Mental health disorders are by far the largest cause of disability in the world. More money is spent on mental health than either diabetes or cardiovascular disease. About 45 million people in the U.S. have a mental illness. Almost every American will, at some point or another, face a mental health challenge. It may be related to depression, anxiety, suicidal thoughts, substance abuse or maybe something more circumstantial like grief over a loss or trouble adjusting to a life change.

Now imagine there wasn’t a psychiatrist or psychologist miles around. This is what life is like in rural America in 2022.

A majority of non-metropolitan counties do not have a psychiatrist.

In rural America, mental health issues are many times treated only when they become a full-blown crisis. Rural areas have a higher suicide rate than non-rural areas, a disparity that has been widening since 2001.

Common psychiatric disorders have a higher prevalence in impoverished, lower socioeconomic status (SES) areas. These patients also tend to receive less specialty care for mental health and instead rely on acute hospital care for medical and psychiatric needs.

Due to a growing elderly patient population aged over 65, there will be greater demand for psychiatrists. The paucity of psychiatrists has led to the rise in psychiatric nurses and PAs performing exactly the same work as board-certified psychiatrists.

Psychiatric services are essential in nursing homes because of the potentially aggressive behavior, psychosis, depression, dementia and other psychiatric symptoms these patients exhibit. Many nursing homes do not have on-site services of a geriatric psychiatric provider.

Veterans and prisoners face greater difficulties gaining access to adequate psychiatric care. Veterans can face difficulties traveling to receive care due to poor public transportation, disabling medical conditions, time constraints, and fear of the mental health stigma secondary to reduced privacy in rural settings.

Getting psychiatrists to work in prisons is a difficult task.

Prisons (mostly found in rural areas) have often been called the “largest psychiatric institution.” I have worked in the prison system for 30 years. The mentally ill are overrepresented in correctional settings, and so there are now more individuals with a serious mental illness in prisons and jails than there are in state mental hospitals.

Suicide, suicidal ideation and self-harm are more prevalent in prison populations than in the general population.

Working as a telepsychiatrist in rural areas of the U.S.

I have worked as a locum tenens since 1995. Locums exist because there simply aren’t enough psychiatrists in the nation. And very few are willing to work in rural areas/prisons etc. Since 2014, from my home in Manhattan, I have treated patients remotely in a very underserved rural community. I evaluate and treat patients with all types of mental illness the same way I would if I was directly in front of the patient. The technology is excellent, and I have a very well-trained nurse always present while the patient is in the office.

During the COVID and during the lockdown, I have had to call many patients to start them on medications and monitor their progress. This would be a major challenge for any specialist.

Therapists, drug and alcohol treatment, partial hospitalization and psych rehab programs are available in this rural clinic.

Both patient and provider acceptance of telepsychiatry is high when measured via surveys given out at the clinic. Many of the negative attitudes concerning telepsychiatry do not manifest themselves in practice indicating that a vital part of the patient-provider relationship in psychiatry can exist even over videoconferencing.

The barriers or obstacles of getting mental health services in rural America

Rural America is quite poor and uneducated. Many who need treatment do not get it until it’s too late. There are insurance snags, dwindling health care funding, hospital and facilities closing, high non-compliance, serious transportation difficulties, the “stigma” attached to having a psychiatric illness, substance abuse and above all, not enough mental health practitioners. In addition, MDs are reimbursed less for services provided to Medicaid and Medicare patients, which further decreases the number of psychiatric practitioners who will accept these patients.

Pitfalls of PCPs treating mental illness in rural USA

Most patients receiving treatment for psychiatric issues are treated solely by primary care providers.

PCPs are not trained in the usage of psychiatric medications. Many PCPs wait a long time — if at all — to refer a patient to a psychiatric physician. Because of the shortage of psychiatrists, these services may be the only option for psychiatric treatment. Studies have found that primary care providers routinely fail to recognize and diagnose psychiatric disorders. I have found that many PCPs prescribe a lot of benzodiazepines and stimulants to appease the patient and provide short-term alleviation of their symptomatology which simply puts a band-aid on a gaping wound. They use low doses of psychotropics that are never raised, modified or changed.

Why a shortage?

The reasons for a shortage of psychiatrists in the rural areas of the U.S. are numerous. Most psychiatrists prefer to practice in big cities or suburban areas. Psychiatry is not high on the list of graduating medical students seeking residency. Most psychiatrists don’t trust telepsychiatry, and unless face to face with a human being, it’s not adequate treatment.

Telepsychiatry

Telepsychiatry is a well-recognized and established method of providing mental health care and is in use in all areas of the United States and in many other countries worldwide. The American Psychiatric Association (APA) fully endorses video conferencing as an effective means of psychiatric health care delivery.

Studies have shown that telepsychiatry, in the form of live videoconferencing, is overall as efficacious as face-to-face psychiatry in every direct comparison assessing psychiatric disorders such as depressive disorder, substance abuse, bipolar disorder, psychotic disorder, and anxiety disorder.

The ability to reduce or eliminate the distance between patient and provider increases access to clinical care, minimizes costs and improves veterans’ quality of life. It’s effectively equivalent to those delivered face-to-face in a clinic, including levels of participant satisfaction with treatment and symptom improvement. Labs and pharmacies all benefit from telepsychiatry. Hospitals that outsource mental health services via telepsychiatry experience cost savings and better meet their specific patient population’s cultural and specialty needs.

Glenn Mark Losack is a psychiatrist and author of The Bonds We Share: Images of Humanity, 40 Years Around the Globe.

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