Images of the countryside are almost emblematic of serenity of mind. But for people who live in rural America, life stress and mental health problems are just as prevalent as for city dwellers, APA's Practice Directorate recently told Congress.

And in particular, APA said in a report delivered to a congressional briefing, for the 30 percent of U.S. women who live in rural areas, problems are often exacerbated by poverty, isolation, a lack of education and economic opportunities and inadequate access to health care, including mental health care.

In presenting the report's overview of current knowledge on the issues, Katherine Nordal, PhD, chair of the APA Committee on Rural Health, and Pamela Mulder, PhD, lead author of the report, indicated that more services should be provided and more research should be conducted on this often invisible group, and that women in rural areas need help in building resources in their own communities. The report, developed by the APA Rural Women's Working Group, points out, for example:

  • The rural economy tends to be unfavorable for women, with fewer employment opportunities or resources, such as child care or extended education opportunities. The poverty rate in nonmetropolitan areas is 15.9 percent as compared with 13.2 percent in cities. Rural women are more likely to have unpaid employment in family businesses.
  • Two recent studies of rural primary-care settings found depressive symptoms in 40 percent and 41 percent of rural women screened, as compared with the 13 percent to 20 percent in urban women.
  • Incidence of rape and spousal abuse in rural areas is equal to that in cities, but in the country perpetrators may use the isolation to continue the abuse without interference from other people. Local services for women, when they exist, may be hampered by the lack of confidentiality and by the woman's family's acquaintance with the providers themselves.
  • Rural women are more likely than their urban counterparts to have a number a health problems, including diabetes, cancer, heart disease, stroke and lung disease. Fetal, infant and maternal mortality are higher in rural areas.

Very little research

Despite these stressors, says the report, these women's representation in the rural health literature is almost nonexistent.

The limited research that has been done, the report says, is often confined to certain geographic areas. But rural women live in settings from Alaskan villages to Midwestern farms to Deep South countryside. And when studies do use larger samples, they usually don't collect information on age, ethnicity or cultural background--limiting what the findings can say about rural women in general.

Indeed, as its first recommendation, the report says that research on rural women's behavioral health care needs should be "addressed aggressively." In particular, the document calls for studies looking at epidemiology, morbidity, provider availability and access for these women.

An emerging area for studies, says the report, is "the science of collaboration," or the study of the best way to encourage interdisciplinary care. It looks, for example, at what the best location for care is, what the cost-effective models for interdisciplinary care are, who should be part of the health-care team, and how to train caregivers to work collaboratively and how to keep them in rural areas.

In other recommendations, the report notes that a rural focus should be part of every professional training program, with a specific emphasis on women's behavioral health-care needs.

"There are so many areas that are not served by a psychologist or even a social worker," notes Mulder, a professor at Marshall University in West Virginia who supervises trainees in rural areas. "If every training program had a rural component or track, maybe we could fill some of these needs in rural areas."

The report also calls on educational institutions to use their unique abilities to gather and disseminate information, promote awareness, provide continuing education for isolated providers and help in the development of telehealth and distance-learning technologies.

Psychologists in rural areas, says the report, can be resources on a volunteer basis to develop projects to empower girls and women, help organize grass-roots movements and provide expertise to local groups. But beyond volunteer efforts, psychologists are also "uniquely qualified," say the authors, to be consultants to professionals and community organizations in promoting collaborative care. And they can teach in regional colleges, offer continuing education at hospitals and clinics, or serve as supervisors or preceptors for trainees considering rural practice.

"Psychologists have the scientific and the mental health background," Mulder says, "to evaluate programs to find out what is really working, to set aside their own value judgments and motivate people to change things for themselves, and to help disparate groups find common ground."

However, some of the biggest issues for improvement fall to public and private insurers and policy-makers, says the report. For example, to be effective, services for people with mental or addictive disorders often need to include a range of ancillary services--such as transportation, child care, employment-related services--that are not funded under health care. Indeed, if the services are offered at all, they are scattered through government agencies. But insurers need to consider that a comprehensive system may be necessary for effective service provision, asserts the report.

Finally, according to the document, there is a critical need to understand the potential effects of the dramatic shift to managed care on behavioral health services in rural areas. For example, will it create barriers to primary-care services? Can it contain costs while overcoming the array of problems, such as distance, shortage of providers, lower levels of insurance participation and limited support services? At this point the research doesn't have those answers, according to the document.

Indeed, Mulder feels it will take more than the current configuration of health care services to deal with the array of barriers.

There are bright spots, says Mulder, and those often have to do with ideas that spring up in isolated communities: creating safe houses for abused women, working to educate law enforcement to provide better protection for women, school programs that provide quality mental health care and transportation networks. A major task for professionals, she says, is to identify and disseminate those programs that work well.

The report has impressed at least some who attended the APA briefing. Donald L. Weaver, MD, the director of the National Health Service Corps (NHSC), for example, said the report "calls us to action to provide services that are integrated."

In particular, he said, the Bureau of Primary Care, NHSC's parent agency, supports the report's recommendation of not only colocating, but really integrating primary and behavioral health services, with the goal of removing the stigma from mental health care.