I had friends who lived so far out in the sticks that the nearest Walmart was a 20-mile drive away and was the only shopping choice other than the feed and grain store.
One of these friends had Dissociative Identity Disorder. To reach a psychiatrist or hospital, he had to drive for an hour to another state.
Not everyone is lucky enough to have psychiatric healthcare that’s even that accessible. A study in the American Journal of Preventive Medicine finds that 65 percent of non-metropolitan counties do not have a psychiatrist and 47 percent of non-metropolitan counties do not have a psychologist.
That mental health services are hard to come by in rural areas is stunning because although “the prevalence of mental illness is similar between rural and urban residents, the services available are very different. Mental healthcare needs are not met in many rural communities across the country because adequate services are not present.”
Western Interstate Commission for Higher Education, in their publication, “Rural Mental Health: Challenges and Opportunities Caring for the Country,” cites accessibility and availability as two difficulties that face people in rural communities who seek treatment for mental illness.
But they also name another one: acceptability. Stigma surrounding seeking mental healthcare is perhaps stronger in rural communities and small towns than in other settings. Even if they could access good mental health care, many sufferers would choose not to go.
Self-reliance is an important facet of rural character. Dealing with their own problems without outside help is deeply ingrained in family farmers and other small-town or rural residents. This may simply be caused by the fact that the rural population, being so distant from resources common in the suburbs and cities, have had to cope with problems without outside help.
Then, too, small-town life means that everyone knows everyone else. The news that a person is seeking help for a mental difficulty could easily get around. There are still fears that such a person might be viewed weak, needy, not committed to Jesus Christ (rates of Christianity tend to be higher outside of large urban areas), or just generally “crazy” in a sector where everyone minds others’ business.
The need for treatment is there, as “the Centers for Disease Control and Prevention found that from 2001 to 2015, Americans in rural counties had higher rates of suicide than those in urban counties.” Isolation and the difficulty of maintaining a small farm or business are among the reasons that depression and anxiety haunt the rural areas. And of course, no one is immune from illnesses that are typically more debilitating, such as bipolar disorder, schizoaffective disorder, and schizophrenia. More than half of people with these illnesses, originating in the physical brain, lack awareness of being ill. Among this subset of the population with mental illness, anosognosia compounds the barriers to people getting the treatment they need in rural areas.
In a report called “The Stigma of Mental Illness in Small Towns,” Emily Gurdon reports on the effects of mental illness of the older rural population in particular and their reluctance to seek treatment. “Researchers at Wake Forest School of Medicine wanted to know why,” she says, “so they questioned 478 adults aged sixty and older in rural North Carolina. The most common barrier to treatment, according to their study? The belief that “I should not need help.” Other commonly cited barriers: not knowing where to go, distance, mistrust of counselors or therapists, [and] ‘not wanting to talk with a stranger about private matters.’”
Viable solutions to the problem do not seem to exist. Telemedicine has been suggested as one, though that alone would not overcome the sense that seeking help is shameful or weak. But psychiatric or psychological help via technology is still in its infancy, and many practitioners have no more slots available.
Only that old standby – education about mental illness – seems likely to reduce stigma and increase the use of what services exist. It seems that until attitudes change, availability of and access to services increases, and anosognosia is addressed, barriers to treatment in rural and small-town populations will not go away, and indeed, may only get worse.
This post first appeared on Lynn Nanos’s blog (https://lynnnanos.com/). Lynn is the author of Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry, available on Amazon (https://amzn.to/2scZ2Z2).
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