When Margie Whichard looks out the windows of her centralVirginia trailer just beyond the Appalachians she sees miles oftrees and fields. The loudest sound she hears is the clucking ofchickens from her barn. The nearest town, Dillwyn, is 15 miles awaydown a narrow, windy highway.
Months ago, events in Whichard's life triggered a depressionthat made her feel her world was collapsing. She sought counseling,but the nearest mental health professional was more than an hour'sdrive from her home. The time and expense of traveling made regulartherapy impossible, and Whichard struggled on her own.
'They were wanting me to come {for counseling} every week, butwe didn't have the money for the gas to get there. It was also quitea bit of time out,' said Whichard, 31. 'I just kind of had acceptedthat I was just going to be depressed. Myself and my family weredealing with it the best way we could.'She eventually found help, however, from a University ofVirginia research project that is studying depressed rural women.Trained mental health professionals provided Whichard, who has nohealth insurance, with extensive home-based counseling. After 12weeks of weekly sessions, she says she feels on much more solidfooting now. Others in rural areas aren't so lucky.Emotional or mental health difficulties can affect anyone,regardless of where a person lives. But for people living in ruralareas, whether in the tobacco fields of the Southeast, theblackberry brambles of Maine or the rain forests of the Northwest,finding treatment for mental health problems can be difficult.Social workers, psychologists and psychiatrists tend to be far awayand expensive to reach. Regular or weekly visits, a common treatmentpattern, are often out of the question. Even when care is available,experts say, the lack of privacy of small-town life deters manypeople from seeking help. Some turn to other sources of care --churches, self-help books, folk medicine, friends.'I think ministers are probably the number one marriagecounselors in this state,' said Jim Clardy, a psychiatrist andassistant professor at the University of Arkansas for MedicalSciences. 'Some of them are very well trained and some don't havetraining at all.'A variety of efforts are being made to improve rural mentalhealth care. They range from traveling social workers to'teletherapy,' in which computers with video capacity are used.Still, experts say, mountain ranges and miles of desert and fieldsare stubborn barriers to providing care.'The issue for people in rural areas is one of both notunderstanding the services that are available, but more particularlythat there aren't services available,' said Jeanne Fox, director ofthe Southeastern Rural Mental Health Center at the University ofVirginia. 'A major issue is there simply aren't providers outthere.'Choices Are FewFor urban dwellers -- and most people in the United Stateslive in metropolitan areas -- some form of mental health care isfairly accessible. A car trip to the therapist's office. A bus rideto the clinic. A taxi to the pharmacy. A walk to the communitycenter for a support group. It may be a hassle to find the best kindof help, and paying for it may not be easy, but options fortreatment are usually available.People living in rural regions, specialists say, often havelittle, if any, choice. Most states have a system of public mentalhealth clinics serving beyond city limits. But as with many publichealth clinics, budgets are tight and services limited. Also, theseclinics may still be miles from where a patient lives. Counselorswho travel to or are based in remote areas are rare.It's impossible, experts say, to define statistically how manyrural residents nationally have mental health care problems, or,what they do when faced with a problem. And while studies generatesome statistics, experts say, measuring mental heath care is limitedby unknowns. Some people never seek help or talk to anyone abouttheir problems.Counting care providers is easier. The federal government,under the Department of Health and Human Services, recognizes areaswith a paucity of mental health care, designating them 'mentalhealth care professional shortage areas.' In 1997, of the 536designated mental health care professional shortage areas in thecountry, 408, or 76 percent, were in non-metropolitan or ruralareas, according to federal data.In many ways, experts say, the difficulties of deliveringrural mental health care mirror those of delivering primary care orbasic medicine in rural areas. Doctor shortages in remote orisolated nooks are much publicized. Still, there tend to be morephysicians in rural regions than mental health care practitioners.And often when rural people are having mental health problems, theyturn first to the local doctor.In many ways, experts say, the difficulties of delivering ruralmental health care mirror those of delivering primary care or basicmedicine in rural areas.'Most mental health in rural areas is done through primarycare practitioners, if you look nationally,' said Michael Blank, apsychologist and assistant professor at the School of Nursing at theUniversity of Virginia.But even if a doctor is within reach, said Blank and others,most 'country docs' are general practitioners without specialtraining in the diagnosis and treatment of mental illness. 'And theydon't recognize it well or treat it particularly effectively,' hesaid. In addition, experts said, unlike doctors in urban settings,these physicians do not have an array of specialists they canconsult with and refer patients to.Also, there are few self-help groups in rural areas (such aschapters of Alcoholics Anonymous), classes in stress reduction orsupport groups for people who are grieving.When rural residents have mental health problems requiringhospitalization, said Peter Beeson, a medical sociologist andadministrator for the Nebraska Health and Human Services System,they can end up in limbo after being discharged and may be forced tostay nearby for post-discharge services. 'At state hospitals you getpsychiatric ghettos. People are admitted from rural areas, butbecause of the lack of services, they're discharged to the townwhere the hospital is,' Beeson said. 'And so, in fact, they areisolated from their family and community.'Riding the CircuitTo address these problems, some rural counties have'circuit-riding' psychiatrists who visit small-town clinics toconsult with local care providers. They may help diagnose a problemor check on a patient trying a new medication. But findingpsychiatrists willing to take a 'circuit-riding' post is tough.'We haven't been able to find one,' said Gary McConahay, whoruns a county mental health clinic in Grants Pass, a town of 17,000in the forested mountains of Josephine County in southern Oregon.McConahay, a psychologist, has been trying for years to find a childpsychiatrist to work in his and neighboring counties. 'Just a littlething like this you don't think about in a big city, wherepsychiatrists are a dime a dozen.'Across the continent in the wilds of rural Maine, Kathy Bubaris having the same problem.'There is no psychiatrist at all in Washington County,' saidBubar, a lawyer who runs a mental health care project in Bangor forat-risk rural children. 'If you need a psychiatrist, you have nochoice but to come to Bangor, which is 90 miles away. Access is ahuge problem.'Nonetheless, McConahay found a reliable way to reach ruralchildren needing regular counseling by placing mental health workersat schools. Josephine County is zigzagged with mountain roads andtiny logging towns. Rather than expecting families to make the extradrive to town for an appointment, McConahay arranged for counselorsto set up shop at schools.'Because of our spread-out nature, we take our therapists tothe clients,' he said.An essential component of Bubar's Maine program is traininghealth workers to assist participants at home.Taking help to clients is also the framework of the Universityof Virginia project that helped Whichard with her depression. Theproject, referred to as the 'depressed women study,' offershome-based counseling to rural women in central Virginia who havebeen diagnosed with depression. At the same time it is studying theeffectiveness of the services provided.Based in New Canton, Va., and serving a five-county area inthe Piedmont region of the state, the project serves about 72 women.Funded by the Federal Office of Rural Mental Health Research at theNational Institute of Mental Health, it is four years old.Whichard and other women in the study receive weekly visits bya social worker trained to educate clients about depression andteach self-help skills. The focus is on giving clients support andpractical tools they can use to help themselves. Weekly sessionslast for 12 weeks and are replaced by less frequent maintenancevisits.The effectiveness of the program is yet to be fully analyzed,said Emily J. Hauenstein, a psychologist, nurse and associateprofessor at the University of Virginia School of Nursing.Interviews with women who have been enrolled in the program showthat depression symptoms for a significant number of them havedecreased, she said.Possibilities of TelemedicineHome-based care makes great therapeutic sense in rural areas,experts say, but in financial and practical terms it is hard to pulloff. It requires a contingent of specialists willing to travelfrequently to remote places and the money to support such a system.'This is extremely hard to do in rural areas,' said Clardy inArkansas. 'That one mental health care worker that might be able tovisit 10 people a day in the city might be able to visit two peoplea day in a rural area.'Some groups have turned to telemedicine or using video systemsor computers to link rural residents with professional help in thecity.With available technology, a general practitioner in a smalltown can arrange for a patient to meet via a video screen with apsychiatrist hundreds of miles away. A farmer on a Midwest wheatfarm who suffers from panic attacks can be hooked up via computer athis home or at the local clinic with a support group. A network ofcaregivers can participate in a video teleconference, outlining thefollow-up care plans for a small-town child about to be dischargedfrom a city hospital.Telemedicine for mental health care has exciting potential,many experts say, but it too is costly. 'It's a steadily growingfield, but telemedicine isn't going to burgeon until it becomescost-effective,' said Catherine Britain, psychologist and programmanager of Rodeo Net, a mental health telemedicine system in easternOregon run by a consortium of organizations.Sometimes a good old-fashioned 800 number makes a differencefor people far from the nearest specialist. In Redfield, Ark.,population about 2,000, Jackie Weser helps staff a toll-free numberfor people with anxiety disorders, called the Anti-Anxiety Network.An anxiety patient herself, Weser is trained to provide simplecounseling over the phone and to make referrals. Many of the peoplewho call live in remote areas, as she does, Weser said. 'I havefound that healing comes from helping others,' she said. The serviceis run by the Arkansas Alliance for the Mentally Ill with help froma state grant.While not a substitute for professional care, Weser said, atoll-free telephone number includes a feature many rural peopledeeply appreciate -- anonymity. Mental health problems areassociated with stigma in communities of all sizes. But stigma canbe more troublesome in rural areas, experts say, because privacy istough to maintain.'If there's one psychologist in your town and you're parkedout front, that's going to come back to you,' said John Fortney, amedical geographer and assistant professor in the department ofpsychiatry at the University of Arkansas for Medical Sciences.'People in the grocery store will talk about you.'Since rural communities tend to be more close-knit than inurban neighborhoods, there is a greater likelihood that ruralresidents will learn personal details about each other's lives,including emotional or mental problems, experts say. 'And this makespeople less likely to go seek help,' said Nebraska sociologistBeeson.The key to mental health care in rural areas is the same as inurban settings: to help people before their problems deteriorate.'When treatment is not really available, people delay it,' saidArkansas psychiatrist Clardy, 'and oftentimes it's worse {by thetime} people are seen.'Kate Darby Rauch is a writer in Berkeley, Calif.
