A number of studies report that rural populations have poor access to mental health services (¹, ²). States in the rural West provide some indication of what such limited access looks like. In 2003, 45 of 56 Montana counties lacked a psychiatrist (³). The same source indicated that those who do practice usually choose to live in the larger cities. Of the 74 licensed psychiatrists listed in this resource file, the majority reside within 5 more urban counties. In Idaho, 31 of 44 counties have no psychiatrist, in North Dakota 47 of 53 counties lack a psychiatrist, and in South Dakota 56 of 66 counties lack a psychiatrist (³).

Bleak as these statistics are, they may actually paint an overly rosy picture. In early 2007, a review of Internet listings (⁴) for psychiatrists in Montana resulted in the identification of only 52. The telephone book’s listing of psychiatrists in Missoula County and surrounding counties included only six psychiatrists (one child and five adults). None of those listed were accepting new patients, and none accepted Medicaid. With further investigation, we were able to locate one provider who accepted one Medicaid patient per year with the next potential opening in 6 months. In recent weeks the situation has worsened as one of Missoula's few remaining psychiatrists announced his retirement. Six hundred patients received letters noting that extensive efforts to locate a replacement were unsuccessful and recommendations for referral could not be provided. A similar pattern emerged when identifying available psychiatrists in Yellowstone County. Only 16 were identified; those in private practice do not accept Medicaid. In fact, the lone psychiatrist who served a 17 county area in rural eastern Montana resigned this year due to "burnout" (⁵). As a result, the mental health team for an area the size of Rhode Island now consists of two psychologists, two counselors, and a licensed counselor with an associate’s degree.

The shortage of trained providers certainly complicates the provision of mental health services in rural areas. To ameliorate this shortage, Nelson et al. (p. 423) suggest that residency training programs should place a greater emphasis on rural psychiatry to increase the number of psychiatrists who choose to practice in rural communities. Psychiatry training programs could provide various levels of rural-focused training, including basic, advanced, and fellowship level experiences. Nelson et al. call for basic competencies in areas such as collaboration and team building, use of information technologies, ethics, and exploration of cultural, economic, health, religious, and political influences of rural settings.

While such training should be incorporated into medical residency programs, the suggested link between a specialized rural residency initiative and a direct increase in the numbers of rural psychiatrists needs further examination. The rural shortage is part of a complex, national problem (⁶). Currently there are about 14 psychiatrists per 100,000 in the U.S., 16 if child psychiatrists are included (⁷). The percentage of U.S. medical graduates entering psychiatry is much lower than the percentage entering other specialties. This slowing of growth began in the mid-1990s; to date, the number of qualified medical graduates who select psychiatry residencies is insufficient to fill all of the residency positions (⁸).

Several factors may contribute to a diminished interest in psychiatry. The shift from psychodynamic and psychotherapy oriented departments to biologically oriented programs has removed an intellectually interesting aspect of psychiatry that differentiated it from other fields (⁸). Economic pressures imposed by managed care have made psychiatry less financially attractive, especially to medical students with large debts (⁸). Indeed, Dr. Daniel Borenstein, former president of the APA, has asserted that the managed care industry took the position that 25% of the existing workforce of psychiatrists was all that was needed (⁸). Such a position would not facilitate the recruitment of medical students into a psychiatry residency program. And finally, various health care sectors are increasingly sharing responsibility for people’s mental health with more care falling to general medical providers rather than specialists (⁹). In many systems psychiatrists now function almost entirely as medication managers (¹⁰).

These general trends within the profession may influence a psychiatrist’s decisions about one’s scope of practice, risk sharing, and patient profiling. For example, in order to accommodate financial constraints, psychiatrists may accept only patients who have a financially acceptable source of payment. Data indicate that having insurance coverage is positively associated with entry into care (¹¹) and access to higher quality of care. On the other hand, having some kind of managed care versus fee-for-service coverage has been associated with lower levels of service use (¹¹). In fact, private, office-based psychiatrists report that only one out of three patients is covered under a managed care plan for which they accept discounted fees (¹⁰). Thus in many U.S. communities, psychiatrists are increasingly accessible only to affluent patients outside the managed care system (¹⁰).

Other trends within the profession may also limit the numbers of psychiatrists who are actually available to treat mental disorders. Psychiatrists may provide only outpatient care; this practice decision can allow them to discontinue hospital privileges including being on-call for the emergency rooms. Others may provide treatment for only specialized conditions like sleep disorders or pain, or may provide only forensic services. Psychiatrists may not accept patients with addictive disorders. The majority of younger psychiatrists and trainees are women, and they train and practice part-time in significantly greater numbers than men; they also report fewer patient contacts (¹⁰, ¹²). Finally, the average age of psychiatrists is over age 55 and the percentage of psychiatrists under the age of 40 continues to decrease, trends that suggest problems in maintaining capacity (¹²). So even if the number of psychiatrists serving a particular geographic area appears to be adequate, trends within the professions may result in inadequate service levels.

In general, it is difficult to attract and retain adequate numbers of health care providers in rural areas. Employers may easily spend $20,000—30,000 and several years trying to recruit a physician (⁵). Efforts to recruit specialists can prove especially troublesome. In Montana, for example, 50 of 56 counties are designated as mental health professional shortage areas (¹³). Given these conditions, many rural health care settings rely heavily on locum or temporary personnel. A nurse who participated in one of our rural ethics studies explained: "Staffing is always an issue. We are relying more on traveling practitioners and sometimes one traveler does orientation for the next" (¹⁴).

Rural states have undertaken efforts to increase the numbers of health care providers who serve rural communities. Montana is one of 5 western states participating in the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) program. This medical education program, coordinated by the University of Washington, is designed for states that lack their own medical schools. Its mission is to train primary care doctors who can then return to small towns and rural areas in their home states. Each year Montana has 20 slots and the return rate is 39%; in Idaho it is 46% (¹⁵). Those rates suggest that efforts to place physicians in rural states are at least partially successful.

However, practitioners who return to their home states do not necessarily choose family practice as their specialty, nor do they necessarily move to communities that experience the greatest shortages of providers. Those who come may only stay in the community for a year or two and then relocate. As one young physician noted when describing the issues he faced in his rural community: "I am overwhelmed, I cannot take it any longer. Nothing prepared me for this" (¹⁶).

Rural practice may prove particularly difficult for those who want to provide specialty services, such as psychiatry. The patient population is comprised of persons who have, when compared to urban counterparts, lower per capita income, lack of health insurance, and higher rates of unemployment (¹⁷, ¹⁸). The Montana psychiatrist who resigned due to burnout, as referenced in the second paragraph of this article, noted that the lack of insurance coupled with many Medicare and Medicaid patients meant that her services were reimbursed at 24 cents on the dollar (⁵). At times, even that level of reimbursement can be jeopardized. In 2003, when the reimbursement structure for Montana’s state supported mental health services was revamped, the number of patients in the state who received treatment from psychiatrists decreased from 502 to 155 between the months of October and November (¹⁹).

Reimbursement issues, however, are only part of a much larger problem. Routine working conditions can include continual on-call coverage, a heavy workload, and profound resource scarcities such as no treatment facilities for people with a wide range of psychiatric illnesses. The practice of the psychiatrist mentioned above included 500 or more active patients plus she received 2—3 calls from emergency departments on a nightly basis (⁵). The medical center at which she was employed wanted her to work 5 days a week, be on call regularly for general medical problems, and remain on call around the clock for psychiatric emergencies. The medical center was advocating for such a heavy commitment because the psychiatrist’s practice had lost $238,000 over a 3 year period, a significant sum of money for a rural facility (⁵). The difficulties of providing care in the resource-challenged rural environment were summarized by a knowledgeable physician-administrator who told us: "I think if we told the average student about rural culture and context, they’d be scrambling for the door. Only the ones who have some other vested interest in frontier life will dare to tackle the challenges!"

It is important to understand these interrelated issues in order to develop effective training programs for mental health services in rural areas. Since most mental healthcare services in rural areas are provided by generalists (²⁰—²³), academic psychiatry could provide needed guidance by developing mental health curricula and networks for clinical support and consultation (²³). The Montana Model for family practice residency serves as an example of such an effort. In this model, the residency training for family practitioners incorporates mental health problems into the spectrum of chronic diseases so that primary care providers can recognize, diagnose, and treat mental health problems independently (¹³). The enhanced longitudinal psychiatry curriculum has been designed to bolster skill levels and influence attitudes toward the treatment of mental illness and substance abuse. Special efforts such as mental health seminars, traineeships, and referral networks may be needed to ensure that primary care providers already in practice have the skills and resources needed to assist patients with mental disorders.

Academic training should also be designed to prepare psychiatrists for a multitiered system in which they will be required to hire, contract, train, coordinate, and supervise midlevel specialists like nurse practitioners, case managers, counselors, social workers, and ministers who can develop local mental health programs, share the burden of care, and establish referral linkages with appropriate specialists. This mentored approach to mental health care makes sense given the overall shortage of psychiatrists and the practice patterns that typify rural America. The supervising psychiatrist could actually live in a more metropolitan area while his or her sphere of influence could extend to multiple counties or even multiple states. Rural communities could then receive services from well-trained local providers who are trained to understand the cultural values that characterize their communities. Moreover, this service pattern could reduce the stigma often associated with seeking mental health care in a small community.

Training programs should also emphasize the use of telemedicine and other communication technologies. A recent study showed that most psychiatrists who serve rural and frontier patients in Montana agree that it is a hardship for many of their patients to travel 100 to 750 roundtrip miles over a 1—3 day period for a 20 minute consultation; telemedicine could be very advantageous for this cohort (²⁴). Indeed, health care providers in the Billings area report that the number one use of telemedicine has been for psychiatric services amounting to hundreds of "visits" a year. Another study of the influence of a computer intervention on the status of chronically ill rural women showed some promise in enhancing levels of self-esteem, social support, and empowerment (²⁵). Telemedicine could not replace traditional mental health services, but there is value in seeking nontraditional ways to improve the mental wellbeing of rural residents. The use of electronic communication will also make it possible for psychiatrists to stay in contact with colleagues across the country and so help stave off the professional isolation and promote adherence to national standards of care (²³).

When designing new approaches for mental health services it is important to build on existing foundations. It is also important to ensure that the expertise of available psychiatrists is used in the most appropriate, efficient, and effective ways. Historically rural communities have relied on medical providers who are trained as generalists and on a loosely organized collection of social workers, ministers, counselors, criminal justice workers, nursing homes, and voluntary service groups; they may need to continue to do so. To the greatest extent possible, organizations need to cooperate and work toward integrative care. In short, there are no single solutions. The kinds of approaches we suggest, however, accommodate trends both within the rural context and the profession of psychiatry as a whole, and may offer a starting point for enhancing the delivery of mental health services to rural populations.