Rachel Harris Blanton 
Public Health Innovation, Fort Collins, CO, USA
Correspondence to: rachel.harris.blanton@gmail.com
Additional information
- Ethical approval: N/a
- Consent: N/a
- Funding: No industry funding
- Conflicts of interest: N/a
- Author contribution: Rachel Harris Blanton – Conceptualization, Writing – original draft, review and editing
- Guarantor: Rachel Harris Blanton
- Provenance and peer-review:
Commissioned and externally peer-reviewed - Data availability statement: N/a
Keywords: Rural pediatric mental health, Telehealth services, School-based health centers, Behavioral health integration, Youth suicide risk.
Peer Review
Received: 11 December 2024
Revised: 18 January 2025
Accepted: 18 January 2025
Published: 31 January 2025
Abstract
Youth mental health (MH) has increasingly been identified as a major area of concern in the United States. Starting in 2022, organizations such as the American Psychological Association, World Health Organization, and Centers for Disease Control have called for increased attention to the “youth behavioral health crisis”.1–3 While all youth deserve a better system of care for their MH, rural youth are at particularly high risk for experiencing barriers to care as compared to their urban counterparts. These risk factors include stigma and lack of access to providers.4 This article explores emerging strategies for improved access to mental healthcare for rural youth such as behavioral health integration, school service coordination, and telehealth through a public mental health conceptual framework.
Background
The state of mental health (MH), particularly youth MH, has gained increasing attention as a public health concern over the past decade. Alarming trends in the increase of depression, anxiety, and suicidal ideation were identified prior to COVID-19, but the spike during the pandemic was exceptionally notable.1 A variety of MH diagnoses including depression, anxiety, and autism spectrum disorder (ASD) have significantly increased since 2000 while reported symptoms of MH disorders have increased at the same time.5 The suicide rate spiked by 47.7% for 12–17 year olds from 2011 to 2021.6 Within these alarming statistics, certain populations have been identified as at higher risk than others. This includes youth experiencing poverty, certain racial/ethnic identities such as American Indian/Native American youth, and youth living in rural areas.7
Current literature is somewhat mixed on the burden of MH conditions within the rural pediatric population. Historically, many researchers have identified higher levels of burden in rural communities.8 However, there have been several publications disputing these findings.9 These discrepancies could be based on a combination of factors including lower access to specialists to identify and diagnose MH conditions in youth as well as generally reduced affirming attitudes among rural communities regarding MH conditions.10,11 What is not disputed is the elevated burden of youth suicide in rural communities, a risk that has been rising at an exceptionally high rate (1.5 times that of urban rates) in the last 10 years.12 There is a documented correlation between distance to MH services and youth suicide risk in rural communities.13 In addition, there is a consistent finding of elevated alcohol and tobacco use among rural youth as compared to their urban peers.4
While a variety of factors have been identified as potentially related to the disparity in MH outcomes among rural youth, access to care has been most consistently acknowledged as central to this issue.14 As depicted in Figure 1, most counties in the country are MH provider shortage areas as defined by the Health Resources and Services Administration.15 However, there is a significant disparity between rural and urban access. In 2019, urban counties had an average of 13.0 psychiatrists per 100,000 residents, while rural counties had 3.5 psychiatrists per 100,000 residents.16 That is just under a fourfold difference. This is reflected in the availability of treatment settings as well. Only 12% of in-patient psychiatric facilities are located in rural communities.17 At the same time, 40% of rural residents report not being aware of any MH resources within their communities.18 Without access to specialty care, primary care providers become the de facto treatment providers in rural communities.
While rates of psychotropic medication use are similar between rural and urban pediatric patients, primary care providers constitute 34.3% of this class of prescriptions for rural youth, while they only represent the primary prescriber for 13.5% of urban youth.19 Thus, while rural residents are less likely to receive any form of treatment for MH, they are more likely to be treated by a primary care provider for MH concerns.20 One implication for youth, in particular, is that they are significantly more likely to be treated for MH conditions with medications as opposed to behavioral therapy, with prescription rates nearly double those of urban pediatric peers.21 Given these disparities in access, treatment, and some outcomes, it is essential for policymakers, healthcare providers, and other community stakeholders to explore opportunities to enhance MH care systems to better serve youth living in rural areas.
Methods
This article reviews current literature in the context of rural youth/pediatric MH. Publications for inclusion in the literature were selected based on thorough searches of academic and peer-reviewed publication databases such as PubMed and Google Scholar. Studies were reviewed for publication date within the last 10 years with the exception of landmark publications published within the last 20 years. Studies were included if they were published in a peer-reviewed or national association setting and aligned with the content focus of the review (Figure 2).
Potential limitations include bias toward publications related to study populations in more population-dense communities and variances in methodological strategies in the referenced studies. This points to the opportunity to enhance opportunities for rural-specific research in the field.
Telehealth
The use of telehealth for youth MH treatment has risen at an incredibly rapid pace over the past 10 years, largely spurred by necessity through the COVID-19 pandemic. From 2019 to the height of the pandemic in 2020, youth telemental health visits spiked 30-fold (3027%).22 This leveled off somewhat through 2022 but was still 1500% higher than pre-pandemic levels.22 Thus, telehealth has been established as a foundational access point for youth mental health in a moderately short period of time. Despite the relative newness of the treatment modality, it has been identified by the Centers for Disease Control and Prevention (CDC) as an emerging policy option for addressing rural youth access to care.14 This model facilitates access by allowing treatment providers outside of the community to treat youth in rural and/or underserved areas. Psychiatrists, social workers, counselors, therapists, and so on can conduct individual and group therapy remotely as well as medication management sessions.23
Telemental health services have been demonstrated to be largely accepted by youth post-COVID-19 pandemic with a strong preference for video as opposed to phone sessions.24 One exception is play therapy, a treatment modality often used for younger children. There is a much weaker evidence base for telemental health play therapy interventions, although family play therapy, in which the child’s family members engage in directed play, has been described as a promising practice.25 In addition, there is strong evidence to suggest high acceptability of telehealth services among youth, with lower no-show rates as compared to in-person visits.26 Thus, telemental health presents an excellent opportunity to expand access to care for rural youth.
Telehealth services for pediatric psychiatry are particularly promising for rural communities. Several states have built upon the collaborative care model (CoCM) to expand the capacity of pediatric psychiatry by leveraging a consultation model. One such model is KIDSMap from the University of Kansas. This model utilizes two consulting pediatric psychiatrists to serve over 80 primary care sites through training for medical and behavioral health providers (master’s and bachelor’s levels) and as-needed consultations with the psychiatry team.27 These types of programs have shown promise in greatly increasing access to care and service availability, and promoting positive outcomes among youth living in rural communities. It should be further explored for implementation in states without existing programs.28 This model should be considered in combination with both SBHCs and behavioral health integration (BHI) as a means of promoting practice at the top of a provider’s license for pediatric MH services, supplemented with specialist consultations only when necessary.
Challenges to telemental health services such as stigma and concerns regarding liability have been greatly reduced in the past 5 years.26 However, challenges, such as sufficient bandwidth for services, appropriate coordination of services, and specific concerns regarding medication management, exist.29,30 Rural communities should consider working with the USDA to increase access to broadband and utilizing formal care compacts to help guide service coordination and appropriate roles and responsibilities in the telehealth model. This will greatly reduce barriers to care for children and complement the other strategies discussed below (Figure 3).
School-Based Health Centers and Programs
School-based health centers (SBHCs) have also risen in popularity in the last 20 years. As of 2019, there were 2315 SBHCs in the United States, a 11% increase over 2011.31 SBHCs are models of care in which healthcare clinics are co-located within a school setting. Students may receive primary care and MH services on-site, thereby significantly increasing their access to care services.31 The relationship between SBHCs and positive outcomes for youth has been long established with previous researchers noting that SBHCs improve access to MH services, improve pediatric health-related quality of life, and reduce total Medicaid spending for students receiving services.32 There is a strong evidence base for SBHCs, particularly in rural areas. The literature shows SBHCs have a positive effect on not only the physical health but also MH and educational outcomes for students.33 In fact, policy leaders and researchers have noted that in the face of provider shortages and lack of access to care, schools have become the most common providers of children’s MH care.34 Approximately 70% of SBHCs offer mental healthcare services through psychologists, psychiatrists, social workers, or substance use providers.35 This helps alleviate the burden of MH care on school counselors and administrators, the majority of whom have little to no training in clinical therapy. In addition, SBHCs have been identified by the United States Community Preventative Services Task Force as a strategy for improving health equity.36
In particular, the CDC has identified SBHCs as one of three strategies to promote access to behavioral health care for children living in rural areas.14 This may be attributed to the relative centrality of schools in rural communities with limited other services.37 When there is no easy access to a MH office or even a pediatrician’s office, school may become the primary site of service access and referrals. When services are embedded in the school, major barriers, such as travel distance, time off work and school for children and families, and poor coordination between school staff and external services, to services can be removed. Coordination of services between a primary care provider and community MH provider can be particularly essential given the strong role the school has in identifying mental and behavioral concerns.38 For example, the school counselor may be aware of a student’s changes in mood and behaviors well before that child would be seen in a healthcare provider’s office, as the school counselor has contact with the child’s teachers and potentially the child’s every school day. In an SBHC setting, the counselor can walk down the hall to discuss these changes with the provider, as long as the appropriate releases of information have been signed, as opposed to communication limited to higher-level behavioral escalations or no communication at all. This means better, more appropriate care for the student.
Challenges for rural SBHCs include differences in state funding, recruitment of providers, the complexity of medical service regulations in the school setting, and increasing regulatory requirements for parental consent in certain states.33 In particular, funding strategies can be particularly challenging for individual schools to address. Barriers such as capital costs for clinic development in the school, often lower than commercial Medicaid reimbursement rates and administrative costs, can be particularly limiting. Environments for practice vary from state to state, but the School-Based Health Alliance has published a map showing funding and policies by state.35 Systems and networks looking to implement SBHC should refer this map. At the policy level, recommended Medicaid policies to support SBHCs include (1) define SBHCs as a provider type; (2) waive prior authorization for SBHCs; and (3) require managed care organizations to reimburse SBHCs.35 If traditional SBHC models are not accessible or an option in a particular rural area, alternatives include utilizing a mobile service (i.e., a mobile van that visits the school once per week) or a co-located model of care for MH services in which an external MH provider leases school office space at low or no cost to provide services on-site.35 In addition, researchers have noted that the success of programs is highly contingent on family and parental involvement and should be a primary target of networks looking to expand SBHCs or similar services.37 Therefore, the model should be considered a community effort to improve youth MH.
BHI
BHI is the basic model of embedding mental/behavioral health services within a primary care setting to promote access to care.39 It has been proven to improve outcomes for a variety of conditions, reduce costs, and improve provider satisfaction.40 In addition, it is now a recommended strategy to enhance access to MH care for rural youth.14 This is due to the fact that primary care providers have become the de facto source of care for children with MH concerns in rural areas.21 Unfortunately, primary care providers in rural communities report being significantly more comfortable assessing and referring than treating children within their own clinic. At the same time, a majority of these primary care providers report difficulties in accessing MH care for their services.41 Thus, embedding MH supports in a primary care clinic creates internal capacity for care and can improve medical providers’ comfort and capacity to treat pediatric MH concerns.18 It can also reduce stigma in accessing services, as parents and children may be more likely to access care in the primary care setting as opposed to a specialty MH setting.37 BHI most commonly involves a master’s level clinician (social worker, counselor, etc.) as a part of the care team delivering brief interventions with patients. Brief interventions can be immensely effective and may reduce inappropriate reliance on medications, notably higher among rural providers than urban–suburban providers.19
However, barriers to BHI in rural settings include training, financial sustainability, and provider recruitment and retention. This can be particularly challenging in low-access communities in the rural United States such as Southern Regions and those with more independent providers.42 Fortunately, over the past decade a variety of tools and resources have been developed to increase access to training and promote financial sustainability.43 Yet provider recruitment and retention remain challenging for many agencies. Key strategies include certification as a National Health Service Corps site to facilitate loan repayment and providing salaried positions for MH providers.44 Policymakers can continue to advocate for policies to support BHI in rural communities such as workforce development programs to facilitate internships in rural communities and improve reimbursement for brief interventions.45
Conclusion
Inequities in rural youth access to care remain persistent. However, there are effective strategies that can be implemented at the local and policy levels. These include telehealth services, SBHCs, and BHI. Strategies can be combined such as in staffing SBHCs with telepsychiatry services or using a teleconsultation model for BHI.46 These models all have the potential to address barriers to care for rural youth so they can have the opportunities to thrive as youth living in any other community through well-managed MH. Emerging opportunities to enhance access and research related to rural youth MH include the use of AI incorporated into telehealth and asynchronous support strategies and community participatory research. These applications should be further explored and defined in the rural context.
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