Several years ago, Sally Domeier’s daughter was in a severe accident.
She lost the use of her right arm, but she also became severely depressed and dependent on the medications doctors prescribed her for the pain.
The family sought help, Domeier said, but what they really needed was a psychiatrist who could balance her medications. Because the family lives between Ord and Burwell, however, Domeier said they had almost no choice but to make regular drives to Omaha — something that would disrupt their lives, jobs and care of their other children.
“I feel like we’ve just been on our own because in this area, you can either get a counselor that doesn’t have the training to deal with the problems, or we have to hunt for someone who has the right training,” she said.
But Domeier is not alone in facing that problem.
Access to mental and behavioral health care in rural areas has been an issue in Nebraska for years, and experts say it’s not getting better.
In fact, many in the field say with the stigma attached to mental illness and challenges getting resources to rural areas, mental health care provider shortages might be more dire than ever.
Dr. Howard Liu, director of the Behavioral Health Education Center of Nebraska, is familiar with the shortage of mental health care providers in the state, and he said it’s not new.
Generally, he said, treatment for those with behavioral health needs has shifted from institutions to serving needs in the community. Nebraska is no different, Liu said, but that’s where the problem arises for the state’s small, rural communities.
“The challenge is not all the resources are there to support them,” he said.
The statistics back that up.
According to the June 2015 Nebraska Behavioral Health Workforce report, 48 of Nebraska’s 93 counties did not have a mental health provider in 2014.
The report studies the licensed behavioral health workforce in the state, which includes psychiatrists, psychologists, advanced practice registered nurses, physician assistants, licensed independent mental health practitioners, licensed mental health practitioners and licensed alcohol and drug counselors.
State and federal shortage areas show the need, as well.
Tom Rauner is the primary care office director for the Office of Rural Health, and he submits the federal shortage designation proposals. Rauner said there is a shortage of mental health providers across the country, but it’s more apparent in rural areas.
The federal shortage designation focuses on psychiatrists, Rauner said, and it is determined using a 30,000-to-one population-to-psychiatrist ratio. Only one area — consisting of Dodge, Washington, Douglas, Sarpy and Cass counties — was not listed as a shortage area in 2015.
State shortage areas for psychiatry and mental health show similar results. They are based on a 10,000-to-one population-to-psychiatrist ratio and do not include areas within a 25-miles radius of Omaha and Lincoln.
Of Nebraska’s counties, just two — Fillmore and Thurston — were not designated shortage areas in the most recent report, and eight were partially designated.
According to the workforce report, more than 84 percent of psychiatrists practice in metropolitan counties.
And according to Liu, the shortage could get worse.
The workforce report shows that more than half of the licensed workforce is over the age of 50. “It’s really going to be truly an acute shortage in the next few years as those folks retire,” Liu said.
A rural stigma
But the challenges in finding mental health care in rural Nebraska are not limited to finding a provider.
Tom Adams is the executive director for the National Alliance on Mental Illness Nebraska, which provides support for those touched by mental illness.
They have support groups across the state, he said, which allow for person-to-person connection. In rural areas of the state, however, Adams said, finding anyone to talk to is sometimes hard. “Just to go to have a place to talk to someone is a huge challenge for us,” he said.
Mental illness is also somewhat of a hidden problem there, Adams said. Farming communities sometimes have a “pull yourself up by your bootstraps” mentality, he said.
Keri Brugger and Mary Howell said they see that, too.
Brugger is a counselor for the Valley County Health System’s Heritage Program, and Howell is the program manager.
The program, Howell said, is Medicare-based and provides people 55 and older group, individual and family sessions to cope with issues such as anxiety, depression and grief. They are one of two programs in the state, she said, and they serve a 30-mile radius around Ord.
In a rural area, Howell said, people are sometimes resigned to the fact that mental issues are just something to deal with. If they do seek help, she said, they might not be able to define something like depression to a general physician, and they might not get the treatment they need.
There’s also a lot of stigma attached to mental health issues, Brugger added.
Because of that, those affected might not want people to see them parked outside the office of a mental health practitioner.
“People don’t want to get treatment for that, especially in the rural areas, because of small-town mentality,” Brugger said.
But hope for mental health care in Nebraska is not lost. Educating people about mental health in schools is one place to start, Brugger said.
Outpatient services for all ages would help in their area, Howell said, and financial resources, such as offering higher wages, might help draw more providers out.
Rauner said state and national student loan repayment programs are helping with that by giving incentive to providers to work in rural areas.
He also said they continue with efforts to get all levels of mental health professionals into rural communities and to find methods that work best for retention.
“The bigger piece is trying to make sure we’re getting the right providers with the needs people have in that area,” he said.
Liu said BHECN, too, aims to support integration of behavioral health services with primary care, which could cut down on the stigma rural consumers feel. The goal would be to add a mental health provider, such as a therapist, into a family practice, so patients could get care at the same time they see their regular physician.
Using telecommunications to provide telehealth care is also promising, he said, allowing a psychiatrist to serve many rural locations.
And it’s important to focus on the future of health care, Liu said.
It’s challenging to recruit providers to practice in rural Nebraska if they have no ties to the state, Liu said. If current high school and college students can receive support and mentorship from providers in the state, they might be more likely to stay and practice here, he said.
“We really have to invest in our local students and mentor them all the way through,” Liu said.
The issue is important, he said, because it’s about health.
Adams, of NAMI Nebraska, agreed. Mental health issues touch everyone, he said, and building a stronger system of access helps to build a stronger state.
“It’s not a matter of just do we have enough psychiatrists … ” he said. “We need to have a state that says ‘This is important to us, we need to take care of it,’ because we want Nebraska to be a place that has compassion and where people can have a good life.”