Several Issues Differentiate MH Care in Rural, Urban Youth

Maria Dryfhout/Shutterstock

Children with high psychiatric impairment who live in rural areas are just as likely as their urban counterparts to be diagnosed and treated for mental health conditions, but rural children with less-acute impairment are less likely to be diagnosed with a psychiatric disorder than are children in urban areas (the exception is attention-deficit/hyperactivity disorder [ADHD]).

Once diagnosed, though, rural children tend to receive prescriptions significantly more often and counseling less often than their urban peers, said Jennifer Lenardson, M.H.S., David Hartley, Ph.D., and colleagues in a new report from the Maine Rural Health Research Center at the University of Southern Maine in Portland. The center has produced a number of reports on mental health in recent years.

“This is an important study that replicates findings from the same source that found that rural adults with depression are less likely to receive any or adequate counseling compared with their urban counterparts,” said John Fortney, Ph.D., a professor in the Department of Psychiatry at the University of Arkansas for Medical Sciences and an investigator at the Central Arkansas Veterans Healthcare System, in an interview with Psychiatric News.

The Maine researchers drew on data from the Medical Expenditure Panel Survey (MEPS) conducted from 2002 through 2008, covering 41,359 urban and 8,432 rural children aged 5 to 17. Respondents’ interview information was verified by additional contacts with providers. The Columbia Impairment Scale was used to identify mental health problems.

The observed variation in mental health impairment—29.8 percent in rural areas vs. 24.8 percent in urban ones—might seem small but translates to almost 450,000 children with mental health impairment in the rural population, a significant difference epidemiologically and clinically, said Fortney, an expert on rural mental health who was not involved with the Maine study.

Higher rates of poverty, public-insurance coverage, and mental health impairment may account for these differences, suggested the authors.

Overall rates of psychiatric diagnoses were similar in both settings. The exception was ADHD rates, which were higher in rural areas (6.2 percent vs. 5.1 percent). About 8 percent of rural children received a prescription for a psychiatric medication, compared with 6.4 percent of urban children.

Whether lower rates of diagnosis among children with subacute mental health problems indicate a need for treatment is not clear, the researchers noted. “[T]he lack of mental health specialty providers in rural areas means there is, in many cases, no provider available to determine whether treatment is indicated.”

Developing tools to help primary care clinicians or school counselors assess children’s needs and suggest referral options might be one way to overcome some of these differences, suggested the authors.

Shortages of mental health specialists in rural areas have left treatment in the hands of primary care providers, who are more likely to prescribe medications than to provide counseling or psychotherapy.

Rural children with “likely” psychiatric impairment received counseling as often as urban youngsters, suggesting that the few available mental health providers in rural areas are focusing on delivering services to those most in need, said Fortney. “This suggests that rural providers are doing a good job of reaching those with the most need.”

Families with a preference for pharmacological treatment may not experience disparities in care because the study found no rural-urban differences in receipt of psychotropic medications, he said.

“The bad news is that most kids with likely mental health impairment were not diagnosed or were not receiving any mental health treatment,” said Fortney. “This suggests that access to services needs to be improved in both urban and rural areas.”

Strategies used in rural areas are likely to be very different than those in urban areas, however.

“In urban areas where there are [many] mental health specialists, a public-awareness campaign might be used to encourage treatment seeking,” Fortney suggested. “In rural areas, the strategies should focus on supporting primary care providers in their treatment of mental health disorders.”

The study was funded by the Office of Rural Health Policy, Health Resources and Services Administration of the U.S. Department of Health and Human Services. ■