Mental Health and Mental Disorders A Rural Challenge

Mental Health and Mental Disorders— A Rural Challenge • Fourth most often identified rural health priority • Suicide rate among rural males and children is higher than among their urban counterparts • Among 1, 253 smaller rural counties with populations of 2, 500 -20, 000 nearly three 0 fourths lack a psychiatrist and 95% lack a child psychiatrist • Suicide, stress, depression and anxiety disorders

Mental Health • Similar problems in urban and rural • Certain characteristics of rural – Poverty, age, being African American, living in rural area—less likely to receive mental health care – African Americans and rural residents underutilize mental health services and seek help later in course of disease – Child and elderly especially disadvantaged

Mental Health • Stress associated with anxiety and depression • Farm crisis of the 1980 s and loss of major employer

Farm Crisis of 1980 • In Hills, Iowa, farmer kills his banker, this neighbor, his wife and then himself • Ruthton, Minnesota, a farmer and his son murder two bank officials. • South Dakota’s Union County, Farmers Home Administration administrator kills his wife, daughter, son and dog before committing suicide. Leaves a note—pressures of his job became too much for him to bear. • Cases of child abuse and neglect rose 10% in rural area of Iowa

Farm Crisis • Early 1970 s—increase in agricultural exports (especially to Russia). • Farm incomes and commodity prices increase sharply. • Rising land values, low interest rates, farmers went into debt to buy land • Farm household income over national average for 10 years

Farm Crisis • Bubble burst 1980 s – Farm land value dropped 60% between 1981 -1985 – More debt and crop values declined – Record harvest—overproduction • Glut of commodity crops—force price down – President Carter • Grain embargo of Russia because invaded Afghanistan • Decreased exports— 20% decline – Commodity prices fell 21% • Other countries filled the need

Farm Crisis • 1/3 of commercial farmers in trouble • Farm foreclosures—rural banks failed • Impacted farm equipment manufacturing, seed and fertilizers • For every farm lost—three non-farm jobs lost

Farm Crisis • 1986 -88 Country singer Willie Nelson organizes first of the Farm Aid concerts to benefit indebted farmers at University of Illinois • Set up hotlines for people to call if in distress • July 2088 -March 2009 – 50% of calls related to mental health issues (in Nebraska) – Offer vouchers to help cover costs

New Farm Crisis? ? • • Farm land prices up Grain prices up Monitoring lending practices Extension at Iowa State – Not the same problem as before – Think will support going forward

Barriers to care • 20% of non-metro counties lack mental health services only 5% in metro counties • 87% of Mental Health Professional Shortage Areas in rural counties • Use is also lower – Stigma attached still – Lack of anonymity

Primary Care • Primary care providers serve the mental health problem – Lack sufficient training – High patient case load – Lack of time – Lack of specialized backup – May underdiagnose • stigma problem • Patient’s acceptance of diagnosis • Future insurablility

Providers • Train primary care – With overload already—can they handle • Counseling license for masters-level graduates – States control privileges – Only work under psychiatrists supervision – Can’t prescribe medications (psychologists also)

From: Improving Access to Mental Health Services for Youth in the United States JAMA. 2013; 309(6): 553 -554. doi: 10. 1001/jama. 2013. 437 Figure Legend: Adapted from data from the 2008 National Survey of Mental Health Treatment Facilities. Date of download: 2/13/2013 Copyright © 2012 American Medical Association. All rights reserved.

Differences in Mental Health Practice in Rural Area • Put Farmer in Charge of His Own Recovery – Farm. Wrap program in Minnesota – Connect with farmer “where he or she is at” – Access to array of services—determine what major factor is • Rural mental health professionals cannot be tourists in rural America – Must not isolate self – Be good rural citizen and steward of rural life

Differences • Ministers –Vital Connection – Often first caregiver to recognize of a problem – Pastor of the church—even if not affiliated with a congregation—will seek help – Mental health practitioners need to be aware of this connection • Farm wives – As all women—in charge of health care – More ready to leave rather than “stick it out”? ?

National Association for Rural Mental Health (NARMH) • 1977 • Develop and enhance rural mental health and substance abuse services • Support mental health providers in rural areas • Proactively support initiative to strengthen the voices of rural consumers • Develop and mentor the next generation of rural mental health leaders