Approximately 62 million people, or 20–23% of the United States’ overall population, live in rural areas, distributed over 75% of the country’s land mass (1–5). Despite this fact, only 9–11% of physicians practice in rural America (1–8). The more specialized the medical discipline, the less likely the physician will be in a rural setting (9, 10). In particular, psychiatrists are less likely to practice in a rural area. This can be seen in the disproportionate number of vacant psychiatrist positions in funded Rural Community Health Centers (7) and the marked disparities in the number of practicing psychiatrists between rural and urban areas (11, 12).

Difficulty in attracting psychiatrists to rural areas suggests there is a need for increased exposure to rural practice in psychiatry residency training programs. Family residency practice programs have demonstrated that providing an exposure can increase the number of trainees choosing rural practice (10, 13–20). The purposes of this article are twofold: (1) to briefly review the variables that affect the delivery of mental health care in rural America, and (2) to offer recommendations to training programs to prepare future psychiatrists for working in rural settings.

Although national data suggest that the prevalence of clinically defined mental health problems among the adult population is similar within rural and urban settings (21, 22), the availability of mental health services is limited for people living in rural and frontier communities (1, 2, 5, 6, 23–28). The majority of Mental Health Professional Shortage Areas (MHPSAs) are in rural counties; “among 1,253 smaller rural counties with populations of 2,500 to 20,000, nearly three fourths of these rural counties lack a psychiatrist, and 95% lack a child psychiatrist” (6, p. 97; 26). An estimated two thirds of US patients with clinical symptoms of mental illness receive no care. Of those who receive formal treatment, approximately 40% receive care from a mental health specialist and 45% from a general medical practitioner (29, 30). Due to the lack of specialty mental heath care, primary care caregivers provide a large proportion of mental health care in rural America (6, 26, 27, 31–35).

Many factors influence the delivery of rural mental health care. These include dual and overlapping relationships, caregiver stress and isolation, limited availability and access to mental health resources, disease stigma, and economic issues.

The most commonly cited variable is that of overlapping, (dual) relationships (36–38). The geographical and social structure of rural communities creates multiple relationships. A psychiatrist might be called upon to treat a neighbor or find that his knowledge of a particular patient’s case impacts on interactions with that patient in other settings. For example, a psychiatrist, also a member of the town’s school board, discovers during a family meeting that a schoolteacher has missed many teaching days because of a significant alcohol problem. The presence of alternative clinicians and facilities in urban areas fosters clearer and separate personal and professional boundaries (5, 6, 36–42).

Because there are few psychiatrists, if any at all, in a small community, everyone tends to know the resident as a “psychiatrist,” in addition to other roles in the community (31, 39, 40, 43–46). A rural psychiatrist is likely to be isolated from other mental health professionals and thus have limited opportunities to discuss ongoing clinical issues (47). Combined with immense clinical responsibilities, these factors may lead to increased caregiver stress on the rural psychiatrist (5, 36).

Stigma regarding mental illness is particularly significant in rural settings (6, 48, 49). Living in a small, isolated rural community where everyone knows each other heightens disease stigma. For example, a patient refuses to go to the psychiatrist’s office because “everyone” will recognize his truck. Rural residents may be uncomfortable with the prospect of disclosing information to the health care provider or not seek necessary care (6, 31, 49–54), leading to underdiagnosis and undertreatment of mental disorders. Disease stigma can undermine the quality of care as well as the provider-patient relationship (5).

Cultural, religious, and personal values of rural residents influence health care decision-making. These values include self-reliance, self-care, a strong work ethic, and a unique perception of health and illness. Rural residents may be more likely to make use of informal supports, such as neighbors, family, churches and other community groups (38). While this may apply in certain urban neighborhoods, it can be characteristic of entire rural communities (5, 36, 55). Psychiatrists trained only in urban settings may be poorly prepared to understand these rural cultural characteristics.

Decreased population density impacts on the rural psychiatrist because of the distance one may need to travel to access other mental health professionals and facilities (5, 6, 38). Distance to such services can be problematic due to the lack of public transportation, challenging roads, and environmental and climatic barriers such as mountain ranges or extreme weather conditions (40). When rural patients need to be admitted or transferred to an urban facility, prohibitive obstacles might be faced, such as distance, reluctance to receive care in a “far away” and unfamiliar city, and knowing that one’s family and friends might be less likely to travel to provide support (5, 36, 38, 56).

Economic factors influence mental health care. Rural populations have a lower income per capita (2), and in most rural areas, a higher percentage of people living below the poverty level compared to urban counterparts (57, 58). In 2000, the prevalence of rural children living in poverty in “non-metro areas” ranged between 18 and 23% (59). Rural residents under the age of 65 are more likely to be underinsured and uninsured (60).

General health status is poorer in rural areas. Although the rural population has about the same age-adjusted mortality rate as the urban population (1), rural residents experience higher rates of infant mortality (61) and morbidity (62, 63). Rural communities have a higher proportion of vulnerable residents, specifically children (5–17 years old) and the elderly (65+), who require more health services (64). Those living in rural and more remote frontier regions are more likely to have chronic health problems and poorer health status compared to urban counterparts (5, 36, 65).

These factors suggest that the practice of rural psychiatry is fundamentally different from practice in urban or metropolitan settings and a disparity exists in the number of psychiatrists practicing in urban and rural areas. An increased emphasis on rural psychiatry in residency could contribute to overcoming barriers to providing quality mental health care in rural settings (6, 31, 32), including the number of psychiatrists choosing to practice in rural communities.

Although personal characteristics of trainees, such as where a person is raised, have been shown to be one predictor of where a clinician chooses to practice, there also is a correlation between where one attended medical school and the choice to practice in a rural setting. Twenty-five percent of physicians practicing in rural settings graduated from 12 medical schools that represent less than 10% of the total number of medical schools in the country (10). A third factor related to practice site decisions is the extent of rural experiences during residency training. In family practice residency programs, the higher the number of required rural training months, a defined rural training mission, location in a rural state, and having a designated rural program director increased the likelihood of graduates selecting rural practices (15, 66–68). Based on the family medicine literature, we suggest that an increased emphasis on rural psychiatry in residency training could increase the number of psychiatrists choosing to practice in rural communities (6, 31, 32).

Because of the size of the rural population and the mental health needs, all psychiatry training programs should provide various levels of rural focused training, including basic, advanced, and fellowship level experiences.

Basic Rural Psychiatry Training

At a minimum, training programs should provide an understanding of the influence of the rural context on mental health care. Directors of training programs need to understand the influence of the rural context on the care of mental health patients and foster opportunities to enhance trainee’s knowledge and skills for providing rural mental health care.

ACGME’s didactic guidelines for years 2–4 include “instruction about American culture and subculture” (69, p. 27). This instruction should include understanding the influence of rural culture and values on mental health. To achieve rural cultural competence, psychiatrists must appreciate cultural differences and similarities within and between various rural settings, as well as compared to urban settings (70, 71).

This basic training necessitates the acquisition of knowledge and interpersonal skills that will increase an understanding and an ability to relate to community-based values, traditions, and customs when addressing mental health problems and/or providers. We believe training should include:

Advanced Rural Psychiatry Training

To potentially increase the number of graduates going into rural psychiatry, residency programs need to make an open commitment to such a goal and enhance their rural focus beyond a basic level. As noted in the family medicine literature, successful rural training programs have a partial or full mission statement aimed at serving rural and/or underserved areas (10, 13–15, 17, 18), a selective admissions process (13, 14, 16, 19), a rural-focused curriculum (10, 13, 14, 16–19), the ability to offer rural experiences with rural mentors or preceptors (14–16, 19, 20), a rural state location (10, 14, 15), and a rural program director (15). The features of advanced rural mental health training include:

Rural Psychiatry Fellowship Training

Training programs, particularly those in or near rural settings, should consider the development of a formal rural psychiatry fellowship.

Developing a fellowship program is a major effort generally driven by a desire to preserve or promote trainees’ interest in rural practices (17). Program directors of rural family medicine tracks report 76% of the graduates enter rural practices (77). The development of a rural fellowship requires overcoming potential attitudinal barriers, including leadership and faculty reluctance and trainee interest (16). Commitment from the sponsoring residency program, recruitment of qualified faculty, and maintaining education standards is essential. Outside funding from state or federal sources may be necessary for planning and implementation of a rural fellowship.

Despite the lack of research on the development of rural psychiatry programs and fellowships (78) much can be learned and applied to psychiatry from the research published on primary and family medicine rural training (79, 80) in developing a rural psychiatry fellowship. Successful family medicine training tracks are associated with a stated rural mission, a rural location, a dedicated curriculum and faculty, and a director with rural experience (80).

The main thrust of a rural psychiatry fellowship would be to provide extensive dedicated rural training experiences with appropriate faculty mentors and supervisors. To complement this experiential effort, there would be didactic seminars that directly relate to the skills essential for general psychiatric practice in rural settings. For example, rural family medicine curricula include training in computer and Internet skills, telemedicine for teaching and consultation, and using scarce rural resources optimally (79). Further education topics for rural psychiatrists should include an awareness of rural health policy, management skills for working with community agencies and hospital boards, communication and consultation skills for working with community leaders and non-psychiatric colleagues such as family physicians, development of professional alliances and networks, and itinerant psychiatric practices (16).

Attracting and retaining psychiatrists in rural America is a longstanding and persistent challenge as most psychiatrists continue to practice in urban settings. A strategy to encourage psychiatrist choice and preparation for rural mental health practice is needed. Psychiatry training directors seeking to develop a rural emphasis can benefit from reviewing the extensive family medicine residency training literature. Psychiatry residency programs that have rural-focused missions, selective admission policies, rural-focused curricula, and abilities to offer rural experiences might have the ability to fulfill this need. The required rural training, as outlined above, would enhance cultural competency for all psychiatrists. Such competency would improve the care of rural Americans, allowing urban psychiatrists to better network with rural providers and build skills for delivering specialty care to rural areas through the use of tele-health technologies. A rural-focused psychiatry residency track or fellowship might enhance the quality of training and mental health care provided in rural America by increasing the number of psychiatrists practicing in rural settings.

The views expressed in this article do not necessarily represent the views of the Department of Veterans Affairs or of the United States government. This work was supported by Veterans Affairs Medical Center, White River Junction, Vermont.