Mentally ill lack treatment options in rural Minnesota

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Editor's note: This is one of several stories about what is called a rural Minnesota health care crisis.

A mentally ill person should not be treated for the disease in an emergency room. Or sitting in a jail.

But that is what often happens in rural Minnesota, where there are not enough health care professionals such as psychiatrists to treat them. And there are not enough psychiatric hospital beds even if the professionals were available.

"There is a disproportionate area in rural Minnesota that (does not) receive mental health treatments," said Barb Peterson, University of Minnesota professor in the doctor of nursing practices program.

About 20 percent of Minnesotans have some form of mental illness, but just about half of them receive treatment.

Often what happens to mentally ill is they get arrested and stay in jail for two days, the maximum allowed under state law, and then are transferred to an emergency room.

Dr. Pete Henry, Essentia Health chief medical officer and an emergency room doctor in Brainerd, said hospitals are required to keep mentally ill patients until they find a long-term solution. "They sit in emergency departments."

Essentia Health-St. Joseph's Medical Center in Brainerd has 14 beds for aggressive mental health patients, but Henry said that lack of staff means they often cannot all be filled.

Many hospitals do not have security space for mentally ill, needed to protect patients and staff.

Ambulances often most take patients on lengthy drives to a psychiatric ward far away.

"It is a very significant strain on resources," Henry said, adding that hospitals often foot much of the bill.

He said his hospital has sent patients as far as Hastings, Minn., 157 miles away.

"You cannot care for these individuals in rural hospitals," Henry said.

State hospitals in Anoka and St. Peter usually are nearly full, or at least at capacity given the staff available.

"The state has abdicated" its responsibility to rural mental health patients, Henry said, calling it a crisis.

In many cases, primary-care doctors are the only professionals in an area to handle mental health issues, said Mark Schoenbaum of the Minnesota Health Department's Office of Rural Health and Primary Care. "It falls to them." A report by the St. Peter-based Center for Rural Policy and Development concluded: "Unfortunately, community services are inconsistent around the state, ranging from adequate to non-existent. No region is immune from a shortage in at least some services, forcing the people who need them to travel long distances or not access them at all."

Mental health care is needed, the study added. "Without it, the seriously ill can find themselves debilitated, unemployed, homeless, in a revolving door of incarceration or worse. At the same time, first responders, hospitals, general practice doctors, families, teachers and employers are finding themselves increasingly on the front lines, confronting and trying to help those whose symptoms have gone out of control."

Peterson at the university is working with the Northern Pines Mental Health Center, with offices in Brainerd, Staples, Long Prairie, Little Falls and Wadena. Part of the goal for Peterson, a former Fargo and Detroit Lakes resident, is to introduce soon-to-be nurse practitioners to rural practice.

The university's program is mostly online, so rural students may enroll without moving to the Twin Cities. Rural students tend to want to return to their home areas.

There is little difference between the care provided by psychiatrists and the mental health care provided by psychiatric-mental health nurse practitioners, Peterson said. Graduates of the nurse practitioner program can even write prescriptions.

A federal grant helps expose seven students to mental health care in rural areas, where the shortage of mental health professionals is greatest.

"The hope is there will be some of these seven students ... will then be interested in getting more experience in the rural communities and will spend the rest of their clinical rotations up there," Peterson said.

The idea is if they spend their two-year rotation in a rural area, they likely will stay.

Part of the answer to help rural patients is to use telehealth, a video and audio connection between a patient and a medical professional who could be hundreds of miles away.

Mary Carpenter had to be convinced video was a good idea.

"I was absolutely going: 'What!? No way!' " the CEO of Range Mental Health Center in Virginia, Minn., recalled about her first reaction to telehealth. She was soon convinced.

Three years ago, a northeastern Minnesota coalition and the state Department of Human Services pioneered a partnership that has brought the technology to schools, hospital emergency rooms and jails from Floodwood to Grand Marais. "We're finding teenagers actually prefer telepresence," Carpenter said.

Mental health changes

People with mental illness tend to face other problems, too, such as drug and alcohol abuse.

That has influenced an increase in aggressiveness by the patients, said Pete Henry, Essentia Health medical director. There also has been an increase in total number of mentally ill patients, he said.

"Mental health is a big problem in outstate in general," said Chief Medical Officer Dr. Ken Flowe of Rice Memorial Hospital in Willmar.

Federal and state officials have decided mentally ill patients are best treated in local communities, so Minnesota closed several massive state facilities that housed then. That basically put the burden on community hospitals.

"The patients are still there," Henry said, but local governments now are charged with the responsibility of providing care. "You cannot care for these individuals in rural hospitals."