Chad Reznicek knows all too well the stigma surrounding mental health in rural Colorado.
Reznicek, the behavioral health specialist with the Colorado Agribility Project, noted that in small towns, it’s not uncommon for communities to be tight-knit and for everyone to know each other’s businesses.
Residents are hesitant to ask for help because they fear being judged, especially when that judgement could put their entire livelihood at risk, he said.
“If me and my neighbor are competing to lease land from another neighbor, and that neighbor sees my truck parked in front of the clinic, it might force him to think, ‘Chad’s too busy. I’ll sell to Bill instead,'” he said.
But stigma isn’t the only barrier to access; a combination of factors have turned rural Colorado into a “mental health desert.”
Mental health facilities are scarce in rural Colorado, and convincing medical workers to leave city conveniences for faraway towns can be difficult.
Officials, experts and advocates have been actively pushing for greater access to mental health services in rural areas, but all agreed there is still much work to be done.
“Twice as hard”
According to the Colorado Rural Health Center, there is one mental health provider for every 1,282 residents in rural Colorado, compared with one for every 755 residents in urban areas.
One obvious reason is the weight of the state’s overall population.
According to census data, rural Colorado makes up about 80 percent of the state’s land area but only about 14 percent of the population.
Michelle Mills, CEO of the Rural Health Center, explains that the challenge doesn’t just end with recruiting mental health providers to rural areas: Finding housing for them is a problem as well, she says.
“Even if we can find people to hire, we still have to make sure people have a place to live,” she said. “I think all of Colorado is a mental health desert, so if we’re struggling to recruit in urban areas, it’s doubly hard in rural areas.”
Adding to the complexity is the requirement that federally qualified rural health clinics must not allocate more than 49 percent of their services to mental health care in order to maintain proper accreditation. This restriction means that even if these clinics could provide more services, they risk losing important benefits of accreditation, such as grant opportunities and regulatory flexibility.
In many rural areas of Colorado, it’s not uncommon to have to travel several miles to reach a neighbor and even further to get to the nearest medical facility. In some areas, patients seeking mental health care may have to drive several towns away to get to a clinic, which may be impractical or impossible for many.
Experts say these factors create a perfect storm: a community struggling with limited mental health services, exacerbated by widespread stigma surrounding mental illness.
Telemedicine is possible — if the internet works
Many are turning to technology to address rural disparities.
For example, telemedicine has grown significantly since the COVID-19 pandemic, making it a promising option for patients in remote areas.
But this isn’t a universal solution, as broadband access remains a major issue in rural Colorado, where more than a dozen counties report that nearly a quarter of the population lacks internet service at home.
Addressing the state’s internet connectivity issues became a priority for the Legislature this year, when policymakers created the Interim Cellular Connectivity Study Group. The new bipartisan committee, which met for the first time in July, is focused on closing the connectivity gap in rural Colorado.
“You just need help, and that needs to be okay.”
Even if mental health care were readily available to all rural Colorado residents who needed it, advocates are skeptical that many would seek it.
Ashley House of the Colorado Agricultural Association attributes this reluctance to a “bootstrap” mentality in rural and farming communities.
“I think in rural communities there’s a reluctance to ask for help,” she said. “Sometimes you need help, and that’s OK.”
House said conversations about mental health in rural communities have improved recently, but there’s still a long way to go.
According to data from the Colorado Rural Health Center, one in five rural Colorado residents report experiencing depression, a figure House attributes to the inherent pressures of farm work, the degree of isolation that comes with rural life, and the economic strain and supply chain disruptions brought on by the pandemic.
The latter is having a significant impact on the mental health of many farmers, she said.
Experts: Help is available
Experts stressed that help is available to those who need and are ready to receive treatment.
Organizations including the Colorado Farm Bureau, Colorado State University Extension, Farm Bureau Foundation and the Colorado Department of Behavioral Health are overseeing the program, which provides farmworkers and their families with vouchers for six free telehealth therapy sessions.
Colorado is one of 19 states with a similar program, and Reznicek reports that Colorado provided more than 400 hours of therapy last year, the highest participation rate in the nation.
All therapists at the Colorado Agricultural Addiction and Mental Health Program have personal experience with agriculture or have received special training to understand the unique lifestyle of farmers.
Reznicek said this customized approach is essential to ensuring the program’s effectiveness.
“There’s a lot of stigma around being able to see a therapist,” he says, “so we’ve been trying to reduce that stigma. But when someone does get to that stage, and you have to spend the first two sessions trying to get them to understand what their life is about and why they can’t just take a vacation from all the stress, it becomes a little bit harder to convince them.”
“So we’re prioritizing the idea that once someone is brave enough to seek help, they’ll come back for a second session, and we think the best way to do that is to make sure there’s a connection,” Reznicek said.
Therapy sessions offered by the Colorado Agricultural Addiction and Mental Health Program are virtual, so patients don’t have to leave the farm for appointments and can meet with providers during working hours.
“Farmers and ranchers are often reluctant to leave the field, and when they return home from the field after the sun goes down, appointments with health care providers aren’t always available,” House says. “Telehealth offers more flexibility in that you don’t have to travel to see a health care provider.”
Virtual visits also ensure patient privacy, which is essential for patients who fear being judged for receiving treatment.
“We knew a big part of this program was keeping people’s information confidential and protecting their identities as much as possible,” House added.
The Farm Bureau Foundation also launched the Neighbor Project initiative, which encourages rural Colorado residents to ask how their neighbors are doing and give them postcards with crisis hotline contact information and information about state programs.
Evidence shows that peer-to-peer connections are one of the most effective ways to address mental health.
“So we’ve been trying to strengthen it and elevate it,” House said.
Growing optimism
There have been numerous legislative efforts at both the federal and state levels to increase access to mental health care in rural areas.
The Rural Wellness Act, introduced by Reps. Yadira Carabeo of Colorado and Brad Finstad of Minnesota, would reauthorize the USDA’s distance learning and telehealth programs, which provide grants to help rural districts implement technology projects such as telehealth treatment for substance use disorder.
In 2023, Sen. Michael Bennet of Colorado, along with Sens. Tammy Baldwin of Wisconsin and Joni Ernst of Iowa, introduced the Farmworkers First Act, which aims to address the issue of farmworker suicide rates being 3.5 times higher than the general population.
The bill would increase funding for the USDA Farm and Ranch Stress Assistance Network, which connects farmworkers to mental health programs and resources.
Both bills were referred to committee but no further action has been taken.
At the state level, lawmakers have sought to address the mental health crisis affecting rural Colorado.
During the 2024 session, Gov. Jared Polis signed Senate Bill 55 into law. The new bill aims to improve access to mental health care in rural areas by establishing the Agriculture and Rural Behavioral Health Program within the state Department of Behavioral Health.
The program will designate a liaison to facilitate collaboration between the Behavioral Health Department, the Department of Agriculture, behavioral health care providers, rural community leaders, the agricultural community, and nonprofit organizations that serve those communities.
The bill also creates a task force of agricultural and behavioral health experts tasked with developing best practices for providing behavioral health care to farmworkers and their families, and creates a grant program for existing or new efforts that address the causes of mental health issues in the agriculture industry and rural communities.
“This bill would really make a big difference,” Reznicek said.
Experts said other strategies, such as expanding broadband, would also have an indirect positive impact on rural mental health care.
“Some of these bills may seem obvious because they have mental health or behavioral health in the name, but there’s also a lot of good nonprofit work going on that’s more tied to investing in local areas and the health of local economies. But a lot of the tertiary or secondary benefits of that investment money are going to accrue to local communities,” House said.
