In the days and weeks following the suicides of celebrity chef Anthony Bourdain and handbag designer Kate Spade, a chorus of social media users urged people with depression to not be “afraid” to ask for help.
But for most Americans, fear isn’t the thing that stands in the way of therapy. It’s having no one to turn to.
This was the case for Sue, 57, who spent over 30 years trying to get effective treatment for bipolar disorder, depression, anxiety and a personality disorder.
For years, whenever Sue felt a major anxiety attack coming on, she’d panic. She would grab her keys, bolt out the door and frantically search for help. In rural Nebraska, that often meant walking up to two miles to the nearest neighbor’s house or emergency room, sometimes in the middle of the night.
Sue estimates that she’s been to the emergency room in crisis about 30 times. Staff members at the local hospitals she visited weren’t usually equipped to treat her and would typically send her home in a matter of hours.
Still, just having someone tell her she would be all right was enough of an incentive for Sue to return to the ER when her anxiety became too much to bear. “I ended up being released and going right back to the condition I was in,” she said. “I would do it again about a month later.”
“If you’re in New York, Chicago, San Francisco, Houston ... you will get the best mental health services we have to offer. If you’re in some of these rural areas, you won’t.”
There is a severe shortage of mental health workers across the U.S., but the problem is most pronounced in rural areas. There isn’t a single psychiatrist in 65 percent of nonmetropolitan counties, and almost half of those counties don’t have a psychologist, according to a report from the American Journal of Preventive Medicine released this month. Patients like Sue, who are desperate for care, will often turn to overburdened emergency rooms, which often don’t have the systems in place to help people with mental health issues.
“People with mental illness will present in the ER because they don’t know what else to do,” said Stephanie Knight, a licensed independent mental health practitioner and the administrative director at Fillmore County Hospital in Geneva, Nebraska.
But even when a rural area does have some mental health workers, they alone usually can’t address the entire population’s needs. Many residents are uninsured or underinsured, and can’t afford regular treatment. Residents may have to travel dozens of miles to get to the nearest town where a therapist works, and may not have access to transportation. Some therapists have irregular office hours and may only visit town a few days a month. The inconsistency can be a deterrent to patients.
Such was the case with Ann, 72, who lives in Crete, Nebraska. She has major depressive disorder and attempted suicide seven years ago. She enjoyed seeing a local therapist, but the therapist only came to her town once a month.
“It was so infrequent,” Ann said. “After a couple of weeks, I’d think: ‘Why go back?’ There was no momentum.”
Rural areas have the highest suicide rates, according to the Centers for Disease Control and Prevention, as well as a high concentration of veterans, who experience higher rates of suicide than nonveterans. Rates of drug overdoses in rural areas have surpassed those in metropolitan areas. There are also more elderly people, who are often socially isolated and at risk for depression, said Ron Manderscheid, executive director of the National Association for Rural Mental Health.
“If I went and looked at all those local communities, I will find a lot of socially isolated people. That is almost as deadly upon you as smoking,” said Manderscheid. “When you put that all together, rural areas are a pretty risky place for being at risk for suicide.”
Not enough people are going into the mental health field, and those in the field are aging, Manderscheid said. The average psychiatrist is in their mid-50s. Other specialists and primary care physicians are, on average, in their mid-40s. Those who do pursue careers in mental health typically find jobs in major cities.
“Historically, mental health has been an urban discipline,” Manderscheid added. “If you’re in New York, Chicago, San Francisco, Houston ― any of our big areas ― you will get the best mental health services we have to offer. If you’re in some of these rural areas, you won’t. It’s just as simple as that.”
While some government incentive programs help repay the student loans of therapists who work in underserved areas, many professionals don’t stick around once they’ve paid off their debts, Knight said.
Manderscheid said improving telehealth programs, which allow patients to call or video chat with therapists in cities, is one potential solution. Encouraging young people from rural areas to go into the mental health field could also help.
“We need to start recruiting some of our providers from these rural areas, and work with people in high schools and colleges,” he said. “They are most likely to go back. They have an appreciation for rurality and living in rural communities.”
Knight, 35, grew up in rural Nebraska and struggled to get access to mental health services as a teenager. She had to travel 45 miles to see a therapist, who only had office hours until about 5 p.m. She’s now working on building a mental health program in Geneva, Nebraska, staffed by people who have a deep understanding and appreciation for rural America. Geneva’s population is just over 2,000 people.
There’s a particularly pressing need for improved mental health programs in Nebraska, which faces longstanding staff shortages and federal funding cuts. Eighty-eight of Nebraska’s 93 counties have behavioral health worker shortages, according to the Lincoln Journal Star, and the state has cut 200 inpatient beds at its three psychiatric hospitals since 2003. Knight said about a handful of psychiatrists serve rural Nebraska. The state didn’t participate in the Medicaid expansion in 2013, which would’ve extended coverage to up to 80,000 residents.
When Knight and other hospital staff members started to lay the groundwork for the therapy program at Fillmore County Hospital in 2011, there was one behavioral health center in Geneva, served by therapists who rotated through the town and other parts of the state.
The program at Fillmore began with just Knight and a van driver to bring patients to the hospital. (They realized that in order to access the patients in greatest need, they would have to trek out to the farms and countryside to reach them.)
Now there are six therapists, most of whom grew up in rural areas. A physician writes an order for patients who are elderly and can no longer drive or who are on disability and can’t afford transportation.
The van is a major expense that the hospital isn’t reimbursed for, but it’s a critical piece of the team’s outreach efforts. The current vehicle already has over 200,000 miles on it and needs to be replaced, but a new one would likely cost $150,000. The driver starts her route at about 6 a.m. and returns to the hospital at 10 a.m. with a handful of seniors who participate in group therapy.
Ann is one of the group members, and she lives about 80 miles away from the hospital. The three-hour round-trip journey is hard on her back, so she only participates once a week, even though her doctor recommended she receive treatment at least three times a week.
In 2013, in response to suicides, overdose cases and requests from community members, Fillmore expanded its mental health offerings and started building its inpatient program.
Last month, the hospital saw 111 patients with mental health needs, not including people who are just being monitored for medication. In April, it had 39 new referrals, an “astronomical” amount for them, Knight noted.
The programs seem to be producing results. Sue, for example, just completed an outpatient therapy program at Fillmore on Wednesday after three and a half years. She hasn’t been to the emergency room since 2015. When she has panic attacks, she turns to a host of coping mechanisms she’s learned in therapy, including deep breathing and listening to music.
“I feel a sense of freedom,” Sue said. “In recent times, I’ve done a really good job of getting my mind off the anxiety. It may take all day. It may take half an hour. I can do it without calling anyone.”
If you or someone you know needs help, call 1-800-273-8255 for the National Suicide Prevention Lifeline. You can also text HOME to 741-741 for free, 24-hour support from the Crisis Text Line. Outside of the U.S., please visit the International Association for Suicide Prevention for a database of resources.