DataWatch
Rural HealthRural Residents With Mental Health Needs Have Fewer Care Visits Than Urban Counterparts
- James B. Kirby ([email protected]) is a senior researcher in the Center for Financing, Access, and Cost Trends at the Agency for Healthcare Research and Quality (AHRQ), in Rockville, Maryland.
- Samuel H. Zuvekas is a senior adviser in the Center for Financing, Access, and Cost Trends, AHRQ.
- Amanda E. Borsky is a dissemination and implementation adviser in the Center for Evidence and Practice Improvement, AHRQ.
- Quyen Ngo-Metzger is a professor of health systems science at the Kaiser Permanente School of Medicine, in Pasadena, California. At the time this article was written, she was scientific director, US Preventive Services Task Force Program, Center for Evidence and Practice Improvement, AHRQ.
Abstract
Analysis of a nationally representative sample of adults with mental health needs shows that rural residents have fewer ambulatory mental health visits than their urban counterparts do. Even among people already on prescription medications for mental health conditions, rural-urban differences are large.
In the 1980s US mortality rates in rural areas surpassed those in urban areas, and the gap has steadily widened since.1 However, this growing mortality differential has not been uniform with respect to cause: The widening of the rural-urban mortality gap over the past decade is due disproportionately to differential death rates from suicide, overdoses, and alcohol-related liver disease.2 Together with the well-documented scarcity of mental health professionals in rural areas (exhibit 1),3 this makes it important to better understand rural-urban differences in access to mental health services. This study extends previous research on rural-urban differences in mental health care access, which is typically based on the supply of providers and overall utilization rates, by describing rural-urban differences in unmet need for mental health services. Specifically, based on a nationally representative sample of adults likely to need mental health care, we present findings on rural-urban differences in ambulatory mental health visits, controlling for mental and physical health status and a variety of sociodemographic characteristics.
Exhibit 1 Distribution of urban, rural-adjacent, and rural-nonadjacent counties, by numbers of psychiatrists per 100,000 residents, 2017–18

Study Data And Methods
Our data for 2010–15 came from the Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the US noninstitutionalized population. We identified the counties in which respondents lived by geocoding the addresses where MEPS interviews took place. Based on this, we grouped respondents into three mutually exclusive rural-urban categories. The analysis was restricted to adults with mental health care needs, defined as those who scored 13 or higher on the Kessler K6 Psychological Distress Scale or 3 or higher on the Patient Health Questionnaire (PHQ)-2 Depression Scale (). Both scales have been validated elsewhere and are effective at identifying people with serious mental disorders.4,5
We classified ambulatory mental health visits as all office-based or hospital outpatient visits in which the respondent reported mental health treatment as the main reason for the visit; a mental health condition was associated with the visit; or the visit was to a psychologist, psychiatrist, social worker, or other mental health specialist. Mental health drug fills included antidepressants, antipsychotics, antianxiety medications, and other medications commonly used to treat mental disorders.
Research suggests that the metropolitan-nonmetropolitan dichotomy, as defined by the Office of Management and Budget, masks important differences across nonmetropolitan areas by their proximity to metropolitan areas.6 We therefore used a categorization scheme that consisted of three groups of counties: “urban” (metropolitan counties), “rural-adjacent” (nonmetropolitan counties adjacent to metropolitan counties), and “rural-nonadjacent” (nonmetropolitan counties not adjacent to metropolitan counties). We estimated utilization differences adjusted for mental health, using the Mental Health Component Scale of the Short-Form Health Survey (SF)-12; self-rated health; the presence of multiple chronic conditions; age; sex; race/ethnicity; household income; and insurance status. This was done by estimating a linear regression model for each outcome variable (see online appendix exhibit A1 for a description of the regression models and exhibit A2 for a table describing the variables used).7
This study had several limitations. First, our identification of mental health visits relied on respondent-reported perceptions of health care encounters, particularly in primary care. Our observed rural-urban differences in mental health care use may partly have reflected differences in the use of primary care that had some component of mental health treatment but was not reported as such by respondents.
Second, we could not assess the extent to which utilization differences were due to differences in access to care versus differences in demand for care. Demand for care is driven not only by medical need, but also by the willingness to seek treatment—which could differ between rural and urban areas. Compared to urban residents, for example, rural residents perceive greater stigma to be associated with mental health conditions,8,9 which might hold down their utilization independent of access to care.
Study Results
There are stark differences in the county-level supply of psychiatrists across rural-urban categories. For example, in 2017–18 about one-third of urban counties had no psychiatrists per 100,000 residents, compared to 79 percent of rural-nonadjacent counties (exhibit 1). This pattern is well documented but does not, by itself, constitute strong evidence of widespread unmet need in rural areas: The supply differences shown in exhibit 1 could simply be a reflection of differences in the demand for care. To assess rural-urban differences in unmet need, we went beyond existing research and examined the actual use of mental health services among people who exhibit need for them. Compared to residents of urban counties (), residents of both rural-adjacent () and rural-nonadjacent () counties had significantly fewer ambulatory mental health visits during the period 2010–15 (exhibit 2). Rural-nonadjacent county residents had 73 percent fewer visits than urban county residents did (0.9 versus 3.3) and 59 percent fewer than rural-adjacent county residents did (0.9 versus 2.2). On average, rural-adjacent county residents had 33 percent fewer ambulatory mental health visits than urban county residents (2.2 versus 3.3). The average number of specialist visits also differed across the rural-urban categories. Rural-nonadjacent county residents had 73 percent fewer visits than urban county residents did (0.6 versus 2.2), while rural-adjacent county residents had 41 percent fewer visits (1.3 versus. 2.2).
Exhibit 2 Adjusted annual mean numbers of visits or prescription drug fills for mental health, by county type, 2010–15

Compared to rural-urban differences in ambulatory mental health visits, differences in the average number of prescription drug fills were smaller. Rural-nonadjacent county residents had 21 percent fewer prescription fills compared to urban county residents (5.2 versus 6.6), and rural-adjacent county residents had 12 percent fewer prescription fills (5.8 versus 6.6).
People on psychotropic medications should be regularly monitored by qualified providers to ensure the safety and efficacy of treatment. We therefore estimated the mean number of ambulatory and specialist visits among people taking at least one prescription medication for mental health. Among those with a prescription drug fill, rural-nonadjacent county residents had 54 percent fewer ambulatory mental health visits than urban county residents did (2.9 versus 6.3) and 55 percent fewer specialist visits (1.9 versus 4.2) (exhibit 3). Rural-adjacent county residents with at least one prescription drug fill had, on average, more ambulatory and specialist visits than their rural-nonadjacent county counterparts, but still fewer than urban county residents.
Exhibit 3 Adjusted annual mean numbers of visits for mental health among those with at least one prescription drug fill for mental health, by county type, 2010–15

Discussion
Our findings demonstrate that among people likely to need mental health treatment, rural residents typically received fewer mental health services than urban residents did in 2010–15, even after mental and physical health and a variety of sociodemographic factors were controlled for. Rural-urban differences in the use of prescription drugs were proportionately smaller than differences in the number of ambulatory visits (for example, rural-nonadjacent county residents had 73 percent fewer ambulatory visits but only 21 percent fewer prescription drug fills, compared to urban county residents). This suggests that barriers to obtaining in-person mental health treatment in rural areas may be more severe than barriers to obtaining pharmacological treatment of mental health conditions. One possible explanation for this is that, unlike psychological therapy, prescriptions can be obtained outside normal working hours and in a variety of locations (for example, retail pharmacies and grocery stores). Given the shortage and geographic dispersion of mental health providers in rural areas, this flexibility could be more valuable to rural residents than to urban residents.
Finally, we found that rural residents who were taking prescription drugs for mental health conditions had far fewer in-person visits than their urban counterparts did. Thus, even among those who demonstrate need for mental health care and willingness to seek it out, large rural-urban differences in the volume of ambulatory mental health visits persist.
There are several possible approaches to improving access to in-person psychological therapy in rural areas. Incentives for providers who practice in underserved rural areas could help ease service shortages. Loan repayment programs such as the National Health Service Corps of the Health Resources and Services Administration might be having some success at doing this.10 However, the latest data on the supply and geographic distribution of mental health professionals still indicate acute shortages in rural areas,11 and projections suggest that shortages are likely to continue.12
Training in mental health treatment for nonphysician providers—together with scope-of-practice regulations that allow advanced practice registered nurses and physician assistants to screen for mental health conditions and provide basic mental health services (including, in some states, writing prescriptions)—is another potential way to increase the availability of mental health services in underserved rural populations.13 This approach requires “task sharing,” or allowing and encouraging local staff to work at the top end of their training, while leaving scarce, highly trained specialists to act more as consultants or supervisors than as direct caregivers. This team approach can enable a small number of high-level mental health providers to serve more people across wider geographic areas than would otherwise be possible.14
Expanding access to telemedicine is another possible approach to increasing access to mental health monitoring and treatment in rural areas. Many states have passed laws mandating parity in insurance reimbursement for telemental health services, but while utilization rates have increased, they remain relatively low and vary widely across states.15 Policy makers may wish to investigate options for increasing the accessibility of telemental health in rural areas, such as expanding the availability of broadband internet access.
Given the role that mental health plays in the widening rural-urban disparities in health and mortality, programs and policies that seek to reduce these disparities should consider putting more emphasis on access to and use of mental health services. While provider location incentives, scope-of-practice expansions, and telemental health have the potential to improve access to mental health treatment in rural areas, research is needed to evaluate their relative costs and effectiveness and to explore ways in which all three approaches might be combined to reduce barriers to and improve the quality of mental health treatment in rural areas.
ACKNOWLEDGMENTS
The views expressed in this article are those of the authors, and no endorsement by the Agency for Healthcare Research and Quality or the Department of Health and Human Services is intended or should be inferred.
NOTES
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