The Changing Context of Rural America: A Call to Examine the Impact of Social Change on Mental Health and Mental Health Care

Residents of the rural United States face serious mental health disparities, including higher rates of suicide (3) and depression (4) compared with residents of urban areas, and substance abuse rates in rural areas now equal those in urban areas (5). Despite experiencing these increased risks, rural dwellers are less likely than their urban counterparts to seek or receive mental health services (6). Shortages of mental health providers are foremost in limiting rural residents’ access to services (7), yet long travel distances to health centers and a lack of culturally competent providers compound these shortages (8).

A complex interplay among the geographic, social, and cultural characteristics of rural settings shapes perceptions of mental health problems and, consequently, the use of mental health services (9). Individuals may be reluctant to be seen seeking mental health services, and cultural values of stoicism and resilience may shame people into enduring their problems on their own (10).

Entrenched poverty has long contributed to serious disparities in mental health and access to services for the 20% of Americans who live in rural areas. The past few decades have brought enormous social changes to the rural United States. With the decline of the agricultural and manufacturing sectors, rural economies have become dominated by low-wage, part-time employment (11). In this context, rural poverty has become increasingly concentrated (12), and opportunities for mobility have declined (11). In response to limited opportunities, many young adults have out-migrated, leaving fewer people to sustain communities (13). As family forms have shifted, more women head their households while negotiating working poverty (14), and those without jobs are more likely to be depressed (15).

Rural areas are becoming increasingly racially and ethnically diverse, with immigration accounting for a disproportionate share of population growth in the rural United States (16). Yet immigrants and African Americans who relocate to rural areas for new social and economic opportunities face the mental health fallout of being excluded within areas that are often predominantly white (17), and they may struggle to access health care despite their increased mental health burden (18).

Meanwhile, in rural areas and beyond, health care and policy changes have introduced psychiatry to a broad audience, with mental health–related information more widely available via the Internet and direct-to-consumer advertising of medications. Telepsychiatry and treatment modalities delivered by mobile application, which comprise an increasing share of mental health treatment options (19), hold great potential to mitigate barriers to access in rural settings. Residents of rural areas receive Social Security disability benefits at a disproportionate rate compared with metropolitan areas (20), and some have become familiar with mental health diagnoses because psychiatric impairment constitutes the largest and fastest-growing category of Social Security Disability Insurance (21). Yet even as these trends demonstrate growing information about mental health, increased treatment modalities, and greater access to mental health–related entitlements, researchers have little understanding of their significance for public understanding of mental health in rural areas and their consequent impact on mental health outcomes.

Fresh perspectives are needed to generate promising avenues for the development of effective treatment and policy interventions for dynamic, deepening rural mental health disparities. Anthropological approaches are both innovative and underused in health services research (22). Decades of research in medical anthropology have robustly demonstrated how the sociocultural context shapes meanings of illness and help-seeking behaviors (23). Anthropological methods of long-term research in real-world settings provide opportunities to learn how persons with mental health problems and their families, health care workers, and communities identify, conceptualize, and respond to mental health challenges (23). The clinical understanding of mental illnesses often clashes with community perspectives that attribute distress to problematic familial, moral, religious, and societal pathways (24). Such divergent perspectives may discourage help seeking if individuals, families, and communities believe that available services do not attend to “what really matters” (25). For example, ethnographic research has offered insight into why severely disenfranchised and ill individuals may purposefully avoid mental health services (26).

Contemporary medical anthropological perspectives explicitly link illness to the broader social, economic, and political conditions that produce inequality and exacerbate suffering (27). This theoretical framework is ideal for examining the intersections between mental health, social changes, and social inequality. Accordingly, intersectional inquiry provides the grounds for examining how social forces overlap and interact to produce health inequities rather than striving to isolate the impact, for example, of poverty, inequality, gender, and rurality as singular factors (28).

A foundation of the proposed research agenda is the anthropological stance of questioning categories (22) and of expressing skepticism of “medicalization.” Rather than accepting categories such as mental health, inequality, or even rurality as givens, anthropological inquiry examines the meanings, boundaries, and content of categories (22). Ethnographic examinations of local categories of distress in rural communities can articulate how individuals, families, and communities make sense of suffering and assess how clinical interpretations can become more useful. This approach can specify whether and how people in rural communities relate suffering to rising inequality and social changes.

In the same way that medical anthropology is rooted in cross-cultural comparison, the study of mental health in rural settings must recognize the diversity between rural and urban contexts and within rural communities (29,30). By generating research that responds to lived experiences in rural areas, anthropological approaches can contribute to designing systems of care that will be effective for rural communities.

To understand how individuals describe the impact of inequality on their mental health, it is important to examine events at the macro and community levels. In the case of the macro level, there are obvious questions about the role of national policies on local economic conditions and, indirectly, mental health issues, as reflected by the resurgence in populist rhetoric during the most recent presidential election. Longitudinal observations can provide insight into the differences between mental health challenges attributed to persistent poverty and those attributed to recent social changes—with particular attention to the perspectives of various age groups and persons with varying histories of employment, underemployment, and unemployment. Such findings could inform the adaptation of supported employment models to align with the harsh economic realities and fraught cultural meanings of employment in underserved rural areas.

On a community level, researchers must document the experience of mental distress in settings at the heart of rural communities’ social and economic shifts—churches and businesses of persons who have recently migrated to the area, the homes of people following job losses, and the offices where disability benefits are sought on the basis of a depression diagnosis. Documenting informal conversations about mental health and inequality and everyday practices within community settings can reveal if depression is normalized and to what extent experiences of demoralization are identified and treated as mental health problems. In addition, ethnographic research can examine how individuals and communities respond to mental health challenges to identify what forms of coping are deemed acceptable or unacceptable, for example, substance use, in particular rural settings. Partnerships with community-based organizations enable researchers to draw together diverse coalitions that have been affected differently by social changes and engender sensitive individual, family, community, and policy strategies to engage the multiple factors that contribute to distress.

Second, it is important to raise questions about how direct-to-consumer advertising and more accessible pharmacological treatment affect the experience of mental health in rural areas. Whereas the higher use of pharmacological treatment for depression in rural areas is likely related to mental health provider shortages (31), has the ubiquity of direct-to-consumer advertising led rural individuals to more readily seek and accept medication? Is medication viewed as sufficient, complete treatment? Given that rural residents carry a higher burden of comorbid chronic diseases, do residents find that psychotropic medications constitute simply one more pill to take? Empirical findings on these topics can inform educational interventions, shape strategies for outreach across the continuum of mental health severity, and illuminate how depression treatment can be incorporated more effectively within complex chronic disease self-management.

Finally, documenting experiences and on-the-ground realities of the rural mental health care workforce is another avenue for anthropologically informed research. With rural areas already facing shortages of specialty mental health providers, how are health and social service providers responding to increased inequality in rural areas? Observations and in-depth interviews with rural providers can uncover how providers mediate the complex intersection between local inequalities and mental health problems. How do their community relationships influence their care? Must they triage patients with severe needs? These perspectives would offer insight into the feasibility and acceptability of shifting mental health care tasks to community health workers. At the same time, qualitative approaches to understanding how social changes affect the organizational context in which providers work could be used to create pragmatic burnout prevention interventions and contribute to better organizational supports.

Rising social inequality in the rural United States presents distinctive challenges. This Open Forum has considered the implications of recent social changes for mental health and treatment seeking among rural populations. To promote truly patient-centered and culturally appropriate services, we advocate inclusion of medical anthropological approaches in rural community-based research, with the ultimate goal of catalyzing meaningful change (32).

The authors thank Emily Hauenstein, Ph.D., R.N., and Robert E. Drake, M.D., Ph.D., for reading earlier drafts of this Open Forum.