Combating the Mental Health Crisis in Rural America

• By School of Medicine
• May 28, 2020

Across America, people are living and staying active longer, crime rates are down, employment is up, entertainment options abound, people have a world of information, goods, and services at their fingertips — and yet surprisingly suicide and substance abuse rates are at an all-time high.

What is going on?

For the one in five Americans currently living with a mental health condition — depression, anxiety, substance abuse, suicidal thoughts, and other psychiatric illnesses — this is the question that weighs on them every day.

“We do not know exactly what causes mental illness,” says M K Zafar, M.D., assistant professor of psychiatry at the Texas Tech University Health Sciences University Medical School in Odessa. “There are different factors, things like stressful work or family life, trauma in early childhood, or not having adequate social support. We know these things contribute to mental health distress but we’re not able to exactly pinpoint what causes what. That is the subject of much research right now.”

Mental health issues seldom result from a single cause but rather a mix of genetics, physical health, and life circumstances. Sometimes an event such as a relationship split or a lost job can switch on a genetic predisposition that triggers a descent into despair.

Taken as an indicator of the mental health crisis, suicide statistics tell a story of a large-scale mental health emergency in the U.S.: An American ends his or her own life roughly every 12 minutes. Suicide is in the top 10 causes of death in the U.S., and for teenagers, it is in the top three causes. The Centers for Disease Control (CDC) reports that suicide has been rising in almost every state in the U.S. — by more than 30% in half of the states — since 1999.

America’s mental health crisis is also spelled out daily in headlines announcing rampant abuse of prescription pain killers. Zafar says that while it’s clear that opioid abuse often co-exists in patients with psychiatric illness, the cause-effect relationship is not very clear. Either people obtain the drugs to treat pain for a medical reason, get addicted, and develop mental illness as a result, or people reach for the drugs to blunt the pain of psychiatric illness. It may well be a complex mix of factors, but the results are dark and staggering: More than 130 Americans die daily from an overdose of opioids, including prescription pain relievers.

The Rural Mental Health Crisis

The percentage of Americans in psychiatric distress living in sparsely populated regions is higher than those living in urban centers, and the gap is widening. A recent report published in the Journal of the American Medical Association (JAMA) found suicide rates are rising faster in rural areas, especially those that have enjoyed fewer modern technological advances than urban centers and that have economies dominated by the extractive industries. The report found that factors driving the mental health crisis in rural America include lower incomes, higher numbers of households owning firearms, higher access to gun shops, a higher percentage of residents who are veterans, and fewer opportunities to make social connections.

People suffering in rural settings may also be more reluctant to reach out for help than their urban counterparts. Despite the prevalence of mental illness and the media attention given to it, the condition still carries some stigma and living in tiny communities can feel anything but anonymous. “People do not access treatment easily because mental health is still considered a private topic and people don’t like to talk about it,” says Zafar. In small communities, people may feel that if they seek mental health services, word will spread and they’ll be the subject of unwanted gossip, attention, or social ostracism.

The CDC also reports that more than half of people who die from suicide were not known to have had a mental health condition. This indicates that a mental health problem can remain hidden until it becomes a mental health emergency, underscoring the critical need for early diagnosis and treatment. “If mental problems are recognized early, we are able to improve the outcome,” says Zafar. “We don’t expect magic but we can see improvements with the treatments we have available.” Unfortunately, too many people suffer in silence without seeking the help they need.

Sometimes, people do seek help, but can’t get it. The JAMA report found a link between high suicide rates and high rates of residences lacking health care insurance. And having a health plan doesn’t necessarily mean having access to mental health services. Plans may offer inadequate coverage or have referral requirements that are difficult for patients and doctors to navigate. Out-of-pocket costs for mental health services can be prohibitive even for Americans who aren’t on the lowest rungs of the income ladder. Compounding the problem, many practitioners don’t even accept insurance, rendering their services out of bounds for low- and even moderate-income patients.

But perhaps the biggest problem is that rural areas are mental health care deserts. According to a study published in the American Journal of Preventive Medicine, two-thirds of rural counties nationwide do not have even one psychiatrist; in West Texas, the number is closer to three-quarters. Half of U.S. rural counties lack any kind of psychologist. This leaves many primary care doctors who have limited training or experience to provide mental health services with potential caseloads they are unable or uncomfortable to manage.

Vastly more care is offered in urban centers and even mid-sized cities, but in an area as expansive and sparsely populated as West Texas, some patients would need to drive upwards of six hours per appointment.

Bobby Jain, M.D.,  is a professor in the TTUHSC School of Medicine’s Department of Psychiatry at the Permian Basin, and the supervisor of the Residency Program in Adult Psychiatry and the Fellowship in Child Psychiatry. He says that often rural residents seeking mental health services can find them only within the type of rural health facility their community happens to have, which is not likely to be a mental health crisis center but rather a small clinic or hospital ill-equipped to manage an ongoing issue or to adequately address a major mental health emergency. “What’s happening, ultimately, is people are looking for psychiatric care at places that are not very qualified to treat psychiatric conditions,” says Jain. “So we see both untreated psychiatric conditions and at the same time poorly managed and poorly treated psychiatric conditions.”

The psychiatrist shortage is stark in the Permian Basin region, the nation’s largest oil patch and an area where Jain says mental health distress is particularly acute. While a recent oil boom has brought many new jobs and families to the region, Jain points out that an economic boost doesn’t always offset the stresses associated with the jobs that drive it. “The population working within the oil industry is very mobile, with long hours of work away from family, and they have very harsh working conditions, particularly in summer,” he says. “The compensation they get is money, but that can’t mitigate the stress these people face.”

Children Take the Hardest Hit

The oil boom has also packed too many students into the existing school infrastructure, a situation that Jain says shortchanges kids both in educational quality and psychiatric intervention. “We have very overcrowded schools with a subpar education and we are inundated by the need for psychiatric care. Children and adolescents are the ones who suffer the most.”

America’s rural mental health crisis hits kids when the adults in their lives are struggling. “Psychiatric illness causes disruption of family and along with that is disruption of care for the children,” says Jain. And children face their own problems. Anxiety, depression, suicidality, and other psychiatric problems affect American children and teens at unprecedented rates. The National Alliance on Mental Illness (NAMI) reports that suicide is the second leading cause of death among people aged ten to 34, and each year, one in six children aged six to 17 experiences some form of a mental health crisis.

While being a kid was never easy, pressures on today’s children include challenges previous generations never faced, such as higher academic requirements in a technology-driven economy, a world imperiled by environmental and climate changes, and the amplifying effect of social media on peer pressure and bullying. When schools are too crowded to effectively educate — plus help kids negotiate these minefields — it amounts to an adolescent mental health emergency.

The Empirical Pillars of Treatment

A number of therapeutic strategies can bring about healing. “We routinely advocate therapy and lifestyle modifications that may include dietary changes, physical activity changes, and socialization,” says Jain. “Those are the empirical pillars of mental health treatment. We advocate these things first before we go to medications.” But because of delays in identifying or treating problems, kids often don’t get to benefit from unmedicated treatments until the situation is urgent. “The problem remains that by the time kids and adolescents come to us, the situation is so dire that we have to go to a full-court press just to reroute the situation.”

America’s mental health crisis is begging to be addressed with modern treatments if only the qualified professional workforce were in place to take it on.

“People want better well-being and better mental health functioning,” Jain emphasizes. “They are knocking on doors and looking for psychiatric help, but we are just not able to meet the need right now because the population has grown and the number of qualified psychiatrists has not. We are striving very hard to fill the gap.”

Bridging the Gap

TTUHSC provides mental health services to the communities in and around Midland, Lubbock, and Amarillo. The Department of Psychiatry at the TTUHSC Medical School in Odessa is working to channel new mental health practitioners into Texas mental health services. “We are very excited and hopeful that psychiatrists who train here will serve our community,” says Zafar.

The Residency Program in Adult Psychiatry allows future psychiatrists to work alongside and under the guidance of professionals while providing world-class mental health care to patients. Interprofessional education is important and plays a major role in the program. Mental health care residents work alongside residents training in other programs within the Medical School so that future health care providers in various specialties learn to recognize mental health issues in their patients and help guide them to the best care.

Child psychiatrists require training beyond that of psychiatrists going into adult practice, but TTUHSC Medical School’s Fellowship in Child Psychiatry is working to produce qualified graduates to ease the shortage of mental health professionals treating children. Jain says that fellows who train in the program tend to stay and set up practice within the region, so the fellowship program holds the promise of significantly enriching the quality and quantity of West Texas mental health services aimed at kids.

Regardless of the number of qualified mental health care providers graduating from TTUHSC’s programs, geography and the prevalence of spread-out communities remain a major challenge to providing care in West Texas. Practitioners in the past traveled from one rural health care clinic to another to meet the needs of patients, but as these doctors retire, fewer doctors are willing to step into their traveling shoes. But in the 21st century, telehealth technology provides an alternative to yesterday’s mobile therapist.

“We train residents to use telepsychiatry to connect various clinical sites across the Permian Basin,” says Jain. “We are using telepsychiatry to see children in schools in Odessa and Midland. Telepsychiatry has been very helpful in training residents and students and also to cover vast areas of West Texas. It expedites medical and psychiatric services to the patients without compromising the quality of care.”

Though the causes of America’s runaway mental health crisis remain hard to pin down, it’s clear that part of the cure lies in increasing the availability of mental health services, especially in rural communities. It is vital for medical universities to train a greater number of psychiatrists and to develop technological innovations for delivering their services to patients. 

To learn more about how TTUHSC is addressing the problem and playing an important role in finding solutions, please visit the TTUHSC School of Medicine Department of Psychiatry program page.