Those of us who live and work in cities often forget there is a whole other way of living alongside our own metropolitan or suburban way of life: A large part of the US is still rural. According to US census bureau director John H Thompson, rural areas cover 97% of our land area and contain 20 percent of our people (60 million people).
Rural America is facing a health crisis. Although the prevalence of mental illness is similar between rural and urban residents, rates of suicide are not. Suicide rates (Reference – See chart attached) have been growing in the US as a whole since 2000; increasing by nearly 30 percent for both adults and children. That alone is cause for concern. But the suicide rate in rural areas has increased by more than 40 percent in the same period. Data from: Trends in Suicide by level of Urbanization – United States, 1999 – 2015
Growing up in the country and on a farm in the 50’s and 60’s gave me some firsthand appreciation of rural health concerns, including mental health. My father became ill with was what then called a “nervous breakdown”. It was something shameful and no one talked it. It was all a personal failing. Besides, the work never stops, how could one take “time off” to recover lost mental health?
I think about this issue every time I drive on our nearest rural county highway. I wonder about the health of my rural neighbors. Most of the farms are family farms and their appearance suggests times are tough.
A report entitled The Stigma of Mental Illness in Small Towns notes another of the barriers contributing to the rise in rural mental health problems is that many residents believe that that “I should not need help.” Or simply don’t know where to go for assistance. Many times there is no mental health professional near and it is a significant burden of time and distance to travel for help.
A study published in the journal JAMA Pediatrics in 2015 analyzed data on US youth suicide rates from 1996 to 2010. It found that the rates of suicides for rural Americans aged 10 to 24 was almost double the rate compared to their urban counterparts. This was attributed to social isolation, greater availability of guns and difficulty accessing healthcare
It seems that the stigma – that mental illness is shameful – may be felt more acutely in small rural communities. And there is a lack of anonymity there.
Again from The Stigma of Mental Illness in Small Towns:
“We as a society have a hard time asking for help, so it’s hard enough to ask for help without feeling that everybody’s going to know it,”……”Your neighbors don’t have a clue in a city if you’re to get some help. But everybody in a small town will know if your pick-up is parked outside the mental health provider’s office.”(same reference; quote by Dennis Mohatt, VP of the behavioral health at Western Interstate Commission for Higher Education (WICHE) and director of the WICHE Center for Rural Mental Health Research.
The upshot is that rural citizens with mental health needs 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.
A policy brief by the National Rural Health Association, The Future of Rural Behavioral Health, February, 2015, makes the case that rural needs can be met by behavioral health reforms addressing the availability, accessibility, affordability and acceptability of services. (new reference). “ Three-fourths of counties with populations of 2,500 to 20,000 lack a psychiatrist and 95 percent lack a child psychiatrist.” Primarily due to this shortage of mental health professionals, primary care caregivers provide a large proportion of mental health care in rural America and may lack the training and experience to handle serious mental health issues.
What would help the situation?
- Increased emphasis on rural practice during professional training
- Rural community residents, such as school counselors and members of the clergy, should receive educational material and information from Medicare, Medicaid, and private insurance companies concerning available resources for mental health issues.
- Programs like Mental Health First Aid (MHA) may be useful in providing basic training to providers and other community resource people and reducing the stigma in the community.
- Paraprofessionals and emerging professions can also augment the mental health workforce. One example is the emerging field of Peer Support Specialists. Peer Support Specialists themselves have personal experiences with mental illness and can offer invaluable perspective to patients in acute care settings.
And we all need to be more supportive of our rural neighbors.