Disparities in Mental Health Services
Between Urban and Rural Communities
In Washington State
Anne Strode and John Roll
• Review of literature and data from national,
state, and local sources
• Interviews with providers and consumers
2006 Estimated Washington State Population
Urban Rural Total
Eastern 900,400 5ll,700 1,412,100 (22%)
Western 4,342,900 620,600 4,963,500 (78%)
Total 5,243,300 1,132,300 (18%) 6,375,600 (100%)
Source: Office of Management and Budget
• Ten percent of the average daily census of Eastern and
Western State Hospitals was composed of consumers
from rural RSNs. Average length of stay was slightly less
than nine days for both urban and rural consumers.
• Four percent of the average daily census for all
community inpatient hospital stays for psychiatric care
was composed of consumers from rural RSNs.
• There are four Children's Long-Term Inpatient Programs
serving the most severely emotionally disturbed children
in the State – all in urban areas of the State.
• Hospitalization rates for all mentally ill in isolated rural
areas were 7 per 1000 individuals, compared with 13
hospitalizations per 1000 individuals in the urban core.
• Treatment days (length of stay) in isolated rural areas
were about 51 percent of the number of treatment days in
the urban core areas.
• Hospitalization rates for severely mentally ill in rural
areas were 34 percent (two versus six discharges per
1000 individuals) of those of urban core areas.
• Hospitalization rates for individuals with chemical
dependency in isolated rural areas were about 76 percent
of those in urban core areas.
• Hospitalizations for those with co-occurring disorders
(chemical dependency and mental illness) in isolated
rural areas were about 67 percent of those from urban
• The average number of individual outpatient treatment
hours was almost 6.6 hours less in rural areas and 8.4
less in rural Eastern Washington
• Urban areas have three times more psychiatrists per
100,000 population and more than 1.5 times non-
psychiatrist mental health providers per 100,000 than
• Twelve rural and zero urban counties had at least 40
percent unmet workforce needs.
General Barriers to Service
• Lack of health care providers, specialty providers and bi-
• Limited public and personal transportation and long
distances to services;
• Limited funding for public mental health services;
• Strict Access to Care Standards;
• Insufficient inpatient bed capacity (crisis, evaluation and
treatment, children's and adult's longer term beds);
• Lack of evidence based practices designed for rural
• Over reliance on law enforcement.
• Ensure there are adequate inpatient beds for adults and
children in rural Washington.
• Increase the number of community outpatient mental
health providers in rural areas.
• Allow providers flexibility in implementing evidence-
• Allow rural providers transportation subsidies to reach
• Expand education programs for rural mental health
professionals. (also primary care physicians)
• Support the efforts of statewide professional organizations
to provide interdisciplinary distant learning, telehealth and
• Support research and collaboration to develop new
evidence-based practices specifically designed for rural
• Continue support of early detection and prevention
programs for infants, youth and adults.
• Develop ways to work with law enforcement (including
criminal justice & prosecution systems) and local providers
to treat mentally ill people without criminalizing them by
providing more training within the adult and juvenile justice
• Explore a mechanism to allow rural counties access to
State-Only dollars to serve the working class poor when
they are in need of mental health services, but unable to
meet Access to Care eligibility criteria.
• Support housing and employment programs for mentally
ill consumers in rural areas.
• Where practical, co-locate primary care and mental
health treatment practitioners to provide a holistic
approach to treatment.
• Study the implications of expanding prescriptive
authority of providers of mental health services by
assessing the experiences of other states’ and the U.S.