Substance Abuse & Mental Health Challenges in Rural America

Welcome and Introduction

Afternoon, everyone, and welcome to today's webinar hosted by Patagonia Health. Today's webinar topic is Substance Abuse and Mental Health Challenges in Rural America. If you are not familiar with the Zoom webinar platform, take a look at the control panel at the bottom of your screen. Here you can configure your audio settings, send chat messages, and ask questions.

Feel free to say hi to us in the chat. We love to see where you're located and what you're up to today. Welcome. We're so excited to hear from today's speaker, Chuck Strand, and he has an impressive biography here. He's going to introduce himself, so I'll just say super quickly that Chuck Strand is the executive director of Rural Minds, which is a nonprofit focused on advocating for rural mental health equity, promoting mental wellness, and providing information and resources to confront rural mental health challenges and the stigma that surrounds it.

So we're really excited to hear from this expert speaker today, and I hope you enjoy it. I'm going to turn off my screen share, and you can go ahead and start.

The Story Behind Rural Minds

Okay, great. Thank you so much. It's great to be here. I appreciate the opportunity. Rural Minds is all about partnerships, so we appreciate these conversations and raising awareness for the mental health challenges in rural communities and the work that we're doing through Rural Minds.

I've got a slide deck here also, and I'll go ahead and share that with all of you. I hope you all can see that. Again, it's a pleasure to be here. We've got it set up, so I'll do this presentation in about 45 minutes. I think that's the correct amount of time. Then we also have a Q&A following this.

Feel free to jump in and ask questions if you want throughout the presentation. The story behind Rural Minds is best told through the video that I'll click on shortly. The founder, Jeff Winton, made a tremendous decision after the suicide of his nephew, Brooks, who's pictured here, died by suicide on the family farm.

This is about a six-minute video, but I think it does a really nice job of framing the work that we do at Rural Minds and why it's so important. I'm going to try one more thing here. I'm going to get out of this and go to the main page. Give it one more shot. We can go without the video, but I'd like to share it if possible.

Let's see if this has a better link. All right. Okay. I'll just tell you about the story of Jeff.

The organization has been around for about four, four and a half years, and back in 2012, Jeff's nephew died by suicide and left behind three-year-old twins. Upon the death of his nephew, Brooks, many people in Jeff's rural farming community assumed that they would just make something up because people just didn't talk about mental health, especially not suicide.

But Jeff and his family made the courageous decision to speak openly about the death of Brooks, recognizing that the stigma surrounding mental illness and suicide is really one of the major contributors to people struggling and, in Brooks' case, dying by suicide. They talked openly about what happened and what led Brooks to pass away from suicide. Substance use disorder was one of the issues in addition to a mental illness.

But they didn't know that. Brooks seemed like he had everything going for him, and no one ever would have guessed that he would be in this dark place. Two days prior to his death, the family celebrated the wedding of Brooks' older brother. It took everyone by complete surprise. So it really made Jeff recognize the need to speak openly.

Once he did, he said he'd give the eulogy at Brooks' funeral. After he did that, people in the community lined up to talk to Jeff privately about something that they had experienced themselves throughout the course of the next few days and following the funeral. It was just an outpouring of people who felt like they finally had the license and the platform to talk about something that happened in their family.

It really made Jeff realize what a gap there was in information about mental health and mental illness in rural communities. So that is what led him to the idea of launching Rural Minds. At the time, as I mentioned, Brooks' twins were three years old, so Jeff wanted to wait several years until Brooks' children would be old enough to understand what was going on, as far as Rural Minds being a nonprofit that truly is a tribute to their father.

Rural Minds' Mission and Vision

The mission of Rural Minds is to serve as the informed voice for mental health in rural America and to provide mental health information and resources. We recognize that there are many organizations that have been doing great work in this space as far as mental health for years. So part of the website that we have, ruralminds.org, includes two pages that list all the public-facing resources that are available, like a great comprehensive one-stop shop in terms of one location.

They're divided into:

• Crisis resources
• Mental health information and resources by topic

So it makes it very easy to access all the great content that's out there. We don't want to reinvent the wheel. We want to make sure that we're pointing people to access that.

Really, what we do is, knowing that with all that great content, the stats for mental health challenges and suicide are so much higher in rural communities, obviously something is not connecting. There are gaps with reaching people in rural communities, and that's really where we come in. That's what we're all about, identifying the gaps by helping to connect with organizations that have a presence in rural communities.

We're listening for what the unmet needs are. We don't create content and say, "Here you go." We want to understand what we can do to supplement what's already out there. So that's kind of how we work, and our vision is really focused on that stigma, eliminating the silent suffering and stigma associated with mental illness, which is to a greater degree in rural communities.

Mental Health and Substance Use Challenges in Rural Communities

There are higher depression rates, higher suicide rates, and due to all the barriers that we'll talk about, people are less likely to get healthcare, whether it's mental healthcare or even just healthcare in general. It's a struggle in rural communities.

Specific to suicide:

• Folks who are living in rural communities are 49% more likely to die by suicide than people who live in large urban areas.
• Farmers in particular are one of the most at-risk occupations, three and a half times more likely to die by suicide.
• One of the most shocking stats is that youth ages 15 to 19 living in rural communities are 74% more likely to die by suicide than their urban counterparts.

This really has led us to developing a program specific to rural youth mental wellness, and we'll talk a little bit more about that later in the presentation.

The other sad reality is that suicide rates for youth are growing at a faster pace in rural communities. Specific to alcohol and substance use, the stats in rural America are, some of them are noted here. Rural youth are more likely to use alcohol, and the research shows that the rates of alcohol use are higher and binge drinking is higher compared to youth in urban areas. There is also the impact of heavy drinking and how it's associated with various harms that are more unique to living in a rural area.

Opioid overdose rates are 45% higher in rural areas than in urban areas. Across the board, with a lot of illicit drugs, the percentages of use in rural communities are not necessarily higher, but the consequences are greater because of those barriers. People are further away from resources that include prevention, treatment, and recovery.

Barriers to Care in Rural America

The barriers really lead with the lack of mental healthcare and the lack of healthcare in general:

• A lot of times, primary care physicians are all that there is as far as a professional.
• A lot of times pharmacists in rural communities fill that role too, as far as being a trained professional who can answer questions.
• There are 20% fewer primary care physicians in rural areas compared to urban areas, and that's per capita, not just the fact that there are greater distances and all.
• There is also a real severe shortage of any kind of mental health professional in rural communities.
• Broadband is also a challenge. We'll talk a little bit more about that, but almost 30% of homes in rural communities don't have internet service.

Building on these inherent barriers to mental health that exist in rural communities, with fewer physicians, it's harder to get an appointment, and it takes more time and more effort to get to an in-person appointment. Unlike people in urban or suburban areas, there is no public transportation. There's not even rideshare, and a lot of times there's not even a taxi service in a small town or an ag community. Telehealth is not an option when you've got 30% of the homes that don't have reliable internet. So it can be a real challenge.

In general, people in rural communities are older, less healthy, and less insured. That lack of health insurance has always been an issue, and now it's even more so with the Medicaid cuts and the premiums that are not going to be subsidized for people who have to buy their own insurance.

Overall, there's always been a volatile economy in rural America, driven mostly by the ag industry. In the best of times, it's tough for farmers, ranchers, and the ag community to predict what their profits might be or how far in debt they're going to be based on the crops that are coming up or not. There have been a lot of additional burdens put on folks in rural communities recently, with additional challenges for financial security and healthcare. There are a lot of people struggling more now than ever.

From a lifestyle perspective, a lot of people in rural communities, and I grew up in a small town in northern Michigan near Lake Superior, so I can relate to this too, solve their own problems. You can't always rely on somebody pulling up in your driveway and fixing your pipe or calling a professional to help you, whether it's a matter of distance, cost, or whatever. So you learn to do things yourself, and this self-reliance and mindset of having to solve your own problems can be one of the biggest problems in terms of the lack of pursuing healthcare, even though it's not that accessible.

That stigma is also based on the fact that a lot of times people in rural communities associate mental illness with weakness, and they think that it's a lack of character or a character flaw or whatever it might be. They don't want to be negatively judged, and they don't trust people in the local community to maintain confidentiality. So there can be this real feeling of isolation, and there's no one you can talk to who really gets it as far as what you're going through in a rural community.

In addition to that, any marginalized segment of the population that you'd find in major cities, those folks are still in rural communities. It's just that they may be feeling even more marginalized and more isolated and alone.

Trusted Sources and Rural Partnerships

People in rural communities tend to want to get their information from someone they know, a trusted source who can look them in the eye, shake their hand, and that kind of goes for news also. Obviously, people in rural communities, like anywhere else in the country, have access to all of the mainstream media and the national news services.

But there's a big reliance also on the smaller newspapers and the smaller radio stations, and just a community having more of a pulse on the community. So we really recognize that it's so important for us to be partnering with organizations that have a presence in rural communities and have that ability to have members of the organization be trusted sources of information, to talk about or at least distribute information that's as highly stigmatized as mental illness.

We partner with a lot of organizations, which include the National Grange and other commodity organizations that have members throughout the country, such as:

• The American Soybean Association
• National Association of Wheat Growers
• National Cattlemen's Beef Association

So we really want to build this network of individuals that serve as partners in terms of helping us understand what the unmet, underserved needs are, what those gaps are, and then helping us be sure that the content we develop is culturally relevant.

Once it's developed on our webpage, it doesn't really do anybody any good unless people are pulling that information down and using it. So we're also looking to those partners to do that, to talk about what's out there. If someone doesn't have internet, print it out or whatever, and just really contribute to raising awareness for the problem and the solutions.

Rural Minds is the only 501(c)(3) nonprofit that's national in terms of the services that we offer for free and is really focused on promoting mental health equity and mental wellness. There are 46 million people living in rural communities, and that includes:

• Ag communities
• Small towns
• Fishing villages
• Mining communities
• All these small, isolated areas
• People who live in the country and not necessarily in any community, just out there by themselves

We want to serve all those people. In order to do that, we've got to have these trusted sources of boots on the ground because it's not like a one-stop shop where we can reach a lot of people with one initiative, which is often possible in urban areas or even suburban areas.

This is how we fall as far as the partnerships that we have. We're in the center of working with the large mental health nonprofits, and then small rural nonprofits and rural organizations, and then donors and corporate sponsors. What we bring to all these different groups of our partnerships is the mental health insight into rural America, how it's different in rural America, and how we can all work together to improve the mental wellness of people who are living in rural communities.

Why Rural Mental Health Matters to Everyone

This is an important point to recognize too, because in the past, I don't always think about that either. This is either when I'm shopping in a grocery store or even looking at a menu in a restaurant. We have this small percentage of people who are in rural communities who are doing work that touches all of us, including:

• Planting, raising, harvesting, and packaging the food we eat
• Producing beef or chicken that's nicely packaged in the refrigerated section
• Growing produce and vegetables
• Providing ingredients for processed products
• Contributing to our clothes
• Producing the ethanol that's 10% of the fuel that we put in our cars

All this comes from a small percentage of the people who are not only doing all this important work, but are being marginalized and not really having the opportunities for mental wellness and physical wellness.

That relationship is so important because even if you don't have a mental illness, when you're impacted with a physical ailment or a health issue, it really elevates your anxiety and your level of stress. So that impacts your mental wellness, and if you're already dealing with a mental illness, that just exacerbates it. That comorbidity just makes it worse.

A couple years ago, the National Grange, which is one of our partners, did this survey. The point of this slide is just to recognize that this is input from rural voters, that the people in rural communities really want more information specific to mental health, resources, and information, and even more of a focus on rural youth in terms of the struggles that they're going through.

Rural Mental Health Resilience Program

This is a partnership, the program that provides a brief overview, the Rural Mental Health Resilience Program, and it was developed with Rural Minds and the National Grange. This is one of the programs on our webpage that is like a foundational resource, and we keep building on this. We've developed from this recently a Farmer Mental Health Resilience Program, and the Youth Mental Wellness Program is also an extension of this.

I'll send this deck later on, and if you all are interested in clicking on the links here, they will take you right to the webpage. This is just like a mosaic of a lot of the content that we have on this particular program webpage. It's really based off starting with a recognition that there truly is a mental health emergency in rural America, with elevated rates of suicide in rural communities, in addition to all the barriers that we've talked about.

Beyond that, we're developing the strategy for this program around the fact that people want to do things themselves. Again, that sense of solving your own problems. You can't treat yourself for a mental illness, but you can learn a lot about mental health and open up conversations, reduce the stigma, and raise awareness for the challenges.

This program is really designed to provide that information for people to be informed about the challenges of mental illness, recognize it as an illness, the various conditions and illnesses, and then be part of the solution by talking about mental health in rural communities. If not talking about it, at least being comfortable with other people talking about it, because it's important, like any other problem, you've got to name it and talk about it in order to move toward a solution.

Some of the program materials through this include:

• Something as simple as a program flyer that people can post on bulletin boards
• Posters
• Wallet cards
• A PowerPoint presentation people can use to present in their local community

That presentation can be used either just as a voice of mental health in rural communities or to have somebody who may be courageous enough to share their story and break through some of that stigma that people might be feeling in the community.

There are also key messages for a TED Talk, and we try to meet people where they're at with a lot of information that might align with the various interests and needs of people who would want to access additional content.

Rural Youth Mental Wellness Program

The Rural Youth Mental Wellness Program is something that we have developed right now as a pilot program with partners in two states, and we're going to be promoting this nationally in September.

We're especially excited about this because the programs that we offer, because we are national and because everything on our website is free and we don't promote paid services, have not been able to really connect with people with any type of mental health engagement as far as addressing something that they might be going through.

What we're doing with the youth program is we partner with the Lab for Scalable Mental Health. It's through Northwestern University in Chicago, the Feinberg School of Medicine, and they have developed single-session interventions, which are digital modules that are online. They're anonymous, they're free, and they're going to be developing culturally relevant modules for youth in rural communities.

There are eight different topics that are aligned with sources of stress or anxiety for youth. When I'm saying youth, it's more like teens and young adults. So people can go onto our webpage for this program, and then there's a link to the Lab for Scalable Mental Health website, and all these modules are:

• Available for free
• Anonymous
• Online
• Only eight minutes long

They've reduced the amount of time. From what I understand, I'm certainly not an expert on this, but what the science behind it is recognizing that if somebody is in ongoing therapy, there are certain milestones that take place in the advancement and someone getting through a situation that they're receiving therapy for.

The SSIs are able to capture some of that content in these short versions of the session. They're not intended to be mental health therapy, nor are they intended to replace that, but they are helpful. We were first introduced to the SSIs through a psychiatrist who practices in Montana, and his section of the practice is treating youth in rural communities with a lot of telehealth. He uses the SSIs.

He works in Montana, Idaho, and Alaska. He was saying that, again, the SSIs don't replace treatment, but a lot of the advancements that we enjoy living in a city or a suburb in terms of the latest treatments, medications, and clinical trials for mental health, people in rural America don't care because they're lucky if they can see a primary care physician, who unfortunately oftentimes misdiagnoses their mental illness and puts them on medications that have side effects. He said a lot of people don't have anything.

They're not ideal. They're not the ultimate solution, but they're better than nothing. Unfortunately, a lot of people who are alone and isolated and struggling with a mental illness or a mental health condition, or even just anxiety or stress, have nothing. So we're going to be really excited to launch this program in September.

Farmer Mental Health Resilience Program

We just launched the Farmer Mental Health Resilience Program in February, and here's a link to that program too, and all these are on our website. Some of the materials here include:

• Some of the basics you would expect as far as facts and stats
• What the barriers are
• A free suicide prevention course, and we've got a link to that too
• Some videos

We've gotten really good feedback on this also, and we're excited about being able to branch out into addressing the specific needs of different segments of the population specific to mental health and wellness. Rural America is certainly not homogeneous, so we're really trying to, as we grow, address the differences in what people are looking for in terms of information and how they want to receive their information through these various segments of the population.

Rural Veterinarians and Other At-Risk Groups

Rural veterinarians are often overlooked as another at-risk segment of the population in rural communities, so they have a high rate of suicide also. We're putting together a program, and we started with really doing research again to understand what's needed before we go ahead and do anything.

We completed the first stage through these interviews with different veterinarians who have been practicing, talking with vets who are one to five years in, and some who have left the practice in a rural community because of the different specific stressors. We'll be doing a continuation of this later this fall, but this is another at-risk population that's important to recognize.

Webinar Series and Resources

We do a webinar series. We've got another webinar coming up next week on the 28th, so if you're interested, it's about addressing the stigma in farming communities. We'll have two members of a farming community in different parts of the country. Actually, not that far apart, but they don't know each other, and they do different work.

That's the model or the framework we use for the webinars because we want to focus on a problem that is specific to rural communities, and then have speakers who are in rural communities who can tell their story, share their story, and share their experience. We sometimes have a mental health professional as part of the webinar also.

Ultimately, we want to provide:

• Action steps
• Resources
• Information
• Solutions
• Tools that people can use to help minimize the problem that we're talking about and, again, be part of the solution

Both of the speakers on the webinar next week are interesting because they are farmers, but they're helping people in the ag community that surrounds them by being able to relate to the problems and relate to the stigma, but almost act like a Sherpa, so to speak, to help those people get past that stigma and connect with the information and resources that are available, and potentially with mental healthcare in their community.

All the webinars are recorded and archived on our website. We have a time-coded agenda, so if people want to check out something, they can jump right to the content that's most interesting.

We have a newsletter that comes out once every two months, and here's a link to that. We also have a progress report. We'll be doing our annual report coming up soon too.

We recently added a webpage for rural policy and legislation, and we try to have a nonpartisan voice to communicate some of these initiatives. Again, from the interest of our vision or our mission of being the informed voice for mental health in rural America, a lot of the policies that affect people in rural America are potentially sources of stress and anxiety. So we want to make people aware of those and, again, give them tools on how they can make their voice be heard.

Media Outreach and Community Awareness

The media outreach, we touched on this earlier, but there's this other level of media that's in rural communities and, as mentioned, the smaller newspapers and radio stations that have a local following. A lot of times what we'll do is we want to get the word out beyond just having the content on our website.

We'll do media outreach to:

• The national outlets
• Smaller newspapers through a mat release, which is a pre-produced print piece that can be just popped into a newspaper
• Radio stations, which a lot of times will put the mat release information on their webpage, even though they're not doing any kind of video coverage of what the program is
• Rancher and farmer networks through an audio news release, so we can distribute recorded audio for radio and reach a lot of the rural population

Here's just an overview of some of the partners that we work with on various levels in different categories.

Anyone Can Be a Voice for Mental Health

This is another great video that we did a couple years ago, and it features the young lady, Ashton, who's shown here in this montage just to the left of the logos. I think it's interesting to note that Ashton took it upon herself to be the voice of mental health for adolescents in her rural community.

She went away to college, and she was struggling with going from being the smartest kid in her small school in a rural area to being one of many smart people in a university. It turns out that a young man she didn't know, but who lived on the same floor in her dorm, was also from a small town, and he died by suicide. It really impacted her as far as recognizing the stresses that she was going through.

So she took it upon herself to really advocate for mental health for adolescents in her rural community. I thought it was great because unlike Jeff Winton, the founder of Rural Minds, who had a personal experience that motivated him to take up the torch for rural mental health, Ashton didn't have that, but yet she saw the importance of that.

It really brings to mind that anybody can be the voice of mental health in rural America, especially with the tools that are being provided through a lot of the programs that we're providing to the public at no charge.

Suicide Prevention and Mental Health Education

This Mental Health Awareness and Suicide Prevention course is available online and through our website too. It's developed through Cornell University and New York FarmNet, which is another nonprofit specific to New York State. It's a short course. It's free, which is a nice thing. A lot of universities don't provide free courses.

It's a nice, quick overview of some of the things that are important as far as recognizing suicide and preventing suicide based on awareness, and just some of the other basic mental health information that a lot of people don't really think about until you go through the course and learn a little bit more about what people aren't talking about.

Talk Saves Lives is one of several different suicide awareness and prevention tools. There's also QPR, which is a shorter version, and then there's Mental Health First Aid, which is like seven hours. There's also a new one that I heard about recently. It's an upstream kind of course. I forget the acronym. But anyway, I think that it's nice to have these suicide awareness and prevention training courses and also courses that kind of just train people on the importance of recognizing people who might be struggling with their mental wellness, and being able to provide tools and information so it minimizes the chances of people being in a dark place.

Being Part of the Solution

Again, we're all about partnerships, and I really encourage everybody to be part of the solution in helping to improve mental health in rural communities by confronting the fact that there is an emergency in local communities and rural areas around the country.

Again, even if somebody's not comfortable, which is understandable, very few people can do what Jeff Winton does by telling a painful personal story in public over and over again. Unfortunately, there are a lot of people who've experienced something similar, but the expectation isn't for everyone to do that, of course.

Just being able to help normalize conversations and not shut them down, knowing the facts about mental health challenges. On our website, we even have short one-page, double-sided fact sheets about the various mental illnesses and conditions that we all hear about, but maybe don't really know all that much about. It's just a quick read on:

• Identifying and defining the illness
• What the symptoms are
• How prevalent it is
• How you diagnose it
• How you treat it
• What some additional resources are

They're free and all that. We're not pointing anybody to any type of specific healthcare facility or a physician. It's just more like general information that's helpful and very objective, and really just focused on each of these illnesses and conditions.

We're just asking people to serve as a trusted source of information. Whether or not you're in a rural community or anywhere you live, the people who are closest to you trust you. So people can talk more about mental health and break down some of that stigma, and that really means a lot because that really is the biggest barrier.

Again, giving people the tools, the information, and the resources can really empower them so they can be part of the solution to improve mental health in their community and across the country. We're really all about speaking on behalf of the people who don't really have a voice, who might be really alone, isolated, and struggling. So the work we're doing together is truly life-saving.

Here's the URL for Rural Minds. My email address is just chuck@ruralminds.org, and I just want to thank you all very much.

Q&A

Thank you so much, Chuck. We do have one question, and if anybody else has any questions, feel free to pop them in the chat or in the Q&A box.

Paul asked, "Regarding lack of broadband connectivity in rural areas, definitely a big challenge, but don't most teens and adults have cell phones that they can use for social media, et cetera? Can they not connect with telepsych services at school, libraries, work, or other mobile or Wi-Fi access areas?"

Yeah. All those are options, and we're hoping that people do that. But it's just so much, especially if you're looking for something that's a confidential space. A lot of times, you want to be able to have the option of accessing internet wherever it suits you best. But it's not like there's, just like there are some physicians, you just have to work harder to get to them. So they're barriers. It's not like they're exclusions.

But the things that we might have in urban and suburban areas that we don't really think twice about are not really that common or accessible for a lot of people in rural communities.

Sure. Okay. Abigail says, "Have you had any experience or have seen anything about telehealth access points in rural communities? For example, a booth in a library or grocery store where a patient can see a provider face-to-face with or without an appointment." Have you ever seen anything like that?

I have not. I've heard of mobile units of mental healthcare providers and healthcare providers that go to rural communities, but as one might expect, it's more like one-offs versus anything you can really rely on. It's a real challenge to have any kind of face time with a healthcare provider or a professional in a rural community, and the primary care physicians often have to do it all.

Any kind of illness that would be physical or mental, it's often the primary care physician or the nurse practitioner who is in charge of diagnosing and managing a treatment for people. Even if you were to go to where the providers are, it's hard to find an appointment and face time with a professional to have that conversation.

So it would be ideal, and there are instances where physicians and mental health professionals go to the folks who are not able to get to them, but it's not very common.

And Abigail, I think that is so cool. I actually have not heard about a booth in a grocery store. That is really awesome.

Patrick comments and says, "We have a privacy booth in our library in Custer County, Colorado, and it is working as planned. A grant helped pay for it."

Wow. That's really cool. It seems we've got to be creative with some of these populations because there are barriers. So I think seeing if there's a cool grant out there or being creative in other ways, that is great.

Yeah, those are great ideas. I agree.

Awesome. Okay, it looks like those are all. Oh, I'm just making sure. No more Q&As. Oh, Abigail said, "Chuck, I will email you."

Great. Please do.

Awesome. Yes. Great. It's chuck@ruralminds.org.

Awesome. Thank you so much, Chuck, and thank you everyone for coming. I just want to say, if this is your first time hearing about us at Patagonia Health, let me quickly introduce us. We are an integrated EHR, practice management, and billing solution serving public health and behavioral health, and we have lots of clients in rural areas.

So we would love to answer any questions you may have. Thank you so much, Chuck, and everyone else. Hope you have an excellent Thursday. Bye, everyone.