People in remote areas have long lacked access to mental health services. The movement to fix that is showing signs of life.
In 1963 when President John F. Kennedy signed the Community Mental Health Act, the effect of the law was to shift mental health care away from large, state-run mental institutions and place it in communities where the focus would be on prevention as well as treatment. But Congress never adequately funded the mental health services that were needed to support the law.
Meanwhile, mental health services were moving away from being a part of primary care and becoming more of a specialized service. Psychiatrists and psychologists tended to set up their practices where they trained, limiting access to therapeutic services to areas with universities. While access to mental health services was limited for a lot of the country, it was even more circumscribed in rural America.
That isn’t to say that there haven’t been rural-focused mental health community programs, especially in the past two decades. From 1999 to 2010, a behavioral health program called Sowing the Seeds of Hope served uninsured or underinsured farmers in the Midwest. From 2002 to 2004, the Iowa Rural Mental Health Initiative provided families with one-on-one mental health care that was culturally competent -- that is, the personnel providing the care were sensitive to rural needs.
But those programs came to an end, not because they weren’t effective, but for a reason that’s all too common. “Too often innovative and frontier model programs are lost after a grant expires or a reimbursement stream ends,” noted a 2006 report from the National Association of Rural Mental Health.
In 2008, the Mental Health Parity Act promised that behavioral health services would now largely be covered by insurers. Even though state enforcement has had a checkered history, Manderscheid sees a bright side: “Mental health was able to get to the table in a way that had never been the case before.”
Even with more health workers in rural areas, Manderscheid fears there still won’t be enough to meet demand. Some rural areas are tackling the issue by upgrading resources already available to them. Most often that means training providers in primary care and community health clinics in the area. The emphasis on primary care is an overarching goal of the Affordable Care Act anyway, and many experts believe it to be the most efficient method of providing health services in rural areas. “The truth is, along the way, mental health has become over-medicalized,” says John Gale, a researcher at the Cutler Institute for Health and Social Policy at the University of Southern Maine. He notes that most of the general population will have to deal with behavioral health problems at some point in their lives. Progress in addressing their issues can be made by arming providers in the primary care setting with more and better mental health training.
This is an approach that Montana, which has the highest suicide rate in the country, is taking. The Billings Clinic, the largest health-care organization in the state, has been working with nurse practitioners to arm them with additional mental health training for the primary care setting. “As long as community health workers have more training, I think that’s a great substitute,” says Eric Arzubi, chair of the department of psychiatry at the Billings Clinic. “For mild to moderate anxiety or depression, that may be all you need. Then you can keep psychiatrists in the bigger towns for the more complex cases.”
The Billings Clinic has also teamed up with the Eastern Montana Telemedicine Network to expand care to the most remote reaches of the state. Telemedicine has proven to be a helpful tool. “In remote clinics, you might not even diagnose someone with a serious mental illness because you don’t know what to do with them,” Arzubi says. “Telemedicine can now help bridge that gap.”
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