The Disparities of Mental Health Care Between Rural and Urban Areas in the United States
By: Shirley J. Davis
Tags: Mental Health, Healthcare Disparities, Rural America

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Receiving appropriate mental health care is crucial to healing. However, an enormous number of American citizens cannot and do not receive the care they need because there simply are no providers in their region to turn to in times of crisis.

In this piece, we shall examine the statistics and costs both monetary and personal of the lack of mental health professionals in rural America as compared to living in or near a major city.

The Essence of the Disparity Problem

More mental health professionals choose to hang out their shingle in urban areas than rural, but why? What are the differences that cause the men and women of the helping professions to decide to stay away from the rural areas of the country?

There are basically three reasons that mental health professionals avoid working in rural settings; poverty, lack of insurance, and lack of opportunities for a provider’s family.

Poverty: The number of people living in rural areas as compared to those living in or near cities is almost double.4

Lack of Insurance: Because of poverty, most people who impoverished are covered by either Medicaid or have no insurance at all. Mental health providers know that Medicaid is notorious for either paying grossly below their fees or not covering their services at all making moving to impoverished rural areas less attractive.4

Lack of Opportunities for the Provider’s Family: Professionals offering mental health services have families and must weigh their wish to service rural areas to the needs of their children. Since rural America has fewer opportunities for good schools and university availability, many choose to remain near cities.

Clearly, mental health professionals need incentives to make the difficult decision to move to a rural area to help those who live there without harming their families.

Other barriers to mental health professionals locating in rural areas may be:

· Lower pay when compared to other settings

· Difficulty of spouses finding employment

· Having fewer social outlets

· Difficulty adjusting to living away from the city

· Professional isolation

The Statistics of the Problem

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In 2018, it is reported that there are approximately 327 million people living in the United States. Of that number, 1 in 5 have a mental illness (20%) meaning approximately 65.4 million live with a mental health diagnosis with 51% of that number having a co-occurring substance abuse problem.1

In 2015, a national survey found that 80% of citizens of the U.S. live in urban areas (in or near cities) as compared to the 20% who live in rural (country) areas. That means that while 262 million American citizens live in or near cities, a whopping 65.4 million live in rural settings.

The inequality of available of care becomes glaringly clear after considering a report published in the American Journal of Preventive Medicine2 in 2018 that states 65% of rural citizens lack a psychiatrist while 47% lack access to a psychologist.

Venture to look at the following other statistics broken down by provider that shows the percentage of mental health professionals comparing urban-rural areas in America:

The Percentages of Available Mental Health Professionals in Urban vs. Rural Areas (those professionals not in private practice)

Psychiatrists:

Urban: 17.5%

Rural: 5.8%

Psychologists:

Urban: 33.2%

Rural: 13.7%

Psychiatric Nurses

Urban: 2.2%

Rural: 1.6%

Social Workers (MSW)

Urban: 80%

Rural: 20%

Note: the figures in this table are from 2015 and may have changed. For instance, there are now more psychiatric nurses practicing in 2019 than in 2015.3

Problems in Receiving Appropriate Mental Health Care in a Rural Setting

There are other barriers to someone living in a rural setting receiving adequate mental health care. These include blockades that may include cultural differences and lack of privacy.

In communities where the majority are of one demographic make-up, (perhaps a conservative community), going to therapy or to see a psychiatrist can lead to the person experiencing discrimination leading to job loss, ostracization, and embarrassment.

There are also cultural differences such as African Americans feeling badly about approaching a mental health professional for help because might be considered a sign of weakness.

All these problems are made much worse by the heavily limited choices people living in rural communities have for help with their mental health challenges. A good example might be a person of African American descent having to see a white American professional. Even if the professional has no biases against their African American client, because they are from a different ethnic group, they may lack understanding of the unique needs of and can thus be ineffectual.

The Monetary Costs of the Lack of Mental Health Care in Rural America

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The monetary disruption to the United States due to the disparity of mental health care is counted in losses in productivity and attendance to work.

Because 1 in 5 working-age adults lives with a mental health disorder (71% of adults listed at least one symptom of stress), the loss of productivity can be very costly. It isn’t only mental health issues that cause absenteeism, but also the physical symptoms and diseases caused or worsened by them. Combined, medical and behavioral health costs $37.6 to $67.8 billion (yes, with a B) a year in lost productivity.6

The losses of productivity caused by poor mental health include but are not limited to the following:

· Negative job performance

· Lack of engagement with work

· Lack of or poor communications with coworkers

· Lowered physical ability and daily functioning

· Inability to finish job tasks

· Absenteeism

Many of these losses are occurring in the urban areas, but clearly, if the loss of monetary wealth of the United States is to end, the lack of mental health professionals in both settings must become a priority of lawmakers and citizens alike.

The High Personal Costs of the Mental Health Disparities in Rural America

According to the Centers for Disease Control and Prevention (CDC), the United States lost 44,193 citizens to suicide in 2015.7 That is approximately one death every twelve minutes. These stats make death by suicide one of the top leading causes of death in the U.S. today. In fact, in 2017, the CDC reported that completed suicide rates had jumped 33% since 1999.8

Death rates by suicide in rural areas outstrip those happening in urban communities and this problem is getting worse. The CDC report listed above also reported that the age-adjusted suicide rate rural in America was almost double (1.8 times) the rate of most urban areas.

Setting statistical information aside for a moment, we cannot forget the extraordinary harm that suicidal thoughts and actions cause its victims and their families. The figures in statistics are talking about human beings with real problems who need to be noticed and helped. Curing the shortage of mental health professionals in rural communities is one way to combat the loss of life happening today in small-town America.

Possibilities to Solve the Problem of Lack of Mental Health Professionals in Rural America

There are no easy solutions to ending the life-altering lack of mental health professionals in rural America. However, there are some programs already in the planning or active stages, such as student loan forgiveness to providers who relocate to rural areas and practice there for a certain number of years.

Two more suggestions to help mental health providers relocate to and practice in rural America might be to offer income tax breaks and educational opportunities for their families.

More must be done to end the lack of adequate care for those who find themselves facing a mental health challenge. Below are a few more ideas that are already beginning to be implemented.

Telepsychiatry. Telepsychiatry has already begun to be used in rural settings. Known as “telepsych”, providers from cities can interact, diagnose, and offer treatment to patients in rural settings. Telepsychiatry offers a cheap and accessible alternative to not having a psychiatrist or therapist at all. However, because humans are social animals, interacting through a computer screen cannot and should not take the place of face to face interactions with a mental health professional.

Online Psychiatry. Today the Internet offers abilities and opportunities for patients to attend therapy online. People living in rural areas can now choose and interact with a therapist through their computer. However, like with telepsychiatry, there are problems with this method.

Certified Peer Support Specialists (CRSSs). A growing movement in the United States is the recognition and implementation of peer support specialists. As the name implies, peer support specialists are people with lived mental health experience who are trained to connect with others who are facing a crisis. Many states, and the federal government offer certifications to those who pass training and take an examination. Peer support specialists are being employed in clinics, hospitals, and private living room projects (cool down centers for those in crisis).

In Closing

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It should not be that people with a mental health diagnosis must either travel for miles for or simply not receive the help they need due to a lack of professionals where they live. If the citizens of the United States wish to stop losing loved ones and neighbors to suicide, we must come together to solve the disparities seen between rural and urban areas.

The costs of not ending the tragedy of mental health disparity are too high both monetarily and personally for us to ignore the problem any longer. Collectively, we who are concerned about the mental health of our rural communities need to raise our voices to make certain our governments both local and federal understand the danger of the lack of professionals in rural areas.

Who should be concerned? All of the citizens of the United States of America should be concerned because losing one life to suicide because there was no help available is far too many.

I realize how precious life is, probably because I’ve seen how it can be taken away. ~ Pierce Bosnan

References

1. Park-Lee, E., Lipari, R. N., Hedden, S. L., Kroutil, L. A., & Porter, J. D. (2017). Receipt of services for substance use and mental health issues among adults: results from the 2016 National Survey on Drug Use and Health. In CBHSQ Data Review. Substance Abuse and Mental Health Services Administration (US).

2. Andrilla, C. H. A., Patterson, D. G., Garberson, L. A., Coulthard, C., & Larson, E. H. (2018). Geographic variation in the supply of selected behavioral health providers. American journal of preventive medicine, 54(6), S199-S207.

Retrieved from: https://www.ajpmonline.org/article/S0749-3797(18)30005-9/fulltext

3. Larson, E. H., Patterson, D. G., Garberson, L. A., & Andrilla, C. H. A. (2016). Supply and distribution of the behavioral health workforce in rural America. Seattle, WA: WWAMI Rural Health Research Center.

Retrieved from: http://depts.washington.edu/fammed/rhrc/wp-content/uploads/sites/4/2016/09/RHRC_DB160_Larson.pdf

4. United States Department of Agriculture, Economic Research Service, (2018). Retrieved from: https://www.ers.usda.gov/topics/rural-economy-population/rural-poverty-well-being/

5. Rural Behavioral Health: Telehealth Challenges and Opportunities, (2016). Substance Abuse and Mental Health Services, Volume 9, Issue 2. Retrieved from:

https://store.samhsa.gov/system/files/sma16-4989.pdf

6. Workplace Health Promotion. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/workplacehealthpromotion/tools-resources/workplace-health/mental-health/index.html

7. Suicide in Rural America. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/ruralhealth/Suicide.html

8. Suicide Mortality in the United States, 1999–2017, (2018). Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/nchs/products/databriefs/db330.htm#targetText=Data%20from%20the%20National%20Vital,10.5%20to%2014.0%20per%20100%2C000.