Women living in rural communities are less likely than urban-dwelling women to receive sufficient mental health care, in large part due to limited access to services and societal stigma, according to medicine and public health researchers.

Some reports indicate that rural women are more likely than urban women to have depressive mood and anxiety symptoms. However rural women do not have adequate access to mental health care, compared with city women. Rural women who do seek mental health help are more likely to receive care from their primary physician than are urban women.

“We asked rural primary care physicians about how they care for women’s mental health,” said Jennifer S. McCall-Hosenfeld, primary care physician and assistant professor of medicine and public health sciences, Penn State College of Medicine. “Theirs is an important perspective because rural primary care physicians provide a substantial proportion of mental health services for their patients.”

McCall-Hosenfeld and colleagues interviewed 19 primary care physicians who provide care to rural women in central Pennsylvania. The physicians answered questions that focused on screening and diagnosis of mental health conditions, barriers to treatment among rural women, management of mental illnesses in rural women and ideas to improve care for this population. The questions focused on practicing medicine in rural areas and specifically about providing care to rural women. The researchers report their findings in the current issue of Mental Health in Family Medicine.

As of 2005, only 7.4 percent of all U.S. psychiatrists practiced in a rural area. Primary care physicians in rural communities experience significant barriers in providing care to rural women with mental health problems. They commonly reported caring for mental health conditions that were often outside the scope of their training.

“I do a lot of psychiatry in my practice that I really wish I didn’t have to do, but I do it because someone’s got to do it,” said one of the primary care physicians interviewed by the researchers.

Another problem, as several primary care physicians reported to the researchers, results from the stigma surrounding mental health.

“Rural women may not want to be seen walking into the office of a mental health care provider due to fear of judgment by family and friends,” the researchers noted in the article.

Identification of mental illnesses was another challenge. About one-third of the physicians reported that they routinely screened for depression, while others stated that time constraints and competing priorities would not allow them to regularly screen patients. Identification of post-traumatic stress disorder among rural women may be particularly challenging because some of the rural doctors did not feel that PTSD was likely to affect rural women. Most of the physicians noted that many of their patients were underinsured and did not have mental health coverage.

“Despite the barriers to optimal healthcare, we found that many of the physicians are seeking creative solutions and developing informal networks with mental health care professionals for consultation,” said McCall-Hosenfeld. “This study reinforced the fact that there are problems with access to health care in rural communities, but also provided some examples of potential solutions to those access issues, such as formalizing and expanding existing consulting networks.

“We need a two-pronged approach. We need to improve access to mental health care in rural communities and we need to address the stigma of mental health issues by helping rural women understand that being depressed, for example, is not something to be ashamed of.”

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Also working on this research was Maria C. Colon-Gonzalez, formerly a resident in family medicine at Penn State, now a fellow and clinical instructor in the department of family medicine, Brown University. Additional researchers from Penn State were Carol S. Weisman, Distinguished Professor of Public Health Sciences and Obstetrics and Gynecology, and Cynthia H. Chuang, associate professor of medicine and public health sciences, both at the College of Medicine; and Marianne M. Hillemeier, professor of health policy and administration and demography, and Amanda N. Perry, graduate student in rural sociology.

The Penn State Clinical and Translational Sciences Institute and the Penn State Building Interdisciplinary Research Careers on Women’s Health Program, supported by National Institutes of Health’s Eunice Kennedy Shriver National Institute of Child Health and Human Development, supported this research.

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Victoria Indivero
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Penn State