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Three Policy Considerations for Mental Health in Rural Areas

April 11, 2017
Rural areas comprise one quarter of America’s population but represent one third of the nation’s poor. [1] As a result, rural areas consistently poll as having poorer mental health compared to urban areas. Although the prevalence of mental illness remains quite constant between urban and suburban regions, the states of mental health care differs significantly between the two.

<p>Image: Suicide by Area in United States</p> <p>Source: Center for Disease Control</p>

Image: Suicide by Area in United States

Source: Center for Disease Control

 

The proportion of rural residents polled to have poor to fair mental health is almost one and a half times than urban residents, indicating that, on average, urban individuals show more signs of healthy living. [1] According to the American Psychological Association, three factors explain the large discrepancy of mental health care between rural and urban areas: [2]

 

  1. Availability: Individuals who live in rural areas often have to travel long distances to seek the mental health treatments that are readily available in urban areas.
  2. Accessibility: Individuals who live in rural areas are less likely to have an understanding of mental illnesses and are less likely to have insurance covering mental health.
  3. Acceptability: Stigmas surrounding mental illnesses propel many individuals who have mental illnesses to not seek treatment due to fear of judgement.

Availability

While individuals who live in metropolitan areas have readily available physicians who are on-call, individuals who live in rural areas may have to travel hours to reach their nearest health care provider. Given the fact that over 90% of all psychologists and psychiatrists and 89% of physicians in general work exclusively in urban areas, receiving proper mental health treatment remains a great difficulty for many of those living in rural areas. [3] In fact, 55 percent of the 3,075 rural counties that exist in the United States do not have any psychologists, psychiatrists, or social workers. [4] As a result, many rural residents — 50 percent to be exact —  use their primary care physician for all their mental health needs. These primary care physicians usually have little training with mental illness. [5] As a result, 50 to 80 percent of these individuals who seek mental health care are not diagnosed or misdiagnosed. [5]

Introducing subsidies for mental health professionals to work in rural areas could possibly address the wage difference between mental health and other healthcare professionals as well as the shortages of mental health professionals in rural areas. This is because a significant difference in wages exists between individuals in the mental health profession compared to other healthcare professions. The median income for psychologists in 2009 was $66,040 and the median income for nurses in the same year was $63,750. [6]. Combined with the fact that doctors often choose to not to live in rural areas because of lower salaries, geographic isolation, and fewer recreational opportunities, which creates many problems for rural residents who are looking for a doctor within a reasonable range from their residence, psychologists are furthermore incentivized to practice in urban areas instead of rural areas. [7]

Although the idea of subsidies to mental health professions has a theoretical appeal, scholarly research seems to indicate that employment subsidies do not have significantly increase employment in a specific sector. The theory is that if mental health workers have their wages subsidized, then their labor would cost less. If labor costs less, then workers would be higher in demand, resulting in more mental health professionals entering the field to restore market equilibrium. Although the idea is appealing in reasoning, there is little practical research to demonstrate that introducing subsidies to low-waged workers would incentivize individuals to join and not leave the labor market of a specific sector. [8]

Since wage subsidies for mental health professionals have not been implemented in the United States, I will be drawing a parallel between mental health professionals and low-skilled workers in the context of the effects of wages subsidies. Although wage subsidies in the traditional sense have not been implemented in the United States, the subsidization of low-skilled workers has been used in Finland. Generally, when this measure had been implemented, hourly wages decreased while monthly wages increased. This has been attributed to employers promoting part-time workers to full-time workers. [8]. The measure, however, remained ineffective in improving the employment of low-skilled workers, possibly indicating that the subsidy was too low or the wage demand was too inelastic. [8]

 

<p>Image: Areas with Shortages in Mental Health in United States</p> <p>Source: Health Resources and Service Administration</p>

Image: Areas with Shortages in Mental Health in United States

Source: Health Resources and Service Administration

Accessibility

The lack of understanding surrounding the necessity of mental health services creates a barrier between individuals who need these services and care providers themselves.  Individuals who live in rural areas are significantly more likely to address mental illnesses not as disease states but as everyday problems. [6] With the attitude that mental illnesses are not chronic medical issues, individuals are less likely to seek clinical help for mental illness because they believe the symptoms to be temporary. Furthermore, many mental health care trainings conducted by hospitals are oriented for urban areas, making it difficult for psychologists and psychiatrists to apply the same models of care in rural areas. [9] Overall, there is a lack of understanding regarding mental health in rural areas due to a lack of research.

By introducing more safety measures such as Medicaid expansions during bust cycles,  natural economic downturns as the result of economic growth, rural residents may become less likely to drop their health insurance and better cope with the financial difficulties that these cycles cause. In general, rural areas are particularly affected by boom and bust cycles, greatly exposing their residents to the mental health effects of these economic cycles. Not only are these individuals susceptible to the high stress that boom periods create, but they are also susceptible to depression and other illnesses during bust periods. [9] Between 1981 and 1986, 650,000 (rural?) residencies were foreclosed, and between 1981 and 1983 500,000 rural jobs were lost. Due to the financial effects of these cycles, affected individuals are more likely to drop their insurance and less likely to seek medical care due to high costs. [9]

The absence of employer provided insurance is the number one reason many Americans remain uninsured. [10] Especially given the economic instability of rural areas, finding stable health insurance for individuals is challenging given the limited access to physicians in the area. Since the demographic in  rural areas is generally poorer, older, and less educated than in urban areas, the economic cycle has greater impacts. [9] If individuals were given subsidies for their health care needs through Medicaid or Medicare, they would be more inclined to keep their health insurance even during difficult times.

Since individuals in rural areas generally use their primary care physician for their mental health needs, I will be addressing mental health care needs through traditional health care. Through the Affordable Care Act, the insurance gap between individuals in rural and urban areas has decreased, but exists nevertheless. [11] Other factors such as the lack of transportation as well as higher patient loads per doctor reduce the frequency and quality of visitation for the inhabitants of rural areas, making it difficult to solve the accessibility issues solely through an expansion in Medicare. [11] Although individuals face other barriers face other barriers to fully utilize their mental health care, any expansion of Medicare would still disproportionately benefits individuals who live in rural areas. [11]

Acceptability

Rural residents are typically less educated than their urban counterparts, but if they were more educated on mental health issues the stigma carried with seeking help would be reduced. [12] These two effects lead two consequences: the stigmatization of weakness makes individuals less likely to admit they have a mental disorder and the mistrust of outsiders lead rural individuals to be less likely to travel for outside consultation when they have an illness. [7]

The limited coverage of mental illness in rural areas creates a large untapped market for health care, but in order for the mental health care industry to increase, these individuals must understand the importance of mental health care. While healthcare has virtually completely inelastic demand, the distrust of outsiders as well as the stigmatization of mental illness creates little potential to tap into this market unless individuals seek care. The use of mental health care providers has grown at a 2.1% from 2008 to 2014 and is expected to grow at a 2.8% from 2014 to 2018. [13] However, only 8 percent of diagnosed patients who require treatment actually receive appropriate care. [13] Introducing legislation that mandates more mental health education and outreach programs in schools could reduce stigmas towards mental health and increase the likelihood of seeking care from an early age

A well-developed understanding of mental health involves familiarity with mental illnesses and their symptoms, knowing how to seek mental health treatment and self-help remedies, and an accepting mental illness as a legitimate problem. [14] Studies have shown that introducing individuals to the idea of mental illness as well as early childhood education about mental illnesses significantly reduces stigma about the subject later in adulthood. [15] A better understanding of mental disorders leads to better treatment for afflicted individuals [14]. With more funding to mental health education, especially in areas where mental health stigma is prevalent, the market for mental health care could be greatly expanded by addressing individuals who lack proper care due to mental health illiteracy.

Conclusion

Since the passage of the Community Mental Health Centers Act in 1963, mental health centers have been more prevalent in rural areas — with 40 percent of the 500 centers built having one or more rural communities in its range — but these centers by no means capture the entirety of individuals needing care in rural areas.  [9] Since 1981, the Alcohol, Drug Abuse, and Mental Health Block Grant transferred the role to create mental health care facilities from the federal government to state governments. [9]> With a combination of many community and federal agencies including the Bureau of Health Care Delivery and Assistance and the Alcohol, Drug Abuse, and Mental Health Administration, states are able to develop curriculum for mental health treatment particular to rural areas as well as create subsidies for psychologists and psychiatrists who decide to work in rural areas.

In order to create effective economic policy for mental health care in rural areas, six key elements should be addressed: data and research on patient needs, mental health professional needs, financial access to mental health care, dissemination of information, coordination and case management, and equal scientific considerations. [9]> Rural areas still do not possess the same coverage as urban areas in terms of mental health care centers and outreach programs, and the mental illness stigma and geographical isolation of rural areas makes mental health a difficult issue to address without education. But if these concerns can be addressed through legislation, then we can better address the disparity in mental health diagnoses and treatment between rural and urban areas.

References

  [1] https://hpi.georgetown.e­­­du/agingsociety/pubhtml/rural/rural.html

  [2] https://www.apa.org/about/gr/issues/gpe/rural-communities.pdf

  [3] https://www.hrsa.gov/advisorycommittees/rural/testimony/testfeb202008.html

  [4] https://www.chausa.org/publications/health-progress/article/september-october-2010/when-there’s-no-place-to-turn

  [5] http://www.health.state.mn.us/divs/orhpc/pubs/profiles/mhprofile.pdf

  [6] http://ruralhealthworks.org/downloads/Economic/RHC%20Mental%20Health%20study%20092210%20FINAL.pdf

  [7] http://www.nejmcareercenter.org/minisites/rpt/rural-hospitalist-recruitment-challenges/

  [8] http://repec.iza.org/dp4931.pdf

  [9] http://psycnet.apa.org/journals/amp/46/3/232.pdf

  [11] http://onlinelibrary.wiley.com/doi/10.1046/j.1440-1584.2000.00303.x/epdf

  [10]
http://s3.amazonaws.com/academia.edu.documents/34398934/03Volume2access-insurance.pdf

  [11] http://journals.sagepub.com/doi/full/10.1177/1077558716688793

  [12] http://onlinelibrary.wiley.com/doi/10.1111/j.1748-0361.1993.tb00495.x/epdf

  [13] http://www.harriswilliams.com/system/files/industry_update/behavioral_health_industry_update.pdf

  [14] https://www.mja.com.au/journal/1997/166/4/mental-health-literacy-survey-publics-ability-recognise-mental-disorders-and?0=ip_login_no_cache%3Da3a93881e7fdff3cd900dbbb3bcfb7c0 

  [15] http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.539.9143&rep=rep1&type=pdf

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