Rural mental health: An opportunity☆

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Rural life often is associated with a low-pace, stress-free existence, without the time compression, crime, and violence of urban living. These beliefs about rural living often conceal the multitude of stressors that are part of the rural lifestyle. Isolation, unemployment, poverty, lack of health care and insurance, substandard housing, and an increasing problem with drugs are faced by rural residents and hardly fit the bucolic notion of living in the country. Mental health problems are no less common in rural areas than they are in cities, but rural residents are less likely to have access to mental health care. There are fewer mental health facilities or qualified professionals, and insurance reimbursement rates often are lower for practitioners in rural areas. The culture and traditions of rural residents also militate against receiving mental health care because of stigma, religious beliefs and sanctions, use of lay healers, and a high value placed on individualism and self-reliance.

What mental health care exists in rural settings has been patterned after urban models of care. The community mental health system tends to be centrally located in cities; some have rural satellite facilities. Some community health centers have outreach programs, especially for those who are seriously mentally ill. Still, the central concept of service delivery in community mental health remains the patient coming to the mental health provider. In remote rural areas, this may entail an hour or more of travel to receive mental health care, and there is ample evidence that as the distance to mental health treatment increases, the likelihood that the mental health consumer will receive adequate, or any care, declines. Recently, there has been an impetus to move mental health treatment into primary care settings in rural areas and elsewhere. This movement is based on many studies in urban settings using a health maintenance organization model of psychiatric treatment. Here, primary care physicians and on-site mental health providers provide mental health treatment. This model does not take into account the likelihood that specialty mental health providers will be unavailable in rural areas and the rural population is unlikely to have the insurance necessary to pay for this service.

Design of mental health service delivery systems that are accessible and acceptable to rural populations is a formidable challenge. Poverty, lack of insurance, lack of providers of all stripes including mental health care specialists, geographic barriers, diverse cultural differences, traditional rural views of health care, stigma, isolation, and long distances to treatment all provide significant barriers to mental health treatment. As the financing of mental health care continues to diminish, the solutions to these problems will require great imagination, innovation, and persistence.

The Southeastern Rural Mental Health Research Center (SRMHRC) at the University of Virginia School of Nursing has provided leadership in devising service delivery solutions for diverse rural populations, especially the impoverished and members of ethnic minority groups. Developed by Dr. Jeanne Fox in 1993, the center has spawned a wealth of research that provides much of what we currently know about mental health service delivery with disenfranchised rural populations. In this special issue of Archives of Psychiatric Nursing, this research is showcased. It is our desire to pique your interest in the challenges of rural mental health care, and perhaps to engage you in partnerships toward its solution.

Three of the articles in this collection are concerned with women with mental health problems living in the rural South, and how the person-environment interaction contributes to the eccentricities of needed treatment. Using the clubhouse as a central setting for a rural sample of women with serious mental illnesses, SRMHRC investigators Debra Lyon and Barbara Parker describe the health care concerns of rural women attending focus groups. Although the women's concerns mirrored those of women without serious mental illness, like other rural groups, access to health care was a commonly named problem. Research on rural women with alcoholism is almost nonexistent. Mary R. Boyd, formerly of the University of Virginia School of Nursing and SRMHRC, and now from the University of South Carolina School of Nursing, is by far the most prominent nursing investigator describing the needs of this otherwise invisible population. Here she explores factors associated with alcohol and drug abuse in these women. Emily Hauenstein, with SRMHRC from its inception, has been working for more than a decade as a clinician and researcher with rural women from both the mountains and the Piedmont of Central Virginia. She weaves the story of depressed rural, impoverished women, and how their environment and culture serves to sustain their depression.

The second group of articles addresses pressing problems of mental health treatment in rural areas. In a secondary data analysis, Stephen Petterson documents the lower rates of mental health treatment in rural areas. In his comprehensive article, Petterson shows a pattern of gaps in services when metro and nonmetro populations are compared. Elizabeth Merwin, Director of SRMHRC, and her colleagues Bruce Dembling and Steven Stern, describe the dire mental health manpower shortages in rural areas and offer an agenda for mental health research with rural populations. Of note in Merwin's article is the finding that registered nurses are the most prevalent health professionals in rural counties, showing the potential for nursing intervention with the rural mentally ill. Technologic innovation with the rural seriously mentally ill is the subject of the article by Sarah Farrell and Caroline McKinnon. These authors review the literature on telehealth and its applications with the seriously mentally ill. They focus on some of the possibilities and problems of applying telehealth in rural communities.

Rural residents always have been marginalized with regard to health care services. Financial constraints in both the private and public sectors of mental health care ensure that additional mental health resources for rural residents are unlikely. The opportunity in this sad state of affairs is the potential for novel and innovative nursing models of treatment. Nurses who have ties to rural communities are more likely to be accepted by rural residents, and are more likely to provide culturally sensitive care. Much more research in this area is needed and this would be furthered by academic partnerships with nurses practicing in rural communities. There is much to be gained from these linkages for both researcher and community nurses. The contributions nurses can make in improving mental health for rural residents is limited only by our imagination and our will.