One in 25 adult Americans has a serious mental illness (SMI) in a given year, but people in rural areas are more likely to experience it, and they face unique barriers to receiving treatment. A recent report from SMI Adviser explores three obstacles to connecting rural and remote populations with mental health care—availability, accessibility and acceptability—and offers solutions developed by clinicians, administrators, and staff in those geographic areas.

The report, “Improving Behavioral Health Services for Individuals with SMI in Rural and Remote Communities,” is designed to provide a resource for practitioners and policymakers working in rural and remote areas to improve the availability, accessibility, and acceptability of behavioral health care for individuals with SMI. The report was developed by SMI Adviser in partnership with the National Association of State Mental Health Program Directors (NASMHPD) and the NASMHPD Research Institute (NRI). SMI Adviser is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and administered at the American Psychiatric Association (APA).

“On National Rural Health Day, it’s critical to make sure mental health is part of the equation,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “Even before the pandemic, rates of serious mental illness were higher in rural areas. To ensure continued improvement in care, we need to remember that tailored solutions for the resources, workforce, and community in rural areas are critical.”

“Some rural communities are utilizing innovative strategies to increase the availability, accessibility, and acceptability of workforce and services to bridge behavioral health gaps,” noted Brian Hepburn, M.D., Executive Director of NASMHPD, when discussing the importance of the report. “In doing so, individuals living in rural and remote communities are able to have equitable access to high-quality care.”

Rural areas often face a lack of availability of mental health care for two reasons: a shortage of behavioral health care clinicians, including psychiatrists, and a higher proportion of people with SMI that use public funding, which not all clinicians will accept due to lower reimbursement rates. Among the solutions the report proposes are:

• Expanding the knowledge of rural primary care providers about SMI.
• Implementing the Collaborative Care model.
• Expanding peer support networks to support care in rural communities.
• Training EMTs and community members on suicide risk assessment and crisis intervention.

Barriers to accessibility of SMI care in rural and remote areas include difficulty finding or affording transportation; lack of reliable childcare; economic disparities impacting those with SMI such as homelessness or low-paying jobs; and issues with broadband. The report proposes solutions, such as:

• Offering mobile mental health services.
• Utilizing telehealth and telepsychiatry, provided that broadband internet infrastructure is also prioritized or use of audio-only telehealth is available.
• Establishing hotlines and warmlines to connect those in crisis with services.

People living with SMI in rural and remote areas can face obstacles with the acceptability of seeking mental health services, specifically stigma. A locality may have a strong culture of self-sufficiency, which could impede the use of mental health services. This can be coupled with the lack of anonymity which exists in some smaller communities. To address stigma, the report recommends:

• Supporting youth-based mental health literacy initiatives.
• Working with community and spiritual leaders to destigmatize mental health care.
• Marketing suicide awareness campaigns where people are most at risk and where people can be reached discretely.

“The powerful part about this report is that its recommendations come from the clinicians, administrators and staff who work directly with people with SMI in rural communities,” said Amy Cohen, Ph.D., Director of SMI Adviser. “What they told us was not exactly what you’d learn in your training, but rather, smart, creative and practical ways to connect individuals with SMI with the care they need. Anyone who is involved in the provision of mental health care in rural areas should examine its recommendations.”

SMI Adviser

SMI Adviser is funded by SAMHSA (Grant No. SM080818) and is administered by the APA. SMI Adviser includes experts in clinical care, health systems, patient and family engagement, recovery, instructional design, technology, marketing, and more. Additionally, SMI Adviser partners with 30 other mental health organizations. For more information visit www.SMIadviser.org.

National Association of State Mental Health Program Directors

The National Association of State Mental Health Program Directors (NASMHPD) is the only member organization representing state executives responsible for the $41 billion public mental health service delivery system serving 7.5 million people annually in all 50 states, 6 territories and pacific jurisdictions, and the District of Columbia. For more information, please visit www.nasmhpd.org.

American Psychiatric Association

The American Psychiatric Association, founded in 1844, is the oldest medical association in the country. The APA is also the largest psychiatric association in the world with more than 37,400 physician members specializing in the diagnosis, treatment, prevention and research of mental illnesses. APA's vision is to ensure access to quality psychiatric diagnosis and treatment. For more information please visit www.psychiatry.org.