Barriers exist for mental health care in rural America

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[Yeager] Hi everyone, I'm Paul Yeager. This is the MToM podcast, a production of Iowa PBS and the Market to Market TV show. We're going to go to a topic that we cover quite a bit, and it's because we feel extremely important about it, especially in rural areas. And that's mental health. But we're also going to talk about the change in how we talk about the issue, not necessarily mental health but brain health. We're going to understand a little bit better and how some treatments have changed. But we're also going to cover four important topics that are true everywhere, but especially in rural areas. And again, this is going to be a little heavier Iowa. But we know that it applies to many other spots across the country. Tarrah Holliday is our guest today. She has a whole lot of names because she has a whole lot of jobs. she is a clinician and medical director at Zion Integrated Behavioral Health Services, based in Atlantic, Iowa, which has eight facilities in Iowa. And they are different than a hospital. They are different than other locations that get treatment. We're going to talk about how four big factors come in this discussion. We're going to talk about accessibility, availability, affordability and acceptability. That is our topic today. This is the MTM podcast. If you have any feedback for me, send me an email at Paul Yeager at Iowa PBS. Let's get to our discussion. Tarrah, the mental health words, hugely broad. So let's let's what does mental health in rural America mean to you?

[Holliday] Well, I feel that we really need to advocate and speak differently about mental health instead of using the verbiage mental health. I think that we need to transition to discussing brain health and normalize that as a part of the body, and that it also requires treatment and it is okay to treat the brain as if you had diabetes or a heart condition. We really need to transition to normalizing that. The brain is in fact part of the body.

[Yeager] Does that help? Maybe understand how we get to where someone does have a condition that needs to be addressed is because of an injury to the brain, not because of something else. That's what it sounds like you're saying.

[Holliday] It can be. Absolutely. There can be brain health concerns that are genetic. Family histories obviously play a role. There are brain injuries which can play a role as well. Some individuals develop early onset dementia or Alzheimer's disease that further complicate things. And we have a crisis in the United States with substance abuse, which further contributes to mental health. And, whether the substance abuse came first and triggered the mental health disorder or whether they are self-medicating because they're not getting proper treatment or adequate treatment from their mental health services. it it can be very complex. And a multitude of reasons that they may need help.

[Yeager] Let's jump straight into the deep end on this one. Let's step back for a minute, Tarrah, and how you got involved in this, what prompted you to kind of spend your career, talking about this topic?

[Holliday] So I have a background in the emergency room and working with a multitude of different age groups. and I have always had a passion for mental health, brain health, and advocating for those that maybe feel there's a stigma and they don't feel comfortable getting help. I want to be a part of normalizing that and, addressing the stigma, lessening the stigma, and providing really good quality care. And some of those patients are not able to maybe they feel judged, maybe they're not able to afford their treatment. And in my setting, we're able to provide those things to them. And so it's incredibly rewarding to see those that are struggling, get a quality of life back and do very, very well.

[Yeager] Well, I want to go back to, one of the things you just said there, people who live in a city or in the country, they're proud either way. And they have this stigma of, I don't want to tell anybody that I might need help. And that's true whether you're driving a tractor or you're driving a Subaru, it's the same. But let's start with stigma first. Where did that come from?

[Holliday] I think it is deep rooted, especially with some of our older generation. They are tough. They work on the farm and they have a mentality. I think you've probably heard a lot of times you just pull your boot, pull yourself up by your bootstraps and, you know, we really need to support them and make it okay to get the help that they need. And I do see a positive transition in that direction, which is encouraging.

[Yeager] It. Was there one watershed moment or is this just a slow evolution?

[Holliday] I think there's a slow evolution to a lesser stigma, but stigma is still a huge issue. in other interviews I've done on this topic, we've talked about telehealth and the Covid era. Really kind of put where we can talk on our phone, like you and I are doing right now, for some type of counseling or treatment or diagnosis, instead of driving the car that everybody knows, or the pickup truck to the clinic and know that we're going in that door, has that assisted in this or. I feel it's absolutely assisted. They feel more comfortable that, you know, in small communities, everybody knows everybody. And so they are, you know, maybe worried that they might be judged. Or will my personal information accidentally be disclosed. And so that has allowed them to feel more comfortable and feel that they can access care in a private setting where they're not going to run into their neighbor or someone that they know in the community.

[Yeager] Well, accessibility is one of those things that I wanted to talk about. There was a recent study done this summer, Common Sense, Iowa looked at where options were in rural versus urban settings and said that, you know, certain access has gone down. What do you see in accessibility for a rural clinic versus an urban clinic that can offer help?

[Holliday] Yeah, that's a great question. Sadly, funding, especially in the state of Iowa, I can speak to that. But I think that it's across the United States that funding is becoming more and more problematic, and therefore there are fewer and fewer resources. There's less psychiatric providers available, and there are less clinics available. That creates a long waitlists for patients. And then sometimes, they become discouraged or they may end up going to their primary care for help. Initially so that they can get in faster. so it is certainly a barrier, unfortunately, to all areas, but especially rural areas, being able to provide care to the I mean, really essentially were inundated with patients seeking care, which is a wonderful thing. We want them to seek care and get what they need. Unfortunately, there's just not very many of us to provide the best care, whether it's a provider or a clinic.

[Yeager] Well, it is political season, we could argue, is the reason there's not those, types of folks like you that are helping is because they're going somewhere else. Or is it just there's just not as many professionals in the industry right now.

[Holliday] I think that the lack of professionals in the industry is certainly a huge problem. and I don't know that I can pinpoint any specific reason as to why, individuals are not going into our field. it is a difficult field. And, you know, especially as mental health transitions there, there is a trend, where mental health facilities are transitioning to a CCP HRC model, which means behavioral health model, where we are treating both mental health and substance abuse. And that adds another layer of complexity.

[Yeager] And I've heard, there's a sheriff in Iowa who was on one of our shows on our network a couple of months ago, and he talked about how there are certain sheriff's departments that have become jails, have become, de facto, treatment facilities for both, either the alcohol or, brain injury type thing. And that's that to me, is probably the last place you want to see someone get health.

[Holliday] Absolutely. That's not what the jails are meant for. That is not what our police department is meant for. Personally, as a provider, I'm very grateful for our police department and what they do. Their job is incredibly difficult. And again, mental health, just further compounds that, and unfortunately, they do end up with a lot of individuals who have mental health issues that or substance abuse, like you mentioned. And they're in the jail not getting the treatment they need. One thing I'm proud to say in our community is that we have built a really great rapport with our police department. They've done a phenomenal job, and we provide telehealth services to those individuals if they request mental health services and get them treatment. And the police actually go to the pharmacy and pick up their medication.

[Yeager] How long has that program been around?

[Holliday] Honestly, it's evolved over the last year and really improved that. We've worked together and put in a great effort to make that happen and improve. I think that they see a need as well in the benefit. And so we've all been able to collaborate and work together so that those individuals, especially while they're in jail, they're in a safe environment, they're in a controlled environment, and we're able to stabilize them and get them the treatment that they need as well.

[Yeager] let's use the medical and the, the, the jail side of things. Are the police officers like your triage nurses right now? Because they can maybe identify they know. Oh, I know where I've been to this address. I know what their background is. I know they're going to need this. I mean, do you think of it in that sense that sometimes they'll. The law officer becomes a triage person for you?

[Holliday] Essentially, absolutely. They are very familiar with these individuals in our community. They build a relationship with them. They know their background. They are definitely a great resource to guide treatment and ensure that they get the treatment that they need. So it's it's a wonderful collaborative relationship.

[Yeager] So then back to the medical clinic. How often to someone in your community, I mean, the hospital where you're based out of is a, I call it a it's a it's just a larger small town. It's less than 10,000 people. but it absolutely in rural America has those have become the centers that are not the large cities that have to have all these services are communities that let's just talk about that 10,000 or under city community, what should staffing numbers look like to be able to address population? Just in a general sense.

[Holliday] So I don't necessarily have an answer for you. That's a really loaded question. especially with us having such a shortage of not only providers but organizations that provide the services. for us personally speaking from a community mental health center, we are not able to turn anyone away. And so if they need services, we figure out how to provide those services and get them in as quickly as possible. We also have a policy that if someone has been hospitalized and they are within our catchment area within 7 to 10 days, we do a hospital follow up with them to ensure that after hospitalization, they remain stable, they're tolerating their medications and they are doing well, and establish rapport so that they can have follow up care thereafter. So there's collaboration between the hospital and our organization as well, to ensure that the bridges gap or the gap is bridged.

[Yeager] Do we go back to the very first thing you and I talked about with the brain injury? And thinking about it in that way, has the language transition been to those clinics? and those hospitals in areas of the way they approach it and figuring out how treatment might be? And yes, medication is likely the outcome here. It's just determining what the medication is. But how do those health care folks understand the ‘what it is’ than ‘how this’ has transitioned in care.

[Holliday] So often they are stabilized on medication. They have been seen by neurology. And so it's a collaborative effort where one of us in our organization take over and manage the medication and continue to collaborate very closely with neurology. That's not to say that they may exceed our level of care and what we are able in a small community to provide. And unfortunately, then we are referring them to the city. But, it's difficult for them because of transportation and things like that. Ultimately, it's what's in their best interest.

[Yeager] And we talked about funds earlier. Is money an issue that can help in this solution?

[Holliday] Thankfully, in the state of Iowa, we do have a lot of mental health grants, and so services can be covered by the mental health grant. we have the heartland region of Iowa in my area. And, so they provide a lot of funding especially I'm affiliated. We have a crisis center. Often times the region is funding a lot of the services for the crisis center, where patients stay 3 to 5 days. We have other options outside of that. The mental health grant, we have other grants for substance abuse that patients may qualify for. We have tickets for transportation to get them to their appointments. And so the transportation concern is often resolved by what we can provide. And then, we have sliding scale fees as well. So we do offer a lot of resources to ensure that they receive care. And we do not refuse anyone for their inability to pay. So even if they can't pay, and we know that they receive services.

[Yeager] Is their insurance company willingness to help in this solution as well? In, in, in helping people. And that doesn't have to rely on a, on a, on a federal grant or a state grant.

[Holliday] I do feel that Iowa medicaid, by and large, does a nice job of paying and supporting mental health and making sure that they are getting their services, whether it be therapy or medication management, through myself or my colleague. And then medications are paid for pretty well. Also, several pharmaceutical companies provide samples that we store in our office. And so oftentimes if a patient has no insurance and the medication may be too costly for them, we're able to provide samples and ensure that they get medication that way as well.

[Yeager] And private insurers are keeping up with what Medicaid is doing, too. Or have they been helpful in this, or are they getting dragged along for the ride? Sorry, that's words in your mouth. I don't mean to do that, Tarrah. Sorry.

[Holliday] That's okay. I feel that they're helpful. Could it be better? Yes. they pay for the services. Very well. private insurance. In regard to some of the newer medications that may be cleaner options. And mindful of the whole body versus just stabilizing the mental health symptoms. are not always covered, which is unfortunate, because that's another piece to this. We need to trance, transform our thought process and move towards really looking at the whole person and what their needs are physically and mentally, both like we talked about when we started. It is the whole person. The brain is part of the physical health and we need to treat it as such. And so therefore being mindful of metabolic and some of those medications that are maybe more detrimental to a patient's, blood sugars, weight gain, kidney function, liver function, cardiac. We need to be very mindful of that and be proactive. And there's some newer medications on the market that are doing that. that with private insurance it's a little more difficult to obtain.

[Yeager] I want to go to the word injury here for a minute, because in my, in my thought process is I think that an injury can be rehabbed, that if I have a bad shoulder, I can medication's going to help me, but it's still, I need that cartilage, and I need that bone to to recover. How does medication help in fixing an injury in the brain? That gets it to a point. And it is it always going to be medication is the answer. Or is there going to be some type of medication that helps us, repair the injury in the brain?

[Holliday] So if there's any imbalance in the brain causes the brain to structurally change. And so it's very important to as quickly as possible, get the care that is necessary and to get the proper diagnosis and the proper medication on board, which corrects the imbalance in the brain that stabilizes things. The brain then communicates normally, because the body itself as a whole, whether it's the brain or other organs, will accommodate for something that is not functioning correctly. The brain does the same thing, and then structural abnormalities happen. And that further complicates things. And so if we can correct that, then long term the patient has a much better outcome.

[Yeager] I'm just fascinated on how things have developed in time. I've said this on this podcast before. My mother was a mental health nurse for decades. And she always talks to me about the importance of medication balance and understanding that getting that cocktail just right is not an easy thing to do. It takes time. And that doesn't sound like that has changed from her time. I mean, she's already been retired a couple of, a few years, but it doesn't sound like that has changed, that we are still trying to find balance, in repair, of the brain and trying to get those neurons to fire with what you said is what's not there in the future is. Do I have that right?

[Holliday] You do? Yes. Yeah. It's very complex. every patient is it has to be individualized. And that's what I love about mental health is the challenge. you get to know people, you build rapport in a relationship with them, and you become a support to them and identifying what truly is going on and what are their needs. And it stems further from just identifying the imbalance in the brain and correcting that with medications, but also how do we help them function better? Do they need community resources such as case management? and collaboration with their primary care so that they're getting appropriate labs and testing? Do they need occupational therapy or physical therapy to assist? There's a lot of different therapies that are necessary. Additionally, I am a huge advocate for counseling. There is a lot of data out there that shows medications in combination with mental health therapy improves outcomes immensely, and I see it every day.

[Yeager] And does that counseling does it always. Can we go back to that? We talked about the the virtual option, if we've got somebody that just isn't in our neighborhood and I shouldn't say neighbor in our county, we don't have to travel 20 miles. We can try travel 20 steps to the living room and have that conversation.

[Holliday] Absolutely. Now it is individual based and depending on the severity of trauma or whatever their needs are, we provide a multitude of different treatment modalities. Some of them are better responded to in person. Some patients, when they are in the therapy setting, prefer being in person. And so it really, again, is individualized to that person. What is their preference? What do they feel they need? And then depending on the treatment modality, it may require them being in person. But often times we're able to navigate that where they can do the telehealth, if that would make them more comfortable.

[Yeager]  So who decides? Is it better to be treated in person or via the phone?

[Holliday] The therapist will evaluate them, typically in person. Ideally, we meet with them in person for medication management and for therapy to identify and see them in person. We need to get wait vitals, and view them in person and identify what their needs are. Are they going to benefit from telehealth and that's going to work for them, or do they need to be seen in person because there are different treatment modalities, like I was discussing with you? There's eMDR, which is a form of therapy for trauma, and there are different things that they do in that therapy that needs to be done in person. And so it's not always as effective via telehealth. So depending on their needs and the treatment modality used determines whether they're appropriate for telehealth or not. 

[Yeager] Do we get the sense folks when we talk about acceptability, it will tell me what that defines. Is it acceptability, in on this issue, more on an individual or more on the system, the society. What is meant here when we talk about acceptability of mental health care.

[Holliday] So I feel that one positive is being a community mental health center. Our patients know that everyone is there to get help for their mental health. And so that has been helpful. and they know that they can get that close relationship. They can reach out to us at any time. my nurse is very involved with patient care. They build rapport with her as well. And so it allows them to feel more and more comfortable. And the more comfortable they feel, the more that they are open to coming. And it is no longer as much of a concern for them.

[Yeager] We talked about four things, that start with a here today. We've talked about accessibility, availability, affordability and acceptability of those. Tarrah, which one do you feel like right now we're having the greatest success?

[Holliday] In the United States?

[Yeager] Yeah, we'll say us. And if you want to, if you want to go down to Iowa for one of them, but as a general whole, which one are we having the greatest success on right now?

[Holliday] You know, I feel that. As a whole, we are really, really trying to put in the effort for both accessibility and availability. I do feel as a whole and collaborate with a lot of mental health providers, and that is always the goal is to get them the treatment that they need and get them in as quickly as possible. There are waitlists, however, we discuss the severity of symptoms and their need, and if it is something that they're needed to be seen sooner, we accommodate that. And so I do feel that that is a great transition and an improvement in the right direction. affordability is getting better. I think there's more of an awareness to mental health and grant funding, insurance companies being more open to supporting these. From another standpoint, the EAP programs for employees, most employers are providing that. And so it's no cost to their employee. Another really great benefit. So on all levels, I would say there's certainly an improvement. Unfortunately, there is still that social stigma, especially in a smaller rural community where everybody knows everybody.

[Yeager] Well, yeah, you kind of answered my follow up then. And so we've had what's our greatest success. Which one's our biggest challenge. And it's still stigma.

[Holliday]   would say. So. Yeah. As a whole, as we close here, Tarrah, do you get the sense that getting over what is it going to take to get over some of that stigma? I mean, because we all have people in our families that deal with the issue. So it can't be the, oh, I don't know anybody. We all do know people.

[Yeager] And so to me, it becomes, is there another hurdle that is going to allow us to have a much more general acceptable is we're going to get treatment for mental health or brain health, just like we are. Broken arm.

[Holliday] I do think we're definitely transitioning in that direction. I think that there is progress every day. are we there yet? No, but we are certainly moving in the right direction, and it is much more acceptable now than it was even a year or two ago. So it's very encouraging to see the acceptability and those that are more open to discuss the topic and I think providers like myself and many other providers that feel very strongly to advocate on behalf of mental health and transition, it to the topic of brain health and normalizing it to part of the body, and that physical health, you would get treatment for anything else. Why not your brain?

[Yeager] Tarrah Holliday, thank you so very much for the time, I appreciate it.

[Holliday] My pleasure.

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