78.

McDonel, E. C., Bond, G. R., Salyers, M., et al., (1997). "Implementing assertive community treatment programs in rural settings." Administration and Policy in Mental Health 25(2): 153-173.

McGrew, J.H., Pescosolido, B. & Wright, E. (2003). Case managers' perspectives on critical ingredients of assertive community treatment and on its implementation. Psychiatric Services, 54(3), 370-376.

Mohatt, D. F. (2000). "Access to mental health services in frontier areas." Journal of The Washington Academy of Sciences 86(3): 35-48.

Motes, P. S., Melton, G., et al. (1999). "Ecologically oriented school-based mental health services: Implications for service system reform." Psychology in the Schools 36(5): 391-401.

Mulder, P. L., Linkey, H., et al. (2003). Needs assessment, identification and mobilization of community resources, and conflict management. Rural behavioral health care: An interdisciplinary guide. B. H. Stamm. Washington, D.C., American Psychological Association: 67-79.

Ricketts T, Slifkin R, Silberman P. The Changing Market, Managed Care and the Future Viability of Safety Net Providers-Special Issues for Rural Providers. Background Paper for the Institute of Medicine. Chapel Hill: Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill; 1998.

Rohland, B. M., Rohrer, J. E. et al., (1998). "Broker model of case management for persons with serious mental illness in rural areas." Administration & Policy in Mental Health 25(5): 549-553.

Santos, A.B., Deci, P.A., Lachance, K.R., et al. (1993). Providing assertive community treatment for severely mentally ill patients in a rural area. Hospital and Community Psychiatry, 44, 34-39.

Sears, S. F., Evans, G. D. , et al. (2003). Rural social service systems as behavioral health delivery systems. Rural behavioral health care: An interdisciplinary guide. B. H. Stamm. Washington, D.C., American Psychological Association: 109-120.

Shelton, D. A. and R. Frank (1995). "Rural mental health coverage under health care reform." Community Mental Health Journal 31(6): 539-552.

Van Hook, M. P. and Ford, M. E., (1998). "The linkage model for delivering mental health services in rural communities." Health & Social Work 23(1): 53-60.

Weist, M. D., Myers, C., et al. (2000). "Expanded school mental health services: Assessing needs related to school level and geography." Community Mental Health Journal 36(3): 259-273.

Notes for Chapter 4

1. http://nhsc.bhpr.hrsa.gov

2. http://bhpr.hrsa.gov/ahec/

3. http://www.cms.hhs.gov/manuals/Downloads/bp102c13.pdf

4. http://www.cms.hhs.gov/hpsapsaphysicianbonuses/

5. http://www.cms.hhs.gov/transmittals/downloads/B000260.PDF

6. http://bhpr.hrsa.gov/Grants/Default.htm

7. Community Health Center

8. http://www.bphc.hrsa.gov/CHC/

9. http://www.globalhealth.gov/waiverannouncement.shtml

Workforce Development

The Scope and Nature of Workforce Shortages in Rural America

Mental health workforce shortages have been a fact of life in rural America for decades (Flax, Wagenfeld, Ive & Weiss, 1979; Murray & Keller, 1991). For instance, consider these statistics identified from the President's New Freedom Commission on Mental Health, Subcommittee on Rural Issues report:

Map 1: Mental Health Professional Shortage Areas (generated at http://datawarehouse.hrsa.gov/)

Map of Mental Health Professional Shortage Areas

More than 85 percent of 1,669 Federally designated mental health professional shortage areas are rural (Bird, Dempsey & Hartley, 2001).
Holzer and colleagues (2000) found that few psychiatrists, psychologists, or clinical social workers practice in rural counties and that the ratio of these providers to the population worsens as rurality increases.
For the past 40 years, approximately 60 percent of rural America has been underserved by mental health professions.
The National Advisory Committee on Rural Health (1993) noted that across the 3,075 counties in the United States, 55 percent had no practicing psychiatrists, psychologists, or social workers, and all of these counties were rural.
These workforce shortages are even worse for specialty areas, such as children's mental health, older adult mental health and minority mental health.

The report goes on to describe factors that have impeded workforce development, which generally included an intricate mix of training, professional, organizational and regulatory issues. (For more details, see the report at http://www.mentalhealthcommission.gov/papers/Rural.pdf).

Bird, Dempsey and Hartley (2001) offer other data that buttresses these statistics. For instance, the lack of mental health professionals is likely a key factor in explaining differences in access and use of mental health services in rural compared to urban areas. Additionally, it is difficult to translate methods for estimating workforce adequacy from health to mental health, as the mental health workforce is characterized by a considerable overlapping of roles. The authors suggest that baseline data on the reality of the mental health workforce in rural areas are needed in order to make adequate projections and/or comparisons. They encourage national and State mental health professional associations to participate in the collection, verification, and analysis of workforce data. State Medicaid agencies are also viewed as a potential resource for workforce data.

In a National Health Policy Forum (NHPF) Issue Brief, Koppelman (2004) describes the shortage of qualified providers to address children's mental disorders, possible causes, the relationship of managed care to practice patterns and difficulties deciding which providers are most qualified to deliver what care. In brief, she identifies issues similar to what has been discussed. For instance, the mental health workforce is described as "in flux," with practice boundaries between psychiatrists, psychologists, counselors and other mental health professionals becoming increasingly blurry to consumers and payers. Some of these professions are described as redefining their roles, which makes it difficult to determine how many more mental health professionals are needed to boost supply.

Furthermore, different mental health disciplines require different levels of training, have different areas of expertise and have different salaries (Koppelman, 2004). Indeed, money is noted to be a fundamental issue regarding the development of an adequate workforce. Education is expensive, health plans favor lower-paid providers and mental health professionals in the public system often get paid less.

The Western InterState Commission for Higher Education (WICHE) Mental Health Program analyzed data (from http://higheredinfo.org/) regarding population projections from 2000 to 2025 for its 15 member States (Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, North Dakota, New Mexico, Oregon, South Dakota, Utah, Washington and Wyoming). If these projections are accurate, only four States-Alaska, California, Hawaii and New Mexico-will have more people entering or in the workforce than leaving it.

Specifically, the 15-WICHE member States will average an 18 percent increase in persons age 18 to 64 (range of 1.4 percent in North Dakota to 37.8 percent in Hawaii) between 2000 and 2025. However, in the same time period, these States will average a 122 percent increase in those entering their retirement years (i.e., 65 years and older) (range of 72.6 percent in South Dakota to 159.7 percent in Utah).

While this is by no means an exhaustive list of issues that define the workforce shortage problem in rural America, one can get a good sense of its scope. Problems such as these will not be solved immediately, but work to address them is underway.

Policy Options & Goals for Rural Workforce Development

Three policy options regarding workforce development in rural America are offered in the New Freedom Commission, rural subcommittee report:

"Policy Option 8: The Secretary of HHS is urged to convene a cross-agency work group to examine existing workforce enhancement programs and make recommendations for ensuring and enhancing their collaborative focus on rural mental health needs" (p. 10).
"Policy Option 9: The Subcommittee encourages the Secretary of HHS to support an effort to articulate a rural mental health workforce strategy that includes a realistic use of and support of mid-level and alternative providers of mental health services" (p. 11).
"Policy Option 10: The Subcommittee proposes that the Administrator of SAMHSA ensure the support of programs that specifically support the training, deployment and continuing education of rural mental health professionals. Such support might focus on strengthening the capacity and competency of the workforce to support an evidence-based practice care delivery system" (p. 11).

Furthermore, three specific goals in the final report to the President directly addressed workforce issues, especially for rural America. These included:

GOAL 3 Disparities in Mental Health Services Are Eliminated:

3.2 Improve access to quality care in rural and geographically remote areas.

GOAL 5 Excellent Mental Health Care Is Delivered and Research Is Accelerated:

5.3 Improve and expand the workforce providing evidence-based mental health services and supports.

GOAL 6 Technology Is Used to Access Mental Health Care and Information:

6.1 Use health technology and telehealth to improve access and coordination of mental health care, especially for Americans in remote areas or in underserved populations.

Additionally, consistent with the six goals of transforming the mental health system established by the President's New Freedom Commission on Mental Health, SAMHSA's Action Plan for Mental Health Systems Transformation includes as key activities in 2005 the creation and implementation of a National Strategic Workforce Development Plan.

Bird, Dempsey and Hartley (2001) make these recommendations:

The National Health Service Corps (NHSC) should allocate resources specifically reserved for mental health workforce development to State loan repayment programs;
Managed care and managed behavioral health organizations should experiment with ways of offering limited behavioral health credentials to primary care practitioners, especially in rural areas;
Credentialing standards should reflect the realities of rural service delivery by recognizing the important contributions of non-physical mental health professionals at all levels (Bachelors and Masters) and
CHCs, RHCs, and CMHCs should make judicious use of non-professional and paraprofessional mental health workers, especially for outreach and prevention activities.

Rural Mental Health Workforce

A number of organizations, agencies and entities have been undertaking workforce development efforts for the past several years. Among these are SAMHSA, HRSA, the National Center for Health Workforce Information and Analysis (a part of HRSA's Bureau of Health Professions), the Annapolis Coalition on Behavioral Health Workforce Education, the Western InterState Commission for Higher Education Mental Health Program, the National Association for Rural Mental Health (NARMH), Edmund S. Muskie School of Public Service, the MacArthur Foundation, the Criminal Justice/Mental Health Consensus Project, the Council on Graduate Medical Education (COGME), the Quentin N. Burdick Rural Health Interdisciplinary Program, as well as the Child Healthcare Crisis Relief Act (H.R. 1359, 2003). Each of these organizations or legislative initiatives will be discussed in turn.

Substance Abuse and Mental Health Services Administration (SAMHSA): Some of the efforts of SAMHSA have been documented above. However, Bird, Dempsey and Hartley (2001) point out that the Center for Mental Health Services (CMHS) in SAMSHA currently administers most of the programs relevant to mental health workforce development and the mental health needs of underserved rural communities. For instance, in partnership with the Annapolis Coalition, SAMHSA has launched a new "Science to Service Agenda" initiative to promote best practices in mental health care (Koppelman, 2004). The initiative includes ongoing development of a national registry of effective programs and practices in mental health and substance abuse. So far, 150 programs are listed (see www.modelprograms.samhsa.gov). SAMHSA is also offering a range of grants to help public mental health systems implement evidence-based practice and develop the most effective ways to reduce service gaps.

Health Resources and Services Administration (HRSA): HRSA directs programs that improve the Nation's health by expanding access to comprehensive, quality health care for all Americans. HRSA works to train a health workforce that is both diverse and motivated to work in underserved communities by offering a number of funding mechanisms for health professions training. Two other major programs are the National Center for Health Workforce Information and Analysis and the National Health Services Corps (NHSC), which are described below.

National Center for Health Workforce Information and Analysis: Provides access to in-depth profiles regarding the supply, demand, distribution, education and use of health personnel. Estimated numbers of workers indicate the size of the State's health workforce. Per capita ratios facilitate comparisons with other States and the Nation. Each Profile has three sections: 1) a brief overview of residents' health status and health services that influence supply of and demand for health workers, 2) health care employment by place of work, including hospitals, nursing homes and other settings and 3) health care employment in more than 25 health professions and occupations, including mental health (see http://bhpr.hrsa.gov/healthworkforce/reports/profiles/).

National Health Service Corps (NHSC): Committed to improving the health of the Nation's underserved by uniting communities in need with caring health professionals supporting communities' efforts to build better systems of care, the NHSC provides comprehensive team-based health care that bridges geographic, financial, cultural and language barriers. The NHSC forms partnerships with communities, States, educational institutions and professional organizations; recruits caring, culturally competent clinicians for communities in need; provides opportunities and professional experiences to students through scholarship and loan repayment programs and a SEARCH (Student/Resident Experiences and Rotations in Community Health) program; establishes systems of care that remain long after an NHSC clinician departs, and shapes the way clinicians practice by building a community of dedicated health professionals who continue to work with the underserved even after their NHSC commitment has been fulfilled (see http://nhsc.bhpr.hrsa.gov/).

The Annapolis Coalition on Behavioral Health Workforce Education: The Coalition, which receives SAMHSA funding, was founded by the American College of Mental Health Administration, a multidisciplinary body, and the Academic Behavioral Health Consortium, a nonprofit group comprised of university departments of psychiatry. In 2003, the Coalition recommended to the President's New Freedom Commission on Mental Health that the Federal government use a number of strategies to improve the behavioral health workforce; including instituting policies in Federally funded health plans to promote appropriately prepared and supervised trainees. As noted earlier, they are also involved in SAMHSA's "Science to Service Agenda." They currently have a number of position papers regarding children's workforce issues, evidence-based teaching strategies, innovation in workforce education, behavioral health competencies (development & assessment) and best practices in workforce education (see http://www.annapoliscoalition.org/position_papers.php or http://www.annapoliscoalition.org/index.php).

The Western InterState Commission for Higher Education (WICHE) Mental Health Program: The Mental Health Program at WICHE was established in 1955 by the Western Regional Council of State Governments. It is governed by the Mental Health Oversight Council (MHOC), composed of the State mental health directors from the 15 WICHE States, plus special advisors and WICHE Commissioners. The mission of the program is twofold: 1) to assist States in improving systems of care for mental health consumers and their families and 2) to advance the preparation of a qualified mental health workforce in the West. The program collaborates with States to meet the challenges of changing environments through regional research and evaluation, policy analysis, program development, technical assistance and information sharing.

During 2004, the Mental Health Program worked with the University of Alaska (UA) system and the Alaska Division of Behavioral Health in a strategic planning effort to enhance collaboration between higher education and the public mental health system. This work evolved from existing efforts in Alaska, which were further focused by a WICHE Mental Health Program sponsored policy roundtable on rural mental health workforce issues held in Reno, Nevada in September 2003.

The Alaska work resulted in the creation of shared goals among the Division of Behavioral Health and University of Alaska system, as well as funding to achieve them. The goals fell into four categories (collaboration, education, funding and research & evaluation) and among them were:

Develop a behavioral health workforce vision and action plan;
Create collaborations to develop more rural-specific training and continuing education opportunities at all levels of competency;
Explore how UA should respond to the integration of mental health and substance abuse disciplines;
Support innovative approaches using distance education to expand access to continuing education that enables rural persons to obtain professional training;
Support the development of an articulated career pathway from paraprofessional through post-graduate training;
Offer financial incentives for graduates to return to or remain in Alaska to practice in rural and underserved areas;
Collect and analyze more data regarding articulation of coursework and training among UA behavioral health programs, as well as workforce needs;
Analyze factors that increase enrollments and declared majors, as well as factors that promote retention and degree completion.

WICHE is currently working on a project similar to Alaska's in Arizona.

In South Dakota and Wyoming, the Mental Health Program is actively engaged in training initiatives for community mental health staff to promote a shift to integrated care for children with serious emotional disturbances.

In Idaho, the WICHE Mental Health Program provided training to primary care providers on behavioral health care. Like in Alaska, the Mental Health Program is working with the Division of Mental Health to enhance collaboration between higher education and the public mental health system to ensure an adequate workforce.

National Association for Rural Mental Health (NARMH): The Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (CMHS, SAMSHA) is currently collaborating with NARMH to review successful rural mental health outreach practices. It should be noted that some rural programs have developed innovative outreach efforts; however, more outreach approaches are still necessary. The most important finding that surfaced by the CMHS, SAMSHA and NARMH workgroup was the successful outreach efforts targeting the needs of consumers as defined by them (the consumers) and that the services are situated in the context of that community (Lambert et al., 2001).

Maine Rural Health Research Center (Edmund S. Muskie School of Public Service): Established in 1992, the Maine Rural Health Research Center (MRHC) draws on the multidisciplinary faculty and research resources and capacity of the Institute for Health Policy within the Edmund S. Muskie School of Public Service, University of Southern Maine. Rural health is one of the primary areas of research and policy analysis focus within the Institute for Health Policy. The Center builds upon the Institute's strong record of research, policy analysis and policy development that addresses critical problems in health care financing and delivery.

The MRHC's mission is to inform health care policymaking and the delivery of rural health services through high quality, policy relevant research, policy analysis and technical assistance on rural health issues of regional and National significance. The Center is committed to enhancing policymaking and improving the delivery and financing of rural health services by effectively linking its research to the policy development process through appropriate dissemination strategies. The Center builds upon a strong record of rural health services research that addresses critical problems in health care financing and delivery and which capitalizes on the health services research and health policy capacity and experience of the University of Southern Maine's Muskie School of Public Service.

Recent publications from MHRC regarding rural mental health workforce address such topics as the role of advanced practice psychiatric nurses (2004), CMHCs as rural safety nets (2002) and the impact of State licensure laws on workforce (2002) (see http://muskie.usm.maine.edu/ihp/ruralhealth/papers.jsp for more; see also http://muskie.usm.maine.edu/ihp/ruralhealth/ for more information on MRHC's other activities).

MacArthur Foundation: The MacArthur Foundation is funding a major effort, the Network on Youth Mental Health, which is reviewing the evidence for therapies to treat the most common childhood disorders and testing methods of delivering evidence-based practices in community mental health centers. The initiative is also studying organizational and payment policies that discourage providers from practicing evidence-based care and will use this knowledge to develop ways to share evidence-based practices with a variety of clinics and providers (Koppelman, 2004).

Criminal Justice/Mental Health Consensus Project: As described at their Web site (http://www.consensusproject.org/about-the-project/history_methodology_ab), the Council of State Governments (CSG) developed the Criminal Justice/Mental Health Consensus Project in response to requests from State government officials for recommendations to improve the criminal justice system's response to people with mental illness. Among the reasons for the undertaking were tragedies involving people with mental illness that seemingly could have been prevented and the enormous strain on criminal justice and State budget resources resulting from the current approach to responding to people with mental illness.

CSG partnered with six organizations: 1) the Police Executive Research Forum (PERF), 2) the Pretrial Services Resource Center (PSRC), 3) the Association of State Correctional Administrators (ASCA), 4) the National Association of State Mental Health Program Directors (NASMHPD), 5) the Bazelon Center for Mental Health Law and 6) the Center for Behavioral Health, Justice and Public Policy. Together, staff from these organizations formed the Consensus Project Steering Committee, which two legislators (Rep. Mike Lawlor of Connecticut and Sen. Robert Thompson of Pennsylvania) co-chaired. The Steering Committee designed an 18-month initiative to build on the ideas developed during the first two working group meetings, to broaden the support base for these recommendations, and to identify efforts in jurisdictions across the country that could help inform the implementation of the recommendations.

Their recommendations include:

Plan to increase the supply of skilled and experienced mental health providers;
Promote the employment of current and former clients in the provision of mental health services;
Provide training that specifically addresses the consumer and family experience of mental illness and
Plan to increase the supply of skilled and experienced mental health providers in rural areas.

Quentin N. Burdick Rural Health Interdisciplinary Program: The goal of this program is to provide or improve access to health care in rural areas. Specifically, projects funded under this authority shall be designed to: 1) use new and innovative methods to train health care practitioners to provide services in rural areas; 2) demonstrate and evaluate innovative interdisciplinary methods and models designed to provide access to cost-effective comprehensive health care; 3) deliver health care services to individuals residing in rural areas, 4) enhance the amount of relevant research conducted concerning health care issues in rural areas and 5) increase the recruitment and retention of health care practitioners from rural areas and make rural practice a more attractive career choice for health care practitioners. The program provides about $5 to 6.5 million a year in support to demonstration programs that offer interdisciplinary learning experiences for clinicians in training and practice (see http://bhpr.hrsa.gov/interdisciplinary/rural.html for more information).

The Child Healthcare Crisis Relief Act (H.R. 1359, 2003): In March 2003, Rep. Patrick Kennedy (D-RI) introduced H.R. 1359, which would use educational incentives to lure more students into the children's mental health professions. The bill would extend Medicare graduate medical education funding to child psychiatry training programs and create a loan forgiveness program for child and adolescent psychiatrists. The bill would also offer scholarships and loan forgiveness to bolster the numbers of school psychologists and social workers, school counselors and psychiatric nurses (Koppelman, 2004).

Taken together, these organizations, agencies and initiatives are making significant strides in addressing strategies to ensure an available and competent rural mental health workforce.

Summary

The troubling reality of mental health workforce shortages in rural America is well-documented and has persisted for decades. However, it is significant that the New Freedom Commission, Subcommittee on Rural Issues report has been one of the first to be released. Indeed, as of this writing, only four of 16 subcommittee reports have been released thus far. Rural America and issues facing rural residents are "back on the map." Moreover, a solid number of organizations, government agencies, advocacy groups and policy initiatives have taken up the call to ensure that workforce shortages will become not a fact of the present, but one of history.

References

Bird, D. C., Dempsey, P. & Hartley, D. (2001). Addressing mental health workforce needs in underserved rural areas: Accomplishments and challenges. Portland, ME: Maine Rural Health Research Center, Muskie Institute, University of Southern Maine.

Flax, J. W., Wagenfeld, M. O., Ive, R. E. & Weiss, R. J. (Eds.). (1979). Mental health and rural America: An overview and annotated bibliography (DHEW Publication No. 78-753rd ed.). Washington, DC: U.S. Government Printing Office.

Holzer, C.E. III, Goldsmith, H. F. & Ciarlo, J.A. (2000). The availability of health and mental health providers by population density. Journal of the Washington Academy of Sciences, 86(3), 25-33.

Koppelman, J. (2004). The provider system for children's mental health: Workforce capacity and effective treatment. NHPF Issue Brief No. 801, National Health Policy Forum, George Washington University. Washington, D.C.

Murray, J. D. & Keller, P.A. (1991). Psychology and rural America. American Psychologist, 46(3): 220-231.

National Advisory Committee on Rural Health. (1993). Sixth Annual Report on RuralHhealth. Rockville, MD: Office of Rural Health Policy, Health Resources and Services Administration, HHS.

New Freedom Commission on Mental Health. Subcommittee of Rural Issues: Background Paper. DHHS Pub. No. SMA-04-3890. Rockville, MD: 2004.

Where to Go From Here: Rural Mental Health in the 21st Century

Information in previous chapters presents two basic ideas. First, rural mental health in the 21st century faces significant challenges. Second, these challenges are being more widely recognized and addressed by organizations and agencies at local, State, regional and Federal levels.

The President's New Freedom Commission on Mental Health (2003) has provided a vision and framework for mental health care across the country. The Commission's six overarching goals are:

Americans understand that mental health is a critical part of overall health;
Mental health is consumer and family driven;
Disparities in mental health services are eliminated;
Early mental health screening, assessment and referral to services are common practice;
Excellent mental health care is delivered and research is accelerated; and,
Technology is used to access mental health care and information.

Specific to rural issues, three sub-goals are identified:

Improve access to quality care in rural and geographically remote areas.
Improve and expand the workforce providing evidence-based mental health services and supports.
Use health technology and telehealth to improve access and coordination of mental health care, especially for Americans in remote areas or in underserved populations.

Looking to the future of rural mental health care, Sawyer and Beeson (1998), Stated that issues remain consistent and include (but are not limited to):

1) increasing needs and limiting resources; 2) geographic and cultural challenges to service delivery; 3) lack of available staff; 4) urban models applied to rural areas and 5) misunderstanding of rural communities by policy makers.

In creating a strategy to address these problems and improve care, Sawyer and Beeson (1998) propose a "Five Cs" approach: Consumers, Competence, Cost, Communicating and Connecting.

Consumer and family involvement is essential to ameliorating mental health services in rural communities. It is critical to identify consumer and family advocates who can articulate rural mental health needs to policy makers at all levels. Consumers should also be active participants in the planning of mental health services.

Second, it is important to understand that delivering care in rural areas requires a specific set of knowledge, skills and abilities in order to meet the unique needs of rural residents. In addition, best practices and evidence-based practice guidelines need to be identified and applied to the provision of mental health services in rural areas.

Third, rural mental health service providers must accurately estimate actual service delivery costs and operate a mental health system that is efficient and responsive to the target population.

Fourth, rural mental health providers who have successfully implemented innovative programs need to increase their communication about these programs with other providers, as well as policy makers.

Finally, rural mental health providers need to link with other organizations to create a viable and solid network of support. This will help to ensure service sustainability and will present a united front to potential funders. It will be important for rural mental health systems to be mindful of and proactive in increasing the visibility of rural mental health needs.

In a report by the Institute of Medicine (IOM), Wakefield (2004), as one of the authors, outlined a 5-pronged strategy to address unique quality challenges in rural communities, which overlaps with the model just described. In addition to enhancing human resource capacity, ensuring financial stability and integrating services, she recommends a prioritized approach to addressing health needs, establishing quality improvement mechanisms and building an information and communications technology infrastructure.

Taking these models together, one can see connections to the three primary issues facing rural mental health care described earlier: availability, accessibility and acceptability. Bearing these themes in mind, four primary areas of work in rural mental health arise: 1) Education and Training, especially as related to licensing; 2) Clinical Programs and Services; 3) Administration, particularly funding and 4) Research and Evaluation.

It is very difficult to determine which of these areas should take precedence, as they are intricately intertwined. Thus, it seems most appropriate to recommend strategies that, to the extent possible, include parallel, interconnected activities at each level. Short of such an approach, organizations or agencies taking on these tasks must decide for themselves which requires the most immediate or primary attention, as determined by available evidence.

Education and Training

Education and training efforts regarding rural mental health apply to two populations: clinicians and consumers.

Mental health clinicians in rural areas encounter a variety of cultural norms, values and ethics, as well as unique ethical dilemmas. However, at present, most clinicians working in rural areas learn about rural culture "on the job," and then only partially if they commute from more urban settings. The most logical place to acculturate clinicians in rural issues is academic institutions, especially universities in largely rural States. In particular, academic institutions offering specialized training in rural mental health, priority placement for projects with a rural emphasis and providing financial assistance to students either from rural areas or those who have a desire to work in rural communities could help meet workforce needs (Mulder et al., 2000).1

Situating some of these educational and training programs in rural communities cannot only help to acculturate students, but also provide them with a larger system of care context in which to understand their training and clinical experiences. Universities or colleges with rural-focused programs can also enter into partnerships with community organizations or agencies in rural areas that offer field training opportunities that include inter- or multidisciplinary experiences with an integrated continuum of services (e.g., collaborations among primary and preventive health care, mental health, substance abuse and social service agencies) (Mulder et al., 2000).

Additionally, all rural mental health academic and training programs should be conducted in a culturally competent manner that recognizes and provides academic and experiential training regarding indigenous and other ethnic groups (NRHA, 1999).

In addition to strengthening clinicians' rural and cultural competency, strategies are needed to increase the number of rural mental health providers. While there have been some attempts to recruit and retain mental health professionals to rural areas, more effective recruitment efforts and incentives must be provided to attract professionals to these mental health professional shortage areas. The National Health Service Corps offers incentives to students in the form of loan repayment in return for service in a professional shortage area. More programs with financial incentives are needed to motivate mental health professionals to specialize in rural mental health. Academic institutions can play a role in outreaching to rural communities to attract applicants. This is particularly true for mid-level and paraprofessional mental health providers, who are likely to become the main group of providers of mental health care in rural areas.

Consumers of mental health services and their families, or persons with mental health problems not currently receiving services, need education about the nature of their difficulties and where to get help. As discussed in previous chapters, rural residents tend to enter treatment later in the course of their disorders, usually in States of significant distress. On the one hand, many may not recognize symptoms or signs of mental health problems, or ascribe them to non-mental health causes. Those who do recognize a problem may be hesitant to pursue treatment for fear of stigma or ostracism, or because they are unsure about where and what treatment is available.

Effective educational and outreach campaigns designed for rural residents would go a long way in helping to connect care with those who need it. Organizations such as the National Alliance for the Mentally Ill (NAMI), the Federation of Families for Children's Mental Health (FFCMH), and numerous other State or local agencies (e.g., UPLIFT in Wyoming) have been instrumental in both educating and advocating for consumers and their families.

Although this section has focused on education for clinicians and consumers, it is very important to recognize the significant need for education campaigns regarding mental health and substance abuse problems for the general public. Indeed, as indicated at the beginning of this chapter, a large public education campaign is the number one goal of the New Freedom Commission.

Furthermore, the Center for Mental Health Services in the Substance Abuse and Mental Health Services Administration (CMHS, SAMSHA) collaborated with the National Association of Rural Mental Health (NARMH) to review successful rural mental health outreach practices. Although some rural programs have developed innovative outreach efforts, a wider variety of approaches are still necessary. The most important finding that surfaced by the CMHS, SAMSHA and NARMH work group was that successful outreach efforts target consumers' needs as defined by consumers, and that such efforts are situated in that community (Lambert et al., 2001).

The American Psychological Association (APA) has been instrumental in drawing increased attention to rural health issues by the formation of several advocacy groups including the Rural Task Force, the Committee on Rural Health and the Rural Women's Work Group. These advocacy groups all incorporate similar goals, including disseminating information to members, legislative bodies, consumers, professionals and other relevant agencies (Mulder et al., 2000).

At the annual APA conference, the Rural Health Forum is a valuable place for mental health professionals to dialogue and strategize about the needs of rural communities. Additional efforts can be made with the publication of professional literature in traditional journals or on-line professional journals. In addition, APA has recognized the need for research on rural populations (Mulder et al., 2000).

A major legislative factor that bears on mental health professionals generally, especially in terms of provider mobility, is State licensure. At present, although most States have similar licensure criteria, there are still difficulties for mental health professionals moving from one State to another. As Jonason and colleagues (2003) indicate, local licensing laws have not embraced the reality that an increasing amount of business is conducted across jurisdictional lines, including mental health professions. Psychology, for example, has taken steps to facilitate mobility through InterState reciprocity (Kim & VandeCreek, 2003) with some level of success, but as yet there are no assurances that other States will recognize and grant equal status (Merrill, 2003).

Kim and VandeCreek (2003) describe efforts to facilitate mobility for psychologists. These include:

In February of 2001, the Committee for the Advancement of Professional Practice (CAPP) was given formal approval by the American Psychological Association (APA) Council of Representatives to continue with plans for the development of professional mobility mechanisms.
The Association of State and Provincial Psychology Boards (ASPPB) and State licensure boards have developed a reciprocity agreement. As of March 2003, 11 States and provinces were participating. Three States are in the process of implementing the reciprocity agreement.
ASPPB has also developed an endorsement mechanism to facilitate mobility: the Certificate of Professional Qualification in Psychology (CPQ). As of March 2003, 26 States and provinces had implemented the CPQ, and an additional 14 States and provinces are in the process of implementing it.
The National Register of Health Service Providers in Psychology credentials individuals who submit education and training information relevant to licensure. As of February 2003, 10 States and all 11 Canadian jurisdictions had approved the register's credential as a mobility mechanism.
The American Board of Professional Psychology (ABPP) awards certification to individuals who demonstrate competency in a specialty area of psychology, and five States accept an individual's certification by this board as a mobility mechanism, typically by waiving one or more licensing board requirements.

Licensure, mobility and reciprocity for healthcare disciplines are made more complex in the age of telemedicine or telehealth, which has been acknowledged by the Federal government. For example, Jonason and colleagues (2003) reported that the Telehealth Improvement Act of 1999 and the Comprehensive Telehealth Act of 1999 created a Joint Working Group charged with compiling data on the number of health care providers performing telehealth services across State lines and tracking efforts to develop uniform national sets of standards for telehealth licensure. The authors indicated that a provision of these legislative proposals is that if States are not making progress in facilitating telehealth services across State lines by eliminating unnecessary requirements and adopting reciprocal licensing arrangements for such services, then the Secretary of Health and Human Services should make recommendations concerning the scope and nature of Federal actions required to do so.

These issues also impact training. As Deleon, Crimmins, and Wolf (2003) observe, professional schools will likely develop innovative distance-learning (i.e., Web-based) oriented degrees or continuing education modules. Thus, these authors argue that "Telehealth compels us to conceive of boundaries in other than geographical terms" and psychology's elected leaders at the State and national association levels will have to address licensure mobility.

Delivering Education & Training

Whether one is targeting rural clinicians, consumers, or the general public, education and training can be difficult for all the reasons noted throughout this book (e.g., geographical distance, lack of funding and so forth). However, the use of technology and distance learning programs is beginning to show promise in breaking down these barriers. For example, clinical treatment via telemedicine has been growing for over a decade. Frontier States, such as Alaska, use distance learning approaches to train Alaska Natives in remote areas.

The WICHE Mental Health Program, through funding from SAMHSA, has been offering a series of live grand rounds webcasts on clinical topics via the internet. In effect, the internet serves as an "E-Classroom" in which speakers and participants can interact in real-time to discuss issues. Presentations can also be stored for later viewing, which helps busy rural providers get needed information as it fits their schedules.

Clinical Programs & Services

One of the most significant trends in mental health generally, as well as, in rural areas is the emphasis on outcome-driven service delivery models. Within the context of connecting science to service, the New Freedom Commission identified the need to increase the use of evidence-based practices (EBPs). Evidence-based practice is "an approach to classifying health care outcome research according to the quality and quantity of empirical evidence supporting a particular intervention" (Anthony, Rogers & Farkas, 2003). It has also been defined by the Institute of Medicine as "the integration of best research evidence with clinical expertise and patient values." The mental health community strives to define practices and treatment interventions that have been demonstrated to be effective in clinical services research (Torrey et al., 2001).

At present, there is a significant time delay between scientific discovery and service delivery. The Commission recommends the use of EBPs via dissemination and demonstration projects, and developing a public-private partnership to guide this process. This recommendation is buttressed by the recent Institute of Medicine (IOM; 2005) report, which endorses using demonstration projects in rural communities, as such locations are smaller and have unique characteristics. Methods for introducing EBPs into service delivery systems include educating clinicians and consumers about the short- and long-term benefits of EBPs, support and promotion by leadership and reimbursement policies to increase EBP use.

The Commission also recommended that the Federal government create a partnership with private, interested funding, advocacy and professional organizations. Potential funding entities may be more willing to provide financial and other resources if evidence-based practices are explained and proposed. However, it is important to consider the need for clearer understanding regarding the degree to which EBPs generalize to different rural areas.

According to the Office of Rural Health Policy (1997), telepsychiatry is one of the five most common applications for telemedicine in rural hospitals. Technology has the potential to decrease the gap in services by increasing education, support and connectedness between the client and the provider. Telemedicine technology allows for two-way interactive physician/patient interviews to take place across long distances (Graham, 1996). The Internet can potentially provide a viable alternative to traditional office visits for rural residents with mental health issues (Ferrell & McKinnon, 2003).

Telemedicine can also be used for purposes other than therapy including case management, medication management, psychiatric consultations and psychiatric referrals (Rost et al., 2002). Evaluations of provider-patient encounters via interactive two-way video have generally demonstrated that the reliability of psychiatric assessment is comparable to that of face-to-face interviews (Baer et al., 1995; Baer et al., 1997; Baigent et al., 1997; Doniger et al., 1986; Rost et al., 2002; and Zarate et al., 1997).

A study by Graham (1996) found preliminary evidence that telehealth consultations between a psychiatrist and a client diagnosed with serious mental illness decreased the incidence of patient re-hospitalization.

Administration

Administrators in mental health agencies are primarily concerned with two issues: 1) delivering high quality, cost-effective services and 2) securing and managing funding or reimbursement for those services.

Service Content and Structure

Delivering high quality, cost-effective care requires attention to service content and structure. Service content refers to the specific kinds of treatments available (e.g., individual or group therapy, residential programs), whereas service structure regards the formal administrative and clinical relationships of providers.

As discussed in an earlier section of this chapter, evidence-based practices are becoming an increasingly important type of treatment. Such treatments are not only based on research indicating their effectiveness, but often involve the use of multiple providers (e.g., Assertive Community Treatment). In this regard, collaborative, inter- or multidisciplinary care is being promoted as a primary form of successful service structures.

A broad framework in which providers, researchers, rural community leaders and policy makers can understand collaborative care is the System of Care model (Dekraai, 2004; Stroul & Friedman, 1986). Although systems of care usually regard services for children and families, the core values and principles can be appropriately applied to adult services. The core values of a system of care are that it is:

Child-centered and family-focused (or, in the case of adults, client-centered), with the needs of the child and family (or client) dictating the types and mix of services provided;
Community-based, with the locus of services as well as decision-making responsibility resting at the community level and
Culturally competent, with agencies, programs and services that are responsive to and respective of the cultural, racial, ethnic, language and value differences of the populations they serve.

The principle components of a System of Care are:

Access to an extensive array of services that address physical, emotional, social and educational needs;
Individualized treatment that matches the unique needs of clients;
Services are provided in the least restrictive, most natural environment;
Families and/or main social support are participants in care;
Integrated services with linkages to other service agencies for planning, developing and coordinating services;
Case management to ensure coordination of services;
Early identification and intervention to increase the likelihood of positive outcomes;
Ensure smooth transition to other services;
Rights of clients should be protected and advocacy efforts should be promoted;
Culturally competent and
Community-based.

Implementing these principles will increase the likelihood of a seamless system of mental health care. Forming community partnerships and relationships should include funders, service providers, consumers and family members, as well as community and faith-based organizations (Dekraai, 2004). However, it is complex and time consuming to facilitate the creation of relationships between agencies that often have different priorities, policies and funding streams.

In terms of specific relationships among various provider groups, there is solid evidence that many rural residents in need of mental health services are initially seen by primary care physicians (PCPs) or other medical professionals (e.g., nurse practitioners, physician's assistants). If mental health professionals cannot be adequately recruited to rural areas, then PCPs will continue to provide the majority of mental health care. Thus, training that increases PCPs skills in identifying signs and symptoms of mental health and/or substance abuse problems is very important.

Increased collaboration between mental health providers and primary health providers would improve efficiency and effectiveness when providing mental health treatment or streamlining referral processes. To help promote collaboration between these provider groups, interdisciplinary training programs should be developed and supported (National Rural Health Association [NRHA], 1999). For example, several programs run through the Health Resources and Services Administration (HRSA) may provide avenues for interdisciplinary training, including the Quentin N. Burdick Rural Interdisciplinary Training Grant Program, Area Health Education Centers and Geriatric Education Centers.

Due to the high prevalence of substance use by people with serious mental illness, the NRHA (1999) suggested that programs provide simultaneous mental health and addiction treatment to rural residents with co-occurring disorders. The New Freedom Commission, Subcommittee on Rural Issues (2004) added that these services need to be linked to primary care settings, where most rural persons turn for assistance. Services can be more efficient if they are streamlined and integrated.

A curriculum for a community-based rural model of training has been published by the American Psychological Association (APA) (1995). Federal and State grants are needed to develop rural mental health services systems through such community-oriented training (NRHA, 1999). Although there are logistical issues in implementing collaborative training (e.g., different disciplines, funding and other resources), cross-training would ultimately foster collaborative relationships between these two groups.

Another potentially effective service structure is the use of telemedicine. Due to the geographical isolation of many rural communities, telehealth strategies may help address transportation and distance barriers faced by rural residents. If transportation services are offered by agencies, they consume part of the budget not incurred by urban services. While research has shown telemedicine's positive impact on access to mental health services (NFC-SRI, 2004), further research is necessary to demonstrate its effectiveness with rural mental health issues. The results of this research can then be used to advocate for increased funding and equipment for rural area service providers. Telehealth cannot only provide increased access for patients requiring care, but also for mental health professionals who may feel isolated in rural areas.

Despite the potential value of telemedicine technology, there are barriers to the successful integration of these advances from an administrative perspective. Graham (1996) detailed some of these obstacles, which include 1) initial and continuing operating costs of technology, 2) professional issues that require the field to reframe the doctor-patient relationship and 3) legal and confidentiality issues. Furthermore, census data indicate that Americans' access to usage of the internet varies greatly depending on socioeconomic level. Urban residents are more than two times as likely to have internet access as those in rural areas at the same lower income levels (Ferrell & McKinnon, 2003).

Funding

Mohatt, LaLumia and Yennie (2004) indicate that before the rural mental health system can be expected to improve, there needs to be an examination of the larger mental health system. In terms of current governance issues present in the United States' mental health system, they report that the major entities providing mental health care (e.g., State psychiatric hospitals, community-based general hospitals, community mental health centers) routinely lack any fiscal or management integration and often operate in virtual isolation from each other. The result is non-shared accountability for ensuring access to care, discontinuity of care, and/or poor use of limited fiscal and human resources. In other words, the system is "complex, confusing, and fragmented" (New Freedom Commission on Mental Health, 2003).

As a part of reform efforts, two strategies have been commonly employed to address the lack of access and integration in mental health systems: 1) developing a single funding envelope that integrates diverse funding streams and 2) establishing a single authority (i.e., organization) accountable for administration and management of public mental health care for a defined geographic area or population (Mohatt, Lalumia & Yennie, 2004).

Decisions affecting the provision of rural mental health care are likely to be made outside of rural communities. This trend requires mental health providers to be fiscally stable and connected to a strong network of resources (Sawyer & Beeson, 1998). Currently, Federal strategies for sustaining mental health infrastructure are non-existent (NFC-SRI, 2004). While a myriad of enhanced financing options are available for rural health care (e.g., Critical Access Hospital Program, Rural Health Clinics Program), no such options to tailor rural financing strategies in mental health exist.

Rural mental health has a long history of being dependent on public sources of funding. However, there has been an increasing trend toward the semi-privatization of mental health services (e.g., transfer of Medicaid programs from government to managed care companies). There are several ramifications with the privatization of mental health services, including the inability of small employers to provide adequate benefit packages and the inability of some rural Americans to afford the cost of health care insurance.

Nevertheless, there are programs that have financial resources to support health care in rural areas. The Federal Office of Rural Health Policy (ORHP) coordinates a series of grants designed to increase access to and improve the quality of health care in rural areas (for further information, see http://ruralhealth.hrsa.gov/funding/).

Parity

Another major effort underway since the early 1990s is to achieve full parity in both private (individual and employer-based) and public (Medicare, Medicaid and other government-sponsored) insurance coverage for mental illnesses.3 Involved in this effort are nationally organized groups, such as the National Alliance for the Mentally Ill (NAMI), Bazelon Center for Mental Health Law, the Mental Health Liaison Group and the Mental Health Association of America, to name just a few.

A fact sheet regarding parity is provided at the Mental Health Liaison Group website (http://www.mhlg.org/parity_4-03.pdf), which provides findings about the costs associated with lost productivity due to mental illness, whether or not mental health parity is affordable, as well as the rationale of and legislative efforts to achieve parity. In brief, the fact sheet indicates that parity in coverage for mental illness can save money, does not result in a significant increase in cost and would end a type of discrimination.

The 1996 Domenici-Wellstone Mental Health Parity Act (MHPA), which prevents employer-sponsored health plans from imposing lifetime and annual dollar limits on mental health benefits that differ from those imposed on medical/surgical benefits, was a first national step toward insurance parity, but fell short of the final goal. For instance, findings from the U.S. General Accounting Office (2000) report titled Compliance with the Mental Health Parity Act of 1996: Effects/Costs of Implementation included:

Eighty-six percent of employers comply with the Federal parity requirements set forth in the MHPA of 1996. However, this does not apply to individuals outside of a group plan, plans with 50 or fewer employees, or plans whose claims costs have increased at least one percent due to compliance.
Despite a high percentage of compliance, employers continue to limit their mental health benefits. More specifically, 87 percent of those who comply end up restricting other mental health services in their health plans.
Initial concerns that the 1996 Act would increase claims costs by more than one percent seem to be unconfirmed. In fact, premium increases were estimated at 0.16 percent and 0.12 percent by Congressional Budget Office (CBO) and Coopers & Lybrand, respectively.
Several States have already enacted parity laws that exceed the Federal parity requirements. Premium cost increases for full parity are estimated to be between two percent and four percent, both nationally and for individual States.
Loopholes and limited scope of the MHPA of 1996 continue to impede overall access to mental health services.

Currently at the Federal level, Senators Pete Domenici (R-NM) and Edward Kennedy (D-MA) and Reps. Jim Ramstad (R-MN) and Patrick Kennedy (D-RI) introduced the Senator Paul Wellstone Mental Health Equitable Treatment Act of 2003. This would expand existing law by addressing limits on deductibles, co-insurance, co-payments, other cost sharing and limitations on the total amount that may be paid with respect to benefits under the plan or health insurance coverage. However, despite widespread support in Congress and by President Bush, the updated legislation has not yet passed.

Other Funding Opportunities for Rural

Hartley & Gale documented potential funding opportunities for rural communities (available online at http://www.ahrq.gov/data/safetynet/hartley.htm), which include:

The Rural Health Services Outreach Grant Program: emphasizes the expansion of service delivery through networking strategies to encourage the development of new health care delivery systems in rural communities.
The Network Development Grant Program: designed to strengthen collaborative relationship between health care organizations by funding rural health networks that focus on strengthening their infrastructure by integrating clinical, administrative and financial systems.
The Network Development Planning Grant Program: provides one year of financial support to rural communities needing assistance in the development of an integrated health care network. The planning grants are to be used to develop a formal network with the purpose of improving the coordination of health services in rural communities and strengthening the rural health care system as a whole. Preference is given to applicants who serve medically underserved populations or in which at least 50 percent of the service area covered by the network is located in a health professional shortage area or medically underserved community.
The Mississippi Delta Rural Development Initiative: targets the Delta region, which covers 205 rural counties in Alabama, Arkansas, Illinois, Kentucky, Louisiana, Missouri, Mississippi and Tennessee. The program includes two components: a grant program to fund the creation of networks that improve access to primary care services and the development of a technical assistance program to help small rural hospitals improve their operations and financial performance.
The Small Rural Hospital Improvement Grant Program: provides funding to small rural hospitals for any one of the following activities: a) costs related to the implementation of Prospective Payment Systems; b) compliance with provisions of the Health Insurance Portability and Accountability Act; or c) reducing medical errors and support quality improvement.

The ORHP also administers two additional grant programs created to support State involvement in meeting State and local rural health needs:

The State Offices of Rural Health Grant Program: has created offices of rural health in all 50 States. The mission of these offices is to help individual rural communities build health care delivery systems.
The Rural Hospital Flexibility Grant Program (Flex Program): a Federal initiative that provides funding to State governments to strengthen rural health. This program: a) allows small hospitals the flexibility to reconfigure operations and be licensed as Critical Access Hospital (CAHs), b) offers cost-based reimbursement for Medicare acute inpatient and outpatient services, c) encourages the development of rural-centric health networks and d) offers grants to States to help implement a CAH program in the context of broader initiatives to strengthen the rural health care infrastructure.

Research & Evaluation

Current definitions of "rural" often fail to capture the relationship between rural characteristics and mental health service use (National Institute of Mental Health, Office of Rural Mental Health Research, 2003). Lewis (2003) indicated that the word "rural" suggests a cultural uniqueness that leads people to see "rurality" more as an abstract concept than a specific region. Others have emphasized that a rural area is not only a physical place but also a social place (Weisheit, Wells & Falcone, 1994). The concept of rural areas as social places requires the application of sensitive approaches to their cultural qualities (Lewis, 2003).

While there may not be one definition of "rural" that is acceptable to everyone, it is critical to, at a minimum, develop a set of definitions that are consistent and understandable when used in different contexts. The New Freedom Commission on Mental Health, Subcommittee on Rural issues (2004) Stated that a formalized process to define rural would be helpful in collecting richer data to use for planning rural initiatives (e.g., workforce development, recruitment, or program development). This would involve going beyond the simple population-based definitions that currently exist and would seek to operationalize other variables (e.g., available mental health services). This process would ultimately help to narrow the definition and offer more specificity when researching different rural communities.

Rural communities have many unique properties that need to be incorporated into and better captured by the research. Rural mental health research needs to be grounded in the rural context and experience. While traditional randomized clinical research allows for causal relationships of factors that influence change, qualitative methods (e.g., ethnographic, process analyses) can more fully demonstrate participant and community perceptions and experiences (Anthony, Rogers & Farkas, 2003). Qualitative methodology (e.g., correlational and quasi-experimental) can be used to guide the development of studies using more traditional research methods (Anthony et al., 2003). It is more important that the quantitative and qualitative research methods employed are complementary and not duplicative (Office of Behavioral and Social Sciences Research, 2001; Anthony et al., 2003).

One rural classification system that captures many of the aspects of rural, especially in relation to more urban areas, is the United States Department of Agriculture Economic Research Service (ERS) Rural-Urban Commuting Area (RUCA) codes. A full description of the RUCA codes can be found at http://www.ers.usda.gov/briefing/Rurality/RuralUrbanCommutingAreas/.

It is beyond the scope of this book to go into elaborate detail of the RUCA codes. However, in brief (and from the Web site), RUCA codes "are based on the same theoretical concepts used by the Office of Management and Budget (OMB) to define county-level metropolitan and micropolitan areas...[applying] similar criteria to measures of population density, urbanization, and daily commuting to identify urban cores and adjacent territory that is economically integrated with those cores." However, the RUCA codes use census tracts-the smallest geographic units-instead of counties as their building blocks to provide "a different and more detailed geographic pattern of settlement classification."

More specifically, the RUCA codes are composed of 10 primary and 30 secondary codes. The primary codes refer to either the primary or single largest commuting share and "offer a relatively straightforward and complete delineation of metropolitan and nonmetropolitan settlement based on the size and direction of primary commuting flows." The secondary codes identify areas where settlement classifications overlap, based on the size and direction of the secondary, or second largest, commuting flow.

Research Agendas and Questions

The NIMH's Office of Rural Mental Health Research (ORMHR) conducted a meeting in 2003 that sought to delineate a rural research agenda. The meeting included researchers, consumers and policy analysts interested in improving mental health services in rural areas. There was consensus that a common definition of "rural" is needed to use consistently in the research. However, as described in an earlier chapter, the Office of Management and Budget (OMB) has developed new definitions of metropolitan and non-metropolitan (or rural) areas (see Chapter 1 for more information).

It was also stressed that research in rural areas is often plagued by small sample sizes and insufficient power to confidently use the "community" as an explanatory variable. Community factors are often "nested" within the layers of a rural community and frequently exert powerful influence over the residents within that community.

ORMHR encouraged researchers to utilize the following methodologies in an attempt to better capture the characteristics and dynamics within a rural community: 1) multi-level studies that represent individuals within communities and communities within regions; 2) multivariate analysis, including structural equations and modeling and 3) methods for analyzing small samples (e.g., longitudinal data, hierarchical linear modeling) that estimate between-community and within-community characteristics (ORMHR, 2003). Six suggestions to improve the research that will eventually inform mental health service delivery in rural areas:

Encourage researchers to use conceptual and theoretical models in order to advance rural mental health research.
Conduct a meta-analysis of databases to inform the development of a typology for identifying rural communities at high risk for increased prevalence of mental illness and/or underutilization of mental health services.
Commission a "white paper" to examine frameworks and typologies for identifying rural communities at risk for disorder and/or service underutilization. These typologies could for example help to a) categorize epidemiological and services studies and b) prioritize research.
Encourage researchers to study the factors that comprise the typologies.
Conduct a four-day "Summer Institute" with senior-level rural mental health investigators and new or emerging investigators to encourage individuals to pursue a rural mental health research career.
Recruit senior- and junior-level rural mental health services researchers on the NIMH Services Research Initial Review Group (IRG). Encourage the Scientific Review Administrators to assemble ad hoc review teams with rural expertise.

The Evaluation Initiative at the National Assistance Center for Children's Mental Health was developed in response to a need for performance measurement, outcomes and system accountability for children's services. This program is housed at the Georgetown University Center for Child and Human Development. Although this initiative was created to address children's mental health services, it can be adapted to evaluate other mental health services. The following goals and tasks were modified to be used with other evaluation projects targeting different populations with various mental health needs.

Facilitate the capacity-building of States and local communities in their evaluation of mental health services;
Identify promising practices in the design and implementation of effective evaluation programs and integrated information systems and
Guarantee quality technical assistance services and products.

The Evaluation Initiative also detailed ongoing tasks in order to further the goals listed above:

Identify State and community evaluators;
Support evaluation efforts and develop integrated information systems;
Showcase promising practices in the design and implementation of evaluation programs and outcomes reporting;
Disseminate information regarding mental health services evaluation that are relevant and easily understood to stakeholders and
Assess the usefulness and impact of technical assistance activities. Evidence-Based Practices, Evaluation, and Management Information Systems.

The rural mental health system could replicate some of these evaluation priorities. It would be useful for rural mental health professionals in partnership with Federal, State and local stakeholders to create standards and indicators of quality care to make the evaluation process more standardized. In addition, the Evaluation Initiative is exemplary in their efforts to be accountable to stakeholders. The ability to provide evidence on how and why services are effective or ineffective is critical to any evaluation project.

Particular research designs including epidemiology, morbidity, provider availability and provider access are more likely to yield useful information on rural residents. In addition, other methodologies including clinical community research (e.g., needs assessment, identification of community resources, program evaluation and efficacy of prevention-based services) may be beneficial in demonstrating the needs of specific communities. Lastly, it is essential to include community leaders and other community consumers as key informants to help ensure culturally sensitive and relevant research initiatives (Mulder et al., 2000).

Finally, Rost and colleagues (2002) identified seven areas for further research specific to the rural mental health agenda. Research suggestions were separated into two groups: 1) identifying and addressing rural-urban disparities in use, quality and outcomes of care and 2) continuing to improve use, quality and outcomes of care in rural areas. The research areas are presented in the form of questions.

Future Research to Identify and Address Rural-Urban Disparities in Use, Quality & Outcomes of Care

Compared to their urban residents, are rural residents of vulnerable or underserved populations (e.g., the impoverished, minority groups, the elderly, youth) less likely to seek care when they need it? If so, what modifiable factors associated with living in rural areas clarify this disparity?
Does living in a rural area increase the probability that an individual entering mental health treatment will not remain in treatment? If so, what interventions can be developed to achieve comparable rates of sustained engagement in treatment between rural residents with serious mental illness and urban residents struggling with similar mental health issues?
Do seriously mentally ill individuals living in rural areas receive a lower quality of care? If so, what are the relative contributions of the provider (e.g., provision of less evidenced-based care) and the patient (e.g., failure to stay engaged in care) to these poor outcomes? What are some characteristics of the rural individual, the health plan or the service system that can be most cost-effectively modified to decrease disparities in outcome?
How do total and out-of-pocket expenditures for mental health care differ for rural and urban individuals with psychiatric disorders? How have these differences changed over time? Do differences in health benefits explain these differences? What policies can be initiated to equalize the cost-sharing burden for rural individuals with psychiatric disorders?
How does managed behavioral health care function in rural compared to urban areas? Does carving-out mental health benefits differentially impact entry in to treatment and/or quality of care in rural individuals with psychiatric disorders compared to urban residents? How do rural-urban differences in credentialing, selective contracting and risk sharing moderate the impact of managed behavioral health care?

Continuing to Improve Use, Quality & Outcomes of Care in Rural Areas

Can entry into treatment by rural individuals with psychiatric disorders be increased by direct marketing campaigns or by better utilizing the unique characteristics of the rural social network to increase the perceived need for and/or access to services?
Can quality of care and outcomes be enhanced by redesigning successful urban initiatives for rural primary and mental health care settings? What unique initiatives need to be developed to improve quality and outcomes for rural individuals with psychiatric disorders?

Summary

Rural mental health has been elevated to a higher priority status within the mental health community. In particular, Federal interest in rural mental health initiatives has helped to increase attention to the needs of rural communities. At the Federal level, the New Freedom Commission on Mental Health, Subcommittee on Rural Issues was one of only four subcommittee reports (out of 16) to be released, and overall goals of the Commission directly target rural issues. There are the Office of Mental Health Research at the National Institute of Mental Health (NIMH) and the Office of Rural Health Policy in the Health Resources and Services Administration (HRSA). These programs have been responsible for creating research and service delivery opportunities. However, there is a lot of work to be done at multiple levels to create and sustain viable mental health systems in rural areas.

Four areas of future activity in rural mental health are education and training, clinical programs and services, administration, as well as research and evaluation. Education and training for clinicians and consumers in rural areas should regard evidence-based practices (EBPs), collaborative care and knowing when and how to access services. EBPs are continuing to be a focus of service delivery across mental health systems in the U.S., but the applicability of these treatments to rural still needs to be determined. The emergence of telehealth has made progress in linking rural mental health consumers with providers in urban areas, especially psychiatrists. The Internet is also becoming a vehicle for increased communication in rural areas. New developments in health care financing (e.g., managed care and for-profit health care corporations) are restructuring delivery systems. Specifically, the semi-privatization of public health insurance programs (e.g., Medicaid and Medicare) has created more incentives for corporate health care providers and insurance companies to enter rural markets.

A consistent theme emphasized in the literature is the importance of involving consumers in research and the planning of services. While this makes intuitive sense, it is common that consumers are left out of the planning processes for transforming mental health delivery systems. Rural communities and consumers should be allowed to speak authentically about their perspectives of their own needs. In order to advocate for the needs of rural communities to policy-makers, it is critical that solid research identifying the most effective services for rural residents is available. Outcome data based on current model programs will also be helpful in marketing the needs of rural communities.

References

Anthony, W., Rogers, E.S. & Farkas, M. (2003). Research on evidence-based practices: Future Directions in an Era of Recovery. Community Mental Health Journal, 39(2), 101-114.

Baer, L., Elford, D.R. & Cukor, P. (1997). Telepsychiatry at forty: What have we learned? Harvard Review of Psychiatry, 5(1), 7-17.

Baer, L., Cukor, P., Jenike, M.A., Leahy, L., O'Laughlen, J. & Coyle, J.T. (1995). Pilot studies of telemedicine for patients with obsessive-compulsive disorder American Journal of Psychiatry, 152(9), 1383-1385.

Baigent, M.F., Lloyd, C.J., Kavanagh, S.J., Ben-Tovim, D.I., Yellowlees, P.M., Kalucy, R.S. & Bond, M.J. (1997). Telepsychiatry: 'tele' yes, but what about the 'psychiatry'? Journal of Telemedicine and Telecare, 3(1), 3-5.

Dekraai, M. (2004, November). Building Child and Family Systems of Care in Rural Areas. Web-cast Presentation facilitated by the Western InterState Commission on Higher Education, Boulder, CO.

Deleon, P.H., Crimmins, D.B. & Wolf, A.W. (2003). Afterword-The 21^st Century has Arrived. Psychotherapy: Theory, Research, Practice, Training, 40, 164-169.

Farrell, S.P. & McKinnon, C. (2003). Technology and rural mental health. Archives of Psychiatric Nursing, 17(1) Feb 2003, 20-26.

Graham, A.M. (1996). Telepsychiatry in Appalachia. American Behavioral Scientist, 39(5) Mar-Apr 1996, 602-615.

IOM Report: Quality Through Collaboration. (November, 2004). Presented by Mary Wakefield, Ph.D at the Office of Rural Health Policy Technical Assistance Meeting of the Rural Health Research Centers, Center for Rural Health.

Jonason, K. R., DeMers, S. T., Vaughn, T. J. & Reaves, R. P. (2003). Professional Mobility for Psychologists Is Rapidly Becoming a Reality. Professional Psychology: Research and Practice, 34, 468-473.

Kim, E. & VandeCreek, L. (2003). Facilitating Mobility for Psychologists: Comparisons With and Lessons From Other Health Care Professions. Professional Psychology: Research and Practice, 34, 480-488.

Lambert, D., Donahue, A., Mitchell, M. & Strauss, R. (2001). Mental health outreach in rural area: Promising practices in rural areas. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.

Lewis, S.H. (2003). Unspoken crimes: Sexual assault in rural America. National Sexual Violence Resource Center.

Merrill, T.S. (2003). Licensure Anachronisms: Is It Time for a Change? Professional Psychology: Research and Practice, 34, 459-462.

Mohatt, D.F., LaLumia, D., Yennie, H. (2004) Western InterState Commission on Higher Education - Mental Health Program, Boulder, CO; Washington State Behavioral Health Reform: An Overview of Governance and Financial Strategies

New Freedom Commission on Mental Health, Subcommittee on Rural Issues: Background Paper. DHHS Pub. No. SMA-04-3890. Rockville, MD: 2004.

Office of Behavioral and Social Sciences Research. (2001). Qualitative methods in health research: Opportunities and considerations in application and review (NIH Publication No. 02-5046). Bethesda, MD: National Institutes of Health.

Office of Rural Mental Health Research. (2003). A rural mental health research agenda: Building on success by planning for the future. Boulder, CO, June 9-10, 2003. (Online). http://www.nimh.nih.gov/ormhr/index.cfm

Sawyer, D. & Beeson, P. (1998). Rural Mental Health: Vision 2000 and Beyond. (Online) http://www.narmh.org/pages/future.html

Stroul, B. A. & Friedman, R.M. (1986). A system of care for seriously emotionally disturbed children and youth. Washington, D.C.: CASSP Technical Assistance Center, Georgetown University Child Development Center.

Torrey, W.C., Drake, R.E., Dixon, L., Burns, B.J., Flynn, L., Rush, A.J., Clark, R.E. & Klatzker, D. (2001). Implementing evidence-based practices for persons with severe mental illness. Psychiatric Services, 52(1), 45-50.

United States Department of Agriculature Economic Research Service (ERS). Rural-urban commuting area (RUCA) codes. http://www.ers.usda.gov/briefing/Rurality/RuralUrbanCommutingAreas/.

Wagenfeld, M.O., Murray, J.D., Mohatt, D.F. & DeBruyn, J.C. (Eds.). (1994). Mental health and rural America: 1980-1993 (NIH Publication No. 94-3500). Washington, D.C.: U.S. Government Printing Office.

Wakefield, M. (2004). IOM Report: Quality Through Collaboration; ORHP Techinical Assistance Meeting of Rural Health Research Centers; Center for Rural Health. November 2, 2004. Powerpoint Presentation.

Weisheit, R.A., Wells, E.L., Falcome, D.N. (1994). Community policing in small town and rural America. Crime & Delinquency, (40)4, 549-567.

Zarate, Jr., C.A., Weinstock, P., Cukor, C., Morabito, L., Leahy, Burns, C., and Baer, L. (1997). Applicability of telemedicine for assessing patients with schizophrenia: Acceptance and reliability. Journal of Clinical Psychiatry, 58(1), 22-25.

Notes for Chapter 6

1. A listing of psychology training programs and internships with a rural emphasis can be found on the American Psychological Association Web site: http://www.apa.org/rural/.

2. The 2005 IOM report takes this recommendation from an earlier IOM report, titled Fostering Rapid Advances in Health Care: Learning from System Demonstrations.

3. A brief history of these efforts can be found at Parity in Insurance Coverage.

A User's Guide to the Annotated Bibliography

For readers wishing to stay abreast of developments in rural mental health, we recommend several journals. Some are specifically focused on rural mental health or human services, while others deal with rural health or rural life, with an occasional article on mental health. Some have devoted special issues or sections to rural mental health. Finally, as anyone who wades through the entire bibliography will note, other professional journals will, on occasion, publish an article on rural mental health. Without getting overly precise or making any claims to completeness, in roughly descending order of focus on rural mental health or related issues, they are as follows.

Journal of Rural Community Psychology
Human Services in the Rural Environment
The Journal of Rural Health
Rural Sociology
Journal of Health Care for the Poor and Underserved
American Journal of Community Psychology
American Psychologist
Journal of Community Psychology
Rural Sociologist
New Directions for Mental Health Services
Hospital and Community Psychiatry
Community Mental Health Journal
Journal of Public Health Policy

Of those listed, the American Journal of Community Psychology, American Psychologist, New Directions for Mental Health Services, and the Journal of Rural Community Psychology have had special issues or devoted sections to the problems of mental health and rural Americans.

References by Topics

To make this annotated bibliography more user friendly, we have arranged the references in terms of topics or key words that correspond roughly to the organization of the overview volumes. A reference can appear under more than one heading.

I. Aspects of Rural Life

A. Demography: 160, 168, 169, 276, 281, 282, 320, 335, 378, 381, 383, 392, 393, 395

B. Characteristics of Rural Life: 060, 071, 085, 091, 103, 104, 110, 120, 127, 132, 160, 161, 206, 244, 265, 272, 273, 275, 298, 320, 335, 336, 340, 358, 383, 392, 395, 403, 414

II. Epidemiology, Prevalence and Correlates of Disorder

A. Alcohol and Other Drugs: 001, 008, 012, 013, 025, 026, 028, 029, 033, 042, 044, 045, 046, 047, 049, 056, 062, 063, 068, 072, 078, 079, 083, 087, 089, 096, 097, 098, 101, 102, 106, 108, 118, 129, 139, 145, 151, 155, 156, 171, 179, 180, 181, 191, 192, 198, 199, 210, 227, 229, 240, 246, 262, 269, 279, 283, 286, 292, 293, 301, 304, 305, 306, 310, 323, 341, 349, 350, 351, 352, 353, 354, 355, 356, 369, 372, 382, 395, 401

B. Mental Disorder: 013, 016, 019, 020, 030, 044, 073, 128, 134, 135, 139, 144, 152, 171, 172, 173, 189, 191, 214, 221, 226, 244, 306, 310, 322, 368, 395

C. Special Populations/Topics

1. Adolescents and Children: 002, 006, 008, 012, 013, 026, 040, 049, 056, 058, 068, 074, 075, 076, 077, 078, 079, 081, 084, 087, 088, 089, 093, 096, 097, 098, 100, 102, 106, 108, 110, 114, 117, 138, 147, 148, 150, 151, 152, 155, 156, 159, 163, 164, 179, 180, 181, 187, 192, 197, 198, 199, 215, 216, 217, 220, 226, 227, 228, 240, 245, 250, 278, 279, 286, 287, 288, 292, 293, 295, 298, 307, 328, 341, 343, 344, 349, 350, 351, 352, 353, 354, 355, 356, 369, 374, 375, 391, 414

2. Severely Mentally Ill: 016, 017, 025, 039, 073, 082, 093, 115, 118, 130, 165, 174, 175, 183, 184, 190, 200, 208, 234, 262, 315, 317, 330, 362
3. Black/African Americans: 008, 013, 038, 039, 087, 088, 223, 384

4. Hispanic Americans: 004, 009, 062, 384, 387, 388

5. Native American/Alaskan Native: 323, 384, 408

6. Elderly: 024, 030, 051, 052, 053, 054, 064, 070, 092, 109, 137, 195, 196, 207, 222, 266, 274, 275, 302, 303, 311, 318, 335, 346

7. Women: 042, 044, 045, 046, 047, 057, 080, 093, 131, 154, 172, 185, 187, 212, 263, 326, 333, 399

8. Inmates/Prisoners: 185, 215, 216, 217, 364

9. Immigrants/Refugees: 107, 224, 225, 379

10. Men: 209

11. Veterans: 043, 219

12. Homeless: 270

13. Suicide: 176, 357

14. Religious/Spiritual: 060, 125, 164, 337, 390

III. Administrative Issues

A. Program Development: 011, 014, 055, 059, 117, 119, 162, 175, 236, 239, 245, 248, 254, 256, 257, 259, 260, 264, 280, 282, 291, 293, 294, 298, 320, 323, 325, 330, 332, 337, 338, 346, 349, 350, 351, 352, 353, 354, 355, 356, 362, 367, 372, 376, 395, 404, 405, 406, 409

B. Reviews and Overviews: 026, 031, 035, 105, 143, 236, 273, 276, 296, 298, 310, 321, 331, 383, 395, 396, 415

C. Needs Assessment: 005, 194, 272, 306, 331, 395, 410, 411

D. Health/Mental Health Linkage: 019, 034, 041, 048, 065, 066, 089, 113, 133, 203, 214, 230, 235, 258, 285, 298, 320, 367, 368, 385, 386, 395

E. Funding: 003, 015, 061, 065, 067, 093, 099, 146, 148, 162, 200, 202, 211, 213, 233, 237, 238, 241, 244, 249, 251, 252, 253, 255, 261, 271, 272, 280, 281, 302, 308, 313, 314, 315, 316, 317, 327, 331, 336, 338, 339, 340, 359, 361, 365, 367, 371, 372, 380, 400

IV. Issues and Models in Services Delivery: 018, 020, 021, 022, 037, 050, 059, 072, 075, 080, 100, 117, 123, 124, 126, 133, 136, 140, 142, 148, 157, 165, 170, 174, 179, 186, 198, 199, 201, 204, 205, 230, 232, 235, 249, 251, 252, 253, 254, 257, 267, 273, 276, 284, 290, 291, 295, 299, 300, 301, 306, 309, 310, 313, 314, 315, 316, 317, 320, 321, 322, 327, 331, 332, 334, 336, 337, 338, 340, 342, 346, 347, 348, 358, 360, 362, 367, 376, 377, 380, 385, 386, 390, 393, 394, 395, 396, 397, 398, 400, 402, 412

A. Alcohol and Other Drugs: 001, 008, 012, 013, 025, 026, 028, 029, 033, 036, 042, 044, 045, 046, 047, 049, 056, 062, 063, 068, 072, 078, 079, 083, 087, 088, 096, 097, 098, 101, 102, 106, 118, 129, 139, 145, 147, 148, 151, 152, 154, 156, 171, 179, 180, 181, 191, 192, 195, 198, 199, 210, 215, 227, 229, 245, 246, 248, 256, 262, 269, 279, 283, 286, 292, 293, 301, 304, 305, 306, 310, 323, 325, 349, 350, 351, 352, 353, 354, 355, 356, 360, 363, 364, 373, 389, 395, 398, 401, 413

B. Mental Disorder: 016, 019, 020, 030, 044, 045, 073, 128, 135, 139, 144, 152, 171, 172, 173, 189, 191, 214, 221, 226, 239, 245, 306, 310, 322, 368, 395

C. Special Populations/Topics

1. Adolescents and Children: 008, 012, 013, 026, 040, 049, 056, 058, 068, 074, 075, 076, 077, 078, 079, 081, 085, 087, 088, 089, 093, 097, 098, 099, 100, 102, 106, 110, 114, 119, 138, 151, 155, 156, 159, 163, 179, 180, 181, 187, 192, 197, 198, 199, 216, 217, 220, 226, 227, 228, 245, 248, 259, 260, 268, 278, 279, 286, 291, 292, 293, 298, 307, 325, 333, 338, 349, 350, 351, 352, 353, 354, 355, 356, 359, 363, 397, 413

2. Severely Mentally Ill: 016, 017, 019, 025, 039, 073, 082, 093, 115, 118, 130, 165, 174, 175, 183, 184, 190, 200, 208, 234, 236, 239, 313, 315, 316, 330, 362, 416

3. Black/African Americans: 008, 013, 038, 039, 087, 088, 223, 384

4. Hispanic Americans: 004, 009, 062, 223, 384, 387, 388

5. Native American/Alaskan Native: 223, 323, 384, 408

6. Elderly: 024, 030, 051, 052, 053, 054, 064, 070, 092, 109, 137, 195, 196, 207, 218, 222, 266, 274, 275, 302, 303, 311, 318, 335, 346, 347

7. Women: 042, 044, 045, 046, 047, 057, 080, 093, 131, 154, 172, 185, 188, 212, 263, 326, 333, 399

8. Inmates/Prisoners: 185, 215, 216, 217, 364

9. Immigrants/Refugees: 023, 107, 224, 225, 379

10. Veterans: 043, 121, 219, 319, 329

11. Homeless: 270

12. Suicide: 158, 176

13. Health/Mental Health Linkage: 019, 034, 041, 048, 065, 066, 089, 113, 133, 150, 203, 214, 230, 235, 258, 285, 299, 320, 367, 368, 385, 386

14. Telehealth/Tele-Mental Health: 020, 021, 022, 069, 090, 095, 110, 116, 142, 182, 193, 205, 247, 312, 345, 370, 377, 407, 416

V. Human Resources

A. Training: 063, 086, 096, 097, 167, 242, 243, 265, 276, 285, 327, 342, 393, 395, 400

B. Recruitment, Retention, Work Satisfaction: 111, 149, 166, 167, 178, 197, 242, 243, 276, 393, 395, 400