Psychiatrist Kenneth Gladieux, M.D., is a transplanted native of the
Washington, D.C., suburbs now practicing at the Ozarks Medical Center in rural
West Plains, Mo. He works closely with Barbara Pearson, L.P.N., who grew up
Credit: Aaron Levin
"Rural psychiatry is not simple psychiatry," said Kenneth
Gladieux, M.D., sitting in his small office in the Ozarks Medical Center in
West Plains, Mo.
The range of diagnoses he sees in this quiet town, where streets are named
after country-music stars and local boys who grew up to play major league
baseball, equals anything psychiatrists see in metropolitan areas, he said.
Finding the resources to provide care is, however, a never-ending balancing
"Our part of America deserves the same level of care as any other
part," added Gladieux's colleague David Evans, L.P.C., a native of the
region. "Poverty and remoteness shouldn't keep people from getting the
care they need."
The Health Resources and Services Administration's (HRSA) Shortage
Designation Branch says there are 1,621 nonmetropolitan areas designated as
mental health Health Professional Shortage Area (HPSA), covering more than 55
To help lessen the shortage of psychiatrists and reach a
population-to-psychiatrist ratio of 30,000:1 (or 20,000:1 where high needs are
indicated) in mental health, HPSAs require an additional 1,113 psychiatrists
in those areas, according to David Bowman, an HRSA spokesperson. The shortage
designation also takes into account needs for other mental health
Those numbers may not even represent the full extent of the problem, since
there may be areas or populations that might qualify as underserved but have
never requested an HPSA designation, he added.
So for the moment, filling the need for psychiatric services in rural
America, as in most underserved areas, requires cobbling together a patchwork
of professionals, programs, and payments to contend with widespread need,
geographic isolation, and cultural mores.
One way to improve mental health care in America's small towns and rural
counties is to bolster the psychiatric knowledge of primary health care
professionals already working there.
For instance, Alan Allmon, D.O., has been a family practitioner outside
Sedalia, Mo., for over 30 years. The last time he'd had any formal psychiatric
training was the month-long rotation he'd spent in Fulton (Mo.) State Hospital
in 1971. About four years ago, he sensed how little he knew about how
psychiatrists today use psychotropic medications. He started reading, first
short works, then standard textbooks on psychiatric drugs. He felt more adept
thinking about drugs eventually, but then wanted more training on how to
diagnose the conditions those drugs treated.
Luckily, Allmon had an option designed for primary care physicians and
nurse practitioners, a program developed at the University of Missouri and
partially supported by the U.S. Department of Labor (Psychiatric
News, December 1, 2006). The course included 84 hours of classroom and
clinical study in general psychiatry, child psychiatry, and
psychopharmacology. Once he finished, Allmon grew more confident in his
ability to differentiate and diagnose the anxiety, depression, bipolar
disorder, and other psychiatric illnesses that he encounters in his private
practice. When faced by more severe or complex cases, he can call for help
from psychiatrists at the university's medical center in Columbia.
"The outpatient psychiatry I do in family practice is more rewarding
than anything else," he said recently. "I can make a real
difference in people's lives."
Another approach has been to encourage graduates of international medical
schools to work in underserved areas under J-1 visa waivers (see "J-1
Baskar Gowda, M.D., works at a clinic in Osage Beach, Mo. He needs more
outpatient substance abuse programs there.
Credit: Aaron Levin
Bhaskar Gowda, M.D., trained in his native India, completed a psychiatry
residency at the University of Missouri and then held an externship in New
York. He came to the United States on a J-1 visa six years ago and now lives
and practices in Osage Beach, Mo.
Although it took some time to break through the social barriers in Osage
Beach, Gowda said, "people here are friendly, and once the community
knows you, it's no different here than in New York City."
The area remains poor and rural, even though it lies on the fringe of a
resort area. Many people in the area don't have access to health care because
they lack private health insurance but don't meet income guidelines for
Medicaid, Gowda said. The area is also short on inpatient services for women
and group outpatient substance abuse programs. His office is now part of a
nonprofit system that operates on a mix of private insurance and subsidies
from the state mental health department.
"We stretch ourselves to cater to our patients," he said."
It's a wonderful experience serving in a rural area."
Down in West Plains, psychiatrist Elizabeth Bhargava, M.D., who was born in
Bangalore, India, has worked at the Ozarks Medical Center on a J-1 visa since
2003. Having a relative who was a cardiologist in the area made the transition
easier, she said. She finds advantages to living in a small American town,
even if the pay is lower than in cities and the nearest major airport is two
"It's more peaceful here; there are lots of open spaces and birds and
animals," said Bhargava, who trained in Chicago. "In a big
American city, you can get overwhelmed. Here you get to know people in the
community who can help you make a difference in the lives of people. My
expertise is useful and important. I've been able to take leadership positions
in the hospital and the medical community in general."
Bhargava is now working on a grant proposal to expand treatment for
Yet another source of mental health professionals lies in HRSA's National
Health Service Corps (NHSC). The NHSC recruits primary care clinicians and
psychiatrists to provide care in underserved communities. The nationwide
program repays medical school loans and offers scholarships for those willing
to commit to service at the start of medical school. There were 229
psychiatrists serving as NHSC scholars or loan repayers in 2005, said HRSA's
That was the route that led Gladieux, to West Plains.
He joined NHSC when he applied to medical school at Virginia Commonwealth
University. His tuition was paid, and he received a stipend while he studied.
In exchange, Gladieux must work one year in the program for each year of
"I think of psychiatry as primary care," said Gladieux during
an interview that took place in the small house where he lives with his wife
and two children in West Plains. "I was always a lot more concerned with
people's emotional well-being as part of their complete health rather than
just the physical elements."
After residency at the University of Virginia, Gladieux was assigned to a
hospital in Helena, Ark.; he came to West Plains in July 2005.
The medical center is a 114-bed, not-for-profit system with its main
hospital in West Plains and a dozen smaller sites scattered around the
surrounding 12-county area. The medical staff includes more than 100
physicians. The center should have a complement of five psychiatrists, but two
staff departures late last year have left it shorthanded, although recruitment
efforts are under way.
A conversation with Gladieux and his colleagues reveals the spectrum of
mental illness in the region and the juggling act they perform to cope with
"The range of pathology is about the same here as in a large
city," said Gladieux. "If there's anything prominent among the
ills of the region, it's substance abuse, especially methamphetamine and
"Meth is a source of easy money for poor, rural people," said
Evans, Gladieux's colleague. "Add alcohol and opiates and you increase
the danger, especially for children in these families. People do bizarre
things—incest, negligence, accidents—and they end up in the
Like Evans, Barbara Pearson, L.P.N., who works closely with Gladieux, grew
up nearby. "I always wanted to take care of people, but I can't believe
the things that happen," she said. "I was very
As happens elsewhere, though, socioeconomic circumstances play a role in
who seeks and who gets treatment. A culture of poverty and disability becomes
more complex as one looks below the surface, said Patty Carson, A.P.R.N.
Disability checks may effectively support a wider circle than just patient and
family, she said, and that may discourage movement toward recovery.
A combination of undereducation and deeply held religious conviction can
exert a paradoxical effect, said Carson. "People have difficulty
understanding concepts of mental illness, but they are also inclined to say `I
couldn't commit suicide because I'd go to hell.'"
Stigma contributes its effects, as it does in most places, said Evans.
People often keep mental illness in the family a secret until danger arises."
It has to get really bad before they come in to see us," he
Sheer distance can complicate staffing and cultural issues. Along with the
psychiatrists, nurses, and counselors, the unit has 23 case workers, paid by
state funds. Each case worker has 20 patients, many living at the end of long
gravel roads. The problems of distance are compounded by a lack of public
transportation. Often, case managers must drive 20 miles out and back on
country roads just to pick up patients and return them home.
Adaptability is a helpful trait in a region where specialists are in short
supply, Gladieux has found. He filled a position formerly held by the only
child and adolescent psychiatrist in the area, even though he had no advanced
training in child psychiatry. Now, he says he's prepared to evaluate anyone of
"It's very rewarding to take care of kids and also more stressful
because you're really treating families," he said. "The problem
really isn't the child, it's the family or their social circumstances. There
are a lot more variables in the assessment. Sometimes I think of myself as a
social worker with a prescription pad."
Dealing with these interconnected medical, psychiatric, and cultural issues
with two fewer psychiatrists has meant the staff must juggle schedules and
assignments. They manage to see all the patients, but individuals may be
shifted to alternate professionals within the behavioral health unit when
demand on the psychiatrists rises.
Recruiting physicians, especially psychiatrists, is difficult because of
the small-town setting, admitted Carol Eck, M.Ed., L.P.C., executive director
of Behavioral Healthcare at Ozarks Medical Center. Time and distance make
professional education hard to arrange. On the other hand, the location can be
attractive for the right person, one who likes country life, she said. West
Plains touts its schools (two elementary, one middle, one high school) and low
crime rates, said Eck. "People come here to raise families."
With one year to go on his contract, Gladieux is open to the thought of
staying in West Plains—his wife likes the area—but he would prefer
a position that grants him more autonomy in making clinical decisions. An
infusion of greater resources could provide both better services to patients
and generate more revenue for the medical center.
"I have no regrets about choosing the NHSC," he said. "I
really do love my profession. I feel that I've done a lot of good in three
years, but I'm looking forward to being captain of my own ship."
He also misses the experience of working with more experienced
"I don't have a mentor now. I don't feel I need other psychiatrists
to learn from, but I do wish I had a mentor who might be there in an area with
a higher concentration of psychiatrists."
Nonetheless, he has learned a lot by having to cope with a variety of
challenges. He sees a wide range of pathologies and does inpatient
consultations with the medical, surgical, and obstetrical wards. "I'm
working in one of the tougher outpatient psychiatric populations, so I've
gotten good experience here."
What's the best part of working far from his hometown in the Washington,
"What other options do these folks have?" he said. "We're
the end of the line for them. That's a big responsibility. It's challenging
and gratifying at the same time. It hasn't always been easy, but I've gotten
experience here I could not have gotten any other way."
Information on the National Health Service Corps is posted at<http://nhsc.bhpr.hrsa.gov>;
on health care shortage areas is posted at<http://bhpr.hrsa.gov/shortage>;
and Criteria for Designation of Areas Having Shortages of Mental Health
Professionals is posted at<http://bhpr.hrsa.gov/shortage/hpsacritmental.htm>.▪