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Mental health in crisis in rural Minnesota

Meg Reid mn2020.org Meg Reid

We who live in more urban areas too often subscribe to the stereotype of rural life as peaceful and idyllic. We assume that, far away from the pollution and stress of city life, people live easily and free from worry. Open air, no traffic, a simple life — great for mental health, right?

Wrong. In reality, people living in rural areas often face a higher burden of mental health problems than their urban counterparts. Agricultural communities can see an accumulation of stressors that result in distress, depression, anxiety, and substance abuse. The Minnesota Department of Health reported in 2005 that rates of depression among rural women were as high as 40 percent, while only 13 to 20 percent of urban women were depressed. In one study, rural patients in treatment for depression were three times as likely to be hospitalized for physical or mental health problems than urban patients. Another found that rural patients with bipolar disorder were four times as likely to have a manic episode during the year after diagnosis and were 17 percent more likely to attempt suicide.

Many factors influence mental health, but let's focus on just one of them: Access to care. Rural Minnesota is facing a critical shortage of mental health providers. The Health Resources and Services Administration (HRSA) reports a shortage equal to 52 full-time equivalent practitioners in Minnesota. The shortage means that patients have to drive longer distances to reach mental health practitioners. Social stigma makes it even more difficult for people to access care, and beyond this, a lack of health insurance among rural residents means that even those able to access care often can’t afford it. HRSA estimates that 1,456,036 Minnesotans do not receive an appropriate amount of mental health services. These patients cannot receive the medication, treatment, or support that would help them.

A fractured system

Emergency medical services and police are too often the ones who must deal with patients facing mental health crises. They must transfer patients to hospitals. Often patients are admitted across the state in order to find an open psychiatric hospital bed. The fractured system can mean that people with serious mental illness end up in county jails.

Let’s take the example of Nobles County. Because there’s no psychiatric unit in Nobles County, any persons deemed to be potentially harmful and put on a 72-hour commitment must be driven by a squad car to Marshall or to Sioux Falls. These patients are interviewed, sometimes multiple times, by social workers who must drive to the place the patient is being held. Each time the person is called back to Nobles for a hearing, he must be transported back. And in the case that the person is deemed able to leave the unit, she must find her own transportation home.

It is essential that we address the shortage of rural mental health services. Attracting practitioners and funding to rural areas is crucial, but we also need innovative solutions that can help mental health patients now.

Telemental health

One such solution is telemental health – long-distance counseling with the help of technology like teleconferencing or video conferencing. Telemental health makes it easier for people to access mental health services because it removes the barrier of transportation. Better access leads to better diagnoses and better treatment for mental health patients. It saves money because people can stay in the community while receiving health care. And it means that psychiatrists can communicate among themselves in order to improve care.

The Itasca County Crisis Response Team coordinates its emergency medical services and its local mental health professionals through telemental health services in order to combat problems with emergency mental health situations. A team of mental health professionals is available to the county’s emergency medical services workers in order to provide face-to-face or telephone intervention, helping patients find care that is nearby and assisting with care from initial contact. Normalizing mental health emergency care to reduce stigma has resulted in better and more efficient care. Itasca county has seen both clinical benefits and savings from this program.

Barriers to this solution

Even for such an innovative solution there are barriers. The Department of Health reports that Minnesota lacks a central telemental health resource to guide organizations on the development of telemental health programs. There is no consistency of reimbursement for telemental health care. The shortage of mental health practitioners means that even with telemental health services there are still few doctors available. Finally, inconsistencies in internet access across rural Minnesota and difficulties with technical support can impede telemental health.

Rural mental health care is in danger. Between the shortage of practitioners, the culture of stigma, and the fractured emergency mental health system that lands patients in jails instead of care facilities, it is clear that we are failing to appropriately address this issue. We can no longer afford to ignore our neighbors. Says Deb Hogenson, social worker in southwest Minnesota, “It’s a crisis – no question about it.”

Meg Reid is an undergraduate research fellow at Minnesota 2020, a progressive, nonpartisan think tank based in St. Paul. This article originally appeared on the organization's website.

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Comments (4)

Living in a rural community

Living in a rural community can also exacerbate mental illness outside of the lack of treatment options. Young people, in particular, have little to do outside of work, go to school, and drink. Alcoholism starts at a young age with little else to do aside from finding a secluded spot and socializing with classmates and cheap beer. Many grow out of it, but some don't.

Often related to the alcoholism, though not always, is domestic violence. Where I grew up, at least, domestic violence was something we all knew happened, but no one talked about let alone interfere. That women suffer from depression in rural areas at higher rates than women in more urban areas probably has less to do with the availability of treatment than it has to do with the overall culture. It's harder to notice violence and abusive behavior against a woman who spends most of her time miles away from her nearest neighbor.

Even if domestic violence and abuse are not a source of depression, loneliness can be. Small communities can be particularly cruel to people perceived as "different," particularly women who don't fit into the social cliques frequently formed in small communities.

While there are certainly wonderful people and communities located in more rural areas, we can't be blind to the fact that there is definitely a dark side. Providing greater access to care certainly would help, but as the author of the article noted, at least one of the obstacles to sufficient care is social stigma and culture.

I'd be careful about telemedicine for psychiatry

I sympathize with the plight of those seeking mental health services in rural communities, but would be careful about viewing telemedicine and exclusively psychiatry as the answer. Psychiatry has more or less become a practice defined by the writing of prescriptions in brief consultations for drugs about which we do not have access to data regarding their safety or efficacy, drugs which invariably lead to the need for more drugs, and which cause demonstrable illness. Currently many in the profession are busily promoting the use of atypical antipsychotics for questionable disorders like bipolar disorder, formerly a rare disorder, now suddenly everywhere, never mind that the drugs cost $400 a month (Abilify, Risperdal, etc.) and cause diabetes.

Mental Health in Minnesota

I applaud Meg Reid. Mental illness isn't easy for us to understand and even harder for us to commit to treat effectively and compassionately. Mental illness contributes to all sorts of senseless violance and it it contributes to a lot of pain for families. But if we are honest, as a society, we just plain have not committed to the care, effective and humane treatment of the mentally ill. There was a time when this state literally warehoused thousands of mentally ill. Most of the "hospitals" were in rural Minnesta. It was not effective. It was not humane. While we now longer live in that era access to services is simply too hard. Effective treatment throughout the state needs to be made available. While we may not change the delivery of medical treatment to the mentally ill overnight champions like Meg Reid may get us there. Judge Kevin Burke

Greater access to what kind of care

We all want better care for the mentally ill. The question is whether expanding access to the current model is a likely path to gaining that objective. According to a compelling new social history, a critical appraisal favorably reviewed in a highly influential New York Review of Books essay by Marcia Angell -- a book called Anatomy of an Epidemic by the journalist Robert Whitaker -- in our era of marketing driven blockbuster psychiatric polypharmacy, disability due to mental illness is going up, not down. That's got to be taken as part of the same problem this article attempts to address, hopefully, even if the answer is not clear to us now. If we are to be serious about caring for the mentally ill we have to step beyond crowd pleasing objectives like "reducing stigma" and the very real problem of access and take a hard look at what will likely be provided to these patients who may not have closee attention or follow up, after taking drugs that come with warning labels concerning their ability to increase the risk of suicide. We also must step up and look at the role of the drug industry in controlling every step of the research pipeline that has made these drugs the sum totality of psychiatric care, drugs which are surely toxic, by the industry's own admissions -- the atypicals, as David Healy has written are better at causing diabetes than treating agitation -- and yet are the go-to treatment offered to champions such as Ms. Reid. If the past is any prediction, the medication protocols that will be provided by brief consultations over a video screen are going to cause more illness, not less. We do need to provide greater services to those in regions under-served, and we do need to change the nature of those services or we are simply going to be replacing one cause of medical distress with another.