As life increasingly shifts online amid the COVID-19 pandemic, so too is mental health care, with a growing number of providers offering virtual services via the web.
For rural Idahoans living in so-called mental health-care deserts, where providers are few and far between, that’s good news, experts say, as expanding behavioral health telemedicine services means improved access to care and resources.
It’s a “silver lining” of the pandemic, as Christina Cernansky, executive director of NAMI Wood River Valley, describes it—and Cernansky and other local experts hope that silver lining is here to stay.
“I think [telemedicine] is a tide that’s going in one direction, and it’s positive for Idahoans, especially Idahoans in rural parts of the state,” said Lee Flinn, director of the Idaho Suicide Prevention Hotline. “I don’t see that turning the other way and going backward.”
A local shortage
The South Central Public Health District—which consists of Blaine, Lincoln, Gooding, Camas, Twin Falls, Cassia, Jerome and Minidoka counties—is a designated mental health professional shortage area, according to the U.S. Health Resources and Services Administration.
It’s not alone. According to the federal agency, every public health district in Idaho—with the exception of the third and fourth districts, which contain Ada and Canyon counties—has a shortage of mental health professionals.
“All across the country there’s a huge shortage of mental health therapists,” Cernansky said. “We do have a lot of challenges [in the Wood River Valley], but we also have a lot of strengths compared to other communities.”
There are social workers and therapists in each school in the Blaine County School District, Cernansky pointed out, and the local NAMI chapter offers support groups and other resources. Still, it can be hard to find a therapist locally who accepts Medicare and Medicaid, Cernansky said. And while some accept health insurance, others only take cash payments.
A growing number of mental and behavioral health care providers offering virtual services online will give Idahoans a wider range of options, Cernansky said, potentially reducing some distance- and cost-related barriers.
The question now: whether those options will remain available post-pandemic.
“We’re having the conversations locally, regionally and statewide about how do we continue offering remote support for people that don’t otherwise have access to transportation or health insurance?” Cernansky said.
Idaho consistently has one of the highest suicide rates in the country, coming in fifth-highest in the nation in 2018 with roughly 24 deaths per 100,000 people, according to the most recent data from the U.S. Centers for Disease Control and Prevention. Suicide was the seventh leading cause of death for Idahoans that year.
Experts attribute Idaho’s high suicide rate in part to a shortage of mental health care professionals and accessible resources. But cultural factors may also play a role, particularly in rural parts of the state.
“There’s more of a mindset and risk for suicide in rural areas than in urban areas,” said Denise Jensen, who oversees the Suicide Prevention Program in Idaho’s Division of Public Health. “Idaho is very much, and even more so in our rural and frontier areas, pull yourself up by your bootstraps and don’t ask for help.”
“There’s still a lot of stigma about mental health,” said Elizabeth Fore, interim director of the Institute of Rural Health at Idaho State University. “People don’t want to ask for help, and that’s not an unusual attitude.”
Some of the factors that can exacerbate depression and risk of suicide—social isolation, anxiety and economic stressors—may be magnified in the coronavirus pandemic, Fore noted.
“We’ve got all that adding up,” she said.
Suicide and COVID-19
The statewide Idaho Suicide Prevention Hotline hasn’t seen a significant increase in calls since COVID-19 arrived in Idaho, according to George Austin, clinical team lead for the hotline, though he estimates that around 1 in 4 calls these days include some mention of coronavirus.
"For some people it's a serious issue," Austin said. "For some people, it's just that their life has changed because of the ripple effects of the lockdown."
While the number of calls has remained consistent with previous years, the hotline has seen some trends in the content of calls since the first cases of coronavirus were confirmed in Idaho, Austin said. In general, there are “much higher rates of anxiety” in callers, he said, as well as more calls stemming from interpersonal conflicts in the home.
Still, Austin said, “there are a lot of risk factors for suicide moving forward.” While Idaho businesses have begun to reopen and statewide self-isolation standards have begun to relax, the economic impact of the pandemic is expected to be felt for months or even years to come—and public health officials have warned of a potential second outbreak later in the year.
“[Idaho] had been struggling with increasing suicide rates for the past 20 years,” Austin said. “This is not going to help us in that fight to reduce those.”
Statewide, health officials and other stakeholders are keeping a close eye on suicide data to see how and whether the pandemic is having an impact, Jensen said.
“When it comes to both suicide and drug overdose, we’re having active conversations right now around what does COVID mean for those and how do we address them?” Jensen said. “I don’t know if we have any really solid answers right now in those arenas, but we’re having those conversations. We’re also very much aware that there’s the potential for a time to come when there will likely be an increase in suicides.”
For Idahoans who cannot easily access—or afford—behavioral health services, the Suicide Prevention Hotline has been an especially important resource in the past.
"There are people who are literally a couple hours drive from the nearest counselor, and for those people it's always been a struggle to figure out ways to support them," Austin said. "The hotline, for many of those people, is a lifeline, because it's somewhere they can talk."
Even as behavioral health care providers expand their online services, the Suicide Prevention Hotline may continue to be the most accessible option for some Idahoans. The growth of telemedicine and video appointments highlights another challenge for some people living in rural and remote areas: internet connectivity.
As a state, Idaho ranks 37th in internet connectivity and last in internet speed, according to statistics presented by the Idaho Broadband Task Force in 2019. About 85 percent of Blaine County residents have broadband access, data from BroadbandNow shows. But the Blaine County School District’s shift to remote online learning at the start of the COVID-19 outbreak in Idaho highlighted the so-called “digital divide” between Blaine County residents with internet connectivity and those without it. At the start of the pandemic, 296 families in the district reported having insufficient or no internet at home.
“If you’re working with rural communities where the internet access is bad, and if you’re talking to older residents who are not comfortable with technology either, all of that creates an additional barrier” to mental health care, Fore said. Rural areas tend to have a slightly higher share of residents 65 or older than urban areas do, U.S. Census Data show.
Earlier this year, the Legislature passed a bill aimed at making telehealth care more accessible to people in rural areas. The bill removed the state’s requirement that doctors and patients communicate using a two-way audio and video connection, theoretically letting them use other methods, such as email, instead. While some medical providers worried that the bill would reduce the quality of care, its supporters said loosening the requirements would make it easier for people who live far from the nearest doctor and have limited internet access at home.
Remembering to connect
At a time when keeping a physical distance from one another is advised by health experts, maintaining social connections is especially important, experts say.
“I think that in general we’re concerned just about what the new norm is and what’s normal,” Cernansky said. “But we have to remember to get back to exactly what we recommend in the first place—connecting with loved ones through safe social distancing.”
Fore encouraged people to check in on friends, family and neighbors with phone calls regularly.
“Just let people know there’s someone out there if they’re needing anything,” Fore said. “Just a take-care-of-your-neighbor attitude.”