2. Mental Health and Mental Disorders— A Rural Challenge Fourth most often identified rural health priority Suicide rate among rural males and children is higher than among their urban counterparts Among 1,253 smaller rural counties with populations of 2,500-20,000 nearly three0fourths lack a psychiatrist and 95% lack a child psychiatrist Suicide, stress, depression and anxiety disorders

3. Mental Health Similar problems in urban and rural Certain characteristics of rural – Poverty, age, being African American, living in rural area—less likely to receive mental health care – African Americans and rural residents underutilize mental health services and seek help later in course of disease – Child and elderly especially disadvantaged

4. Mental Health Stress associated with anxiety and depression Farm crisis of the 1980s and loss of major employer

5. Farm Crisis of 1980 In Hills, Iowa, farmer kills his banker, this neighbor, his wife and then himself Ruthton, Minnesota, a farmer and his son murder two bank officials. South Dakota’s Union County, Farmers Home Administration administrator kills his wife, daughter, son and dog before committing suicide. Leaves a note—pressures of his job became too much for him to bear. Cases of child abuse and neglect rose 10% in rural area of Iowa

6. Farm Crisis Early 1970s—increase in agricultural exports (especially to Russia). Farm incomes and commodity prices increase sharply. Rising land values, low interest rates, farmers went into debt to buy land Farm household income over national average for 10 years

7. Farm Crisis Bubble burst 1980s – Farm land value dropped 60% between 1981-1985 – More debt and crop values declined – Record harvest—overproduction Glut of commodity crops—force price down – President Carter Grain embargo of Russia because invaded Afghanistan Decreased exports—20% decline – Commodity prices fell 21% Other countries filled the need

8. Farm Crisis 1/3 of commercial farmers in trouble Farm foreclosures—rural banks failed Impacted farm equipment manufacturing, seed and fertilizers For every farm lost—three non-farm jobs lost

9. Farm Crisis 1986-88 Country singer Willie Nelson organizes first of the Farm Aid concerts to benefit indebted farmers at University of Illinois Set up hotlines for people to call if in distress July 2088-March 2009 –50% of calls related to mental health issues (in Nebraska) – Offer vouchers to help cover costs

10. New Farm Crisis?? Farm land prices up Grain prices up Monitoring lending practices Extension at Iowa State – Not the same problem as before – Think will support going forward

11. Barriers to care 20% of non-metro counties lack mental health services only 5% in metro counties 87% of Mental Health Professional Shortage Areas in rural counties Use is also lower – Stigma attached still – Lack of anonymity

12. Primary Care Primary care providers serve the mental health problem – Lack sufficient training – High patient case load – Lack of time – Lack of specialized backup – May underdiagnose stigma problem Patient’s acceptance of diagnosis Future insurablility

13. Providers Train primary care – With overload already—can they handle Counseling license for masters-level graduates – States control privileges – Only work under psychiatrists supervision – Can’t prescribe medications (psychologists also)

14. Date of download: 2/13/2013 Copyright © 2012 American Medical Association. All rights reserved. From: Improving Access to Mental Health Services for Youth in the United States JAMA. 2013;309(6):553-554. doi:10.1001/jama.2013.437 Adapted from data from the 2008 National Survey of Mental Health Treatment Facilities. Figure Legend :

15. Differences in Mental Health Practice in Rural Area Put Farmer in Charge of His Own Recovery – FarmWrap program in Minnesota – Connect with farmer “where he or she is at” – Access to array of services—determine what major factor is Rural mental health professionals cannot be tourists in rural America – Must not isolate self – Be good rural citizen and steward of rural life

16. Differences Ministers –Vital Connection – Often first caregiver to recognize of a problem – Pastor of the church—even if not affiliated with a congregation—will seek help – Mental health practitioners need to be aware of this connection Farm wives – As all women—in charge of health care – More ready to leave rather than “stick it out”??

17. National Association for Rural Mental Health (NARMH) 1977 Develop and enhance rural mental health and substance abuse services Support mental health providers in rural areas Proactively support initiative to strengthen the voices of rural consumers Develop and mentor the next generation of rural mental health leaders