In recent years, stories about of the growing mental health crisis in rural America and the shortage of mental health professionals have become increasingly frequent and alarming. However, few delve into why these shortages exist and offer solutions.
This past February, the Center for Rural Policy & Development partnered with the Center for Rural Behavioral Health, Minnesota State University Mankato, to study rural mental health needs and the roadblocks to expanding care.
“Rural residents have dealt with diminishing access to healthcare services for decades, largely because the continuous increase in the costs of providing services makes sparsely populated rural communities less economically feasible to serve than densely populated urban areas,” the report states.
Rural Minnesota residents have higher rates of mental health symptoms than people living in metropolitan areas, the study says. “Negative attitudes toward mental health issues in some rural communities and the challenges that long distances to services create all compound the problem of unmet need in rural communities,” the report states.
Rural Minnesota’s rising suicide rate shows the seriousness of the challenge. It has been going up at a quicker pace than the rate in metropolitan areas of the state. “In 2021, suicide accounted for two-thirds of gun deaths in Minnesota, and the largest proportion of those deaths were in the state’s most rural areas,” the report says.
Young people face significant mental health struggles as starkly pointed out in the 2022 Minnesota Student Survey results. It measures the health and well-being of the state’s students in the fifth, eighth, ninth, and 11th grades.
“This group of students reported greater struggles with mental health, such as depression and anxiety, than at any other time in the history of the survey, which began in 1989 and occurs every three years,” it reported.
“Students in 11th grade who identified as female at birth saw an increase in mental health issues in 2022, with nearly half, or 45%, reporting long-term mental health, behavioral or emotional problems. That was up from 35% in 2019, 27% in 2016, and 16% in 2013,” it said.
Early intervention for those suffering from mental health problems is essential to preventing worse outcomes, including alcohol and drug addictions, self-harm including suicide, spending time in jail, and becoming a growing expense and staff challenge for county social services.
The CRPD and the Center for Rural Behavioral Health studies found three factors frustrating efforts to improve rural mental health care – accessibility, availability, and acceptability.
Accessibility is closely tied to affordability. Rural Minnesota small-town employers are less likely to offer health insurance, including mental health coverage. If a person is on Medicare, Medicaid, and MinnesotaCare in a rural area, there are providers who won’t take the insurance because it doesn’t fully reimburse them for their costs.
Getting to and from appointments can be part of the problem for people living in sparsely populated areas of the state.
Rural mental health providers are overwhelmed with their caseloads. “While in metropolitan areas there is one licensed mental health provider for every 197 residents, that ratio goes up as the population density goes down, with 741 residents for every one provider in the most rural areas,” the report from the two centers says.
Finally, those seeking mental health care have to overcome feelings of the stigma, acceptability, of their treatment. They don’t want to be seen as “crazy.” Tough, rural “self-reliance” pride gets in the way.
As with many rural businesses and professions, attracting people to rural Minnesota is difficult and frustrating. “In every interview from clinics as far north as the Iron Range to the southern parts of the state, the message is the same: It’s nearly impossible to hire mental health professionals to serve rural communities,” the report from the two centers says.
Rural clinics sometimes can’t pay salaries or wages equivalent to those in metro areas and some people are not interested in living in a rural setting.
State student loan forgiveness programs offering up to $33,000 for mental health providers are being offered if a student spends three years in a rural area, but it is not enough of an incentive. Combine loan forgiveness with a rural internship program, and the odds of attracting and retaining a mental health professional go up.
“Interviewees reported that providing internship opportunities were more effective than any other recruiting strategy, making it much easier to hire their interns upon graduation,” the report said.
Paying students while they intern would motivate more to pursue the profession and help pay their living expenses until they get established, the report says.
Attracting more mental health professionals to rural Minnesota is essential to stabilizing services. “According to those interviewed, one of the leading causes of professionals leaving rural clinics is burnout,” the report said. It is “a key factor in the workforce shortage both now and into the future.”
Another factor creating the shortage of rural mental health professionals is the lack of college professors to teach all the students seeking to enter the profession. Ten of the 15 schools contacted about their educational challenges said they turned students away – as many as 100 annually between them.
Additional financial support for educational institutions to boost the number of faculty available would increase the number of mental health professionals graduating.
Increasing the pay for mental health professionals has to be a priority if they are to be retained. They are likely to leave the field if they see other jobs that pay as well, or better, without the stress.
“As the need and demand for mental health services grow, the lack of services in rural areas becomes more obvious. Anything that helps close this gap, whether it is financial assistance for students, for rural clinics to provide more training opportunities, or for colleges and universities to help them accept more students, can only improve the landscape for mental health services in rural Minnesota,” the report says.
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