While the prevalence of mental illness is similar between rural and urban residents, the services available can
very different. Mental healthcare needs are often not met in many rural communities across the country because
adequate services are not present. Providing mental health services can be challenging in rural areas. According
to the National
Rural Health Association, the following factors are particular
challenges to the provision of mental health services in rural communities:
Accessibility – Rural residents often travel long distances to receive services, are
less likely to be insured for mental health services, and providers are less likely to recognize a mental
Availability – Chronic shortages of mental health professionals exist and mental
health providers are more likely to practice in urban centers.
Affordability – Some rural residents may not be able to afford the cost of health
insurance or the cost of out-of-pocket care if they lack health insurance.
Acceptability – Rural residents may be more susceptible to the stigma of needing or
receiving mental healthcare in small communities where everyone knows each other and fewer choices of
trained professionals can lead to a lack of faith in confidentiality, as well as a reliance on the informal
care of family members, close friends, and religious leaders.
This topic guide focuses on mental health in rural areas and helps health and human services providers in their
efforts to develop, maintain, and expand mental health services in rural communities. It also highlights
challenges and important issues in mental healthcare delivery, such as workforce shortages, access issues,
anonymity, stigma, integration of mental health services into primary care, and suicide prevention. Information
regarding substance use disorder (SUD) can be found in RHIhub's Substance Use and Misuse in Rural Areas topic guide.
The Mental Health in Rural Communities Toolkit features
evidence-based models, resources, and program examples for the successful development and implementation
of mental health programs to serve rural communities.
The Rural Suicide Prevention Toolkit highlights innovative,
evidence-based models and resources to develop and implement successful suicide prevention programs in
Topics with data applicable to rural mental health include:
Mental illness in the past year
Co-occurring mental illness with substance use disorder
Serious mental illness
Mental health treatment/counseling
Unmet mental health needs
The incidence/prevalence of serious thoughts of suicide
The data for these topics are available by age, geographic characteristics and socioeconomic characteristics.
geographic characteristics are detailed by geographic region of the U.S. and county type. County type is divided
into population data classes:
Large metro – population of 1 million or more
Small metro – population of 50,000 – 999,999
Nonmetro – includes subcategories:
Urbanized – population of 20,000 – 49,999 in urbanized areas
Less urbanized – population of 2,500 – 19,999 in urbanized areas
Completely rural – population of < 2,500 in urbanized areas
What are the workforce challenges in providing rural mental health services?
According to a 2018 study, the
most significant challenge
preventing rural Americans from receiving care is the lack of mental health professionals providing mental
health services in rural and frontier areas.
To further complicate the challenges of providing mental health services, the most disadvantaged and
under-resourced communities are often those with the greatest need for mental healthcare providers.
As of September 30, 2021, HRSA had designated 3,426 Mental Health Professional Shortage Areas in rural areas. It
estimated that it would take 1,597 practitioners to remove the designations. For the most current figures, see
This map identifies nonmetro Mental Health HPSAs based on April 2022 data.HRSA.gov data:
What other challenges affect access and the provision of mental health services in rural areas?
Travel distance, lack of public transportation, and the lack of health insurance covering mental health services
are commonly identified as challenges to accessing healthcare in rural areas. Reimbursement issues and the
social stigma associated with mental health services are also identified as significant challenges that affect
access and the provision of mental health services in rural areas.
The reimbursement offered by payers such as Medicaid, Medicare, and private insurers has a significant impact on
the ability of rural providers to offer mental health services. The publication Encouraging
Rural Health Clinics to Provide Mental Health Services: What are the Options? notes that Rural Health
Clinics may be reluctant to start providing mental health services when reimbursement rates are low. In
addition, high no-show rates among mental health clients and high numbers of uninsured patients further
exacerbate the issue of low reimbursement rates paid by Medicaid and others.
Providing mental health services via telehealth, sometimes referred to as telemental health or telebehavioral
health, has shown promise in helping to alleviate the lack of mental health services in rural areas. However,
reimbursement is also a challenge for telehealth services. For additional information about telehealth services
and associated reimbursement issues, see RHIhub's Telehealth Use in Rural
Healthcare topic guide.
Nearly 1 in 5 adults in the U.S. experiences a mental disorder within any given year according to the National Alliance on
Mental Illness. Yet, the misconceptions, myths, and cultural stigma associated with mental illness are
significant barriers that keep people with mental health disorders from seeking and receiving treatment in rural
Factors that may influence rural residents to avoid seeking care include such issues as:
Lack of understanding and knowledge of mental illness, sometimes even among healthcare staff
Prejudice or stigma towards people with mental health disorders, often based on fear and unease
Secrecy about mental illness in the community and general hesitancy to seek care
Perception of a lack of confidentiality and privacy in small towns with closely-tied social networks
While there are drawbacks to small communities when it comes to mental health, there are positives as well. The
close-knit nature of rural communities can also mean that residents are more likely to rally around each other
and provide community support in times of need. A strong external support group can help facilitate a
person's success in treatment and also help support the family's efforts in attending to the care seeker.
What can a rural community or healthcare facility do to minimize the challenges of accessing and providing
mental health services in a rural area?
There are several approaches that can be tried in rural communities to minimize the challenges of providing
mental health services and expanding the mental health workforce. Some of the most commonly cited practices to
deal with workforce issues include:
Expanding the use of telemental health services
Offering loan repayment programs and state tax waivers to recent behavioral health professions graduates
Providing clinical rotations in a rural setting to expose future health care professionals to the qualities
of working in rural areas
Another approach to improving access and providing mental health services is the School-Based Health Center
(SBHC) model for children in rural areas. SBHCs work with the school and community to improve children's mental
health by providing onsite healthcare services delivered by an interdisciplinary team of primary care and
health clinicians. Services may range from wellness exams to mental health services. SBHCs can screen children
for mental, behavioral, or developmental disorders (MBDDs) including anxiety, depression, and
attention-deficit/hyperactivity disorder (ADHD). In addition, SBHCs can provide customized care for children
with special needs who may be at a higher risk for MBDDs by monitoring medication and assisting in developing
Individualized Education Plans (IEPs).
In addition, education and awareness efforts targeted toward rural residents have been used to increase
familiarity and comfort with mental health issues. An example of this is the Mental Health First Aid public
education program. This program helps rural residents identify, understand (and thereby reduce the stigma), and
respond to signs of mental illnesses and substance use disorders.
What are some of the benefits of integration of mental health services into primary care in a rural
In recent years, health policy experts and healthcare providers have begun to encourage closer integration
of mental or behavioral health and primary care services. It is assumed that integration will
increase access to mental healthcare services, particularly in rural communities, as well as increase quality of
care through enhanced coordination of services. In rural areas, where behavioral health workers and primary care
providers are in short supply, integration is vitally important. Integration of these services is an effective
strategy for maximizing the use of scarce rural healthcare resources and improving the quality of care for both
behavioral health and primary care patients.
According to a 2010
Maine Rural Health Research Center report, patients in rural areas who need mental
health services typically see their primary care provider first. Often it is the primary care provider who
initially diagnoses the need for mental health services. In addition, a high percentage of mental healthcare for
rural patients is already provided by primary care providers, so integrating the services of a mental healthcare
provider into the primary care setting can expand on what is already being done. Efficiency of service and ease
of use also create a level of coordinated care and access that benefits both the patient and the provider.
The integration, or even the co-location, of mental health services with primary care services
can also help to reduce or eliminate the effects of the powerful social stigma associated with mental illness in
many rural areas. Social stigma prevents many rural citizens from obtaining needed services, but it is less of a
deterrent when behavioral health professionals see patients in primary care settings. The integration of
behavioral health and primary care services also reduces the challenge of maintaining anonymity. Rural patients
may be reluctant to be seen in settings where their privacy might be compromised but more willing to seek mental
healthcare from the more common and accepted primary care clinic. Primary Care, Behavioral Health, Provider
Colocation, and Rurality discusses how co-location, although different from integration, offers the
potential of future collaboration with primary care providers, as well as opportunities for care coordination.
How has COVID-19 affected rural mental healthcare access and outcomes?
The COVID-19 pandemic and the resulting social and economic upheaval have affected health outcomes and
healthcare access in rural communities across the nation. Mental health is no exception. According to a 2020 CDC MMWR report, approximately 30% of
rural adults who responded to a survey suffered from anxiety or depression and approximately 10% seriously
considered suicide in the past 30 days in June of 2020.
This has led to an increase in demand for mental health services in rural areas that were already experiencing
significant provider shortages. Across the country, many mental health services transitioned to telehealth,
which has created both opportunities and challenges for rural communities. According to a 2021
report, 43% of rural adults who received behavioral health treatment over the last year said they used
telehealth at least once a month. Telehealth options allowed many rural residents to maintain their treatment,
and in some cases improved the convenience of access to those services. However, in some rural and remote areas
lacking broadband access, video-based telehealth was not feasible. On March 1, 2020, as a provision of the CARES Act, CMS waived the video
requirement during the Public Health Emergency, allowing telehealth to be conducted via audio-only sessions. A
2020 article from the Commonwealth Fund highlights that the overall lack of mental health providers,
combined with the increased demand for services due to the pandemic, has made access to mental health services
difficult regardless of telehealth capabilities, as many mental health providers were already operating at full
or nearly full capacity before the pandemic began.
The pandemic also had a significant effect on the economy. Many of the workers who lost their jobs due to the
pandemic also lost health insurance coverage. According to a report from the UDSA-ERS, the unemployment
rate in rural areas rose from 4.9% in March 2020 to 13.6% in April. A 2021 study of COVID-19's impact on the well-being
of rural communities in the West found that 21% of people who had previously been employed full-time had lost
that status due to the pandemic. Roughly half of those who lost full-time jobs became temporarily unemployed and
around 28% had shifted to part-time work. For part-time workers, 41% changed status, and 73% of these former
part-time workers were temporarily unemployed. Of those surveyed for this study, 44% reported that the pandemic
caused some level of negative impact to their mental health.
A similar study on mental
health and work status in rural Appalachia found that 66% of people surveyed suffered from at least one
mental health issue during the pandemic, such as isolation/loneliness, depression, hopelessness, or anxiety. Of
the various types of workers who reported suffering from mental health issues, the highest percentage (69%) were
workers who switched from in-person to remote work during the shutdown. The workers who continued to work
outside the home, however, were more likely to face reduced income.
Is there a resource for rural primary care providers and other healthcare professionals that can connect
patients to mental health services and treatment?
When there are few resources to provide direct mental health services in a community, local healthcare
professionals may need to refer patients to facilities outside of the community. The Substance Abuse and Mental
Health Services Administration (SAMHSA) maintains a Behavioral
Health Treatment Services Locator, which helps locate mental health services in your area, and the National
Directory of Mental Health Treatment Facilities 2020, an online listing of federal, state and local
government, and private facilities that provide mental health treatment services.
Where can rural veterans and rural healthcare providers assisting veterans find information about mental health
services in their rural areas?
Rural healthcare providers and veterans can find information about mental health services for veterans in their
area by contacting either their closest VA medical center or community-based outpatient clinic (CBOC). To access
contact information, go to the
VA Locations tool and choose a state to
access a list of CBOCs, VA Medical Centers, and Vet Centers. See the
VA Mental Health
website for a broad overview of mental health programs available to veterans. Additional information can
be found in the
Guide to VA
Health Services for Veterans & Families.
According to a 2020 report from the CDC,
from 2000 to 2018, the rural suicide rate increased by 48% while urban rates increased by 34%. In 2018, the
suicide rate in rural counties was 19.4 deaths per 100,000 compared with urban counties at 13.4 deaths per
Additional information regarding the impact of suicide in rural communities can be found in Understanding
the Impact of Suicide in Rural America. This policy brief developed by the National Advisory Committee
on Rural Health and Human Services (NACRHHS) also discusses prevention strategies available at the state and
national level and provides recommendations to the Department of Health and Human Services urging it “to focus
more explicitly on emphasizing and including the rural dimensions of suicide into their programs, research,
and outreach to address existing knowledge gaps and strengthen the evidence base.”
How can our community take action to prevent suicides?
The Suicide Prevention Resource Center (SPRC) is a premiere source of
information on the topic of suicide prevention. The following resources and tools can be helpful to rural
communities working on suicide prevention efforts:
States and Communities – Find out what your state is doing
prevent suicide. Includes state suicide prevention plans, state data, and how to contact people involved in
suicide prevention in your state.
You can also contact the Suicide Prevention Resource Center for
assistance. SPRC can connect you with people, organizations, and resources in your rural community, state and
nationally and provide technical assistance and training on suicide prevention.
What resources are available for suicide prevention efforts?
The U.S. Department of Health and Human Services (HHS) considers suicide a significant public health problem and
is involved in prevention activities. Several federal agencies collaborate and direct necessary prevention
resources, services, and programs that are both public and private. Federal resources on suicide prevention
How can our school take action to prevent suicides?
According to the Centers
for Disease Control and Prevention, suicide is the second leading cause of death among youth (ages
10-24) in America. Rural schools can play an important role in preventing suicide among rural youth by:
Becoming involved with your state or community's suicide prevention coalition to learn how to coordinate
your school's efforts with state or community efforts.