Rural–Urban Mental Health Disparities

The United States has more confirmed deaths from coronavirus 2019 (COVID-19) than any other country in the world. State governors made decisions around social distancing in their jurisdictions, which caused schools and businesses to close. Those with broadband access continued a sense or normalcy in their lives. However, for the more than 20 million people who do not have broadband access, a different set of barriers has been experienced. These challenges are especially prominent in rural communities throughout various states. The present commentary addresses how health disparities for preexisting conditions place rural residents at greater risk for morbidity during COVID-19. Reasons for physical and mental health disparities, such as limited access to hospitals or specialty providers (e.g., psychiatrists), are described. Whereas telehealth is promoted as a way to meet health access needs, especially during a pandemic, this luxury is not readily available for all U.S. residents. Recent actions brought about by the government (e.g., the CARES Act) have tried to address the rural–urban gap in telehealth, but more is needed.Rural–Urban Mental Health Disparities

Keywords: COVID-19, rural, mental health, telehealth, broadband

By April 2020, the United States had more confirmed corona- virus 2019 (COVID-19) cases and deaths than any other country in the world (World Health Organization, 2020). The geographical dispersion of the population made it challenging to address COVID-19 systematically. Each state governor proposed its own restrictions. Within each state, counties underwent unequal infec- tion rates. More research is necessary to understand the magnitude of threat this pandemic poses in rural counties. Around 85% of the population resides in urban counties, yet 63% percent of U.S. counties classify as rural (Rothwell, Madans, & Arispe, 2014). However, in truth, rural–urban health disparities are a risk now more ever.

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Rural communities are disproportionately affected by several health issues, such as heart disease (Kulshreshtha, Goyal, Dabhad- kar, Veledar, & Vaccarino, 2014), cancer, and stroke (Moy et al., 2017), which primes them for higher risk of morbidity during COVID-19. Rural communities often have a higher percentage of people who struggle with substance use and mental health prob- lems (Eberhardt & Pamuk, 2004). Between 2001 and 2015, the

suicide rate was nearly 1.5 times higher in rural than in urban counties (Ivey-Stephenson, Crosby, Jack, Haileyesus, & Kresnow- Sedacca, 2017).

Two reasons behind mental health disparities are (a) poor access to health care and (b) limited availability to skilled mental health providers. Rural hospitals faced an increasing risk of closures. Between 2010 and 2019, 98 rural hospitals closed (Seigel, 2019). Rural counties also have fewer psychiatrists and psychologists than urban counties (Centers for Disease Control and Prevention, 2020). Table 1 and Table 2 present a selection of states and identifies the proportion of nonmetro counties based on standards set through the Urban–Rural Continuum Code from the United States Department of Agriculture (USDA). Data show that in some states, more than 50% of their counties do not have a psychiatrist (see Table 1) or psychologist (see Table 2). Also, a higher pro- portion of nonmetro counties consistently lack a psychiatrist (see Table 1) or psychologist (see Table 2) in comparison with metro counties.

These preexisting reasons for health disparities, as well as other challenges posed by living in a rural community, exacerbate men- tal health issues during COVID-19. Around the world, anxiety has driven people to respond by panic buying (Dholakia, 2020). Social distancing practices introduced feelings of isolation, disconnection from routines, and put residents at risk for depression. The state of mental health in the United States is further complicated by the fear felt by 22 million people unemployed (Long, 2020). Yet, for rural communities, the situation was more odious because they were experiencing all of these issues along with higher rates of preexisting conditions and lower access to health care.

One approach to addressing mental health needs during COVID-19 is telehealth (Leite, Hodgkinson, & Gruber, 2020; Ohannessian, Duong, & Odone, 2020; Zhou et al., 2020). How- ever, telehealth requires broadband access, the capacity to pay for

Editor’s Note. This commentary received rapid review due to the time- sensitive nature of the content. It was reviewed by the Journal Editor.— KKT

Rural–Urban Mental Health Disparities