Rural and Remote Psychiatry

Abstract

The pronounced differences between rural and urban areas relate to access to care and psychiatric resources with nearly every rural county (96%) having a shortage of psychiatrists. Studies on urban-rural differences in psychiatric disorders have shown that urban environments are associated with increased risk for mental illness generally and with a greater range of psychiatric disorders. Urban-rural differences lie in social networks. Barriers to care include having an ideal of selfreliance and believing that mental illness is a weakness. The maturing field of rural health research supports the robust impact of the "neighborhood effect" on health, which includes community and social networks, and finds, in rural areas, that immersion in traditional cultures and networks are health-enhancing. Moving from rural to urban areas is often found to be a risk factor for mental illness, though the odds ratio for substance abuse disorders has been found to be the same. Providers and organizations in rural areas struggle with issues of access, recruitment, and professional burnout or exhaustion in traditional models. Systems of training must be considered for rural psychiatry that tap traditional and community-based systems of healing and health care; assess and intervene with "neighborhood" community, family, and social networks; and are less enamored with psychopharmacology. Primary care teams have an essential role in the treatment of rural mental illness and are most effective when inserted into a collaborative care model for disease management. Affiliating and understanding the natural helpers and social networks in any location is a key aspect to being in rural and remote psychiatry. Open Dialogue was developed in a rural and remote part of northwestern Finland. The implementation of Open Dialogue style approaches which are highly compatible with most indigenous cultures (Western Lappland in Finland is the traditional home of the Lapp people) puts psychiatry in a new perspective for rural and remote mental healthpsychiatrists are considered to be just another team member and not necessarily the leader or the most important team member. The difficulty inherent in telemedicine approaches is the lack of community engagement. Psychiatry, like anthropology, has garnered distrust in rural and remote communities related to its "helicopter" approach of coming to a community with little knowledge of the traditions, beliefs, customs, and ideas about mind and mental health, applying a biomedical model of diagnosis and treatment, prescribing medications, and leaving. Effective rural psychiatry will recruit well-trained psychiatrists akin to rural primary care providers who enjoy and value a broader scope of practice and who, while they are experts in pharmacotherapy, also desire to practice psychotherapy and systems development that advantage already existing community social networks and helpers.