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Mental Health and Rural America: Challenges and Opportunities


>> WEBINAR OPERATOR: Hello and thank you for joining the National Institute of Mental Health Office for Research on Disparities and Global Mental Health 2018 webinar series.  This presentation is entitled Mental Health and Rural America:  Challenges and Opportunities.  Please note all lines are in listen only mode.  If you would like to ask a question during today's presentation, you may do so at any time through the Q&A box located in the lower right hand corner of your screen.

This call is being recorded.  It is now my pleasure to turn today's call over to Roberto Delgado.  Please go ahead.

>> ROBERTO DELGADO: Thank you, Miranda. Hello everyone.  My name is Roberto Delgado, I'm the Program Chief for Rural Mental Health Research in the Office for Research on Disparities and Global Mental Health at the U.S. National Institute of Mental Health or the NIMH.  I want to welcome everyone today for the second offering in our 2018 webinar series.  As a quick reminder, also the third installment will come up next month, June 27th and addresses Mobile Technologies for Global Mental Health Research.  Further, before we begin today's presentation I want to draw your attention to a smaller entity within the NIMH, namely the Office of Rural Mental Health Research, which is congressionally mandated to coordinate the research activities of the Department of Health and Human Services as they relate to mental health of residents in rural areas; also to conduct research on conditions that are unique to rural residents; to conduct research on improving the delivery of services in rural areas; as well as disseminate information to the appropriate public and non profit entities.  Today's presentation will provide an overview of mental health in non metropolitan areas of the United States looking at the critical issues facing rural residents and their systems of care.

As our presenter will explain there is not a single or one rural America, and the webinar will provide examples of unique responses of the challenges to serving rural communities.  It is now my privilege to introduce our featured speaker, Dennis Mohatt.  Dennis is the Vice President for Behavioral Health at the Western Interstate Commission for Higher Education or WICHE and he directs the Mental Health Program and their Center for Rural Mental Health Research.  Dennis is very distinguished, has over three decades experience in mental health services policy and analysis research.  And as I mentioned currently directs the WICHE Mental Health Program, which is a collaborative venture comprising 15 western states and Pacific territories and affiliated states.  Dennis is actively engaged in a number of efforts, focus on improving services to veterans, guard and reserve as well as families on rural mental health policy, workforce development, and increasing adoption of integrated approaches to behavioral and primary care practice.  His graduate training was I’m happy to say supported in part by NIMH fellowship and focused on rural community clinical psychology.

So, I'll turn it over to you now, Dennis.

>> DENNIS MOHATT: Thanks, Roberto.

As Roberto said, there's not one rural America, and what most people think about when they picture persons with mental illness are people like the gentleman in the picture on this, who is sitting on a city street and is likely homeless.  They think of an out of control teenager in a large metropolitan school.  They think of a person locked on a psychiatric hospital ward.  They think about people making poor choices, but most of all I think they think about someone else, and the just world hypothesis is alive and well when it comes to mental health where many of us easily can imagine our risk for cancer and other disorders.  We don't often think about our risk for mental illnesses.

What few people, what few Americans picture is a guy like in the picture here, a farmer or a rancher with serious depression.  They don't think about the stress associated with a changing rural economy where a single tweet on trade by the President can tank soy bean prices across the Midwest.  They don't think about someone driving 150 or more miles to access care, let alone a psychiatrist or a psychologist or a different mental health professional driving a circuit to deliver care like the circuit riders of the past.  They certainly don't think about the refugees and the migrants that travel across this country harvesting the food that we all eat, but most of all they don't think about rural America.  And when a lot of people think about rural America, they think about a place to go for vacation, and I think that also sets up a barrier to understanding the challenges that are faced by rural people, because if a rural environment is where you go to relax, it's then    you're sort of predisposed not to look under the covers and see what the problems lurk beneath, and so that sets up a barrier, a psychological barrier.

>> ROBERTO DELGADO: Dennis, I'm sorry to interrupt, this is Roberto. We're hearing feedback or static from your line.  I don't know if there's something you can do about that.

>> DENNIS MOHATT: Is this better?

>> ROBERTO DELGADO: Speak again clearly.

>> DENNIS MOHATT: Is this better.

>> ROBERTO DELGADO: Yes, that seems to eliminate the noise, thank you.

>> DENNIS MOHATT: Okay, great.

The cold hard facts about mental health and rural America is that more than 60% of rural Americans live in mental health professional shortage areas, that more than 90% of all psychologists and psychiatrists and 80% of Masters of Social Work, work exclusively in metropolitan areas.  More than 65% of rural Americans get their mental health care from primary healthcare provider, and the mental health crisis responder for most rural Americans is a law enforcement officer.

Some of those things are pretty imprecise.  We don't really ask and track where people practice.  So we know where psychologists and psychiatrists licenses are granted and where they live.  We don't necessarily know if they travel out to rural areas, and we don't have a good tracking system to follow that.

When we look at MSWs as we all know, not all MSWs are clinical MSWs and we don't track that very well either.  And so it's hard to really get right down to who is available in rural areas to help.  And if we, researchers and policymakers, have a hard time putting our thumb on who is there to help, the typical person seeking care has an even harder time.

So what is different in the country besides like a picture here of a long straight road going across the plains?

It's not prevalence.  Certainly rural urban rates of mental disorders are pretty much the same.  There are differences, to be sure.  But if you put an urban community under the same stressor, you would have the same sort of reaction.  It's more around incidence than prevalence.

But what is different is the experience of mental health issue in a rural area or the provision of mental healthcare in a rural area, that is different.

And accessibility is different.  Getting there and paying for it, availability, that there's actually someone there when you get there.  And acceptability, choice quality and knowledge of you and your problem and the challenges you face.

When we look at accessibility, we know that rural Americans travel further to provide and receive services, but I want to caution around that too.  Rural Americans travel further to get just about everything.  You travel further to get your groceries.  You travel further to send your kids to school.  Your kids are on the bus longer.

I remember when our daughter was young, she would get picked up by the school bus at 6:45 in the morning.  We were starting to get her up around 5:00 in the morning to get breakfast and on the road.

So, rural people, while they face this challenge, they face these challenges every day.

Prior to the Affordable Care Act, Americans were less likely to have insurance benefits for mental health care.  We know that many    that most rural states have the fewest choices in the ACA Marketplace.  And that's only    that problem is only deepening, and now what we're seeing with some of the more recent laws that have been passed, rules that have been passed, rather, that people can again purchase insurance policies that have a less robust level of benefit.  What we don't know is whether those less robust policies will have the mental health coverage that people need. I can speculate that that's one thing that won't be there, because typically in the past it wasn't.

And, finally, rural Americans are less likely to recognize mental illness and understand their care options.  That is one area of disparity and difference that has been documented several times, is that around mental health literacy, knowing the symptoms and the issues of a behavioral health disorder and where to turn for help. Rural Americans have much less mental health literacy than their urban peers.

The next slide is a picture of around the whole notion of choice and competition in the ACA exchanges, and what you can see there is the most rural states have the least amount of choice.  And the urban    the more urban states have the most choice.  I guess that's not all that surprising, but it is certainly something that is demonstrated on this slide, and even in a state like California that is so rich in resources, the thing that jumps out to me right away is the lack of resources that you see in northern California.  So, those things, I think, are only... it's something that we need to understand, because if the marketplace is not there, then that impacts the ability for providers to actually have a viable practice in a rural area and provide the care that is necessary.

Around availability, there's a picture of a street that is sort of wide open in the middle of the Nebraska plains, and there's plenty of cars on the street, but plenty of office space to rent.  Rural areas suffer from chronic shortages of mental health professionals.  About a decade ago, more than a decade ago I had the opportunity to serve as the chief consultant on rural issues to the president's new Freedom Commission on Mental Health, and we looked back at the previous presidential commissions, and the first    by the Eisenhower administration in the late 1950s and the second during the reauthorization of (inaudible) during the Carter administration, and both of those presidential commissions, the Eisenhower and the Carter administration, about 60%, 62% of rural Americans lived in mental health professional shortage areas, and in 2003 when we looked at the data, about 62% of Americans lived in mental health professional shortage areas, and today around 60% of rural Americans live in mental health professional shortage areas.

The bad news is that we haven't made much of a dent in under service for rural Americans.  The good news in that is we've held our own.  And when you look at the out migration from rural areas and the shift in populations, I think that it's    there's a strength there that shouldn't be overlooked in that we have held our own across over 60 years of time.  But we still don't have a plan for moving ahead and improving that.

Specialty providers are highly unlikely to be available in rural areas.  It's true in mental health, true in other areas as well.  States like Nebraska really has one or two burn centers for people that have experienced serious burns.  You have centers of excellence for cardiovascular disease, but mental health is significantly different.

South Dakota, the last time I looked, which was go or three years ago, there were four child psychiatrists in the entire state of South Dakota, and one of them was retiring and one of those was at the state psychiatric hospital and didn't have a practice outside.  So for all practical purposes, the retiring psychiatrist was not taking new patients.  The child psychiatrist at the state hospital only served those people that were admitted to the state hospital.  And so there were really only two child psychiatrists, one in Sioux Falls and one in Rapid City to serve the entire state of South Dakota.

Comprehensive services as a result are not available.  It's pretty hard to put together an interdisciplinary team and to provide a comprehensive array of servicing.  What you find in most rural provider settings are generalists.  You have to know how to deal with most everything that comes, every problem that presents, you have to at least be able to help a person identify what that is and do your best to meet that need, and that may be referring them into somebody else.

I can tell you, when I was    when I did my clinical internship in 1983, I'll never forget one of my first days at work, I was interviewing an older person that had probably the most significant level of depression that I have ever worked with up until that point, certainly as an intern, but even since, and that person had actually lived on a ranch out in the middle of northern Arizona and did not come to attention for the need for care until their husband died and they lost their caregiver, and they had never ever sought    that person had never sought care.  And I knew immediately that I needed to get a psychiatric consult, that this person desperately needed medication.  And I went out to... I that was still during my orientation period, and my supervisor was gone for a while, and I went out and asked the receptionist when I could get the client in to see a psychiatrist.  And she said, well, she'll be here two Fridays from now, but she's totally booked.  I said, well, how often does she come?  And it was every other Friday.  So twice a month that psychiatrist came and was booked out for six or eight weeks. And so, you know, I walked across the parking lot and got with a primary care doc to do the best we could do to help that person. But that is the nature of the beast in most rural places, is that the access to the    to specialty care is very hard to provide.

Community mental health centers primarily focus on persons with serious mental illness.  That's where the funding has devolved to over the last 25 to 30 years.  But in rural areas there's an expectation that the community mental health center will provide a level of access to care for the entire community.  Even though the funding streams may not be there.

The next slide is a picture of the Health Professional Shortage Areas for mental health, and it's pretty clear that when you look west of the Mississippi, that the areas in green, which are the Mental Health Professional Shortage Areas, dominate the landscape.

Acceptability is really about services being arrayed in such a way to fit the needs of the people being served.  Today there are very few programs that trained, that specifically train people to work competently in rural places.

From internships for the applied level of care to actual specific rural training programs simply are not very plentiful.  Today when I did my graduate training in the 1980s as Roberto mentioned, I was funded through an NIH training fellowship in rural psychology.  Those rural training fellowships don't exist anymore.  And there are very few programs, if you look through the offerings, the most likely rural specific training program that you'll find is a rural social work program, and that may, in fact, be an advanced generalist program. 

Rural people often lack choice of providers.  Oftentimes think about this from a very basic political stand in that when we think about the discussion, the dialogue we've had for the past 40 years about going to a single payer or universal healthcare plan in the United States, one of the things    the political arguments that is made extremely rapidly is that    besides we don't want government involved in our healthcare, but we also want choice of provider.  If you think back to one of the reactions during post Affordable Care Act was the promise by the President that people could keep their provider and the notion that that promise wasn't kept. And so, choice is something that Americans gravitate towards.  It's something that we want.  We want to be able to choose our providers.  Yet for most rural people, there isn't much choice.  You have what is available there or you're going to have to drive a significant distance to exercise that choice.

But, again, I want to mention that that's not dissimilar to other areas of rural life, where there may be one grocery store.  There may be one lumberyard, and if you want more, you're going to have to drive to a larger regional hub to be able to get that.

Stigma.  There is a higher level of stigma in rural areas that is discussed in the literature quite a bit.  But I think that more than stigma is lack of anonymity.  When you're in a rural environment and you access care, it's pretty obvious that you're doing so.  And there's just... and then as a provider, providing care in a rural place, boundaries are hard to keep.  I remember during my training how much we talked about dual relationships, and then I went and did my rural internship and, you know, I sat next to people in church on Sunday that I had cared for during the week.

When I went to the grocery store to shop, I would encounter somebody that I did a DUI assessment on.  It was routine in a rural environment that the people you served were also the people that you lived with and you saw them all the time.  And so there was    as a provider, there was that fish bowl that you were... that there was a lot of scrutiny that was given to you, and I think that it's also true to the people that we serve, our partners in care.  Because we    they too were in a fish bowl.  People knew they had problems and people knew they were seeking help.  And so that lack of anonymity and that closeness of relationships is something real, and it's not something that is talked a lot in our training program.

And last but not least around acceptability is that urban models are assumed to work in rural, that you just sort of have to downsize them.  You just tweak them a little bit to make them work in rural.  Of the evidence based practices that have been adopted widely for persons with serious mental illness, none of the trials involved rural people, whether you're talking about supported employment, supported housing, community treatment, etc., none of those original studies to establish the evidence based practice ever had a real rural clinical trial.  And so how do we know that they work in rural?  And as we all know about evidence based practice, it's important to have fidelity.  And if you begin to modify these practices to fit without really careful scientific inquiry, how do you really know that the changes you're making are effective?

So, how should it be?  How it should be is much like the picture I have there of harvest in a wheat field.  I mean, things need to work together.  And there needs to be a comprehensive continuum of care.  There needs to be quick, easy, convenient access to care.  Providers need to be culturally competent.  They need to understand not just the rural environment but the rural cultures that are at play.

Rural America is a diverse place and people need to understand that diversity.  Systems and providers need to work together and they need to share resources and focus on what works in their rural area, and there needs to be no wrong door.  The last thing that a person in need needs is to walk in and ask for help and be told "I'm sorry, we don't do that here."  We really need to engage in that partnership of care and help people to get from whatever door they walk in to the care that they need.

But that's not the way it is.  Rural people are oftentimes not well informed about either mental health conditions or the options for care.  Providers are actually pretty isolated from each other.  I am dumbfounded on a routine basis, and I've been doing this for over 30 years, of having community meetings and bringing people together to do some strategic planning in a rural community, and you get everybody together and almost every time there are people in the room that other people in that community didn't know were doing the things that they do. And so even in rural communities there are people that are working in isolation from each other.

Service access is confusing and complex.  Any of us that has ever sought care for a loved one, no matter how sophisticated we are about the healthcare system, we know that it's not easy to get from that moment that you know you need help to actually being able to access that help and get the care that you need.  It's complex to navigate.  And for those of us that are extremely sophisticated in our knowledge of the system, and it's even more so for those that are not.

Services are fragmented.  People do little pieces of the pie.  They don't do the full array of services.  Many states have carved things up, and so you have an adult provider, you have a child provider, you have other services for people that are spread out in other little agencies.  And sometimes I think that the only rural professional that there's not a shortage of is executive directors.

Providers plan what pays.  We don't often plan what works.  I've been in this work for a long time and I ran a rural mental health center for eight years, and I don't think once in that eight years that I planned a program based on really what I thought would work.  I planned on it based on here was a funding opportunity that I could follow the money and I could get the job done with that, and I would fit people's needs and service needs into whatever the funding stream happened to be from Medicaid or from the state.  And I think we do that and we repeat that over and over and over again in behavioral health.

All that results in something.  And what it results this is that rural people enter care later in the course of their disorder, and because of that they enter it more sick and they have a higher level of cost and need.  We know this.  I mean, we know this about all health conditions.  It does not help the positive outcomes for cancer if you do not have early detection and early intervention.

And it doesn't work in mental illness and in substance abuse.  The longer you let something stew, the worse it gets.

So, how did it get this way?  Well, certainly stigma and discrimination.  But also because there's not a rural plan.  One of the things that we recommended in the president's new Freedom Commission set of recommendations is that there actually would be developed a rural plan, and we don't have one.  We have in public health, we have    we do plans.  We do Healthy People 2020, and we do other planning initiatives.  We set standards and we set goals, rather, and objectives, and then we set off in developing strategies to reach those objectives and goals.  We don't have one.  So, we have this chronic shortage of mental health professionals in rural areas and it's been at 60% for ages.  So is that our goal?  That 60% of rural Americans live in shortages, or do we want to reduce that?  So what do we want to reduce it to?  40%?  30%?  We don't have a standard.  We don't have a goal.  So it's really important that we actually develop a rural plan.  How long should it take for somebody in crisis to be responded to? We don't have that standard.  And the rest of the EMS system, the Emergency Medical System, you know, we talk about the Golden Hour.  We don't talk about that in behavioral health.  So what's our plan?  And we need to develop one.

We have lack of sustained effort to prepare and deploy professionals for rural practice.  We haven't made the investment in developing of strategies to train people to serve in the places that we need them.  And we have this sort of notion of one size fits all planning and funding, and we all know that it doesn't.

And the other thing is that mental health care is optional.  That's another reason that we got here.  When you look at the Medicaid system in this country, dental care, mental health care were optional services.  And I think there's a certain cache that comes with the notion of "optional." And that means that states can exercise their option not to provide it.  And really I think it speaks volumes to how we look at mental health care in this country as optional when we all know that it's not.

So what can we do to change this picture of a barren landscape?  Obviously one thing is advocacy.  We need to begin to talk more about it and we need to specifically push for a rural plan and to make things better.

Public education.  I mean, we know that there is this mental health literacy issue.  Well there's great public health education strategies to change that.  We do it with all sorts of healthcare situations and other situations.  So, we know that public education efforts work, and we can change it by doing that.

We need to improve primary care and mental health integration.  I think there has been a sustained effort in that regard for several years now and we need to deepen that.

One thing that I would mention there is that depending on where you're sitting in the integration framework, you really    there's really a different perspective of what integration of primary care and mental health care means.  When I talked to my primary care colleagues, oftentimes when I talk to them about integration of mental health and primary care, they'll talk about the co occurrence of obesity and depression, of changing behaviors to bring about better health outcomes.  They don't usually talk to me about better care for persons with schizophrenia or changing the mortality rates of persons with serious mental illnesses compared to the non SMI population.  Of course, when you talk to folks on the mental health side of the discussion on integration, they're talking more about ensuring that the people that they work with, their partners in care receive adequate healthcare services, to bend that mortality curve and to have better coordination around side effects of medication, etc.

And so depending on where you're sitting in that dialogue and the integration, sometimes you're the locomotive and sometimes you're standing on the tracks.  And more than anything else, I think that we need to take rural into account and we need to get a plan.

One of the things I wanted to talk about is programs that work, things that have been done that really make a difference.

Back during the farm crisis in the 1980s and as sustained across decades was a partnership between the state of Nebraska and the Center for Rural Affairs.  It operated a program that it trained its hotline workers about mental health.  They actually set up a hotline for farmers so farmers could get help when they were dealing with the economic challenges of the changes in the farm industry.  And what they found very early was that people were calling up and they were having family and mental health problems.  So they trained their hotline workers about mental health and what to do, and they trained mental health worker that were seeing these folks present in their practices about farm issues.  And finally provided vouchers for rural people in need to obtain services from a range of providers.

And that was something that sort of changed the dynamic and got a lot of people help and really sort of broadened the net of people that could help in the ways to get it paid for.

In Illinois, it started as the Farm Resource Center, and basically there was the notion there was that the people that were    that if you waited for farmers and ranchers to come into the clinic to access care, you were going to be waiting too long, and so they recruited professionals and para professionals with farming and rural backgrounds and trained them to serve as outreach workers and sit around the table at the farmhouse and help people figure out what they needed and provide that outreach to people.  And they provided short term crisis support information and referral.  It was much like the program in Nebraska and it was highly effective.

In South Dakota, the state actually developed Assertive Community Treatment teams in four areas.  They've worked very    they've done a lot of research to be able to right size the Assertive Community Treatment to small community reality, and now they're in the midst of developing rural specific fidelity measures.

In Alaska, I mean, I often tell people, if you want to see how you do things in rural, go to Alaska, because I could actually do an hour of just Alaska.  But one of the things I wanted to talk about in Alaska is they knew they were never going to get master's level folks out to the small villages in remote Alaska, but that didn't mean that people in remote places of Alaska didn't need help.  And so decades ago they began the Village Health Aide Program, and with the Village Health Aides, they're sort of super-paramedics. They’re paramedics that provide primary care and prevention.  And they actually developed    what they did is they saw that working in primary care and moved on and developed the Village Behavioral Health Aides to do the same thing.  They worked around support and care of people in the villages and serve as extenders to the professional staff, and in the last decade they've developed Village Dental Health Aides, which are sort of super-dental hygienists if you will, and who  can provide basic dentistry as well as basic dental hygiene. And those programs work, and they get people into the communities that are part of the communities to provide care. And it's been amazingly positive.

In Colorado, the Managed Care Organization here worked to develop warm lines staffed by peer specialists to provide persons in need access to someone just to talk to.  Not in a mental health crisis, but just to be able to talk about the help with daily living issues.  And it too has helped provide information and support and referral and has reduced the amount of crisis response needed.

In the Northern Marianas Islands, a program we've been involved with in the territories, very remote, very rural.  They had    they developed an academic partnership between the local community college and the University of Alaska Fairbanks to provide social work education.  There were only two social workers in the Northern Marianas Islands and they needed more.  And so it's a two plus two degree program, so the students go the first two years in a traditional community college academic transfer program, and the last two years are delivered via distance education from the University of Alaska Fairbanks, which has a lot of experience in serving remote populations, and it uses very low tech technology to be able to deliver that.  And the thing that really helps it work is that the program in Alaska is designed for working professionals that go to school in the evening and lo and behold, the evening in Alaska is morning the next day in the Northern Marianas, and so students are able to access that without any kind of big time barrier.

At WICHE we developed a Psychology Internship Initiative because what we saw that people were not    did not have access to those training opportunities, and in our rural states of the west, our doctoral level psychology programs were producing eight to ten to twelve doctoral-level psychologists each year and they were all leaving the state because there were no psychology internships available in state and there were not rural sites.  And so, we started in Alaska and developed the Alaska psychology internship consortium and have expanded to Colorado, Hawaii, Nevada, Oregon, and we're developing new ones right now, just beginning in Utah and New Mexico and Idaho. And 60% of the graduates are WICHE psychology internship programs, have remained in public mental health services in the rural settings that they're trained in.  And so we're pretty convinced that if you build it and you train people to work in rural, they'll stay in rural.

I think the last thing I wanted to just talk about for a minute is the most vital rural resource, charismatic leadership.  I think that's true no matter where we are, but it's especially true in rural area, where one person can really make a difference.  And one person leaving can make an equally unequal difference to change things, that it's really important that we nurture each other in the delivery of rural care, whether we're peers and we're supporting peer to peer or whether we're providers and supporting providers to providers.  I think we really need to think about growing our own.  The rural people are there and can be trained to be the workforce that we need, and we have the technology today that people don't have to leave their rural area to receive that training.  And our rural resource to answer our workforce challenge can be training rural people.

And in the past, in higher education, I mean, I sit in a higher education organization, and we often have talked about rural people as being place bound, and I really dislike that term and we are trying to discontinue that in our speak, because rural bound oftentimes sort of leaves the impression of rural trapped.  And so lately what we have been doing, and we learned this from Alaska, is we talk about rural learners as place committed, and our job is to ensure that educational outreach reaches people who are committed to living in rural places.

And last but not least is the notion of PIE.  And what that stands for is Proximity, Immediacy and Enthusiastically.  To be effective care needs to be delivered close to the person in need.  It needs to be proximal.  That's why in the military every soldier that goes into battle carries a trauma kit.  It's why we have forward medical units, it's why we have Airvac.

Immediacy.  That people in need get care as close to the need and the trauma as possible.

And then enthusiastically.  We need to train    we need to care with hope.  We need to instill hope.  And too often in our mental health system we've stolen hope.  We use words like "chronic," and I listen to people oftentimes talking about Assertive Community Treatment, for example, where you don't get out.  It's like a life sentence.  And people recover and we need to embrace recovery, and people do get better.  And that every day people get better and live fuller lives, and we need to embrace that and give hope.  The last thing that a parent needs to hear is that their child has a mental illness and that they'll never get better.  What we need to do is talk about how we help people get better.

And with that, I'm going to just wrap up.  I have a slide here with the pictures of the WICHE team and contact information on how to get in touch with WICHE.  And at this point in time I think we can turn it over and you can use the question and answer field to ask any questions you might have, and we'll do our best to answer those.

Thank you!

>> ROBERTO DELGADO: Thank you so much, Dennis.  That was an incredible overview on both challenges that many rural communities face, as well as some promising practices and programs that are working to advance mental health services in rural communities.

To our participants, again, yes, for those that have questions, please make sure you type them in the Q&A box on the right hand side of your screen.  I see that there are a couple questions already.  So, I'll begin.

So Dennis, one of our participants is asking:  Based on the program that you described toward the end of your presentation across the different states, how do they navigate any licensure issues, particularly when implementing some of these task sharing models?  And the participant asks about the Village Health Aides in Alaska.

>> DENNIS MOHATT: In Alaska they promulgated rules that enable the scope of practice that a Village Health Aide or a Village Behavioral Health Aide or Village Dental Health Aide provides, they govern that and they stood the test of time.  I mean I think you have to be thoughtful of that and the other thing is that everyone has to    it's a competency driven system, and the people who are providing that have to, much like you do when    like when you're a provider of EMT, you have to do annual refreshers.  You have to have your certification to do that.  And you have to be able to demonstrate your competency and your ability to do that, and then Alaska has also invested a lot of time to ensure that the supervision is there for aides, so that they    so the supervisors have to be trained both to help the aide develop the competencies to do their scope of practice, and then they have to be    and then they're also trained to be able to enhance those competencies and ensure that those competencies are  current.

>> ROBERTO DELGADO: Thank you, Dennis.  I hope that answers that participant's question.  A second question we have is with regard to child and adolescent mental health, specifically what is the status of school based mental health services in rural areas?  Are there any similar examples of successful models implemented within or in partnership with schools?

>> DENNIS MOHATT: There's an array of programs that have been developed, and, for example, I know of programs where the community mental health centers have moved their clinical staff for child and family into the schools and enrolled the settings in schools as clinical sites.  And so students only have to leave class for the time that they are receiving services, and then most of those programs also operate after school to enable parents to access family care.  I think that there's... in Hawaii, for instance, that was in Michigan that the former example was from.  In Hawaii, the mental health system for children and families is actually embedded in the school system and clinical staff are actually employed by the school district.  So this is actually what you typically would see in a children's mental health system operating in the community.  It's just that it's actually formally put in the school system, and the school system has the money for the children's mental health system up to a certain point.

>> ROBERTO DELGADO: Thank you, Dennis.  I see a third question that has come in from one of our NIMH colleagues, and something I intended to ask as well, and that is, what are, in your mind, or in your view, some pressing research questions?  I think I would have said, what are some of the pressing gaps in mental health research?  And follow on to that, what are areas that actually can be addressed?  Maybe think about short term, middle, long term time frames as well.

>> DENNIS MOHATT: Well, I think that certainly some of the research... I think that we've had sort of this laser focus on researching what is the difference between prevalence and incidence to various mental health disorders, and I don't think we've had enough research or hardly any research on just what is the experience, what is the human experience of mental illness in a rural environment as compared to an urban environment?  Because I think that    it's questions about that, that human experience of an illness that helps us then develop the service array that we need.

You know, depression is depression, whether it occurs in a rural environment or an urban area, but what are the    what are the experiential aspects of that disorder, that we need to ensure that our services meet? And I don't think we've done enough around that. 

I think the other thing we haven't done much research on is we've had sort of, again, a focus a lot on the biology of various conditions and we haven't had enough research on just sort of what kinds of services are economically viable for rural areas.  So services research is something that hasn't been given a lot of attention in the last several decades really.  But--so, you know, what I see happening a lot is, you know, for example, just Assertive Community Treatment, where we've been involved with that a lot.  There's been a lot of modification of Assertive Community Treatment to fit a rural environment, but there hasn't really been a solid research study around creating a rural specific ACT model.  And what would that look like?  And how would it function?  And the question I get from    you know, certainly in the last ten years or so, since the federally qualified health centers have really been expanding the provision of mental health care, and also just regular rural clinics beginning to think more about integrated mental health care.  The question I get all the time is:  Well, what kind of mental health professional do I need?  You know, and so, for example, if we're going to provide primary care, we know we can add a physician assistant or a nurse practitioner.  But in the mental health field, we have psychologists, psychiatrists, social workers, counselors, marriage and family therapists, etc., etc., ad nauseam.  And we never really said, well, what are the core competencies and capabilities that a person really needs to practice in a generalist mental health provider in a rural environment?  And I think that would be extremely valuable to the system.  And then finally, sort of just the health economics end of research, health economics research, what is the marketplace, and what would    how would you design a mental health system that fits various kinds of rural environments?  That's the other question I get all the time. And then there really hasn't been that research done, sort of blends health economics and market analysis to the design of a system that fits.

>> ROBERTO DELGADO: Thank you Dennis.  Thank you very much for that very complete answer.

I don't see another question from participants, but I just want    I have    I'll take moderator's privilege here and follow up on one thing you mentioned during your presentation around acceptability, and we were talking about stigma and how you sort of shifted the conversation to lack of anonymity in many of these rural communities.  And my question to you is:  How can we begin to overcome that, if at all?  You know, are technologies in place that could be useful?  Or are there other efforts that are being put forward to try to overcome the lack of anonymity?

>> DENNIS MOHATT: Well, I think that there's no    I mean, obviously, if you're using technology that is at your home, you know, if you were using a telehealth service that emanated from your own personal device, you would tackle some of that anonymity issue.  And certainly when people, I think to the degree we integrate healthcare and, you know, you're sitting in the waiting room with everybody else in a primary care setting and you get called back for your appointment, they don't know whether you're going to    folks don't know where you're going or what you're doing, and that begins to get after that I can say that in my own personal experience, we    you know, in the N of one, when we close down our satellite clinics and integrated our mental health services into two primary care settings, our referral catch, what we call referral catch, when a primary care doc or provider would make a referral to care, and then the patient    the client actually coming to care, we dramatically increased our referral catch, because they didn't have to go from point A to point B, and you lose people between point A and point B.  And people reported to us in our satisfaction surveys that they felt more comfortable going to that primary care setting than they did coming into the    our previous satellite clinics or into the main community mental health center.  I would like to say I was brilliant in doing that, but basically I knew this primary care group that had office space and they wanted to fill it and we could share reception staff, and I was able to cut my costs and they were able to recover more cost for their space to help reduce some of their economic tensions.  And so it was really an economic decision more than anything else at that time.

But the thing that we learned during the process is that the providers became close to each other, the primary care providers and the mental health care providers, and they began to provide professional peer support to each other.  And then the clients were more happy in that setting.

I think the last thing around anonymity is we've created some of this ourselves.  I mean, it stems from sort of our Freudian roots and we've developed all of these sort of notions about what we can say and can't say, and I know that when I was in training we talked about this, and we talked about how you would tell your client... I think about this, how many times I've said this to a client:  You know, we may run into each other in the community, and I'm going to leave it up to you whether or not you want to acknowledge me and say "hi" or whatever.  You have that power.  It's up to you.  I won't call you out and put you in an uncomfortable situation.

So I've had that conversation with hundreds of people in one shape or form.  And at this point I always say, "has your primary care provider ever had that conversation with you"?

So we create some of this stigma by saying what we're doing is somehow not normal and not acceptable and it needs to be super quiet and private.

And when that really came to my    just put right in my face was actually sort of recently in the last 10 or 15 years ago, I ran into my primary care doc in the grocery store one day and she had her child along with her and she said, hey, Dennis, how you doing?  And introduced me to her daughter, who is 12 or 13, and just said, this is Dennis, and Dennis and I    I see Dennis at work.  And it was just like normal, right?  There was nothing abnormal about that.  We were two people that happened to have a professional relationship.  Now, that was in Lincoln, Nebraska, it wasn't in a small rural community, but it really brought it right to    it was just normal.  We ran into each other in the vegetable aisle and we greeted each other, and she introduced me to her child.  I mean, I was just normal. And so, I think that we never have    we don't have that dialogue much about how much we as a profession contribute to the stigma by making anonymity such a big deal.

>> ROBERTO DELGADO: Interesting story.  Thank you for sharing, Dennis.  I see one more question that has come in.  That is:  What role do you see in the use of telehealth in shrinking the distance people need to travel in bringing specialists to rural areas?

>> DENNIS MOHATT: I think that there's    well, I think it plays a big role, and I think we see a greater use of it all the time.  I was involved in an iPad project in Alaska where case workers, outreach works would have an iPad with them, and when they were meeting with a client in the community, they could immediately access a psychiatrist to do a med check and do it from the comfort of somebody's home.

And so I think that    and you see that.  I mean, the VA is a great    the Veterans Administration is a great example of utilizing all sorts of different technologies to provide veterans access to services.

I think that we don't talk a lot about the inequities in broadband between rural and urban, and where all    many of us take for granted our 4G and 5G connection rates and gigapops.  I mean I live outside of Boulder, and we're about 20 miles in our little community is a gigapop community, and so it's... but in a lot of rural place, connectivity is still an issue and then who pays for how you distribute the pay.  I think some states    I just    one of the things I want to mention, the use of telehealth, is to have an expansive notion of who can provide it.  Alaska, for example, has a very expansive... and so a psychiatrist from New York City could conceptually be a provider in Alaska.  And they would allow the licensure in New York to govern, and there's a push in psychology, I know, to have reciprocity for distance delivery, but in some states there's been restrictive laws passed about who can provide the care.  And so, for example in Nebraska where I used to be HHS Deputy Director, a Medicare beneficiary could go to Rochester, Minnesota, and receive cancer care. But if they were back in Nebraska and tried to do that on telehealth, that cancer care provider in Rochester would have to be licensed in Nebraska.

So if you don't have sort of a    some sort of reciprocity agreements put in place, it's too burdensome to expect providers to have multi state licensures, that's expensive. And so there needs to be reciprocity in place to expand access.  Because if you take, for example, the South Dakota example where you have two child psychiatrists, if they were the only two child psychiatrists that could provide access, giving them    letting them do it via telehealth, I mean, I don't think it was going to lower the    they were booked solid, period.  And so if you only use your native pool providers, you're probably not going to expand access very much with technology.  And so, you really have to sort of blow up and expand the pool of eligible providers to really make a dent in access, in my opinion.

>> ROBERTO DELGADO: Thank you, Dennis.  I think you're on point there.

I think I will close the webinar.  I don't have any more questions.  And we've taken up a lot of your time already.  Thank you, Dennis, again, for a very comprehensive overview on rural mental health, as well as the insights and responses that you gave to the participants and their questions.

And just as a segue, given the last question around telehealth, I want to remind all the participants who are still on the line that our next webinar will be on June 27th this year, focusing on mobile technology for global mental health research,  in which part of the presentation will focus on advances in digital technologies, that have created unprecedented opportunities to assess and improve health behavior and health outcomes.  Part of our office does global mental health research, focusing on low- and middle-income countries, in low resource settings that are very similar and comparable to rural communities here in the United States. And so, some of the work that we’re supporting in our global mental health research also has important applications to rural communities here in the United States, as well as I think there is overlap with tribal communities as well, which is another area of focus for our office.  So I want to thank you, Dennis, again, once more, and all the participants for joining us, and look forward to having equally engaging webinar on June 27th.

So thank you very much, everyone!

>> DENNIS MOHATT: Thank you.  Goodbye!

>> WEBINAR OPERATOR: That concludes today's program.  Thank you for your participation.  You may disconnect at any time.  Have a wonderful day.