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The Rural Elderly 

Access to Mental Healthcare


By Richard B. Miller, Ph.D.


Life in many small towns is full of friendly neighbors, fresh air, spectacular sunsets, close-knit communities, and endless horizons. The pace of life doesn’t match the frenetic pace of the city. However, despite the obvious benefits of living in rural areas, rural residents face many challenges, including a lack of competent healthcare professionals and facilities. This is especially true for the rural elderly.

Older persons living in rural areas are at substantial risk for experiencing “double jeopardy” in mental healthcare. Not only are there insufficient mental health services for older people—in general, rural residents of all ages face inadequate mental health care in rural areas (Lawrence & McCulloch, 2001). Consequently, the rural elderly face the double impact of having poor mental health care because of their age and their rural location.

Although the United States and Canada over the past century have changed from primarily rural to largely urban societies, a substantial proportion of the population still lives on farms or in small towns. Recent research suggests that about 25% of the U.S. population lives in rural areas (Letvak, 2002), and 15 states have more than one-half of their population residing in nonmetropolitan areas (Shelton, & Frank, 1995).

Rural residents face a number of significant economic and mental health disadvantages compared to their urban counterparts. People living in rural areas struggle with lower incomes, higher unemployment rates, higher poverty rates, less health insurance, and more substandard housing (Lawrence & McCulloch, 2001; Shelton & Frank, 1995). They also experience higher levels of depression, substance abuse, and cognitive deficits than urban residents. Suicide rates in rural communities are as much as three times higher than in cities (Letvak, 2002).

Despite these higher risks, the rural population is plagued by a dramatic lack of resources to meet these mental health needs. Compared to urban areas, rural mental health systems receive substantially less mental health funding (Rathbone-McCuan, 2001). This inequity is compounded by the inability of numerous depressed rural communities to raise the matching local funds necessary to qualify for state and federal grant money (Bull, 1998). The results are too few programs that stretch across too many miles.

In addition to a lack of mental health agencies and programs, rural communities struggle to recruit and retain mental health professionals. Fifty-five percent of the counties in the United States, all of them rural, have no practicing psychiatrists, social workers, or psychologists (Lawrence & McCulloch, 2001). A recent study found that, in one state, there are five times more mental health practitioners per capita in cities than in rural areas (Rost, Owen, Smith, & Smith, 1998). Not surprisingly, 60% of rural areas have been designated “mental health profession shortage areas” (Letvak, 2002).

Rural areas have an especially high concentration of elderly people. Young families often migrate to urban centers in search of steady employment and higher incomes, leaving rural areas with a disproportionate percentage of elderly. Consequently, although the elderly comprise only 12% of the overall U.S. population, 25% of the rural population is over the age of 65 (Letvak, 2002).

Moreover, rural elderly have higher levels of needs for medical and mental health care. For example, sixteen percent of the rural older population receives Medicare benefits, compared to 13% of urban-dwelling elderly (Howland, 1995).

Because the rural elderly have access to fewer mental health agencies, programs, and professionals, they are forced to rely more on their informal support networks (Bane & Bull, 2001). Despite the perception that rural communities are characterized by a close network of friends and neighbors who are able to provide help and support to the elderly, research suggests that the rural elderly are more likely than city dwellers to depend solely upon family members for assistance (Hofferth & Iceland, 1998).

Consequently, family members are the most important component in the care of older persons struggling with mental health problems. It would seem appropriate, then, that care for older persons requiring mental health services be provided from a family systems perspective. For example, the professional treatment of an older person suffering from Alzheimer ’s disease would be best approached by viewing the older person as a member of a family system in which the other family members are an integral part of the care of the person. Marriage and family therapists have the training and experience to provide the family-centered treatment that is appropriate for many older persons struggling with mental health problems.

Ironically, MFTs are currently not eligible to provide mental health services to the elderly through the Medicare program. This policy barrier significantly impacts the ability of the elderly to receive appropriate mental health services for two reasons. First, with the acute shortage of mental health professionals in rural settings, where the population is disproportionately elderly, recognizing MFTs will dramatically increase the availability of qualified providers. In fact, MFTs are present in 36% of rural counties, over half of which have no psychiatrists (AAMFT, 2002). Furthermore, as previously mentioned, the inclusion of MFTs in Medicare would provide a treatment perspective that incorporates the family and is an ideal fit with the needs and circumstances of the rural elderly. Policymakers should consider opportunities to expand access to mental health services for the elderly by recognizing MFTs under the Medicare program.

Richard B. Miller, Ph.D. is an Associate Professor at Brigham Young University.


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