Harnessing Digital Innovation: Addressing Mental Health Disparities in Rural America

fotoworld/AdobeStock

We live and work in rural communities. I (Jeff) am the founder and chairman of Rural Minds and from rural upstate New York. I (John) spend part of my time in the least populated county of North Carolina and serve as the chief medical officer and executive vice president at Otsuka in the US. Our experiences in rural America have shown us that in rural communities, though unique in their people and landscapes, mental health inequity is ubiquitous. Across the country, rural residents are struggling to address the growing and seemingly intractable mental health crisis.

For me (Jeff), this crisis is my lived experience.¹ I come from a long line of farmers and growing up I witnessed the silent struggles of local individuals with mental illness. Tragically, my nephew Brooks, a farmer and father of 3-year-old twins, died by suicide.² Despite pressure to conceal the truth, my family, led by my late mother, chose to confront the issue head on, determined to break the silence and stigma surrounding mental health challenges. Even today, there remains a lack of understanding and information about mental illness and many still do not recognize mental health conditions as chronic illnesses, like cancer, heart disease, or diabetes.

In 2022 alone, over 7.7 million adults in nonmetropolitan areas reported a mental illness and 1.9 million contemplated suicide.³ We also know that individuals in rural communities historically have faced higher rates of opioid use disorder and overdose.⁴ If we look even closer at marginalized populations, we know these challenges disproportionately affect people of color and Indigenous peoples. For example, the rate of suicide is particularly high in the Native American community.⁵ Between 2016 and 2020, the number of excess premature mental and behavioral health-related deaths among Indigenous populations and people of color was 116,722.⁶

According to a recent analysis from The School of Global Health at Meharry Medical College, the US currently spends an estimated $477.5 billion annually in avoidable and unnecessary expenses related to mental health inequities.⁷ This excess spending is expected to grow to $1.3 trillion annually by 2040.⁵ For lower-income individuals and minority populations, the burden of mental health and chronic conditions is disproportionately high. We know that mental and physical health are connected, only exacerbating the economic and human impact on these groups.

Despite these mounting challenges, we see promise. There are 4 areas where psychiatrists and other mental health care providers, as well as industry and mental health advocates, can partner to help ameliorate the mental health crisis in rural America in ways that align to these communities’ needs.

Community Collaboration to Change Perceptions

Recognizing we cannot impart lasting change without community input and participation, Otsuka and Rural Minds share in our commitment to change how mental illness is treated. We welcome multiple perspectives, and each of us can contribute solutions to this crisis. First, we need to immerse ourselves in the complexities facing rural communities.

Unique to rural areas is a weakening agricultural economy, financial instability, job scarcity, and the greater likelihood of social isolation.⁸ The stigma around serious mental illness is heavy—rural Americans are known for having a strong work ethic and willpower, but this leaves many to suffer in silence for fear of speaking up and appearing “weak” or simply because they think they have nowhere to turn. This prompted me (Jeff) to start Rural Minds because too many of my community members lacked the information to address their mental health challenges. Through Rural Minds, we are working to confront the stigma and change the misconceptions about serious mental illness by creating and sharing resources and information with rural communities through webinars, community events, social media, and condition fact sheets.⁹

No Access Without Providers

Exacerbating the crisis is the overwhelming shortage of health care and mental health professionals. Throughout my (John) career, I have held many different roles within the field of psychiatry but have always prioritized serving patients from rural and underserved communities within the public health setting because I have seen firsthand that they have great need and there are not enough qualified providers to meet it.

Statistics paint a staggering picture of the reality rural residents face: Rural communities in the US are short on health care staff with less than 10% of US doctors currently practicing in rural areas.¹⁰ Moreover, there is a lack of psychiatrists in 65% of rural counties,¹¹ a lack of psychiatric nurse practitioners in 81% of rural counties, and a lack of psychologists in 47% of rural counties.¹¹ Because of insufficient services for those most in need, the mental health crisis responder for most rural Americans is a law enforcement officer. It is imperative we continue to push for accessible pathways for medical (and other provider) licensure to allow remote treatment in other states (eg, interstate compacts and/or special purpose telehealth registries or licenses).¹²

There really cannot be a conversation about increasing access to care without also seriously addressing the provider shortage or finding new ways to connect people. That is where the promise of technology comes into play.

Technology for Good

There is a tension between the promise of digital solutions in the health care industry and the reality of rural America with an astounding 30% of rural homes lacking broadband internet.¹³ Driving change in these communities means bridging the digital divide and removing barriers. Rural Minds is advocating for government programs, such as the Broadband Equity Access and Deployment (BEAD) initiative, a government program that provides $42.45 billion to expand high-speed internet, enabling clinicians, caregivers, and patients to connect.¹⁴

It might not seem obvious that psychiatrists could weigh in on telecommunications policy. But advocating for BEAD and similar initiatives can help ensure patients get the help they need for access to telehealth services for physical and mental health, including serious mental illness.

Harnessing the Power of Digital Innovation

Beyond teletherapy, growth in prescription digital therapeutics could potentially offer additional benefits for rural mental health. These therapeutics deliver medical interventions directly to patients from their smartphones using software programs that are subject to clinical evidence requirements and regulatory oversight and are recognized as medical devices by the US Food and Drug Administration. Although there is still more progress to be made, prescription digital therapeutics are poised to help tackle some of the most pressing challenges of the mental health crisis and offer nonpharmacological options to patients. They could be of special importance to those living in rural communities with great barriers to care.

I (John) also see ample opportunity to increase participation in mental health research for those in rural communities. We need rural research participation to better inform treatments for serious mental illness, but we need to meet people where they already are. Further, resources need to be made available such that reliable, evidence-based treatments can be delivered anywhere.

For example, virtual visits can be incorporated into everyday treatment plans and clinical trials. It is imperative we have community participation in mental health research to foster trust and provide treatment options that work for different populations.

Where You Can Start

1. Advocate for change: Use your voice to support policies that improve access to mental health care and digital connectivity in rural areas.
2. Collaborate locally: Connect with local advocates and organizations to address mental health stigma and enhance community collaboration. Attend community events, share resources, and if possible, lend your time and expertise to rural communities.
3. Build the provider pipeline: Advocate for pathways that increase the number of health care professionals in rural areas. Participate in mentorship programs for medical students who may be deciding on their specialty area. Support initiatives that allow for remote treatment and telehealth services across state lines.
4. Promote research participation: Encourage participation in mental health research to develop treatments and practices that are inclusive and applicable to rural populations.

Psychiatrists have valuable expertise and experiences to bring to the table, and together with partners from across the industry and rural communities, we can make swifter progress to conquer this crisis.

Dr Kraus is the executive vice president and chief medical officer of Otsuka. Dr Kraus has over 25 years of experience in clinical, academic, pharmaceutical medicine and drug development. His holistic approach to overcoming challenges places patients at the center and inspires impactful change. He previously worked on rural mental health care legislation while a Daniel X. Freedman Congressional Fellow, supported by the American Psychiatric Foundation, and is dedicated to addressing the gaps in treatment and advancing care for underserved patients. He spends part of his time in Tyrrell County, NC—the least populated county in the state.

Mr Winton is founder and chairman of Rural Minds. In response to the suicide of his nephew on the family dairy farm, Jeff founded Rural Minds, the only national 501c3 nonprofit focused solely on providing the 46 million people in rural America with free information and resources to confront rural mental health challenges and the stigma that surrounds mental illness. In addition to serving as Founder and Chairman of Rural Minds, Jeff is CEO of Jeff Winton Associates, a full-service communications and corporate affairs agency that he cofounded in 2020 after a communications career with major US and international biopharmaceutical companies.

References

1. Winton J. Medical Information Sharing Consent Form. Otsuka American Pharmaceutical; 2024.

2. Jeffrey Winton. Rural Minds. Accessed September 12, 2024. https://www.ruralminds.org/jeffrey-winton-bio

3. 2023 NSDUH Detailed Tables. Substance Abuse and Mental Health Services Administration. 2023. Accessed August 4, 2024. https://www.samhsa.gov/data/report/2023-nsduh-detailed-tables

4. Grimm CA. Geographic disparities affect access to buprenorphine services for opioid use disorder. US Department of Health and Human Services. January 29, 2020. Accessed September 12, 2024. https://oig.hhs.gov/oei/reports/oei-12-17-00240.asp

5. Health disparities in suicide. Centers for Disease Control and Prevention. January 17, 2024. Accessed September 12, 2024. https://www.cdc.gov/suicide/disparities/?CDC_AAref_Val=https://www.cdc.gov/suicide/facts/disparities-in-suicide.html

6. Dawes DE, Amador CA, Jha M, et al. The Economic Burden of Mental Health Inequities in the United States Report. Satcher Health Leadership Institute. September 2022. Accessed September 12, 2024 https://satcherinstitute.org/wp-content/uploads/2022/09/The-Economic-Burden-of-Mental-Health-Inequities-in-the-US-Report-Final-single-pages.V6.pdf

7. Dawes DE, Bhatt J, Dunlap N, et al. Projected Cost and Economic Impact of Mental Health Inequities in the United States. Meharry School of Global Health; 2024.

8. Winton J. Confronting Mental Health Challenges in Rural America. National Alliance on Mental Health. November 17, 2022. Accessed September 12, 2024. https://www.nami.org/advocate/confronting-mental-health-challenges-in-rural-america/

9. Rural mental health.Rural Mental Health Information Hub. Accessed September 12, 2024. https://www.ruralhealthinfo.org/topics/mental-health

10. Challenges facing rural communities and the roadmap to ensure local access to high-quality, affordable care. American Hospital Association. 2019. Accessed September 12, 2024. https://www.aha.org/system/files/2019-02/rural-report-2019.pdf

11. Andrilla CHA, Patterson DG, Garberson LA, et al. Geographic variation in the supply of selected behavioral health providers. Am J Prev Med. 2018;54(6):199-207.

12. AMA issue brief: telehealth licensure. Updated May 8, 2023. Accessed September 12, 2024. https://www.ama-assn.org/system/files/issue-brief-telehealth-licensure.pdf

13. Vogels EA. Some digital divides persist between rural, urban and suburban America. Pew Research Center. August 19, 2021. Accessed September 12, 2024. https://www.pewresearch.org/short-reads/2021/08/19/some-digital-divides-persist-between-rural-urban-and-suburban-america/

14. Broadband Equity, Access, And Deployment (BEAD) Program. National Telecommunications and Information Administration. Accessed September 12, 2024. https://www.ntia.gov/funding-programs/internet-all/broadband-equity-access-and-deployment-bead-program