The successes and failures of mental health care in rural Ohio
Last March, Evey Weisblat ’21 was brought to the emergency room at Knox Community Hospital (KCH). Weisblat, who had harmed herself that previous fall, relapsed after returning from spring break. “Compared to the first time, I was so out of it,” Weisblat said. “I couldn’t even comprehend what was happening to me.” Weisblat spent the next two-and-a-half days in an observation room, a room with a glass front that allows nurses to keep an eye on at-risk patients, while she waited for her case to be processed. “During that time no one really responded to my requests for water,” Weisblat said. “I didn’t know whether I was allowed to go to the bathroom or not.” On top of this, Weisblat did not have access to her medication. At one point, Weisblat was told by a nurse that she would be moved to another wing to free up bed space, although this move never took place. Weisblat remembers feeling alone and abandoned. “That’s probably a common experience, being in a psych ward,” Weisblat said, “but I wasn’t even in a psych ward — it was just an emergency room.”
This story is not unfamiliar to Jordan Levin ’19, who volunteered for the emergency room at KCH for four hours a week as part of his biomedical analysis course. “Our whole emergency system right now is not set up to treat psych patients,” Levin said, referring to his experience in the emergency rooms of rural areas. He recalled seeing the same psychiatric patients over and over again when he worked as an EMT in rural Vermont, waiting to be placed in a facility. “They get placed into some rehabilitation center,” Levin said. “They go there, go through a couple procedures, then they’re back on the street and they get placed back in the ER, because they didn’t really get help.” Often, emergency rooms in rural areas struggle with insufficient bed space, which, according to Levin, sometimes leads to patients lying in cots in the hallways of KCH’s emergency room, waiting to be treated. This lack of bedspace, combined with a trend of patients without health insurance going to the emergency room to treat minor illnesses such as the flu, leads to occasional congestion that makes it harder for lower priority cases, such as psychiatric patients, to receive care.
Levin’s experience in Vermont points to an unfortunate truth: The lack of mental health resources in rural areas is a national problem. Assistant Professor of Sociology Shaun Golding, who has worked in the Office of Rural Health in Wisconsin, says that rural hospitals often act as a “triage” for their patients, connecting them to other facilities that are better able to address their problem. However, finding that care can be difficult. Seven percent of adults and five percent of children in Knox County don’t have any form of health insurance. “If you’re dealing with a population that, by the numbers, is less likely to have health insurance, then you are tasked with finding a bed with somebody who would be willing to accept them with no health insurance,” Golding said. “Those beds are few and far between. There are private facilities that people can get access to, but those require health insurance, or a lot of money.”
Although Knox County is on par with other rural areas in the number of residents suffering mental health problems, it is severely lacking in mental health care providers, due to a perfect storm of insufficient wages, a remote location, and a high caseload. Carmen Barbuto, a public health educator at the Knox County Health Department, analyzes health data for the county. “We’ve got those challenges of getting people to come here and provide for a small community, as opposed to Columbus,” Barbuto said, noting that it is difficult to incentivize Knox County residents to drive over an hour to receive mental health care. This lack of coverage is also true of social workers, especially in the face of the opioid crisis: In the past year, Job and Family Services in Knox County saw their caseload go from 35 to 115. “They don’t have caseworkers to handle that,” Barbuto said. “It’s the same with counselors.”
But why is mental health such a blind spot in rural healthcare? Golding attributes it to a shift in how Americans view mental illness. “Historically, states would run facilities that were essentially insane asylums,” Golding said. “Compared to today, they were probably well funded, but society was also quick to dismiss people it couldn’t handle to these places where they’d be forgotten about for the rest of their lives.” As states gained a better understanding of mental health and developed more humane treatments, mental health care broadened to treat those with less severe mental illnesses, such as depression or anxiety. At the same time as this expansion, public funding for these programs shrank. This change was especially felt in rural communities, because of their comparative lack of staff and resources.
Another motivation for this change was profitability. Although Knox Community Health never had a separate psychiatric facility, according to Director of Marketing and Development Jeffery Scott, at one point the hospital did offer psychiatric services. There could be a number of reasons these services closed, but Scott cited the difficulty in recruiting mental health specialists to the area, as well as a change in how insurance companies reimburse hospitals of KCH’s size for mental health care as likely possibilities. “I don’t think that anyone understood like we do now how interconnected behavioral health and mental is to physical health,” Scott said.
Without any inpatient facilities, Knox Community Health mostly relies on outpatient services, unaffiliated services located outside the hospital, to take care of its patients. Although not-for-profit outpatient services like BHP have been able to pick up much of the slack, it is difficult to imagine that they could replace the sustained and focused care of an inpatient psychiatric program. Golding believes that it is difficult for these outpatient services to handle cases that are more complicated and ingrained in the community. “There are different levels of psychiatric care,” Golding said. “There’s group homes, that are more like halfway houses that allow people to be integrated into the community, there’s psychiatric visiting nurses that go to people’s houses to work with them there, so there’s lots of different stages of care between the outpatient counselor and the inpatient lock-down facility.” This is not to mention the potential trauma inflicted on someone like Weisblat, who was isolated without access to medication for over 72 hours.
Melissa Valentine is a counselor at the Knox County Health Department who is trained in several therapeutic methods and whose patients range from young children to senior citizens. During her time as a counselor, she has seen increased interest in seeking mental health care in the area. Valentine has also observed an increase in the amount of working counselors. “There are not a lot of providers in our community,” Valentine said, “but there are more in the last few years than I think there have ever been.” The Health Department’s office acts as a Federally Qualified Health Center, which is subsidized by the federal government, allowing the center to offer care that patients might otherwise be unable to afford.
Behavioral Healthcare Partners (BHP), a nonprofit organization, has a direct relationship with the hospital in Knox County. The hospital employs BHP workers to assess patients to see if they are fit to be released, transferred to an outside facility, or referred to a psychiatrist. Although most patients are only held for seven to 10 days, both the hospital and BHP have the power to hold a patient for much longer. If the police, the hospital, or BHP believe that a patient is an active danger to themselves or others, they can issue a “pink slip.” After the pink slip is issued, the hospital and BHP are given 24 hours to determine if the patient is mentally ill. If they are, they can be held for an additional 72 hours. The hospital can then issue an order of detention, which, if it holds up in a court hearing, can hold a patient in a psychiatric facility for up to 90 days. After those 90 days, a second order of detention can be filed, which could last up to two years. BHP has also employed psychiatrists, who can prescribe psychotropic medication, such as antidepressants, anti-psychotics, and mood stabilizers.
As well as leading the crisis intervention team which oversees this process, Andy Gillespie works as the site director for Licking County. Like many in his profession, Gillespie wears many hats: outpatient therapist, adult and child case manager, overseeing the housing department. Although much of Gillespie’s day is taken up by administering, he tries to make some time for counseling clients, the part of his job he loves the most. “I currently have three clients that I am working with,” Gillespie said. “Some of these clients, they were my clients probably 20 years before. They were kids, and they’ve now come back as adults.” What Gillespie would like to change about BHP should be predictable by now: He would like to hire more employees. “There’s always a need to have more staff in the schools, but that again goes back to the ability to even recruit staff that are available,” Gillespie said. “I know that Ohio State University graduates probably at least a couple graduates in social work every year. But that seems to get funneled pretty quickly into the Franklin County area.”
It seems that mental health care is, or was, viewed by many as a flagrant expense, a program that could be cut if budgets were tight. However, more and more studies have linked mental illness and opioid abuse, despite the direction of causality being unclear. “This is something that is not happening in a vacuum,” Golding said. “The same socioeconomic predeterminants of addiction are the predeterminants of poor mental health as well: feeling like you have no control over your life.” There were 28 drug overdose deaths for every 100,000 people in the county from 2012 to 2014. While this may sound like a small number compared to other counties in Ohio, overdose deaths are not a fair indicator of the rate of addiction in an area, which is much more difficult to measure. Valentine noted that a significant number of her patients were also suffering from addiction. “Absolutely there is [a correlation], in some way or another,” Valentine said. “It could even just be eating. It could be food addiction. Not just substance use, but lots of ways that people can self-medicate.”
Most clients that come through the door of the Knox County Health Department are handed an Adverse Childhood Experience (ACE) test. This test asks clients if they ever witnessed domestic violence, had a family member who was imprisoned, or were sexually assaulted. If the score on this test is a four or higher, the client has a 50 percent chance of experiencing mental health issues. “They all have the same thing in common,” Barbuto said. “Their ACE scores are off the charts. They’re all sixes, sevens, some people are eights and tens.” Knox County is significantly better off than its neighbors. Employment rates are high, and it is home to three institutions of higher education, as well as a burgeoning tourism industry. The area is fortunate to have the services BHP and the Health Department provide, but the experiences detailed in the ACE are still commonplace, and their adverse effects can be seen long into adulthood.
However, attitudes seem to be changing. KCH has recently hired Dr. Shailesh C. Patel: While his precise role at the hospital was not made clear, it was suggested that he will serve in some capacity as a resident psychiatrist. More Knox County residents are getting help than ever before, but changes need to be made if stable, consistent care will ever be in reach.