SAMHSA

Disaster Technical Assistance Center 

Supplemental Research Bulletin

Challenges and Solutions for Disaster 

Behavioral Health in Rural and Remote 

Communities

April 2023
CONTENTS

INTRODUCTION 3

SCOPE OF RURAL AND REMOTE BEHAVIORAL HEALTH NEEDS AND CHALLENGES 3

Coping With Behavioral Healthcare Disparities: Sources of Strength, Sources of Struggle 4

How Stigma Shapes Behavioral Health in Rural Areas 6

RESPONDING TO DISASTER BEHAVIORAL HEALTH NEEDS IN REMOTE AND RURAL 

COMMUNITIES 7

Governmental & Policy Approaches 8

Community-based Approaches 9

Grounded Mental Wellness Approaches: Meeting Communities Where They Are 9

Task Shifting for Behavioral Health: Realizing the Resources You Already Have 11

Telemedicine Approaches for Meeting Behavioral Health Needs in a Disaster Response 12

Telemedicine for Behavioral Health Emergency Care (“TeleED”) 13

Telemedicine for Community Behavioral Health Care 14

LIMITATIONS 14

CONCLUSION 15

REFERENCES 16

The focus of the Supplemental Research Bulletin is to provide an overview of the current literature on a specific 

topic and make it easy to understand for disaster behavioral health professionals who are not otherwise exposed 

to the research. The product aims to assist professionals and paraprofessionals involved in all-hazards planning, 

disaster behavioral health response and recovery, and/or Crisis Counseling Assistance and Training Program 

grant activities.

Would you like to see a Supplemental Research Bulletin on a topic we haven’t yet covered? Contact us with 

topic ideas and feedback via email at dtac@samhsa.hhs.gov or phone at 1–800–308–3515.
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INTRODUCTION

This issue of the Supplemental Research Bulletin focuses on challenges and potential solutions for 

delivering behavioral health care in disaster response in rural and remote areas. To investigate this topic, 

in July 2022 we conducted an initial exploratory query for literature related to behavioral health in rural 

and remote communities and disaster response. Using those initial articles, our team created a modified 

snowball sample (using a sample of relevant articles to identify additional articles for inclusion) using the 

National Library of Medicine’s “Similar Articles” function in PubMed.1

We limited our review to articles that:

• Were published in the last 5 years (in and after 2017)

• Were published in English

• Focused on behavioral health topics (i.e., mental health, substance use, treatments)

• Described research conducted in the United States2

• Focused on rural and/or remote populations, or at least not solely on urban populations

We recognize rural settings are not interchangeable, and challenges and strengths in any rural 

community are heavily influenced by culture, economic situation, demographics, geography, and state 

and national policy context. We present these findings as a starting point for further exploration in specific 

communities, especially when translating an existing approach to a new setting.

SCOPE OF RURAL AND REMOTE BEHAVIORAL HEALTH NEEDS AND 

CHALLENGES

In the United States, the opioid epidemic—especially the recognition of its increasing prevalence and 

impact in rural areas—has highlighted the behavioral health disparities and vulnerabilities that rural and 

remote communities contend with. While the scope of this review includes more than just opioid use 

disorder (OUD), much of the literature deals with OUD or substance use disorder (SUD) because this 

behavioral health condition shows how economic and social stressors, lack of healthcare infrastructure, 

and the physical challenges of providing care to a population over a wide geographic area came together 

in a behavioral health crisis. Findling and colleagues (2020) conducted a telephone (cell and landline) 

survey about health and economic issues among rural Americans over two years, 2018 and 2019, with a 

sample size of 1,300 and 1,405 respondents, respectively. When asked an open-ended question about 

the biggest problem their community faced, 25 percent identified opioid or other drug addiction or abuse, 

and 21 percent reported economic concerns, including availability of jobs, poverty, businesses closing, 

cost of living, and low wages. Rural adults also described difficulty affording medical care in the past few 

1 More information on how the National Library of Medicine’s National Center for Biotechnology Information (NCBI) 

computes and identifies “similar articles” in relation to the reference article can be found in the PubMed User 

Guide at https://pubmed.ncbi.nlm.nih.gov/help/#computation-of-similar-articles (NCBI, 2023).

2 If an article was relevant to the topic and not well-covered in U.S. settings—such as an article about behavioral 

health response to a disaster in remote areas in another country—the article was included. However, we opted 

not to include responses that required a significantly different health policy context than the United States (such 

as universal health insurance coverage).
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years (32 percent of respondents), including 45 percent who chose not to get care because they could not 

afford it. Of those who did get care, 23 percent reported problems with inaccessible healthcare locations, 

22 percent had difficulty getting appointments, and 19 percent could not find a physician who would 

accept their health insurance.

However, despite sharing stressors and vulnerabilities, behavioral health needs vary across communities 

and by demographics within communities. Nor is OUD the sole behavioral health concern for these 

communities: Findling and colleagues’ 2020 survey revealed that adults in rural Appalachia3 were 

significantly more likely to report opioid or other drug use as the biggest problem in their community 

(42 percent of respondents), compared to rural communities in the Northeast (19 percent; p = 0.003), 

Midwest (19 percent, p <0.001), South (19 percent, p <0.001), and West (28 percent, p = 0.02). Binet and 

colleagues (2021) found that, among survivors of the Fort McMurray wildfires, women were 1.5, 1.55, and 

1.86 times more likely than men to receive information, medication, and psychological help, respectively. 

Those who were White, those who had higher levels of education (postsecondary or higher), and those 

who were married were also more likely to utilize all three types of services. When looking at prescription 

opioid misuse among Black populations in urban and rural areas, Rigg and Nicholson (2019) observed 

that urban and rural populations had similar rates of misuse. Instead, rurality affected which factors were 

correlated with misuse: For example, having a high school education was not associated with lower opioid 

use in rural areas as it was in urban areas, and previous arrest was a risk factor in rural areas but not 

urban ones.

Coping With Behavioral Healthcare Disparities: Sources of Strength, Sources of Struggle

Rural and remote areas are characterized by smaller, less dense populations (Jenkins & Hagan, 2020), 

and this often translates to fewer resources available for behavioral health: less investment from large 

health systems (in both staff and facilities), less investment of state funds for public health initiatives, 

and limited ability to raise revenue to support new programs. In some states, more than 50 percent of 

non-metropolitan counties do not have a psychiatrist or psychologist: 58 percent in Michigan, 76 percent 

in Illinois, and 83 percent in Louisiana (Summers-Gabr, 2020). Hospitals in rural areas face increased 

risk of closure (Summers-Gabr, 2020), and even those that remain open are less likely to have specialty 

psychiatric services, with only 30 percent of U.S. rural hospitals having psychiatrists on staff or available 

for consultation, compared to 57 percent of urban hospitals, and telepsychiatry more likely to be used in 

rural hospitals (Ellison et al., 2022). 

Rural health providers also recognize they are un- or under-prepared to deliver behavioral health care 

to match the need in their practice areas (Lister et al., 2020). Saloner and colleagues’ 2022 regression 

analyses of Medicaid claims data revealed that living more than 20 miles from a physician offering 

medication-assisted treatment (MAT) for OUD under a buprenorphine waiver (using 2015 listings) was 

associated with an average of 17 days’ less treatment in non-metro areas. Where providers within 

feasible driving distance may exist, they may be already serving their maximum patient capacity: Ali and 

3 “Appalachia” is defined by the Appalachian Regional Commission as 423 counties in 13 states, from southern 

New York to northern Mississippi (Appalachian Regional Commission, n.d.).
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Ghertner (2022) found that, as of 2021, 67 percent of rural county residents did not have access to a 

buprenorphine prescriber within 30 miles who had the capacity to take on new patients. In Salvador and 

colleagues’ 2019 study of a program to increase MAT-delivery capacity among primary care clinicians, 

those providers that struggled with attendance cited a lack of practice-level support, despite interest in 

and clear need for increased capacity for MAT. Pasman and colleagues’ (2022) regression analysis of 

barriers to getting and staying in MAT revealed that the top barriers were travel time and work conflict 

(which is indirectly affected by travel time). These disparities are recognized by members of rural 

communities, as described in the studies below, many of whom struggle with behavioral health issues in 

isolation because the health infrastructure is lacking.

In their qualitative study of drivers of OUD, Thompson et al. (2020) interviewed members of a rural 

Pennsylvania community to collect evidence for structural factors that increased risk of OUD. Participants 

described how circumstances—a sense of normalized opioid use, lack of economic opportunity and 

investment, loss of wider social support for coping with stressors or getting into recovery—created a 

cycle that exposed people to behavioral health risks and offered no solutions. Hargrove and colleagues 

(2022) uncovered a similar finding in focus groups with members of an Appalachian community in Virginia 

(with focus groups including family and friends of opioid users, recovery service providers, treatment 

service providers, and decision-makers and policymakers). Healthcare professionals and others in the 

community described a convergence in their community of larger phenomena: a manual labor economy 

(with resulting increased pain and injury management needs), economic disinvestment (closing factories, 

reducing workforce), and heavy promotion of opioids by pharmaceutical companies followed by a 

backlash against prescribing opioids once addiction had become widespread. Community members saw 

the close family ties in their community both as a source of strength (for prevention and recovery) and a 

vulnerability (intergenerational opioid use, emotional and financial toll of having a loved one struggling 

with SUD). 

This emotional impact of the community’s economic situation echoes Snell-Rood and colleagues’ 

extensive qualitative research (2017; 2018; Snell-Rood, Jenkins, et al., 2019; Snell-Rood, Staton, & 

Kheibari, 2019) with 28 low-income women in Appalachian Kentucky. Depression and mental health 

issues are expected, given what is happening in their community—economic stagnation, financial anxiety, 

and the sense of being “trapped” (Snell-Rood & Carpenter-Song, 2018). Cultural principles of “selfreliance” and avoiding “negative thinking” would become coping strategies of working harder, leading to 

further isolation from social supports to avoid stigma for depression (Snell-Rood et al., 2017). Women 

in Snell-Rood’s research also observed that substance use was a strategy to deal with poorly managed 

mental health symptoms when adequate, appropriate, high-quality care was not available (Snell-Rood, 

Staton, & Kheibari, 2019; Snell-Rood et al., 2017).

As described by Weaver et al. (2018) in their analysis of the National Survey of American Life, Black 

members of rural and remote communities experience many of the same mental health stressors 

as non-Hispanic White rural communities, especially the association of increased material hardship 

with increased likelihood of reporting depressive symptoms, with the addition of racial discrimination. 

In Haynes and colleagues’ (2017) qualitative research in Jefferson County, Arkansas, stakeholders 

(n = 50; primary care providers, faith community representatives, college students and administrators, 

and individuals living with mental illness) identified determinants and barriers to mental wellness that 

were similar to those mentioned in Snell-Rood’s (2017–2019) work (in a sample that was predominantly 
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White): poverty and economic instability, feelings of hopelessness, stigma against seeking mental health 

care except in the most severe cases. A few participants, however, mentioned a cultural distinction 

between “experiencing mental unwellness” and “mental illness” (which they associated with a severe 

form of distress). Participants shared fears about seeking mental health care precisely because of that 

association with severe, “dangerous” instances of mental illness.

Rural and remote Indigenous communities’ behavioral health needs and responses are influenced by 

the meeting of cultures (community culture and “mainstream”/Western culture). In their scoping review of 

Indigenous community-based mental wellness initiatives (covering communities in Canada, the United 

States, Australia, and New Zealand), Venugopal et al. (2021) describe the legacy of cultural disruption 

in Indigenous communities as a shared, intergenerational trauma that is layered with the impact of a 

disaster. The authors describe several studies covering the interrelatedness of land, culture, and mental 

wellness for Indigenous communities, which can be a vulnerability in disasters that result in long-term 

displacement. Venugopal et al. also identified the challenge of intermittent funding for mental health 

services, which Fitzpatrick and colleagues (2021) also explored in their qualitative research with mental 

health service providers (both Indigenous and non-Indigenous) who serve the First Nations and Métis 

communities in Alberta, Canada’s Regional Municipality of Wood Buffalo. Providers described frustration 

with the inconsistency of mental health services before and after the 2016 Horse River wildfire, which had 

established a relationship with the communities that was characterized by instability and insufficiency. 

This fractured relationship made it difficult to trust the influx of disaster-response providers and 

organizations.

How Stigma Shapes Behavioral Health in Rural Areas

As described above, hesitancy about engaging in behavioral health care can be a response to a 

resource-poor environment: Without available providers within reasonable travel distance, “engaging” 

in care may not be feasible. As described in Ibragimov et al.’s 2020 literature review and Snell-Rood 

and colleagues’ research with Appalachian communities (2017–2019), a failure in self-management of 

behavioral health issues carries a stigma that, unfortunately, makes it harder to seek additional help.

Stigma related to SUD in rural communities reflects the cultural, economic, and social conditions of rural 

life: strongly interconnected social networks, frustration with limited economic and medical resources, 

and recognition of risks shared by people with and without SUD. In their qualitative research with a 

wide array of stakeholders in rural Illinois, Ezell and colleagues described multiple divides between “us” 

(“the hardworking and upstanding”) and “them” (“the irresponsible, difficult, and parasitic drains on our 

time, energy, and resources”). Ezell and colleagues’ (2021) research showed professional stakeholders 

(pharmacists, law enforcement, community health workers, and even those working in SUD treatment) 

struggling to reconcile their desire to avoid treating anyone differently with the need to identify who 

may be living with SUD. For those stakeholders, that identification often entailed observing behavior, 

hygiene, mannerisms, and even dress/styling, which people with SUD recognized and responded to with 

avoidance (especially in encounters with law enforcement). People with SUD also expressed their own 

frustration with others with SUD who engaged in behaviors (like drug seeking or crime) that brought about 

more stigma or suspicion and made it more difficult to be treated with respect by professionals, replicating 

the “us/them” divide among people with SUD.
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Stigma can result in interventions to reduce SUD and OUD facing pushback in rural communities about 

their long-term effectiveness. Richard et al. (2020) explored this with a small number of professional 

stakeholders (12 healthcare professionals, 12 substance use treatment providers, 7 law enforcement 

agents and judicial officials, and 3 members of relevant organizations) in Appalachian Ohio. These 

stakeholders shared community perceptions of MAT that made seeking services more difficult: that 

OUD medication is “trading one addiction for another,” that starting substance use is a “choice” not 

everyone makes, and that total abstinence is necessary to be considered “clean.” Even among those who 

understood addiction as a disease, there was still judgment around the decision to first use substances. 

Ibragimov et al. (2020) describe several qualitative studies with similar findings, where participants 

expressed a tension between compassion for those with SUD and frustration with dealing with the harms 

of widespread SUD and very little infrastructure for supporting recovery. 

High rates of stigma are correlated with low levels of knowledge about harm reduction (Baker et al., 2020; 

Curcija et al., 2022). In Franz and colleagues’ survey of 274 Ohio physicians, only 19 percent of rural 

physicians practiced in a county that had an existing syringe services program, compared to 68 percent 

of physicians practicing in urban counties. Ibragimov and colleagues (2020) observe that stigma against 

those with SUD can translate to silence among those individuals about the successes of harm-reduction 

programs (since total abstinence is the only non-stigmatized outcome). However, coming to understand 

OUD as a chronic illness is correlated with more positive attitudes toward MAT, harm reduction services, 

and people with OUD, and education can bring about this understanding (Beachler et al., 2021; Curcija 

et al., 2022; Zeller et al., 2021). In Franz and colleagues’ (2021) survey of 274 physicians in Ohio (in 

both rural and urban settings), working in addiction medicine was significantly associated (p <0.001) 

with reduced bias towards people with OUD. Curcija and colleagues (2022) conducted a survey of 789 

members of rural Colorado communities to measure the impact of campaigns to increase awareness 

of and knowledge about MAT for OUD. Nearly half of those surveyed had been exposed to a campaign 

product, and greater exposure was significantly associated with beliefs that opioid use was a problem in 

rural communities (p <0.0001), opioid addiction is a chronic disease (p = 0.032), and that OUD can be 

treated locally (p = 0.003). 

RESPONDING TO DISASTER BEHAVIORAL HEALTH NEEDS IN REMOTE AND 

RURAL COMMUNITIES 

Rural and remote communities have a unique set of strengths and vulnerabilities that should inform the 

delivery of behavioral health care after a disaster, including under-treated behavioral health issues and 

(depending on the community) a high prevalence of SUD. Rural communities that experience multiple 

disasters are at particularly high risk for severe behavioral health issues, such as the Fort McMurray 

community in Alberta, Canada (which experienced a 2016 wildfire and both flooding and the COVID-19 

pandemic in 2020). Agyapong et al. (2022) surveyed 186 community members (of a population of 

111,687) to understand the association of experiencing multiple disasters with mental health effects, 

finding that those who were not affected by wildfire or flooding had lower likelihood of major depressive 

disorder, generalized anxiety disorder, PTSD, or general measures of low mental health resilience. 

Batterham et al. (2021) saw similar findings in their systematic review of environment and mental health 

in rural areas: that degradation of the environment, especially extreme climate or weather events, was 

associated with poorer mental health and well-being at a community level. With the increasing frequency 
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of extreme weather events and weather-related disasters, understanding the individual and long-term 

impacts of environment on mental health in rural areas will only become more important.

Disaster survivors may be more likely to try informal approaches or use preexisting coping solutions 

instead of or before seeking mental health services. In a secondary analysis of survey data from a rural 

telehealth initiative, Newman et al. (2021) observed that rural participants were less likely to initiate 

psychotherapy (odds ratio [OR] = 0.67, adjusted p = 0.036) or perceive a need for treatment (OR = 0.67, 

adjusted p = 0.040), which was a strong predictor of initiating treatment. Participants in Binet et al.’s 

survey (n = 1,510) cited barriers to seeking information on mental health care: preference to self-manage 

(26.8 percent), not knowing how or where to get information (23.2 percent), and thinking about it but 

not getting around to doing it (17.9 percent). The most common medication barriers were preference to 

self-manage (47.2 percent), thinking about it but not getting around to doing it (17.0 percent), not being 

able to afford to pay (9.4 percent), and reluctance to take medication (9.4 percent). Finally, reasons for 

not receiving psychotherapy or counseling included a preference to self-manage (50.7 percent), thinking 

about it but not getting around to doing it (13.0 percent), and thinking it would not help (7.7 percent). 

These barriers did not vary by gender.

In this section, we organize the findings related to rural and remote behavioral health disaster 

response into three areas: 1) governmental and policy approaches to remove barriers and close gaps, 

2) community initiatives to respond to behavioral health needs after a disaster or crisis, and 3) the 

applicability of tele-behavioral health approaches to disaster response.

Governmental & Policy Approaches

As described by Jenkins and Hagan (2020) in their review, because of their smaller population size, rural 

and remote areas are a lower priority for funding and other resources, even among states with policy and 

economic investments in public health, behavioral health, and harm reduction. Jenkins and Hagan also 

note that policymaking stakeholder relationships in rural areas work differently: Health commissioners 

may need to work directly with law enforcement and long-term residents’ buy-in is critical for any 

approach to succeed. 

In a disaster response, those who are currently in MAT or living with SUD need an environment where 

they can be honest about their health needs without experiencing stigma, sharing of health information 

outside of the encounter, or unwanted involvement of law enforcement (Ellis et al., 2020). Behavioral 

health services involving prescribing controlled substances, like MAT, are highly regulated, which makes 

adapting to disaster responses challenging (Salamanca-Buentello et al., 2022). Federal healthcare 

partners, such as the U.S. Department of Veterans Affairs, have played a role in disaster response, and 

their access to nationwide behavioral health resources (including mobile behavioral health units and telebehavioral health) can be integrated into a local disaster response (Wyte-Lake et al., 2021).

With a smaller population, rural and remote areas are limited in how much revenue they can raise for 

behavioral health solutions (Jenkins & Hagan, 2020). The shortage of behavioral health staff and facilities 

requires large-scale, long-term policy and economic interventions; however, some areas have come up 

with creative ways to tap their existing resources to close gaps. In a short commentary report, Flaherty et 

al. (2018) describe a policymaking response to unmet behavioral health needs in Hancock County, Ohio, 

that engaged stakeholders from law enforcement to academic medical programs. County leadership met 
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with health and citizen leaders to identify gaps in the continuum of care for substance use, and where 

opportunities to engage people with SUD take place. First responders were trained on and supplied with 

naloxone, treatment providers were integrated into the court system, and MAT maintenance and naloxone 

distribution were added to jail and re-entry systems. 

In addition to adding behavioral health capacity in existing positions, county leadership created three 

professional development initiatives: 1) academic training and certification for health sciences students 

at the area university with a parallel track for peer workforce certification; 2) turning an underutilized 

community drop-in center into a recovery-focused drop-in center staffed by peer leaders; and 3) a 

hospital-led collaboration between the health department, community physicians, and hospital staff 

on improving knowledge of and expanding services for addiction (inpatient withdrawal management, 

specialized programs for pre- and neonatal SUD). As a result, the authors report that Hancock County 

has reduced overdose deaths among those seeking treatment (from 18 percent in 2009 to 6 percent 

in 2017) while serving a larger number of community members (72 seeking treatment in 2009 vs. 

594 in 2017).

Community-based Approaches

Although rural and remote areas are challenged by an overall lack of resources (relative to the density 

and scope of resources in urban areas), approaches that address what is important to a community 

can increase impact without necessarily requiring more resources. Examples of these approaches 

are provided below; despite their differences, what they share is an intentional, deep understanding of 

community assets and desires. 

GROUNDED MENTAL WELLNESS APPROACHES: MEETING COMMUNITIES WHERE THEY ARE

Using findings from deep, qualitative research among women in Appalachian Kentucky, Snell-Rood, 

Jenkins, et al. (2019) adapted and implemented a mental wellness program, Wellness Recovery Action 

Planning (WRAP), for women in their study community. Key to this approach was understanding how 

patients conceptualized mental illness and distress: a chronic illness, an understandable reaction to 

what’s happening in the community, a shared experience of symptoms (appetite, sleep, sense of being 

overwhelmed) (Snell-Rood, Jenkins, et al., 2019). Although not a replacement for mental health treatment, 

WRAP uses nonclinical terms to describe mental health and focuses on wellness and self-management. 

This focus allowed for participants to gain strategies and resources regardless of their interpretations 

of distress, depression, and mental illness, and could be customized to address participants’ symptoms 

and their clinical treatment plans (if any). For this adaptation, Snell-Rood and colleagues identified how 

community culture can shape pressures that become mental health stressors (such as social isolation, 

stigma against severe mental illness) and provided the strategies to manage those stressors, like 

interpersonal communication strategies (Snell-Rood, Jenkins, et al., 2019). 

The 37 participants reported lower depression scores on the Patient Health Questionnaire-9 postintervention (p = 0.02) and improved ability to deal with daily problems (p = 0.04) and accomplish goals 

(p = 0.02). One surprising, qualitative finding was the recognition that not only did many women in their 

community struggle with juggling many obligations (familial, financial, social, educational), they all shared 

a sense of isolation in being the only one struggling. Participating in the WRAP adaptation gave them an 

appreciation for their own strength in the face of hardship and a recognition that these challenges were 
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not theirs alone. In a post-disaster setting, the WRAP model could be adapted to a community’s shared 

hardships: Rather than delivering behavioral health services based on screening and triage, a symptomsand strategies-based Action Plan could acknowledge the shared impact of the disaster event (reducing 

the isolation of those struggling with behavioral health issues) while allowing for responses to be 

customized based on individuals’ most urgent needs and different concepts of “mental illness/wellness,” 

“trauma,” or “distress.”

Where behavioral health care providers are not available, or as a complement or alternative to a 

medicalized approach, communities use church community and clergy as one method of coping with 

mental distress or seeking behavioral health help. Weaver and colleagues (2019) surveyed members of 

two churches in rural Midwestern communities (n = 100) and found high rates of openness to informal 

and formal depression treatment delivered in church-based group: Almost two-thirds of respondents 

would consider attending a church-based group depression intervention, 80 percent would recommend 

it to a friend, and 60 percent saw benefit for their community. Schultz et al. (2021) conducted similar 

research in a rural Indiana community, combining surveys (n = 82) with focus groups (n = 4 and n = 7). 

Most respondents (60 percent) preferred to meet with a counselor who was from outside the community, 

and only 37 percent wanted to join a self-help group of peers. However, focus group participants clarified 

that while they preferred the relative anonymity of an “outsider” provider, they also wanted that person to 

be known to a trusted community member.

Lalani et al. (2021) conducted qualitative research with survivors of the Fort McMurray wildfire (n = 65) 

on the role spirituality played in their recovery after disaster. Although the geography and economy of 

the Regional Municipality of Wood Buffalo differ from other rural communities in this study (namely, 

the economic presence of the oil industry), the community shared similar stories of isolation, unstable 

population, and concern for children and youth who represented the future of their community. Hope—

for individuals’ recovery, for community regrowth—was how many community members coped with 

the post-wildfire hardships, and faith practice was central to how community members fostered that 

hope in themselves and others. Churches served as a physical space to find community and engage 

in community-building activities, and faith value systems helped participants look for positive, hopeful 

aspects of post-disaster growth.

Addressing behavioral health among children is critical to preventing further behavioral health issues 

in adults, and limited access to pediatric behavioral health may mean wait times of weeks or months 

for services. In a survey of 118 parents in a rural pediatric primary care practice in the Midwestern 

United States, Fehr et al. (2020) found that only half of parents could identify treatment options in their 

community. Rural children and youth are also disproportionately more likely to experience serious, 

negative mental health outcomes: For example, suicide rates among rural adolescents are nearly twice 

that of urban adolescents (Runkle et al., 2022). By integrating behavioral health into school settings, 

children and youth can receive much-needed services in a familiar setting where they already spend 

much of their time. However, the lack of behavioral health providers remains a universal challenge. 

Berryhill et al. (2022) examined three group-based cognitive behavioral interventions and one yoga 

intervention, delivered in classroom settings, to increase coping skills and reduce depression symptoms. 

Although these interventions showed some improvement in coping skills and symptoms, students at 

higher risk for depression were the least likely to sustain these improvements. Additionally, Berryhill et al. 
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note that none of these interventions addressed anxiety, one of the most common mental health issues 

among children and adolescents.

TASK SHIFTING FOR BEHAVIORAL HEALTH: REALIZING THE RESOURCES YOU ALREADY HAVE

The concept of “task shifting” or “task sharing”—moving tasks among individuals of different training 

levels so that each individual is carrying out the most complex or specialized tasks they can perform—

has been used in international health, particularly in global HIV/AIDS work (World Health Organization, 

2008). Hoeft et al. (2017) conducted a literature review to better understand how this approach may 

be used to address what they describe as a “persistent shortage of mental health specialists.” Overall, 

Hoeft et al. note that the strongest evidence supports collaborative care—coordination of care between 

primary care, mental and/or behavioral health, case management, and sometimes community health 

workers (CHWs)—for depression and anxiety. Collaborative care lends itself well to a task-sharing model 

because each member of the team can perform specialized tasks to address clients’ complex needs. For 

example, case managers can identify social supports that might relieve some of the economic stressors 

exacerbating anxiety.

Hoeft and colleagues also revealed evidence supporting augmenting a collaborative care model with 

telemedicine when specialties are not locally available. Telemedicine can also be used to deliver training 

and supervision, which increases individual staff capacity (training in skills and scope) and organizational 

capacity (supervision and consulting). However, the authors also note that remote learning and 

supervision alone may not be sufficient for all learning/management approaches. Finally, while Hoeft et al. 

found less evidence for incorporating CHWs into mental health care, they also found great interest, given 

the success of CHWs in other contexts and the importance of having trusted individuals who understand 

the community’s culture. This may be especially important in a disaster response when healthcare 

capacity may also need to deal with physical trauma care and other urgent health needs.

Raviola et al. (2020) describe a task-shared community-based mental health system developed in Haiti 

between 2010 and 2019, a period in which several natural disasters (earthquake, hurricane) and social 

unrest severely disrupted the preexisting mental healthcare system. Existing NGO health organizations 

built on past work and recognition in the communities to become a central, credible resource for mental 

health care. Standardized requirements and interventions for different staff roles (CHWs, social workers, 

psychologists, and physicians) were developed on a condition-specific basis, starting with depression and 

adding in additional mental health areas. These organizations also conducted ongoing identification of 

training needs for new stakeholder roles (nurses, community leaders, traditional healers, teachers, quality 

improvement professionals) to assess how these stakeholders could share the burden and make sure no 

one role was overloaded.

In a U.S. setting, Gainey et al. (2018) describe the use of mobile integrated health (MIH) teams—

paramedics who provide health care using mobile resources—after flooding in Richland County, South 

Carolina, in 2015. County emergency medical services personnel who joined MIH teams received 

additional training, such as medication reviews, patient evaluation, and chronic disease management. 

They were also paired with community providers (pharmacists and social workers) to be trained on patient 

care. Although not originally trained for disaster response, MIH teams identified medically vulnerable 
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community members, ensured prescriptions were continued for community members who lost medication, 

transported separated family members, conducted wellness checks, and delivered food and water.

Telemedicine Approaches for Meeting Behavioral Health Needs in a Disaster Response

Telemedicine seeks to solve some of the challenges in delivering care to members of rural communities: 

the distance between patients and providers, the challenge of finding an accessible provider accepting 

insurance, and challenges with long wait times for appointments. In Findling et al.’s 2020 survey, 24 

percent of rural adults had received a healthcare diagnosis or treatment via telehealth. Of those who had 

used telehealth, 69 percent chose to use it because it was the most convenient way to get diagnosis or 

treatment. As described in detail in the August 2022 Supplemental Research Bulletin, “Adaptations and 

Innovations for Delivering Mental Health and Substance Use Disorder Treatment Services During the 

COVID-19 Pandemic,” expanded use of telehealth (especially changes in reimbursement policies for 

telehealth services) helped behavioral health providers maintain and initiate services. 

Telemedicine (especially video-calling, which requires a high-speed, broadband internet connection) can 

serve rural county residents who have access to broadband internet but lack a local behavioral health 

provider. Ali and Ghertner (2022) estimate that 63 percent of residents in high broadband availability 

areas lack buprenorphine providers within 30 miles with capacity to take on new patients. However, areas 

with lower broadband availability (less than 90 percent of the population with access to an internet service 

provider offering broadband speeds) also had fewer providers: As many as 82 percent of residents 

in lower availability areas did not have a provider with capacity within 30 miles. Ali and Ghertner also 

note that availability of broadband does not always equal affordability of broadband, and those whose 

economic instability puts them at greater risk of SUD are also least able to afford high-speed connections.

Telemedicine for behavioral health has obvious advantages in a disaster situation. As described in 

Augusterfer and colleagues’ review (2020), tele-behavioral health can:

• Augment local communities’ capacity for behavioral health in a period of increased need and 

reduced resources

• Provide quick access to specialty care in areas where it has been historically lacking

• Assist with task-sharing approaches by providing lay and professional health workers with remote 

supervision and support

Augusterfer et al. also note challenges with delivering remote behavioral care via telemedicine: 

• Ensuring that the trainings for staff are standardized (ensuring quality and reliability of service) 

but also culturally competent (using community values) and flexible enough to respond to 

emergent needs

• Monitoring health workers for burnout, overload when supervisors are remote

• Maintaining patient safety during a tele-behavioral health encounter: preventing harm to patients 

who are agitated, express suicidality, or other imminent threats to their health

For survivors of a disaster, tele-behavioral health delivery modes need to be relevant to and appropriate 

for participants’ symptoms: Békés et al. (2022) conducted a randomized controlled trial of a tele-mental 

health intervention for survivors of the Fort McMurray wildfires in Alberta, Canada. The RESILIENT 
| Page 13

intervention combined online educational modules on topics like PTSD or sleep management with 

30-minute, synchronous, cognitive-behavioral therapy sessions conducted by video or phone conference. 

Trial participants were screened for PTSD, depression, and insomnia, and either assigned to the 

treatment group or a wait list. Therapists observed that clients’ symptoms determined their engagement 

with the intervention: If clients believed the education or therapy was not addressing their symptoms, 

or if their symptoms were too severe to engage (either at baseline or after beginning the intervention), 

they were more likely to drop out. Bunnell and colleagues’ (2017) comparison of access to a web-based 

mental health intervention between rural and urban/suburban families (n = 1,321 families) in parts of 

Missouri and Alabama that had been affected by a tornado in 2011 had a similar finding: They observed 

no geographic differences in accessing the web-based intervention. When asked about reasons for not 

accessing the intervention, participants shared that they were too busy, forgot to access the site, or that 

the site was not relevant to their present concerns.

The randomized controlled trial evaluating RESILIENT (the tele-mental health intervention implemented 

by Békés et al.) showed that, compared to those on the waiting list, intervention participants had 

decreases in PTSD, depression, and insomnia symptoms, as well as reduced symptom severity and 

disability (Belleville et al., 2022). However, as discussed above, symptom severity was often a reason 

for discontinuing treatment, and Belleville et al. noted larger effect sizes in those who completed at 

least half of the intervention. This research raises important questions about the suitability of similar 

interventions for severe symptoms, but therapists in the implementation did find success in retaining 

clients with severe symptoms with modifications, such as increasing the therapy sessions and reducing 

self-directed learning.

TELEMEDICINE FOR BEHAVIORAL HEALTH EMERGENCY CARE (“TELEED”)

Behavioral health issues often result in emergency department (ED) visits. With limited psychiatric 

specialists available, many EDs in rural and remote settings rely on telemedicine to close the gap. 

In Heppner et al.’s (2021) cohort analysis of six rural tele-emergency medicine grants, mental 

and behavioral health made up almost 10 percent of the uses of “teleED.” Looking specifically at 

telepsychiatry, Freeman and colleagues (2020) conducted two surveys of EDs: one survey of all 5,375 

U.S. emergency departments and one follow-up survey with a sample of those using telepsychiatry. 

Of those EDs that responded (4,507 or 84 percent), 885 reported receiving telepsychiatry. EDs in 

rural locations and in critical access hospitals were more likely to report telepsychiatry. Of the EDs 

that reported using telepsychiatry, most (59 percent) also stated it was their only form of emergency 

psychiatric services available, and 62 percent used it 6 days a week (with 25 percent using it at least 

once per day). In Natafgi and colleagues’ review (2021) of emergency telemedicine during the COVID-19 

pandemic, the authors observed that emergency telepsychiatry decreased wait times to see a provider, 

increased overall ED efficiency, reduced odds of subsequent behavioral health ED visits, and were 

well-accepted by patients. (Providers had some concerns about reading nonverbal language, but they 

appreciated the access to peers with specialized expertise.)

Emergency telepsychiatry may increase access and decrease wait times for behavioral health triage 

but a lack of facilities available for patient care after the ED remains a challenge. Fairchild et al. (2019) 

compared cases where patients at critical access hospitals received telehealth-based behavioral health 

care through Indiana’s Wabash Valley Rural Telehealth Network with similar patient cases from before 
| Page 14

the implementation of the WVRTN. Mean wait time before being seen by a provider decreased from 27 

to 12 minutes (statistically significant at the p = 0.012 level). There were some differences in disposition 

(telehealth patients were more likely to be transferred to another facility, less likely to be admitted) but 

none were statistically significant, and a similar percentage of patients were routinely discharged. Similar 

to other studies, mean ED length of stay was statistically significantly longer for telehealth patients 

(318 minutes vs. 147, p <0.001), only 55 minutes of which consisted of the telehealth visit. However, the 

longest wait times between the end of the telehealth visit and departure for the emergency room were 

for admitted and transferred patients, which the authors propose may be due to bed capacity in critical 

access hospitals and behavioral health facilities. 

TELEMEDICINE FOR COMMUNITY BEHAVIORAL HEALTH CARE

While tele-behavioral health in EDs is helpful for emergency care, ongoing behavioral health needs 

cannot be met in hospitals alone. A few studies in this review looked at possibilities of offering telebehavioral health in primary care and outpatient settings. Agley et al. (2022) conducted a feasibility 

pilot of telehealth psychiatric triage in community primary care settings: two community primary care 

practices, one faith community nurse, and remote behavioral health staff (social worker and advancedpractice psychiatric nurse) in the mental health arm of the hospital and healthcare system of an adjacent 

county’s hospital. Patient Health Questionnaire (PHQ-9) screening and providers’ clinical judgment were 

used to identify patients who may benefit from triage; those patients were offered the option of telehealth 

assessment or, if requested, in-person assessment. Of the 68 referrals, only 2 (3 percent) had a previous 

psychiatric diagnosis in their medical record, 50 (74 percent) accepted a telehealth assessment and 

46 (68 percent) enrolled in free psychiatric care offered by the pilot program. (In some cases, clients 

presented with psychiatric symptoms because of unmet social needs, so 11 clients ended up working with 

a social worker to solve those challenges.) This pilot successfully identified unmet mental health needs 

in a rural population and provided a capacity-building solution acceptable to patients, but changes to 

workflow or increased burden were not studied.

Sizer and colleagues (2022) analyzed users of telepsychiatric services in rural parishes across Louisiana 

(n = 1,115) to understand the demographic and clinical characteristics of those who benefited from and 

those who struggled with tele-behavioral health during the COVID-19 pandemic. From early 2020 through 

early 2022, the Northeast Delta Human Services Authority (which provides behavioral health care for rural 

communities in northeastern Louisiana) sharply increased their use of telemedicine visits and sharply 

decreased their in-person visits. The authors found that being younger, female, and having higher levels 

of education were positively associated with tele-behavioral health visits. Sizer and colleagues also 

noted an asymmetric substitution: Telemedicine visits did not replace in-person visits at a 1:1 rate, so 

visits overall dropped during the 2020–2021 period, especially among older adults. Race and income did 

not appear to have an effect on utilization of telemedicine visits, although the authors note that only 62 

percent of households in the service communities subscribe to internet service.

LIMITATIONS

This review is not an exhaustive summary of behavioral health challenges in rural communities, which 

include historical, economic, cultural, political, and geographic barriers to establishing a robust behavioral 

healthcare infrastructure. In the literature, many are small, community-specific and often qualitative 
| Page 15

studies (that provide rich data on a particular community) or larger, quantitative studies that compare all 

rural areas across the United States or a state (ignoring the differences in demographics, economies, 

geography, and culture between rural areas). We present interventions as examples of how one may 

solve some of the challenges to delivering behavioral health care in rural and remote communities; how 

applicable or adaptable any of these interventions are to a specific community may vary, especially 

Indigenous rural and remote communities. Finally, the choice to limit articles to the last five years was 

both to focus on the latest research but also account for the increased publication volume related to 

responses to the COVID-19 pandemic. Older articles may still provide important strategies and starting 

points for disaster response but did not happen to be included in the scope of this review.

CONCLUSION

Behavioral health disaster response solutions for rural communities are not “one size fits all.” An 

understanding is required of general differences between urban and rural behavioral health needs but 

also the characteristics of the specific community or communities, especially strengths that can be tapped 

and historical and social challenges that need to be navigated. When developing a behavioral health 

disaster response, a thorough understanding of the community may be the most critical factor determining 

how successful a response will be when tested. 

Important questions to ask when developing a behavioral health disaster plan include:

• What kinds of disaster risk does the community face, and what kinds of disruptions would those 

cause to behavioral health services?

• Who lives in the community, and how do their demographic characteristics (age, gender, race, 

education, income) inform their behavioral health needs? 

• What are the preexisting vulnerabilities in the community (economic stressors, unmet mental health 

and SUD treatment needs, the prevalence and types of substance misuse)?

• What are the preexisting strengths and values of the community (civic pride, faith practices, social 

connectedness, shared culture, connection to the land)?

• What are the preexisting resources that can be tapped during a disaster (healthcare infrastructure, 

community-based organizations, formal and informal volunteer organizations providing social 

support)? What relationships and connections need to be forged so that these resources can meet 

behavioral health needs?

SAMHSA is not responsible for the information provided by any of the web pages, materials, or organizations 

referenced in this communication. Although the Supplemental Research Bulletin includes valuable information 

and links, SAMHSA does not necessarily endorse any specific products or services provided by public or private 

organizations unless expressly stated. In addition, SAMHSA does not necessarily endorse the views expressed 

by such sites or organizations nor does SAMHSA warrant the validity of any information or its fitness for any 

particular purpose.
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