Youth living in Rural America have increased rates of mental illness and inadequate resources to address their mental health concerns. Programs and systems are currently available to build capacity in pediatric clinicians to care for youth with mental illness and to recruit and support rural clinicians. Such programs should continue to be supported with federal and state funding and additional novel programs aimed at addressing the youth mental health crisis in North America should be developed and funded.
Key points
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Rural youth are more likely struggle with mental illness, less likely to receive mental health care, and more likely to die by suicide than their urban peers.
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The United States currently has fewer than one-fifth of the needed child and adolescent psychiatrists to care for youth with severe psychiatric needs.
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Psychiatrists, psychologists, social workers, and therapists are needed to work alongside PCPs to carry out evidence-based mental health care for rural youth and families.
Introduction
Most of the United States has been deemed “rural” by the Health Resources and Services Administration (HRSA). While a firm definition of “rural” does not exist, HRSA utilizes guidance from the US Census and the Office of Management and Budget making a functional description of rural to include any non-metropolitan and non-urban areas (or less than the defined threshold of 50,000 persons). This definition identifies 15% to 19% of the population and 72% to 97% of the land as rural. Twenty-two percent of youth under age 18 live in rural areas. , Coupled with inadequate health care provision, much of the United States is underserved ( Fig. 1 ) with access to mental health care for children and adolescents (youth) being especially problematic.
The American Academy of Child and Adolescent Psychiatrists (AACAP) estimates at least 47 Child and Adolescent Psychiatrists (CAPs) are needed per 100,000 youth under age 18. Only New York, Maine, Vermont, Massachusetts, and Hawaii meet this threshold, with the remaining 45 states and Puerto Rico having a “severe shortage.” The Substance Abuse and Mental Health Services Administration estimates 57,497 CAPs are needed to care for just the youth who meet criteria for severe emotional disturbances (SED). Currently, there are less than 10,000 CAPs in the country. Unfortunately, the shortage is not only for CAPs; even more stark gaps have been identified for psychologists, social workers, non-physician prescribers, and other support professionals.
Scope of the problem
Youth today are struggling with mental illness at unprecedented rates. Emergency departments, primary care clinics, and schools are seeing more youth with mental and behavioral health concerns than they have resources to support. Primary care professionals (PCPs) feel out of their depth in diagnosing and managing youth with mental illness and lack specialists to whom youth can be referred.
This crisis has been recognized by the American Academy of Pediatrics (AAP), the AACAP, the Children’s Hospital Association, and the American Academy of Family Physicians. , Although the need permeates all geographic sites within North America, the hardship is especially prominent in Rural America. Not only are rural youth more likely to struggle with mental illness than their urban peers, but they are also more likely to have parents who struggle financially, have poorer mental health themselves, and have lower education levels than those living in urban communities. , , Added to a backdrop of limited access to health care, these disparities can become a matter of life or death. , , Adolescents in rural communities are more likely to die by suicide and fewer than half of adolescents with a mental health disorder receive treatment. Rural youth are less likely than urban youth to have access to appropriate mental health care, especially doctoral-level health professionals. ,
There is a dearth of CAPs nationwide, with 70% of counties in the nation lacking a CAP ( Fig. 2 ). All mental health professionals, including CAPs, are more likely to practice in higher income and metropolitan counties, where residents also have higher levels of post-secondary education. In fact, the rural states of Indiana, Idaho, Kansas, North Dakota, South Carolina, and South Dakota saw a decline in the ratio of CAPs to youth between 2007 and 2016.
As noted earlier, the United States currently has fewer than one-fifth of the needed CAPs to care for the youth with severe psychiatric needs. In the rural state of Kansas, 400 CAPs are needed to care for youth with SEDs, yet only 70 CAPs are practicing; only 10 practice outside the most urban area of the state (Northeast metro areas) ( Fig. 3 ).
The discrepancy in supply and demand for specialist pediatric mental health care expertise obligates PCPs to address mental health concerns from their patients. Approximately 25% of pediatric health visits include a mental health complaint. This is likely an underestimate of the need given that 42% of high school students endorse feelings of sadness or hopelessness and 1 in 10 have attempted suicide in the past year. While many PCPs would prefer to refer youth out for mental health management, the lack of available specialists negates this preference and leaves PCPs with the choice of managing patients themselves or making referrals despite exceptional wait times. Wait times to see specialists can be upward of 12 months, an unacceptable amount of time to wait to access potentially life-saving care. ,
Like the workforce gap in mental health care access, rural states face shortages in primary care access (see Fig. 2 ). The shortage in general pediatricians is especially pronounced in the rural state of Idaho where there are only 35 pediatricians per 100,000 youth. While some states have up to 80 pediatricians per 100,000 youth, states that lack sufficient expertise in pediatric care suffer. Many rural communities rely on non-physician-level health care professionals to provide health care both in primary care and emergency settings. For instance, in Nebraska, very few counties have a pediatric primary care physician ( Fig. 4 ) and overall numbers of physicians in practice have been steadily declining. As of 2021, only 1675 physicians were practicing pediatrics in Nebraska as compared to 1087 physicians’ assistants and 2048 advanced practice registered nurses.
According to Medicaid data in a mid-Atlantic state, prescribing by physicians (both psychiatrists and non-psychiatrists) decreased between 2012 and 2014 while a 50% increase was seen in prescribing of psychotropic medications by nurse practitioners. Additionally, while psychiatrists and psychiatric nurse practitioners accounted for the majority (61.9%) of psychotropic prescriptions, over one-third (38.1%) of prescriptions were by non-specialists. This is concerning, as research shows the use of antipsychotic medications in youth has risen dramatically. Specifically, within preschool-aged children there has been a 2-fold to 5-fold rise in antipsychotic prescribing. This increase is occurring despite lack of evidence, known risk of harm, and lack of Food and Drug Administration approval for use in this age group. , Of further concern is that rural youth are more likely to receive psychopharmacotherapy for mental illness than counseling despite evidence showing treatment with medication and counseling is superior to medication alone in many disorders in youth. ,
Increased psychotropic prescriptions by non-specialists, highlights both the increase in mental health concerns in youth and the limited access to specialist care. Although multiple professional organizations have called pediatric clinicians to action to address the current mental health crisis, , pediatric clinicians throughout North America feel ill-equipped to treat mental illness in youth. This is not surprising given the lack of training in pediatric mental health received by PCPs. Canadian pediatric PCPs view pediatric mental health care as a highly specialized area of medicine and cite many barriers to providing this care. In fact, specialists do receive far more training in psychiatry than PCPs. A physician specialized in general psychiatry completes roughly 200 hours of supervised clinical time each month of a 4-year residency totaling nearly 10,000 hours over the course of specialization; CAPs then have an additional 2 years of pediatric-specific psychiatry training. While studies quantifying the actual hours of psychiatric training for pediatric clinicians are sorely lacking, we know for PCPs, the number of training hours drastically decreases. According to the Accreditation Council for Graduate Medical Education, pediatricians are required to have 4 weeks each in 2 mental health-heavy rotations: developmental and behavioral pediatrics, and adolescent medicine; and beginning in 2025, an additional 4 weeks of mental health will be required. Other than these standardized rotations, pediatric and family medicine residents manage mental illness during continuity clinics and specialty rotations and can choose from mental health-related electives, including child and adolescent psychiatry where they are precepted by the most specialized experts in child mental illness. Physicians also receive some training in mental health during undergraduate medical training although this is also not well quantified and may range from 0 to 130 hours depending on the medical school attended. Comparatively, nurse practitioners specializing in psychiatric care are required to have 500 hours of supervised clinical time in psychiatry over a 5-year period, although this time is not necessarily specific to youth with psychiatric illnesses. Additional Pediatric Primary Care Mental Health Specialty certification can be sought by nurse practitioners and requires between 1000 and 2000 post-graduate hours over 5 years, but preceptor supervision is not required bringing into question the fidelity to evidence-based medicine and quality of care. Physician assistants and general nurse practitioners receive the least amount of pediatric mental health training and while literature quantifying this training is even more scant, interviews reveal that in some programs no in-depth pediatric mental health training occurs (Harris K.R., MD, Interview scripts unpublished data 2024).
There have been efforts to remedy this lack of education in training. The AAP published “Mental Health Competencies for Pediatric Practice” in 2019 as a revision to their 2009 policy statement. This affirms the important role pediatricians have in preventing, identifying, and managing mental illness. Additionally, the AAP has a 2-part guideline to assist pediatric clinicians in the management of adolescent depression in primary care. , Unfortunately, these recommendations are less than a decade old and there is a known practice gap of 16 to 17 years for new recommendations to reach clinical practice. Simultaneously, the rate of emergency room visits for mental health disorders has been increasing. The federal government has adopted policy and provided funding to support pediatric clinicians both in practice and in training, as well as grow the workforce in multiple disciplines required for high-level pediatric mental health care.
Current interventions
Telehealth
Telehealth alleviates many barriers to accessing mental health care, especially for rural patients. Since the coronavirus disease 2019 pandemic, the use of telehealth has greatly expanded. Emergency orders both kept people at home and expanded the allowances for telehealth. New policies addressed historical barriers clinicians faced including low reimbursement rates for televisits, which were increased during and upheld following the pandemic. Telehealth allowed rural patients to seek care from the comfort of home rather than traveling to a distant clinic. , Telehealth access may have also helped decrease stigma around mental health care, a challenge that occurs more in rural communities than urban ones. This is partly due to the unique challenges of providing mental health care in rural communities. Social and professional challenges exist for patients and clinicians as both likely work, live, and interact with each other outside of their patient-professional relationship. Receiving care virtually from a professional outside of the local community may help alleviate some of these unique challenges of providing and receiving mental health care in smaller, rural communities.
Albeit helpful in some ways, telehealth far from addresses all access barriers. Lab work is unavailable virtually and lack of in-person visits can hinder rapport between clinician and patient. Telehealth has been described as an “intermediate” step to health care: helpful for preliminary screening and follow-up but not appropriate for all care. Further, while telehealth can address maldistribution of mental health specialists, the overall issue of workforce shortage remains unsolved. If a psychiatrist in an urban town blocks time to care for rural youth virtually, they sacrifice time seeing youth in-person. So, while this may help in other fields of medicine where there is a sufficient supply of professionals, it does not help the overall workforce crisis in pediatric mental health. Still, the increased availability of telehealth care has been a welcomed change in service provision allowing youth to miss less school for travel to specialists and keeping adults more productive in rural communities. Telehealth has also been utilized to offer consultations to pediatric clinicians to both educate on mental health care and extend management ( Box 1 ). Programs like Pediatric Mental Health Care Access (PMHCA) Programs or Child Psychiatry Access Programs (CPAP) utilize telehealth for direct consultations with psychiatrists and as a learning tool for pediatric clinicians to build expertise and comfort in pediatric mental health care. ,
In an innovative program in rural Colorado, child and adolescent psychiatrists work as part of an integrated care team to provide interprofessional mental health care to pediatric patients. The model includes masters-level behavioral health clinicians (BHC), pediatric primary care professionals (PCPs), psychologists, and a child and adolescent psychiatrist (CAP). The PCPs serve as team leads and manage all patient care and prescriptions but can request a consult from the CAP for care beyond their comfort level. The consult is then organized by the BHC. The BHC participates in the consult with the CAP, patient, and family and this direct care is followed by a wrap up session with the same team and including the psychologist and PCP. The PCP then carries out any management plans.
From (A multidisciplinary, team-based teleconsultation approach to enhance child mental health services in rural pediatrics) ; with permission.
Pediatric Mental Health Access Programs/Child Psychiatry Access Programs
Funded through HRSA beginning in 2018, 54 PMHCA programs now exist across the United States ( Fig. 5 ). Based on the original CPAP in Massachusetts, the overarching goal of PMHCA programs is to “promote behavioral health integration into pediatric primary care by using telehealth modalities to provide high-quality and timely detection, assessment, treatment, and referral for children and adolescents, with behavioral health conditions, using evidence-based practices and methods.” Although this goal is integral to each program, each PMHCA has unique components ( Fig. 6 ).
Most rely on CAPs and child psychologists to provide consultation to pediatric clinicians regarding management of mental illness. Data supporting uptake, satisfaction, and utilization by pediatric clinicians have been reported for PMHCA/CPAP programs and pediatric clinicians have reported a gain in skills, knowledge, comfort, and confidence following engagement in programs.
North Dakota, a vastly rural and frontier state, hosts a PMHCA that provides peer-to-peer consultation between PCP and specialists. Care coordination for patients and families are also available through a PMHCA-partnering organization. The North Dakota program also offers ongoing trainings to pediatric clinicians through Project Extension for Community Healthcare Outcomes and annual symposiums.
Mental Health Training Programs
Excellent primary care training is necessary for pediatric clinicians practicing in rural communities; however, historically, this has not included pediatric mental health care. To train PCPs in pediatric mental health care, psychiatric specialists are needed in rural communities. CAPs are the most highly trained experts in pediatric mental illness. As outlined earlier, training for these specialist physicians requires 4 years of undergraduate medical education, 3 to 4 years of general psychiatry residency training, and an additional 2 years of child and adolescent fellowship training. CAPs are trained in pathophysiological, psychopharmacological, and psychotherapeutic management of pediatric mental illness. No other health professional has this level of training in pediatric mental illness. This expertise makes them the most qualified to teach pediatric clinicians about mental health disorders. Regrettably, there are not enough CAPs to meet patient care needs, let alone teaching needs. It has become imperative, that pediatric clinicians become well-trained, knowledgeable, and comfortable managing less complex mental illness so that youth with more complex psychiatric needs can be seen by these specialists. Several new training programs have recently been funded through HRSA that aim to equip pediatric clinicians with these skills. Further, programs now exist to train CAPs and child psychologists with an emphasis on underserved and rural populations.
At least 2 current Primary Care Training and Enhancement (PCTE) programs funded by HRSA provide training to pediatric clinicians related to mental and behavioral health care. The purpose of the PCTE-Physician Assistant Rural Training in Behavioral Health program is to develop clinical rotations regarding behavioral health and substance use for physician assistant students in rural communities. The purpose of the PCTE-Residency Training in Mental and Behavioral Health (PCTE-RTMB) is to train primary care physician residents in mental, behavioral, and substance use care for pediatric, adolescent, young adult, and other at-risk or exposed populations. Both programs should help equip future rural pediatric clinicians with expertise to manage youth with mental health disorders. , A third HRSA program, Behavioral Health Workforce Education and Training (BHWET) Program for Professionals is working to increase and improve distribution of behavioral health professionals especially those focused on the care of youth and young adults. The BHWET program becomes increasingly important as the need for these specialists increases both for patient care and for the education of other health professionals. These 3 HRSA programs overlap with the goals of the PMHCA programs and can integrate synergistically to achieve the common goal of improved mental and behavioral health care in rural communities ( Box 2 ).
