Behavioral Health: Setting the Rural Health Research Agenda

Behavioral Health: Setting the Rural Health Research Agenda

David Hartley, P h D , Catherine Britain, and Stephm Sulzbacher, Ph.D.

ABSTRACT This article seeks to identify current research priorities in the area of rural behavioral healfh. The method for accomplishing this task begins by identifying several domains where policy has a potential to effect improzmnents in access or quality but has been hampered by lack of empirical k m l e d g e . In each domain a synthesis of current research sum- marizes what is known and draws attention to knowledge gaps. Research questions in each domain are proposed. The policy domains are theoretically based, using a conceptual model of access to health care, with a focus on illness level (prevalence), enabling factors (the delivery system, organization and financing, the promise of telemedicine), and predisposing factors (special populations, beliefs, mlues, stigma).

‘ n general, forums that focus on rural health rel- egate mental health concerns to a minor role or overlook such concerns entirely. For example the 1987 conference, Rural Health Services Research I Agenda, sponsored by the National Rural

Health Association and the Foundation for Health Ser- vices Research, did not include a paper on mental health (Patton, 1989). On the other hand when the subject of a research or policy forum is mental health, the special mental health needs of rural Americans often receive little attention. Thus, the concerns of rural mental health and substance abuse service consumers and providers are often overlooked as these systems undergo financial and organizational changes such as those associated with mental health parity or perenni- al modifications to state Medicaid programs. An en- couraging change in this pattern has occurred over the

For firther information, contact: David Hartley, Ph. D., Associate Professor, Mus,kie School of Public Service, PO Box 9300, University o f Southern Maim, Portland, ME 04104; e-mail davidhQusm.maine.edu.

past 2 years with the publication of three papers pro- posing a rural mental health agenda, including this one (Keller, Murray, & Hargrove, 1999; Rost, Fortney, Fisher, & Smith, 2001). Although system changes raise many concerns about quality, appropriateness, cost, and equity, this article will focus primarily on those where research can inform rural-specific issues that have implications for policy, financing, or organizational or clinical initiatives.

As with primary care, hospital care, emergency services, and a number of other segments of the health services system, the rural-specific issue is often one of access. To a large extent, the history of rural health policy is a history of addressing access barriers, whether it is the physical location of providers and services, or other individual and structural barriers. Moreover despite the complexity of issues affecting access, researchers have of ten identified access problems initially by means of measures of utilization. This may be an artifact of the reliance on administrative data sets as measures of utilization or the belief that the ”observed demand’’ embodied in utilization data are

The Journal o f Rural Health 242 Vol. 18, No. S

an adequate measure of underlying need. In either case, a classic theoretical model of access and utilization provides an appropriate framework for identifying a number of mental health policy issues that have a rural-specific component. (In a brief overview of research needs in rural mental health, Keller et al. [1999] began by articulating the need for theoretical frame- works to guide research.)

nearly 30 years ago and continues to be relevant as a theoretical framework (Aday & Andersen, 1974). At the individual level, this model identifies three sets of underlying conditions that contribute to the volume of health services that an individual uses: predisposing conditions, enabling conditions, and illness level. In the case of mental health services, relevant predisposing conditions include age; sex; education; place of residence; and knowledge, values, and attitudes con- cerning health, mental health, and mental illness (including stigma). Enabling conditions include income and insurance, having a regular source of care, local and regional supply of providers and services, region of the country, and urban-rural residence. The illness level includes the individual’s perceived symptoms as well as the symptoms and diagnoses after being evaluated by a mental health or primary health practitioner.

This model helps one to identify a more narrowly focused set of mental health policy issues that have a rural-specific component, primarily because they are components of this access model. We begin with a section on prevalence that addresses Aday and Ander- sen’s illness level component. Following are sections on the rural mental health infrastructure and mental health organization and financing, two key conditions of the model’s enabling component.

Perhaps not foreseen by Aday and Andersen, and not explicitly addressed in their model, telemedicine is a new technology that has potential for overcoming barriers to access. By extending access to scarce providers, telemental health has the potential to enable greater access and is easily accommodated by the classic access model.

Finally, we offer thoughts on certain special populations who, because of predisposing factors such as age (children and adolescents), occupation (those displaced from their occupation because of regional economic trauma), or values (rural residents whose culture es- chews help-seeking), may need population-specific research and policy initiatives.

In each of these areas suggested by the model we summarize, as briefly as possible, what is known on the basis of current research, and identify significant

Such a model was proposed by Aday and Andersen

knowledge gaps where research is needed. Specific research issues and questions are posed at the end of each section.

Although the Aday and Andersen model allows us to subdivide the issue of access into its component parts, the quality of rural mental health services must also be raised. In the section on the rural mental health infrastructure we introduce the problem of the tradeoff between access and quality. These two issues, particularly in the context of discussions about the credentials of mental health providers, seem to be difficult to address separately. Therefore, our discussion of rural mental health quality is embedded in our discussion of the rural mental health infrastructure.

1. I1 lness Level: Pveva lence

We acknowledge that the Aday and Andersen model does not investigate fully the relationship between need and utilization. We also acknowledge that there is a broad spectrum of emotional and psychiatric states that may or may not be diagnosed and for which the affected individuals may or may not seek help from the formal health/mental health system. Thus, available prevalence data are an imperfect measure of need and the impact of untreated mental illness on worker productivity, individual physical health, and other social services such as law enforcement, education, and various state and local welfare services is not accounted for by merely measuring prevalence.

The most recent national data available suggest that the overall prevalence of clinically defined mental health problems among rural adult populations is similar to that among their urban counterparts (Kessler et al., 1994). The 12-month and lifetime prevalence of any affective or anxiety disorders is slightly lower in rural than in urban areas, and the lifetime prevalence of any anxiety disorder appears to be roughly equivalent regardless of residence location. These findings are corroborated by the National Household Survey on Drug Abuse, which also reveals no major geographic differences in prevalence for a variety of common psychiatric diagnoses.

It is generally assumed that rural residents whose mental health problems are so persistent that they require ongoing professional care must often move to urban areas where these services are readily available. Similarly, with fewer mental health specialists in rural areas, primary care practitioners (PCPs) would typi-

Hartley, Britain and Sulzbacher 243 Supplamtal 2002

cally have to send serious psychiatric cases to an urban hospital for diagnosis and treatment. Such a referral pattern was shown in a study of all pediatric hospi tal discharges in Washington State (Melzer, Gross- man, Hart, & Rosenblatt, 1997), where 80% of psychiatric disorders were discharged from urban hospitals. Although such patterns could be expected to lower the observed prevalence of serious and persistent mental illness in rural areas somewhat, available data do not support this supposition (Kessler, Zhao, Blazer, & Swartz, 1997). Current studies indicate that approximately a quarter of individuals served by the public mental health system have a serious and persistent mental illness and this proportion is observed in both rural and urban areas (Greenley et al., 1992). Thus the extent of this migration of high users of mental health services and the resulting influence on observed prevalence rates is not known.

Prevalence studies such as those reported in the previous paragraph rely on diagnosis as a means of identifying mental health disorders. However, diagnosis may be an imperfect means of identifying cases (and thereby establishing incidence and prevalence rates) in rural areas, where often the mental health provider is a primary care practitioner for whom establishing an accurate diagnosis is not a priority. This is especially true in the case of affective disorders. That the true prevalence of depression may, in fact, be higher than reported in rural areas is suggested by higher rates of suicide in rural than in urban areas (17.9 vs. 14.9 deaths per 100,000 reported in Hartley, Bird, & Dempsey, 1999).

substance use among adults also does not appear to vary appreciably between rural and urban areas, although the types of preferred substances may differ somewhat. The National Comorbidity Survey found comparable lifetime and 12-month prevalence rates for any substance abuse disorder among its respondents regardless of residence (Kessler et al., 1994). A survey conducted by the Monitoring the Future Study (John- son, OMalley, & Bachman, 1994) found that young adult residents of rural areas generally experienced lower rates of use of alcohol, marijuana, stimulants, and cocaine than their urban counterparts, although they did indicate higher use of cigarettes. Many of the rural-urban differences that are observed in these studies may be attributable to factors such as the so- cioeconomic status or ethnicity of residents, or to population density or adjacency to urban areas (Conger, 1997).

Because of the problem of respondent bias in sur-

Similarly, the overall prevalence of alcohol and other

veys about alcohol and other substance use and abuse, other measures can and should be used as proxies. Arrests for driving under the influence (DUI) are an important indicator of alcohol and other substance abuse problems. A Department of Justice study revealed a considerably elevated rate of DUI arrests for rural counties in the United States compared with urban and suburban areas (United States Department of Justice, Federal Bureau of Investigation, 1996).

No national epidemiological studies of serious emotional disturbance among children and adolescents have been conducted in the United States (Costello, 1989; Friedman, Katz-Leavy, Manderscheid, & Sond- heimer, 1996). As a consequence, researchers and policy makers are dependent on regional studies, surveys, and proxy measures for prevalence information. This lack of data makes it difficult to compare rural, suburban, and urban populations of children and adolescents accurately. Many researchers are of the opinion that factors other than place of residence are more likely to predict mental health or substance abuse problems among children and adolescents (Oetting, Edwards, Kelly, & Beauvais, 1997).

The 1995 National Household Survey on Drug Abuse included a series of questions aimed at eliciting information on the mental health status of adolescents aged 12 to 17. Findings from this survey suggest that adolescent males living in nonmetropolitan areas experience higher rates of delinquent and aggressive behavior than their urban and suburban counterparts.

As is the case with adults, child and adolescent suicide is often used as a proxy measure for mental health problems among this population. The rate of suicides among nonmetropolitan children and adolescents is indeed higher than the metropolitan rate (7.45 deaths per 100,000 in rural areas vs. 5.60 deaths per 100,000 in metro areas, reported in Hartley et al., 1999).

Rural Minorities. Some rural ethnic minority populations may experience a higher than average national prevalence of certain mental health and substance abuse problems. This may be attributable in part to the social and environmental stresses of poverty or cultural isolation (Neighbors et al., 1992; Rogler, Cor- tes, & Malgady, 1991). In most instances, the data are inadequate to document the extent of these differences. This is attributable in part to the fact that the prevalence data are often obtained from service utilization records. Although the reasons are not well-documented, it is widely understood that ethnic minorities in

The journal of Rural Health 244 Vol. IS, No. S

the United States underutilize mental health services (Takeuchi & Uehara, 1996).

fy ethnic and cultural differences in prevalence and access to care, there is evidence that lack of cultural competence within the delivery system may cause under-reporting as well as undertreatment. For example, qualitative research done among Mexican-American migrant workers in Florida found that instruments typically used to measure presence of mental illness in this population may yield inaccurate findings because of cultural differences in the way physical and mental disorders are perceived and described (Baer, 1996). Similarly, there are multiple barriers to reporting and treatment of mental health problems for children of migrant Hispanic farmworkers. There is economic pressure on these families to have children work in the fields rather than attend school and if children are enrolled, they are often present in a school district only briefly. Because we rely on school- based screening programs to identify such handicap- ping conditions as attention deficit hyperactivity disorder (ADHD) and autism, affected children of migrant families may not be identified. Moreover for migrants who are not U.S. citizens, there is the fear that identification of such disorders could jeopardize work status or citizenship.

In this section, we have identified the following issues for future research:

0 What is the prevalence of serious mental illness in

Although more research is clearly needed to quanti-

rural areas? To what extent are observed prevalence rates affected by the lower availability of services in rural areas for those with serious mental illness?

0 What can regional suicide clusters tell us about the relationship between economic trauma and mental health problems?

0 A national epidemiological study of the prevalence of emotional disturbances among children and adolescents is needed, with sampling power to estimate prevalence rates in rural and frontier populations.

(reported) prevalence rates? What is the effect of cultural factors on observed

2. Enabling Factors: The Behavioral Health Delivery System

Most rural areas of the United States have fewer mental health services than the national average (Hu- man & Wassem, 1991). As of 1990, only 79.5% of nonmetro counties in the United States had any mental

health services, leaving the other 20.5% with no mental health services of any kind (Center for Mental Health Services, 1996). The average number of specialty mental health organizations in nonmetro counties is also substantially lower than the average number in metro counties. In general, we associate lower availability of services with lower access to services. For example, a study conducted in Maine found that supply of mental health professionals explained much of the observed difference in access to and use of mental health (Lambert & Agger, 1995). Recent data show consistently lower availability of hospital-based inpatient and outpatient services, both psychiatric and substance abuse, in rural areas (Hartley et al., 1999). This suggests that people with acute mental illness residing in rural communities may travel to urban areas to receive inpatient care or may not receive such care in a timely manner. Although current data on hospital- based services is readily available from the American Hospital Association’s annual survey, the difficulty of obtaining current data on the distribution of nonhos- pital-based services as well as nonphysician providers is a major barrier to accurate identification of workforce shortages and access problems.

Community Mental Health Centers. The 1963 Com- munity Mental Health Centers (CMHCs) Act, strengthened by its 1975 amendments, required mental health programs to provide five core elements of service: outpatient, inpatient, consultation and education, partial hospitalization, and emergency/crisis in- tervention (Wagenfeld et al., 1994). Categorical grant funding allowed CHMCs to serve all members of the community, regardless of ability to pay, effectively cre- ating a mental health safety net. CMHCs were not a uniquely rural provider type. In fact, by 1975 only 181 rural CMHCs had been funded compared to 240 urban and 91 mixed urban-rural centers (Bass, 1981). However, those in rural areas have typically been the major, if not the only source of mental health services in rural areas, aside from services provided in primary care settings. Although many multiple service mental health providers that were formally designated as CMHCs continue to operate in rural areas, their ability to serve as a safety net for the poor is unknown.

Following deinstitutionalization of those with serious mental illness in the 1980s, many rural CMHCs abandoned their roles as multiple service agencies to devote an increasing portion of their resources to the needs of patients who were defined by their states as members of a seriously mentally ill population. The shift from categorical grants to block grants abetted

Hartley, Britain and Sukbaclw 245 Supplmenfal2002

this change of roles. (Since 1981, CMHCs have not been formally identified as such by the federal government because of the loss of direct federal funding.) Some have claimed that CMHCs responded inade- quately to the farm crisis of the 1980s because of this shift in focus, away from meeting the mental health needs of the community toward meeting the needs of special populations (Bergland, 1988; Cecil, 1988). Whether this is a fair assessment is a researchable question. The evolving roles of these centers, their current geographic distribution, and the types of services that can reasonably be expected of a multiple service agency in a rural area are not well established. Simi- larly, there is no consensus as to how any mental health agency should respond to regional economic crisis.

Outpatient Services. From 1969 to 1992, the number of patient visits to outpatient psychiatric facilities and programs grew by about 2-1 /2 times (Redick, Witkin, Atay, & Manderscheid, 1996). A substantial part of this increase took place during the 1970s, when feder- ally funded community mental health centers were in their initial growth phase and the deinstitutionalization movement was accelerating. Managed care has influenced the shift from inpatient to outpatient care as well (Meyer & Sotsky, 1995). Outpatient mental health services remain less accessible in most rural communities than they are in urban locations. For example, as of 1995 hospital-based outpatient psychiatric care was offered by 13.3% of nonmetro hospitals compared to 33.4% of metro hospitals (Hartley et al., 1999). This metro-nometro difference is most pronounced in the East North Central states, as well as the South Central region. Similarly, less than 11% of nonmetro hospitals offer outpatient alcohol and other drug abuse treatment services compared with 26.5% of metro hospitals (Hartley et al., 1999). (Most outpatient mental health services are not hospital based but whereas urban-rural. comparison data are readily available for hospitals, this is not so for free-standing agencies.)

Mental Health Professionals. The mental health professions encompass several disciplines including psychiatry, psychology, social work, marriage and family therapy, counseling, and psychiatric nursing. Pro- fessionals in these disciplines typically have a formal advanced degree and are licensed by their respective state boards. In most states, psychiatrists are the only mental health professionals licensed to write prescrip- tions, although many states now extend prescribing privileges to psychiatric nurse practitioners. Many oth-

er mental health treatments, such as counseling or group therapy, can be provided by various other mental health professionals (Edmunds et al., 1997). Be- cause of state-to-state variations in scope of practice for these professions, the scope of services that may be provided by different professionals varies. More- over, the overlap in scope of services among mental health professionals also varies, making an accurate assessment of shortages difficult. Substance abuse treatment services are provided typically by licensed substance abuse counselors. In some settings, lay people without professional training or paraprofessionals with associates’ degrees may provide mental health or substance abuse treatment services under the supervision of a professional (Ivey, Scheffler, & Zazzali, 1998). This becomes an especially important option in rural communities, which may lack specialty mental health professionals, or among cultural groups, which may resist receiving care from a professional from outside the community (Bierman, 1997). Rural ethnic minorities in particular are more likely to seek needed mental health or substance abuse treatment for themselves or their children if the service providers are from the same ethnic group and speak the same language (Snowden & Hu, 1996).

most rural areas of the United States have been documented for some time (Keller & Zimmerman, 1980; Knesper, Wheeler, & Pagnucco, 1984; Murray & Keller, 1991; Stuve, Beeson, & Hartig, 1989). As of December 31, 1997, 76% of the 518 designated Mental Health Professions Shortage Areas in the United States were located in nonmetropolitan areas with a total population of over 30 million (Hartley et al., 1999). States are permitted to choose between two methods of shortage designation. Prior to 1993, mental health shortage des- ignations were based only on the availability of psychiatrists. With the addition of the other four core mental health professions (psychologists, clinical social workers, marriage and family counselors, and psychiatric nurses) states may choose the old, psychiatrist- only method or the new method, using all five provider types. Unfortunately, data on the practice location of all mental health professionals are not available for the nation as a whole, nor for many states. Al- though the Physician Masterfile (compiled by the American Medical Association) offers a reasonable data set for psychiatrists, data for the other health professions is limited and omits key information needed to establish the availability of these professionals in nonmetro counties. Thus, nearly all states continue to use the older method (Bird, Dempsey, & Hartley,

Shortages of specialty mental health professionals in

T b i p loumal of Rural Health 246 Vol. 18, No. S

2001). There is no clear strategy at the federal level for improving access to data on the mental health workforce so as to facilitate accurate assessments of shortages.

It is questionable to assume that the measurement of access to behavioral health services or providers should mimic the methods used for primary care access. Because many behavioral health problems are nonemergent, waiting lists for such services are often considered acceptable. Likewise, travel to a distant provider may also be thought acceptable and has been used to justify large catchment areas in designating shortages of psychiatrists. However, increased travel time was found to be associated with poor treatment compliance and outcomes of treatment for depression in a recent study (Fortney, Rost, Zhang, & Warren, 1999).

Mental Health Services in the Primary Care Sec- tor. An estimated two-thirds of US. patients with clinical symptoms of mental illness receive no care at all for such symptoms. Of those who do receive formal treatment, approximately 40% receive care from a mental health specialist and 45% from a general medical practitioner (Regier & Narrow, 1993). Because of the documented lack of specialty mental health services, primary care practitioners (PCPs) probably provide an even more significant portion of mental health care in rural America. In fact, rural residents under continuing treatment for mental health conditions have been found significantly more likely to receive this care exclusively from a general medical practitioner (Rost, Owen, Smith, & Smith, 1998).

The problem is even more acute for rural children with mental health problems. PCPs and mental health specialists in rural settings, while comfortable treating adults, generally lack specific training in child psycho- pathology and child psychopharmacology. A survey of family practice physicians in Washington State listed ”pediatric care” and ”medical psychology” among the top needs for continuing education among these rural physicians (Baker, 1999). This problem extends to those communities fortunate enough to have an itiner- ant general psychiatrist, who will often decline to assess or treat children. The probability of service use for children with ADHD, for example, was found to be lower for rural residents (Bussing, Zima, & Belin, 1998).

One index of the prevalence and seriousness of the pediatric emotional and behavioral problems facing PCPs is their referral pattern to secondary and tertiary specialists. Between 1992 and 1999, Children’s Hospi-

tal and Regional Medical Center (CHRMC) in Seattle conducted 199 pediatric outreach clinics in isolated rural counties of Washington State (Shurtleff & Shurtleff, 1999). Forty-eight percent of the 1,498 patients referred to these clinics were diagnosed with ADHD or a behavioral/psychiatric condition.

The debate over the appropriateness and effectiveness of having PCPs provide basic mental health care has raged for years and covered a number of issues without fully resolving any of them. PCPs have long been criticized for under-recognition of mental health problems (Eisenberg, 1992; Gonzales, Magruder & Keith, 1994). Rost and colleagues (1995), for example, found that rural family practice physicians were about half as likely as their urban counterparts to detect depression in their patients. Others argue that PCPs may choose not to enter a psychiatric diagnosis into the medical record, because of the increased stigma rural residents associate with mental illness (Hoyt & Con- ger, 1997; Susman, Crabtree & Essink, 1995). PCPs with appropriate training and interest in mental health problems such as depression appear to be willing to assume responsibility for treating those problems in their patients (Hartley, Korsen, Bird, & Agger, 1998; Main, Lutz, Barrett, Matthew, & Miller, 1993). Whereas Rost, Williams, Wherry and Smith (1995) noted that rural PCPs were likely to prescribe medica- tions at levels below those recommended by the Guidelines for the Treatment of Major Depression (De- pression Guideline Panel, 1993), research conducted by Olfson et al. (1995) suggests that PCPs in general en- gage in informal psychological interventions with patients considerably more often than is typically assumed.

Concerns about the quality and effectiveness of mental health care provided by PCPs have led some to conclude that mental health treatment should be provided by specialty mental health professionals, despite many areas having an undersupply of such professionals (Mechanic, 1990). In 1997, Montana’s new Medicaid managed behavioral health plan required that all services be provided by licensed mental health and substance abuse treatment professionals. The plan’s failure to accept PCPs as legitimate providers of mental health services meant that Medicaid patients in 24 rural counties had no local mental health services at all (Lambert, Hartley, Bird, Ralph, & Saucier, 1998).

Because of limited prescribing privileges for most nonmedical mental health providers, PCPs do the vast majority of prescribing of psychoactive drugs in areas where psychiatrists are in short supply. Unfortunately, as generalists, PCPs cannot be expected to keep up

247 Supplemental 2002 Hartley, Britain and Sulzbacher

with changes in the current mental health pharmaco- poeia. Models that team PCPs with mental health specialists, through colocation, telephone consultation, In- ternet, or telemedicine, need to be developed and evaluated to assure quality for rural mental health services.

With PCPs and a variety of nonphysician mental health specialty practitioners offering various mental health services, with a significant amount of overlap in services offered, it has become extremely difficult to assess the adequacy of the mental health workforce. Differences in the quality of treatment provided have been detected between PCPs and psychiatrists (Sturm & Wells, 1995) as well as between urban and rural PCPs (Rost et al., 1995). Differences in outcomes between doctorate- and master’s-prepared therapists, on the other hand, have not been studied conclusively. In any case, if researchers were to find that a master’s- prepared therapist did not achieve outcomes comparable to a psychiatrist for certain disorders, then such evidence would need to be weighed against the limited number of psychiatrists serving rural areas. Re- search or theory addressing the acceptability of trad- ing quality for access is lacking. Such work must acknowledge the contribution of interactive video tele- conferencing allowing urban-based mental health specialists to diagnose mental illness without an in- person visit and provide the advice needed to enable rural generalists to implement high-quality treatment.

Crisis Services. A lack of services or professionals in the immediate area does not always mean a com- plete lack of access. Rural residents are often willing to drive to urban areas for services. In fact, they sometimes prefer to do this for the sake of anonymity. On the other hand, when a psychiatric or substance abuse crisis occurs, local services are essential to avoid the trauma of transport to the state psychiatric hospital in a law enforcement vehicle and to prevent escalation of the problem to a level that may require more intensive care (Wilson, Wackwitz, Demmler, & Cole- man, 1995). Unfortunately, the lack of professionals often means that rural hospitals cannot provide crisis services. Among nonmetro hospitals nationwide, 18.6% provided emergency psychiatric services in 1995 compared with 37.4% of metro hospitals (Hartley, Bird & Ilempsey, 1999). The net effect of this lack of available emergency psychiatric services on treatment process and outcomes, such as symptom escalation, ad- mission to inpatient care, or both, is not documented.

In this section, we have identified the following research issues and questions for future research:

0 Demonstrate and evaluate new models for the early identification and treatment of depression in rural areas not served by psychiatrists.

0 Substitute master’s-prepared mental health practitioners and PCPs for doctorate-level psychologists and psychiatrists. What are the differential outcomes of treatment by rural PCP alone, rural PCP teamed with master’s-level therapist, telemental health, and so forth for various mental illnesses?

0 Examine current status and role of services formerly known as CMHCs. Do CMHCs act as a rural mental health safety net for all (such as those affected by rural sociological and economic changes), or only for those with severe mental illness, or special populations identified by state mental health funding agencies? What is the appropriate role for CMHCs in addressing the emotional impact on a population of economic trauma (e.g., the farm crisis) or natural or manmade disasters (e.g., the flooding of the Red River Valley in North Dakota, or broad impacts of terrorist attacks)? What is the current status of workforce data? What are some ”best practices” in gathering, maintaining and using such data?

0 What are some more sophisticated ways of measuring access (other than location of providers)? For example, because we know that many rural residents do not want to receive mental health services in their home communities, what are appropriate and acceptable alternatives that maintain privacy without requiring unacceptable travel costs? How should telemental health be factored into access measurement? Does telemedicine have a role to play in re- cruitment and retention?

3. Enabling Factors: Organization and Financing

Because managed care has, in many cases, affected both the insurance and financing aspect of access and the ways in which mental health care providers and services are organized, these two aspects of the access model are discussed together in this section.

Medicaid and Managed Care. Through the Medic- aid program, as well as state departments of mental health, the states have been major funders of mental health services. In an effort to save money, most states are currently enrolling some or all of their Medicaid population in managed care and many are choosing

248 Vol. 18, No. S The / o u m l @Rural Health

to separate the financing and management of mental health from physical health benefits. These arrange- ments are often referred to as mental health carve- outs. Most mental health carve-outs are designed to work with panels of mental heath providers and to reign in mental health utilization. However, rural mental health service delivery systems are very different from urban systems. Primary care practitioners provide a greater proportion of mental health care, although psychiatrists are rarely available. In addition, mental health utilization is historically much lower in rural areas, an indication of access problems. Efforts to reign in utilization have a potential to exacerbate long-standing access problems (Hartley, Lambert, Bird, & Ralph, 1999; Lambert et al., 1998).

A detailed study of all 50 states (Slifkin, Hoag, Sil- berman, Felt-Lisk & Popkin, 1998) has revealed much about rural Medicaid managed care, but says little about rural Medicaid managed behavioral health services. Some general observations on rural managed behavioral health have been offered by the Frontier Mental Health Services Resource Network (Keller, 1998), and case studies have been completed by the Maine Rural Health Research Center, as well as a recent project tracking the implementation of Medicaid Managed Behavioral Health in 22 states (Hartley et al., 1999; Lambert, Gale, Bird, & Hartley, 2001). What is known from these studies is that, in general, managed behavioral health has not exacerbated access problems.

However in some cases, such as in Montana, the failure of a managed behavioral health organization (MBHO) to include PCPs on its panel has left Medic- aid enrollees with no mental health provider in their county. Under such circumstances, it is likely that PCPs continue to provide some level of mental health services but must code such visits as general health visits if they wish to be reimbursed. Similarly, anecdotal evidence suggests that access to child mental health specialists may be an emerging problem under some rural managed behavioral health programs because the MBHO does not recognize the distinction between child psychologists and psychiatrists vs. the general psychiatrist on the panel for that area.

Because a major strategy of MBHOs is to reduce inpatient lengths of stay, there is a potential for patients from rural areas to be discharged early on the as- sumption that community-based services will provide aftercare and a transition back to community life. Be- cause few rural areas have adequate community based services, this practice may cause an increase in post- discharge relapse and readmission rates. This scenario has not been confirmed by empirical research.

'

Managed behavioral health has penetrated the non- Medicaid rural population as well. A recent study found that switching a group of commercially insured state employees to a managed behavioral health plan increased utilization by increasing the number of first- time users of out-patient services, while slightly reducing the number of visits per user (Hartley, 2001). Be- cause the MBHO in this study was not at financial risk, the effects of a risk-based arrangement on such a population are unknown. Similarly, the MBHO under study allowed beneficiaries to receive mental health benefits from their PCPs. MBHOs that insist on using only credentialed mental health practitioners are likely to bring about a significantly different utilization pattern in rural areas.

Parity. The Mental Health Parity Act of 1996 re- quires employers that offer benefits for mental health services to provide benefits that are comparable to physical health benefits in terms of annual and lifetime limits. The effects of this potential increase in mental health benefits have been discussed in terms of potential cost increases and the ability of managed care to control such costs. A recent study suggests that such increases in benefits do not amount to "parity" if the benefits are managed more stringently than physical health benefits (Mechanic & McAlpine, 1999). A study of state employees who experienced an increase in mental health benefits similar to what would be expected under a parity increase found a large increase in the demand for out-patient mental health services. For this population, whereas the utilization rates of rural beneficiaries increased, they remained significantly lower than urban rates. Moreover, the proportion of mental health care delivered by primary care practitioners increased following the increase in benefits, with the greatest increase observed in rural areas (Hartley, 2001). This study suggests that the promise of mental health parity may not be realized in rural areas because of a lack of mental health practitioners and an already overburdened primary care workforce.

search issues and questions for future research:

0 How have PCPs fared under managed behavioral health? Are they credentialed to provide mental health services? Are they reimbursed by MBHOs? Are they considered part of the MBHO's provider network? Have early hospital discharges brought about increases in relapse and readmission for rural resi-

In this section, we have identified the following re-

Hartley, Brit& and Sulzbacher 249 Supplemental 2002

dents who are hospitalized for serious mental illness under managed care? If not, is it because these patients have moved to urban areas following hospitalization to access community-based services there, or because there are “best practices” already employed but still to be identified for organization and delivery of community-based services in rural areas? -

4. Enabling Factors: The Promise of Telemedicine in Overcoming Barriers to Access

Telemental health has been considered one of the most robust applications of telemedicine, with the sec- ond highest use rates among grantees of the Office of Rural Health Policy’s (ORHP’s) telemedicine grants (Britain, 1999; Smith & Allison, 1998). The growth of telemental health programs increased in the late 1990s, growing from 6 programs with significant telemental health applications in 1995 to 25 such programs in 1996 (Britain, 1999). These programs use telecommunications technologies for psychiatric consultation, evaluation, medication management, treatment and discharge planning, and legal hearings. A few sites also use these technologies for psychotherapy and psychological testing. Recent federal legislation requiring Medicare to pay for telemedicine services to rural areas is a major breakthrough, addressing the problem of reimbursement for providers at both ends of the connection.

Despite this rapid growth, many questions are un- answered about both the financial and clinical effectiveness of telemental health. Providers have been slow to make regular use of new systems. Benefits to both patient and clinician are numerous, (reduced travel time, improved relationships between local doctors and mental health clinicians, teaching and clinical supervision, etc.). However, some patients do not do well with the system and some clinicians need more flexibility or more direct contact to feel comfortable diagnosing and treating a patient.

Little research has been published offering answers to outstanding questions. There is no agreement among providers regarding the level of telecommunications technology (e.g., POTS, which is standard telephone service; two-way video; desktop computer) needed to provide mental health services in rural areas. One of the leading pieces of research in this area found that the value provided by the addition of video

conferencing technology was the creation of social presence for those participating (Cukor et al., 1998). Most clinical information was gathered auditorily or provided by support staff at the remote site. The use of video was deemed important by both providers and clients because they knew what the other person looked like, they had the feeling that they shared the same space, there was the impression of better inter- personal contact through nonverbal cues, and there was the assurance that each was paying full attention to the conversation. The Cukor study was conducted with POTS-based videophones. The authors suggest that the use of expensive video systems for telemental health applications may be questionable and that lower cost systems may be all that is needed. Another study is attempting to assess the differential impact of home-based video, home-based speakerphone, and office-based counseling on the level of improvement, se- verity, and frequency of specific problems identified by rural diabetic teens who are at-risk for behavioral problems and their families (Glueckauf et al., 1998). Additionally, the investigators are assessing the effects of the three counseling modalities on the therapeutic relationship between family members and counselors. Preliminary findings show that there was ”substantial and equivalent problem improvement across all three modalities. A similar pattern was observed for therapeutic alliance.’’ These results suggest that the use of telecommunications for counseling may be as good as office-based face-to-face counseling. This study was conducted with speakerphones and Integrated Servic- es Digital Network (1SDN)-based videophones. Similar studies should be conducted using these and other telecommunications technologies to determine the most efficient, effective, and appropriate technologies for various rural applications. The impact for rural mental health is significant because similar results from other studies would suggest that rural mental health providers could offer services at significantly less cost than previously assumed.

improve access to care particularly for vulnerable rural populations (children, elders)? Does it improve access to ongoing care? To subspecialty care? Are rural clients more likely to seek mental health care if it is available via telemental health? Will rural clients seek mental health care if they don’t have to travel long distances, take time off work, pay for travel costs, leave family members, and so forth? Is it effective in reducing the stigma associated with receiving mental health care? Will nonacute clients be more comfortable receiving mental health care in their homes through

Additional questions remain: Does telemental health

The Journal of Rural Health 250 Vol. 18, No. S

telecommunications rather than by going to a rural clinic and risking the stigmatization of being seen there? Will clients who are gay or lesbian or who have HIV/AIDS be more apt to participate in groups through telecommunications? Does the availability of telemental health technology increase the likelihood that providers will come to and remain in rural areas? Is immediate access to peers, specialists and information an incentive for providers to establish, join, and remain in rural-frontier practices?

Key research questions suggested by this section are:

Does telemental health improve access to mental health services in rural and frontier areas as mea- sured by increased utilization? By improved outcomes? What is the differential effect of different telemental health modalities on clients perceived anonymity and the stigmatization of treatment? Is there an urban-rural difference?

5. Predisposing Factors: Populations Needing Special Attention

Rural Communities in Economic Crisis. Although the ”farm crisis” and its effects on rural families are familiar to many, less is known about the ”other rur- als” where the single, vulnerable economic base is not farming (e.g., fishing, logging, and mining). In many of these communities, stress has been experienced over years of uncertainty. In 1999, two issues of the Party Line, a publication of the National Association of Rural Mental Health, featured personal narratives and descriptions of rural residents experiencing extreme stress as a result of economic trauma.

The men (and very occasionally women) in New England who harvest the ocean for fish, lobsters, urchins and clams and other shellfish are experiencing very hard times. Due to overfishing of most species, changes in fishing methods, the complexi- ties of what scientists call “post-human influenced marine ecosystems,” and the Sustainable Fisheries Act of 1996, local fishing economies of coastal New England will continue to decline well into the 21st century. . . . The stressors on rural fishing families appear to have escalated substantially. Boat owners who were formerly at sea for 5 days at a time are now at sea for longer periods, with longer waiting periods in between.. . . Substance abuse.. .is a serious problem, as is domestic violence. (Landon, 1999)

Another outreach worker reported:

My visit will be with a laid-off coal miner, who has been suffering from stress due to job loss. . . . I am a mental health outreach worker and my job is to meet with these people and begin to help them deal with their problems. . . . The reason that I have been called is because these people know that I will ,meet them in the privacy of their home and that I myself, am a laid-off coal miner.. . . These men will not address their problems with just anybody; but they will openly talk with someone who is a part of the culture in which they live. Some of the problems that I help these people through are stress caused by financial issues, marital problems, family problems, personal/emotional problems, health issues and employment opportunities. Very seldom do we just work on one issue. (Stuzen, 1999)

Whereas the farm crisis of the 1980s was originally perceived as an economic crisis, studies have shown that it was also a “sociological, and emotional crisis.” (Cecil, 1988; Jurich & Russell, 1987; Thompson & McCubbin, 1987). Some studies have suggested that the mental health services delivery system did not respond quickly or appropriately to the farm crisis of the 1980s attributable, in part, to the changing role of the community mental health center. With directives from funders to target services to those with serious and persistent mental illness, it has been suggested that these institutions (often the only source of mental health services in a rural community), no longer have a mission to serve as a safety net for their communities (Beeson, Johnson & Ortega, 1991; Cecil, 1988; Wagenfeld, Murray, Mohatt, & DeBruyn, 1994). On the other hand, as mentioned in a previous section of this article, there is no consensus on the appropriate re- sponse of a community mental health provider to a regional economic crisis.

The study of the farm crisis and other rural economic trauma has been, for the most part, qualitative or anecdotal. Because many rural residents experiencing these crises do not seek help from mental health practitioners, suicide rates have been one of the few epidemiological indicators of regional incidence that might result from regional economic trauma. As mentioned in the first section of this article, rural suicide rates have been significantly higher than urban rates. However, whether regional suicide clusters may reflect the stress associated with regional economic trauma has not been demonstrated. Improvements in outreach to rural residents who are reluctant to seek services may also improve our understanding of how individ-

Hartley, Britain and Sulzbacher 251 Supplemental 2002

uals respond to these stresses and how best to serve them.

Child and Adolescent Mental Health. The Great Smoky Mountains Study of Youth, funded by the Na- tional Institute of Mental Health, found that children with diagnosed mental health problems receive related services in a variety of settings. These include not only the mental health and general health care systems, but also school, child welfare agencies, and the juvenile justice system (Burns et al., 1995). A comparison of the rural and urban areas included in the study indicates that youths in urban areas were significantly more likely to use some type of service to address a n emotional, behavioral or substance use problem than youths in rural areas.

The federal rules and regulations governing mandated special education services for children with special health care needs (including those with behavioral problems), which followed the 1997 Individuals with Disabilities Education Act Amendments to the special education law, pose a particular burden on rural school districts. Not only will school districts have difficulty funding such services as those mandated in the recent Supreme Court ruling in Cedar Rapids Communi- t y School District u Garret E (29 IDELR 966, US 2999), but also in many cases the required specialists are simply not available in the local community. This appears to be a situation where interactive video telecon- ferencing may allow outside specialists to help broker innovative interagency agreements betureen rural mental agencies and school districts to help the latter meet new federal standards (and provide needed mental health care to children). Local educational agencies, in particular, need outside experts to validate the quality and quantity of services they provide for children with behavior problems.

search issues and questions for future research: 0 What are the effects of rural economic trauma on

In this section, we have identified the following re-

short-term and long-term mental health and what prevention and outreach responses are effective in specific rural environments?

0 What are appropriate ways for rural children and adolescents to access specialty care?

6. Predisposing Factors: Beliefs, Values and Stigma

Rural residents may be less likely to seek mental health services than their urban counterparts because

of "agrarian values" that include an emphasis on self- reliance, a lessened sense of confidentiality, and increased pressure to conform (Hoyt et al., 1997). Out- reach methods have been developed to overcome these factors and some are being evaluated. Initiatives using mental health extenders or lay workers, who are more readily accepted than professionals into the homes of rural residents, have been used successfully in some settings (May, 1998). Another model has used the extension service associated with state land grant mi- versities as a resource for needs assessment and tech- nical assistance (Molgard, 1997). Several approaches have been developed that intervene in the schools to address the behavioral health needs of children (Bier- man, 1997; Burns et al., 1995). In addition, it is be- lieved that simply locating mental health services within a primary care setting helps to ensure anonymity and overcome stigma.

Closely related to the barrier posed by concerns over anonymity and stigma is the difficulty of establishing therapeutic trust when a therapist does not understand the culture of the patient and his or her community. The "cultural competence" issue has been raised as a barrier to mental health care access in rural areas by policy and consumer advocates (National Rural Health Association, 1999). While a culture-spiecif- ic curriculum for the training of rural mental health practitioners has been advocated and a model for such a curriculum has been proposed by the American Psy- chological Association (APA Office of Rural Health, 1995), no substantive evidence has been presented it0 establish that such training makes a difference in overcoming this barrier. Similarly, it is not clear that the term cultural competence has the same meaning when applied to a rural culture as it does when applied to racially or ethnically defined cultures. One might argue, in fact, that the diversity of rural culture pre- cludes the relevance of a "rural curriculum," and that the only way of ensuring cultural competence in the rural context is to recruit practitioners already famnliar with the local culture through family ties. The need to define rurality in its complexity and its cultural im- portance as a starting point in addressing rural mental health issues was articulated by Keller et al. (1999).

In this section, we have identified the following K@- search issues and questions for future research:

0 How can we overcome the barrier presented by the stigma associated with seeking mental health services in rural communities where anonymity is difficult to maintain?

0 Are there elements of a rural-specific training madel

The ]ouml of Rural Health 252 Vol. 18, !'Jo. S

that help to ensure cultural competence in practitioners in all rural settings, or must training be modified for each unique rural setting?

Conclusion

This article has reviewed several policy issues in behavioral health that have a distinctive rural element that might be informed by further research. We acknowledge that two recent articles have had a similar goal (Keller et al., 1999; Rost et al., 2001). We hope that these three research agendas will not be perceived as competing but, rather, as complementing and in some cases affirming one another. For example, all three articles have found telemental health to be an important new development in need of research and evaluation. Similarly, all three have found managed care and mental health carve-outs to be a research priority. From notably different theoretical perspectives, all three articles have also shared some concern over the idea of rural, the diversity of rural culture, and the need to better understand how interventions, treatment approaches, and delivery systems should be modified for varying rural environments or cultures. - Notes

1. Throughout this paper we use the term "specialty mental health professionals" to refer to providers who are licensed to provide mental health services. This group includes psychiatrists, psychologists, social workers, marriage and family therapists, licensed counselors, and psychiatric nurse specialists. We have chosen this term to draw attention to the fact that mental health services are provided by generalists, such as family practice and general internal medicine physicians, nurse practitioners, and physician assistants.

References

American Psychological Association Office of Rural Health (1995). Caring for the rural community: A n interdisciplinary curriculum. Washington, DC: American Psychological Association.

Aday, L., & Andersen, R. (1974), A framework for the study of access to medical care. Health Services Research. 9Q), 208-220.

Baer, R. D. (1996). Health and mental health among Mexican Ameri- can migrants: Implications for survey research. Human Organi- zation 55(1), 58-66.

Baker, R. (1999). WAFP doctors report CME preferences. Washington Family Physician 26(3), 28-29.

Bass, R. D. (1981). Personal communication reported in Dowel1 DA, and Ciarlo, JA (1983). Overview of the community mental

health centers program from an evaluation perspective. Conzmu- nity Mental Health Journal, 19(2), 95-125.

Beeson, P., Johnson, D., & Ortega, S. (1991). Thefarm crisis and mental health: A longitudinal (2981, 1986, 1989) and comnparative study of the economy and mental health status. Unpublished manuscript.

Bergland, B. (1988). Rural mental health report of the National Ac- tion Commission on the mental health of rural America. J Rural Conzmunity Psychology, 9(2), 29-39.

Bierman, K. L. (1997). Implementing a comprehensive program for the prevention of conduct problems in rural communities: The fast track experience. American Journal of Community Psychology 25(4), 493-514.

Bird, D. C., Dempsey, P., & Hartley, D. (2001). Addressing mental health workforce needs in underserved rural areas: Acconiplishnzents and challenges (Working Paper #23). Portland: Maine Rural Health Research Center, Edmund S. Muskie School of Public Service, University of Southern Maine.

Britain, C. (1999). Personal communication. Burns, B. J., Costello, E. J., Angold, A., Tweed, D., Stangl, D., Farm-

er, E. M. Z., & Erkanli, A. (1995). Children's mental health service use across service sectors. Health Affairs 24(3), 147-159.

Bussing, R., Zima, B. T., & Belin, T. R. (1998). Differential access to care for children with ADHD in special education programs. Psychiatric Services, 49, 1226-1229.

Castro, F. G., & Gutierres, S. (1997). Drug and alcohol use among rural Mexican-Americans. In E. B. Robertson, 2 . Sloboda, G. M. Boyd, L. Beatty, & N. J. Kozel (Eds.), Rural substance abuse: State of knuzuledge and issues (498-530). Rockville, MD: National Insti- tute on Drug Abuse.

Cecil, H. (1988). Stress: Country style. J Rural Community Psychology,

Conger, R. D. (1997). The special nature of rural America. In E. B. 9, 51-60.

Robertson, Z. Sloboda, G. M. Boyd, L. Beatty, & N. J. Kozel (Eds.), Rural substance abuse: State of knavledge and issues (37-52). Rockville, MD: National Institute on Drug Abuse.

Costello, E. J. (1989). Developments in child psychiatric epidemiolo- gy. Journal of the American Academy of Child and Adolescent Psychi- atry 28(6), 836-841.

Cukor, P., Baer, L., O'Laughlen, J., Murphey, M. E., Withers, M., & Martin, E. (1998). Use of videophones and low-cost standard telephone lines to provide a social presence in telepsychiatry. Elmedicine Journal, 4(4), 313-21.

Volumes 1&2: Treatment of Major Depression. Rockville, MD US Dept of Health and Human Services. Public Health Service. Agency for Health Care Policy and Research. AHCPR publication 93-0551. Clinical Practice Guideline # 5. [NOTE: Agency is now called Agency for Healthcare Research and Quality.]

Edmunds, M., Frank, R., Hogan, M., McCarty, D., Robinson-Beale, R., & Weisner, C. (Eds.). (1997). Managing managed care; Quality improvement in behavioral healtk. Washington, DC: National Acad- emy Press.

Eisenberg, L. (1992). Treating depression and anxiety in primary care. Nrw England Journal of Medicine, 326(16), 1080-1084.

Fortney, J., Rost, K., Zhang, M., & Warren, J. (1999). The impact of geographic accessibility on the intensity and quality of depression treatment. Medical Care, 37(9), 884-893.

Friedman, R. M., Katz-Leavy, J. W., Manderscheid, R. W., & Sondhei- mer, D. L. (1996). Prevalence of serious emotional disturbance in children and adolescents. In R. W. Manderscheid, & D. L. Sondheimer (Eds.), Mental healtk, United States, 2996 (71-89). Washington, DC: Center for Mental Health Services.

Depression Guideline Panel. (1993). Depression in Primary Care:

Havtley, Britain and Sulzbacher 253

Glueckauf, R., Whitton, J., Baxter, J., Kain, J., Vogelesang, S., Hud- son, M., Wright, D., Falco, M., Falco, J., & Falco, B. (1998, March). Videocounseling for families of rural teens with epilep- sy-Project update. Tekhealth News. Vol. 2, No. 1 Retreived from http: / / telehealth.net/newsletter-4a.html.

Gonzales, J. J., Magruder, K. M., & Keith, S. J. (1994). Mental disorders in primary care services: An update. Public Health Reports,

Greenley, J. R., Barry, K., Fleming, M., Greenberg, J., Hollingsworth, 109(2), 251-258.

E. J., McKee, D., & Schulz, R. (1992). Rural mental health services: Research at the Mental Health Research Center, University of Wisconsin. Outlook, 2(3), 24-25.

Hartley, D. (2001). Effects of manged mental health care on service use in urban and rural Maine. J Rural Health, 7 7(2), 95-104.

Hartley, D., Bird, D., & Dempsey, P. (1999). Mental health and substance abuse. In T. Ricketts (Ed.), Rural health in the United States. pp. 159-178. New York Oxford University Press.

Hartley, D., Lambert, D., Bird, D. & Ralph, R. (1999), Best practices for maintaining and enhancing delivery of mental health care in rural areas under Medicaid managed behavioral health care (Working Pa- per # 15). Portland Maine Rural Health Research Center, Ed- mund S. Muskie School of Public Service, University of South- em Maine.

Hartley, D., Korsen, N., Bird, D., & Agger, M. (1998), Management of depression by rural primary care practitioners. Archives of Family Medicine, 75(4), 563-588.

logical distress and help seeking in rural America. American Journal of Community Psychology, 25(4), 449-470.

American Psychologist, 46(3), 232-239.

the mental health workforce: Implications for health policy. The Milbank Quarterly, 76(1), 25-58.

Johnson, L. D., OMalley, P. M., & Bachman, J. G. (1994). National survey results on drug abuse, in monitoring thefuture study, 1975- 1993. Rockville, MD: National Institute on Drug Abuse.

Jurich, A. P., & Russel, C. S. (1987). Family therapy with rural families in a time of farm crisis. Family Relations, 36(4), 364-367.

Keller, A. (1998) Managed behavioral healthcare in the frontier: Will the frontier manage and how? Letter to the field #9. Denver, CO Frontier Mental Health Service Network. Internet http:/ / www.du.edu/frontier-mh/letter9.html.

health research agenda: Defining context and setting priorities. Journal of Rural Health, 25(3), 316-325.

Keller, P. A., & Zimmerman, M. F. (1980) Geographic distribution of psychiatrists in the northeastern United States. J Rural Commu- nity Psychology, 1(1), 18-24.

M., Eshleman, S., Wittchen, H.-U., & Kendler, K. S. (1994). Life- time and 12-month prevalence of DSM-111-R psychiatric disorders in the United States. Archives of General Psychiatry, 51, 8-19.

lence, correlates, and course of minor depression and major depression in the National Comorbidity Survey. Journal of Affective Disorders, 45, 19-30.

Knesper, D. J., Wheeler, J. R., & Pagnucco, D. J. (1984). Mental health services providers' distribution across counties in the United States. American Psychologist, 39(12), 1424-1434.

Lantbert, D., Gale, J., Bird, D., & Hartley, D. (2001). Medicaid managed behavioral health in rural areas (Working Paper #24). Portland:

Hoyt, D. R., Conger, R. D., Valde, J. G., & Weihs, K. (1997). Psycho-

Human, J., & Wassem, C. (1991). Rural mental health in America.

Ivey, S. L., Scheffler, R., & Zazzali, J. L. (1998). Supply dynamics of

Keller, l?, Murray, J. D., & Hargrove, D. S. (1999). A rural mental

Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes,

Kesder, R. C., Zhao, S., Blazer, D. G., & Swartz, M. (1997). Preva-

Maine Rural Health Research Center, Muskie School of PuMc Service, University of Southem Maine.

Lambert, D., & Agger, M. S. (1995). Access of rural AFDC Medicaid beneficiaries to mental health services. Health Care Financing Re- vim, 17(1), 133-145.

Medicaid mental health carve-outs: Impact and issues in rural areus (Working Paper # 9). Portland: Maine Rural Health Research Center, Muskie School of Public Service, University of Southern Maine.

Landon, B. (1999). Commercial fishing in rural New England: Unad- dressed mental health issues. Party Line, 7(6), 9-11.

Main, D. S., Lutz, L. J., Barrett, J. E., Matthew, J., & Miller, R. S. (1993). The role of primary clinician attitudes, beliefs, and training in the diagnosis and treatment of depression. Archiws @ Family Medicine, 2, 1061-1066.

health United States, 2996 (DHHS Publication No. SMA 96-3398). Washington, DC: Center for Mental Health Services.

York farmers and farm families. Journal of Agricultural Safettj and Health, 4(1), 9-14.

Mechanic, D., & McAlpine, D. (1999). Mission unfulfilled: Potholes on the road to mental health parity. Health Affairs, 18(5), 7-21.

Mechanic, D. (1990). Treating mental illness: Generalist versus specialist. Health Affairs, 9(4), 61-75.

Melzer, S. M., Grossman, D. C., Hart, L. G., & Rosenblatt, R. A. (1997). Hospital services for rural children in Washington ?%ate. Pediatrics, 99, 196-203.

Meyer, R. E., & Sotsky, S. M. (1995). Managed care and the role and training of psychiatrists. Health Affairs, 14(3), 65-77.

Molgard, V. (1997). The extension service as a key mechanism Eor research and services delivery for prevention of mental health disorders in rural areas. American Journal of Community Psycholo- gy, 25(4), 515-544.

Murray, J. D., & Keller, P. A. (1991). Psychology and rural America: Current status and future directions. American Psychologist, 46(3), 220-231.

National Rural Health Association. (1999). Mental health in rural" America. Retrieved November 2001 from http:/ /www.nrharural. org/dc/issuepapers/ipaperl4.html.

& Shannon, G. (1992). Ethnic minority mental health service delivery: A review of the literature. Research in Community and Mental Health, 7, 55-71.

Oetting, E. R., Edwards, R. W., Kelly, K., & Beauvais, F. (1997). Rsk and protective factors for drug use among rural American youth. In Robertson, E. B., Sloboda, Z., Boyd, G. M., Beatty, L., & Kozel, N. J. (Eds.), Rural substance abuse: State of knowledge and issues (90-130). Rockville, MD: National Institute on Drug Abuse.

Olfson, M., Weissman, M. M., Lean, A. C., Higgins, E. S., Barrekt, J. E., & Blacklow, R. S. (1995). Psychological management by family practitioners. J Family Practice, 41(6), 543-550.

The congressional perspective. Health Services Research, 23(61,

Lambert, D., Hartley, D., Bird, D., Ralph, R., & Saucier, P. (1998).

Manderscheid, R., & Sonnenschein, M. A. (Eds.). (1996). Mental

May, J. (1998). Clinically significant occupational stressors in New

Neighbors, H. W., Bashshur, R., Price, R., Selig, S., Donabedian, A.,

Patton, L. (1989). Setting the rural health services research agenda:

1005-1 05 1. Redick, R. W., Witkin, M. J., Atay, J. E., & Manderscheid, R. W.

(1996). Highlights of organized mental health services in 1992 and major national and state trends. In R. W. Manderscheid, & M. A. Sonnenschein (Eds.), Mental health, United States, 1996

The \oumal of Rural Health 254 Vol. 18, No. S

(90-111). Rockville, MD: Substance Abuse and Mental Health Services Administration.

addictive disorders service system. Archives of General Psychiatry, 50, 85-94.

and mental health status among Hispanics: Convergence and new directions for research. American Psychologist, 46(6), 585- 597.

Rost, K., Fortney, J., Fisher, E., & Smith, J. (2001). Use, quality and outcomes of care for mfntal health: The rural perspective. Little Rock Centers for Mental Health Care Research, Department of Psy- chiatry, University of Arkansas for Medical Sciences.

Rost, K., Owen, R., Smith, J., & Smith, G. R. (1998). Rural-urban differences in service use and course of illness in bipolar disorder. Journal of Rural Health, 24(2), 6-43.

and outcomes of care for major depression in rural family practice settings. The journal of Rural Health, 22(2), 114-121.

Shurtleff, D. B., & Shurtleff, C. K. (1999). Washington state children’s community health access project (WSCCHAP) for children with special health care needs and their families: Final report. Seat- tle: University of Washington.

Medicaid managed care programs in rural areas: A fifty state overview. Health Affairs, 27(6), 217-227.

Smith, H. A,, & Allison, R. A. (1998). Telemental health: Delivering mental health care at a distance. Rockville, MD: Health Resources and Services Administration Office for the Advancement of Telehealth.

Regier, D. A,, & Narrow, W. E. (1993). The de facto US mental and

Rogler, L. H., Cortes, D. E., & Malgady, R. G. (1991). Acculturation

Rost, K., Williams, C., Wherry, J., & Smith, R. (1995). The process

Slifkin, R., Hoag, S. D., Silberman, P., Felt-Lisk, S., & Popkin, B.

Snowden, L. R., & Hu, T.-W. (1996). Outpatient service use in minority-serving mental health programs. Administration and P o k y in Mental Health, 24(2), 149-159.

more cost effective? Journal of the American Medical Association, Sturm, R., & Wells, K. (1995). How can care for depression become

273, 51-58. Stuve, I?, Beeson, P. G., & Hartig, I? (1989). Trends in the rural com-

munity mental health work force: A case study. Hospital and Community Psychiatry, 40(9), 932-936.

Stuzen, D. (1999). Mental health services in coal mining communities. Party Line, 7(6), 11-12.

Susman, J. L., Crabtree, B. F., & Essink, G. (1995). Depression in rural family practice. Archives of Family Medicine, 4, 427431.

Takeuchi, D. T., & Uehara, E. S. (1996). Ethnic minority mental health services: Current research and future conceptual directions. In Levin, 8. L., & Petrila, J. (Eds.), Mental health services: A public health perspecfive (pp. 63-80). New York: Oxford Universi- ty Press.

Thompson, E. A., & McCubbin, H. I. (1987). Farm families in crisis: An overview of resources. Family Relations, 36(4), 461467.

United States Department of Justice, Federal Bureau of Investigation. (1996). Crime in the United States, 1995 (pp. 234, 252, 261). Wash- ington, DC: US. Government Printing Office.

Wagenfeld, M., Murray, D., Mohatt, D., & DeBruyn, J. (1994). Mental health and rural America: 198&2993. Rockville, MD: National In- stitute of Mental Health.

(1995). The Colorado rural crisis study. Proceedings from the fifth annual national conference on State Mental Health Agency services research and program evaluation. San Antonio, TX: National Asso- ciation of State Mental Health Program Directors.

Wilson, N. Z., Wackwitz, J. H., Demmler, J., & Coleman, S. C.

Hartley, Britain and Sulzbacher 255 Supplemental 2002

Behavioral Health: Setting the Rural Health Research Agenda

Documents

Transcript of Behavioral Health: Setting the Rural Health Research Agenda