The mental health burden in rural Minnesota has become increasingly prevalent. In 2005, the Minnesota Department of Health reported that depression rates in women living in rural counties were as high as 40 percent, whereas rates were only 13 to 20 percent in urban counties. In more recent years, a report produced by the Minnesota Hospital Association indicated that from 2007 to 2014, there was a 40 percent increase in emergency department use for mental illness encounters in Greater Minnesota, compared to only a 34 percent increase in the Twin Cities.
Untreated mental illness is a public health concern because it can lead to debilitating and costly conditions such as substance abuse, homelessness, and incarceration. Further, there are times that rural counties are left scrambling to respond to a mental illness crisis because of limited resources.
This chaos is commonly attributed to a lack of available inpatient beds in psychiatric facilities. Yet, there are too many times mental health crises could have and should have been prevented. In fact, mental illness can often be managed with access to the right combination of treatment, such as behavioral therapy and psychotropic medication. However, recent findings from the Substance Abuse and Mental Health Services Administration (SAMHSA) suggest that approximately half of Minnesotans with mental illness are not receiving treatment.
These findings prompt the question: How many more mental health crises will occur before we address the treatment gap in rural Minnesota?
First, it is important to recognize that barriers to receiving mental health treatment are often intensified in rural Minnesota. For instance, a patient with mental illness may experience significant social stigma to obtaining services, have a greater distance to drive, and undergo increased wait times for an appointment with a trusted provider.
Psychiatrist workforce shortage
When considering these barriers, a chief concern that warrants immediate attention is the psychiatrist shortage in rural Minnesota. Recent data from the Minnesota Department of Health indicate 9 of 11 state regions in Minnesota, all outside of the twin-cities, were designated Health Professional Shortage Areas (HPSAs). This means these regions had a population per psychiatrist ratio of greater than 35,000 to 1.
Unfortunately, this shortage cannot simply be amended with a Band-Aid approach because there are longstanding forces that are heavily intertwined with this problem. In a recent review, insufficient salaries, an aging workforce, and competing political priorities were listed as just some of the many contributors to the lack of behavioral health professionals. While existing policies and programs such as Minnesota Rural Physician Loan Forgiveness Program have attempted to address this shortage, these approaches do not always guarantee that a psychiatrist will stay for the long haul in a rural community.
Telepsychiatry
One strategy that has shown effective promise for addressing this shortage is telepsychiatry, which allows patients to obtain psychiatric services from a provider at a distant location through technology such as video consultations. The Minnesota Telemedicine Act of 2015 has already increased the availability of psychiatrists to rural Minnesota by requiring parity such that reimbursement and coverage for telepsychiatry must be equivalent to face-to-face interactions for Medicaid, MinnesotaCare, and commercial health plans. However, restrictions such as a patient having to pursue services at an originating site exist. Specifically, a patient may still have to travel a significant distance to pursue telepsychiatry services at a designated “spoke” site.
Overcoming barriers
Eliminating the originating site requirement would encourage patients to seek mental health treatment by affording them the option to pursue telepsychiatry services in the convenience of their homes. For example, Washington legislation is now allowing patients to choose where they receive telemedicine services. Expanding the reach of telepsychiatry also addresses barriers that commonly prevent rural Minnesotans from having access to mental health services, such as transportation. In addition, this approach would offset costs associated with downstream untreated mental illness crises.
Many of our state’s most vulnerable mental health populations are located in rural Minnesota, where there is limited access to psychiatrists. Given the psychiatrist workforce shortage and growing demand for mental health services in rural Minnesota, the Minnesota Legislature should act now and increase access to telepsychiatry to these regions. Removing the originating site requirement is an immediate action our state legislature can take to increase access to mental health services for patients when and where they need it.
Maria Stevens is a second-year MPH student in the Executive-Public Health Administration and Policy program at the University of Minnesota and has an MA in clinical psychology from Minnesota State University, Mankato.
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APRNs?
Great piece. But you missed a significant (and growing) segment of the mental health workforce. In large part to the tireless efforts of leaders like Dr. Mary Chesney in the U of M School of Nursing, psychiatric and mental health (PMH) advanced practice nurses in Minnesota have a broad, independent scope of practice nearly identical to that of physicians. This includes the ability to diagnose conditions and to prescribe medication without the oversight of physicians. Many of us have doctoral degrees, and in fact the Doctor of Nursing Practice (DNP) degree is becoming more and more an expected qualification for NPs newly joining the work force. There can be a misconception that we are not as competent as our physician colleagues, but more training does not necessarily mean better outcomes. Our approach is different — not better, not “less than,” just different. Our education and training prepares us to collaborate with patients and their families, and to care for the whole person, not simply try to treat disease. It’s not unusual for patients to be initially disappointed when they can “only” get an appointment with a nurse practitioner, but plenty of these patients are surprised and pleased with not only the level of psychiatric care that we provide but also the time we spend getting to know them as human beings. We hear time and again that patients see us once, and the next time they make an appointment, they specifically ask to see a nurse practitioner. (This phenomenon is true in other APRN specialties, such as family practice and women’s health.) The shortage of physician psychiatry providers makes us an even more essential force in making mental health care more accessible and affordable.