Mental Health in a Pandemic: Q&A with Thomasine Heitkamp and Dennis Mohatt

by Allee Mead

Thomasine Heitkamp and Dennis Mohatt are co-project directors of the Mountain Plains Mental Health Technology Transfer Center (Mountain Plains MHTTC), a SAMHSA-funded MHTTC Network member that serves Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming. Mountain Plains MHTTC provides technical assistance, trainings, and other resources related to mental health.

Heitkamp is a Chester Fritz Distinguished Professor at the University of North Dakota, and Mohatt is the Vice President for Behavioral Health at the Western Interstate Commission for Higher Education (WICHE). Together, they discuss the coronavirus outbreak's effects on mental health, telehealth services, and the disparities already present in rural communities.

What concerns are you hearing from rural communities and providers regarding the mental health of their residents during this pandemic?

Mohatt: The concerns that we're hearing are probably mirrored across rural and urban, and the rurality just sort of compounds the same sort of issues. In rural, some of those issues are long-standing and chronic: being able to access care and having providers available to meet their needs. I think that people are struggling on the provider side to rapidly switch how they practice, from a person-to-person encounter to a virtual relationship and heavy usage of telehealth. Everybody is struggling with that, but in rural you compound it with that lack of good broadband connectivity and that can be the provider who doesn't have great internet or it could be the person seeking care who doesn't have great internet.

Heitkamp: I hear increased concerns about the impact of social isolation and the exacerbation of rural poverty, which was a serious problem prior to the pandemic but is now exacerbated. As we know, poverty affects personal well-being and has a negative impact on mental health. Fears of eviction are a reality with no access to shelters in remote rural areas.

My hope is there will be increased access to mental health treatment because of COVID-19. My hope is the expansion of telehealth will continue post-COVID-19. So, there's an opportunity here for increased access to mental health services.

What opportunities are coming out of this difficult experience?

Mohatt: Before, not all insurers would pay for telehealth. Some insurers paid less if the person receiving telehealth was accessing it from home instead of an approved site, or some insurers only provided coverage for telehealth if both the provider and the recipient of care were in approved telehealth sites. All of that is gone. I think for the most part all providers are paying for telehealth. They're not paying less for telehealth that's emanating and being delivered from homes to homes. In that regard, things are much better.

Heitkamp: I think some of the issues in rural communities have become more apparent because there's media attention. You rarely turn on the TV where they don't talk about the limitations of healthcare due to remoteness and some of the limitations of care that might exist in Critical Access Hospitals, including access to ventilators. The issues of rural healthcare and wellness and food scarcity are being raised, so I think there's an opportunity here for people to understand rural better.

What new challenges are there?

Heitkamp: One challenge is changing how we provide care and support for people with substance use disorders. The need for online support groups to maintain sobriety is critical, as 12-step programs are no longer in-person support. That access to online support groups has greatly expanded. We also have the opportunity to continue to expand access to medication-assisted treatment with the increased ability to access supports outside a clinic setting during the pandemic. Providers are reporting to me that people are indeed accessing services during the pandemic, but the access is different.

Providers are more focused on serving people who are homeless, and this requires expertise on poverty, social inequities, and co-occurring disorders. So being able to identify at-risk individuals who now could have COVID-19 has brought more attention to people with a co-occurring disorder of mental health and substance use disorders. The one piece that I think requires attention in rural communities is access to housing. Like other states, North Dakota is opening up hotels for people who are homeless and monitoring people who have COVID-19, trying to contain it, deploying retired nurses to do that work. And this is happening around the country.

The good side is that we're learning a lot about how you can provide that care in this kind of an environment that will have benefits. We're going to find some things that we'd never tried before and that will open doors to better serve people in the future.

Mohatt: When most people think of mental healthcare, they think of an individual in an office talking to a provider. That one-on-one care is only one part of the system of care, which is an array of services and supports that includes multiple services and an array of providers. There's a lot of group care that goes on and that's been impacted. The entire healthcare system has a difficulty in getting personal protective equipment (PPE), and mental health systems have that problem as well. But there are a number of treatment modalities. For example, the care for persons with serious mental illness called Assertive Community Treatment is delivered through the collaborative care model. It's delivered by a team, and it's very hard right now to provide that care and to do it with fidelity to the evidence-based model of delivery. And so you're seeing a lot of struggle around that. The good side is that we're learning a lot about how you can provide that care in this kind of an environment that will have benefits. We're going to find some things that we'd never tried before and that will open doors to better serve people in the future. But right now it's certainly struggling through that and not knowing, "Gee, if I try this, will I have the same impact as doing it the way the manual says to do it?"

What additional challenges are there for rural people dealing with grief?

Heitkamp: People are figuring out how to do a funeral when only 10 people can attend and when people can't travel from out of state. It is a fear that you're not going to do it right, with limited capacity to really memorialize someone. How do you do that in a way that has equity, that has fairness, and that people will look back on and say, "This mattered on some level to me," live-streaming a service from a church, live-streaming outside, physical distancing at the gravesites?

Mohatt: When you look at grief, it's about the ability to share your story, having people around you to share that experience with and to grieve and hug through it. For grief counseling, you do group work with other people who have similar experiences, so that's going to be impaired and impeded. Another big part of recovering from grief is to return to normalcy, and there's now a new normal.

There are people who have been hit with COVID-19 and they're recovering with some lasting impairments. We're not talking a whole bunch about that, but you don't get intubated and go through this kind of an assault on your upper respiratory system without a percentage of those people having enduring difficulties. And then the grief associated with that. I don't know anybody who is an expert in this area, maybe people who have provided these kinds of services in a war zone where everybody's being impacted and it's ongoing and enduring. I've heard a lot of creative things going on out there of people being able to check in and connect with folks, reaching out.

What populations are especially at risk of mental health issues?

Mohatt: College students who have been sent home to finish the term. A percentage of those folks were receiving services from campus-based counseling programs and are losing the ability to continue those services as they go home. Some of those students went home to a different state and, because of restrictions on interstate practice, they may not have access (depending on the state and the provider type) to that provider they had been working with effectively on campus. And not all the waivers around telehealth took that into consideration. Those students now are at home, and their parents may not know that they were seeing anybody; they don't have the same level of privacy in their homes. Sometimes they may not be able to access local services because that local system is stretched dealing with their existing clients. There may not be access for somebody who's just there for an indefinite period of time. There are all these complications at work, especially if it's a student who's gone home to a rural area. They may not have access to the level of care they were receiving while they were in school.

Heitkamp: I would definitely add children and women primarily living in homes where there's violence and there's less access among providers to check in on their safety.

Mohatt: Older adults. There's the extra stress of knowing that they're a vulnerable population, and they're a population of people who as a whole are underserved in the mental health system. You have very few geriatric specialists in rural. Older adults were underserved previously and now they're still underserved and at particular risk.

There are all these economic stressors that were already there. You go across rural and there are those economic hits that are exacerbating stress on families and that stress in the family can come up in all kinds of different ways.

In addition, we already had a farm crisis going on before this ever hit. With some segments of agriculture, this is only exacerbating that farm crisis and the level of economic stress that farmers and ranchers are feeling, with dairy farmers having to basically throw away milk because that entire commercial need for milk for restaurants and food services has pretty much disappeared. In the energy segment, the price of a barrel of oil has tanked, and we have more surplus than we ever had. You have a part of the western United States that's heavily into energy production where those workers have been impacted. There are all these economic stressors that were already there. You go across rural and there are those economic hits that are exacerbating stress on families and that stress in the family can come up in all kinds of different ways.

Heitkamp: Right now, we know on the farming side and the energy production side that the purchasing is not offsetting the production. We have farmers who could package in the Red River Valley several hundred pounds of potatoes that would go to a school. Right now, people are buying five pounds of potatoes at the grocery store, with schools not purchasing agricultural products in bulk, with restaurants not purchasing in bulk. This large-scale purchasing that was occurring is no longer occurring. So, you already have this storm of issues around the markets. Now you combine that with a pandemic that creates a very different structure for marketing and that's really a big issue in a rural community. As Dennis said, these economic issues greatly impact the family environment in terms of sense of security and safety and all kinds of measures of well-being.

Mohatt: Almost all family farms are dependent on off-farm income to make ends meet. But those town jobs are disappearing as well. So not only do you have the stresses on agriculture on the farm family, but that off-farm income has dried up and things are tough.

Heitkamp: And that off-farm income is often for healthcare, just to access health insurance.

How do suicide prevention and other mental healthcare change under quarantine and afterwards? What can healthcare providers do? What can communities do?

Heitkamp: We are running a series on suicide interventions and responses for youth with our partner agency at the University of Utah, the Mountain Plains Prevention Technology Transfer Center. They're our sister agency on the prevention side. And what we're seeing is tremendous interest in this and we are going to expand. In fact, we're going to be doing our telehealth series on suicide with a national expert in May as part of Mental Health Awareness Month. So this is the area where people are looking for content like telehealth and how to deal with using telehealth. This is a piece of the work that I feel our Mental Health Technology Transfer Center is taking up and will continue to pick up post-COVID-19.

Mohatt: It's certainly doing that pivot and figuring out how to do evidence-based suicide prevention in this new way where there's not much science available in this area and how to do harm reduction when you can't easily do community engagement, and that's one of the key areas of suicide prevention. We have a big project on suicide prevention with rural veterans (WICHE's Together with Veterans implementation toolkit). And we're struggling through that ourselves: How do we keep those rural veterans engaged? How do we keep talking with one another? And we make sure that the suicide prevention strategies that are being employed are effective and science-driven.

What is telehealth's role in mental healthcare during this pandemic? How is telehealth evolving and changing the provision of care?

Mohatt: It's really doing most of the strategies that we're talking about. I think this is one of those situations where rural was probably a lot better prepared. Now, we don't have the broadband coverage, and there are some real tech issues, but you don't find too many rural providers who haven't had at least some experience with delivering care that's supported by technology. I've heard more questions from urban providers who basically didn't know there was a camera on their laptop and had never really thought about how they would set up their office to afford a sense of privacy and connectivity to a client. It's one thing to do a Zoom call with a friend. It's a whole other thing to deliver healthcare. Rural providers, the ones I've talked to, were a lot better prepared for this and were able to do that pivot. The internet that they have at their home is probably not the same internet that they had in their office, so there are real issues around connectivity.

Heitkamp: We've offered a telehealth learning series where we've had over a thousand people register for each of the five sessions these past five weeks. We just wrapped it up and the recordings are being looked at, the slides are being worked out, and we have additional question-and-answer products as part of each session. We put a COVID-19 page together (no longer available online) to ensure access to resources and we have developed several new products in response to the pandemic. It's Dennis's and my passion in responding to this.

What are we going to learn from this experience? What worked, what didn't work, what works with teaching kids at home? What works with telehealth? What's working with access to broadband? Because if we don't have that capacity to look at what worked and what didn't, we'll have lost an opportunity.

What are we going to learn from this experience? What worked, what didn't work, what works with teaching kids at home? What works with telehealth? What's working with access to broadband? Because if we don't have that capacity to look at what worked and what didn't, we'll have lost an opportunity.

What are ways we can take care of our mental health?

Mohatt: One way you can attend to your own mental health during something like this is to tell your story, connect with other people, keep your social group together. In our WICHE work group, every other Friday we do sort of a happy hour. Then we play online games with one another and we've probably had 30 or 40 people there. People have their kids with them playing. In some ways we're probably connecting more than we typically do. It's doing things like that, staying connected, reaching out to folks, having as much normalcy in your environment as you can, because that lack of normalcy is part of the problem. Having movie night with your family or doing things with your family, that helps bring a sense of normalcy. We have a thing here in Colorado where every night at 7:00 people go out on their porches and howl to thank the first responders. Every night, 7:00, we're out on the front porch and waving at one another and whooping it up.

Getting off Facebook and stopping yourself from just being totally immersed in all of the negativity, taking a step back from that is really helpful.

Heitkamp: All of our executive functions are struggling, due to this physical distancing. Many of the mental health therapists are experiencing the same stressor their patients or clients are experiencing, so that piece about keeping yourself healthy is really important. This morning I was in a meeting with a group of MHTTC directors and some of them are limiting their meetings to 40-45 minutes just to allow bathroom breaks, to allow time to breathe, to allow time for many of them to check in on children, to spend less time on the internet. Most days I'm spending up to six hours on Zoom, and I'm thinking forward in terms of what the impact of that high-level screen time will be.

Mohatt: People have to think about whatever it is they're doing to themselves and manage that, because it's really easy to wake up in the morning and just dive right into work. It's really hard sometimes to just regulate that. WICHE goes from the Dakotas all the way to Guam and the Pacific territories. So it's really easy to have a call with South Dakota or North Dakota that might start at 8:00 Central, which is 7:00 Mountain. And then 7:00 in the morning in Guam is 3:00 in the afternoon for us, so it can be a much longer workday than is healthy.

The needs of people in rural communities are similar to the needs anywhere…But sometimes they're just more complicated when you live in a rural area.

Heitkamp: What will be the capacity for thinking about rural health differently post-COVID-19? Because the needs of people in rural communities are similar to the needs anywhere. They want healthy families. They don't want to feel depressed and anxious. They want care for their child who might have a serious emotional disturbance. They want access to their medication. Those needs aren't any different. But sometimes they're just more complicated when you live in a rural area.

Opinions expressed are those of the interviewees and do not necessarily reflect the views of the Rural Health Information Hub.