DES MOINES - The Iowa House and Senate moved legislation last week that has the state taking a greater role in taking care of the mentally ill.
But whether it's the House plan that offers property tax relief or the Senate plan that creates eight mental health regions in the state or some sort of hybrid, there still will be the problem of getting mental health services to rural communities.
"The primary concern for rural Iowa is really related to recruiting psychiatrists to practice in rural parts of the state," said Dr. Bhasker Dave, superintendent of the state-run Mental Health Institute of Independence. "It becomes an access issue for the people who live there."
Iowa ranks 47th in the U.S. in the number of psychiatrists per capita and 46th per capita in the number of psychologists, according to the most recent figures available from the U.S. Department of Health and Human Services.
According to Roger Tracy, assistant dean at the University of Iowa's Carver College of Medicine, as of December 2010, more than a quarter of the available psychiatrist jobs in the state - these are positions that are budgeted for - are unfilled, and this is the lowest percentage since 2006.
Furthermore, of the 235 adult and child psychiatrists working in the state, 60 percent of them work in Polk, Linn or Johnson counties while the majority of the counties don't have a practitioner within their borders.
There are a variety of potential answers to the problem, including the increased use of psychiatric physician assistants, nurses with specialty certifications in psychiatric health and telepsychiatry, which is treatment of patients from remote locations via computer link.
But none is a panacea.
"I think it has to be parts of all of those," said Chuck Palmer, director of the Iowa Department of Human Services, who has suggested offering scholarships and other incentives to bring psychiatrists to the state and keep them here. "There is no one thing, but there has to be a discussion about money."
Dr. Alan Whitters, a Cedar Rapids psychiatrist, has treated 100 patients from his home while they stay close to theirs. He was one of the state's earliest adapters of telepsychiatry in which patient and doctor are connected by computer link.
"All of them were rural patients," Whitters said. "They would be hooked up at their local hospital or their clinic for a visit, and they came from a lot of different areas."
Whitters talks his patients in the past-tense because he stopped using telepsychiatry when he left the country for work in New Zealand. He's back now and plans to begin his telepsychiatry practice again with a partner.
He says telepsychiatry allows him to see more patients over greater distances than would otherwise be possible. It also allows rural patients the chance to get emergency help that might otherwise not be available save for a long trip into an urban center.
"The disadvantage is to do really good care, we need to smell and see and observe the patient," he said. "This observation gives us clues to what's going on that we might not otherwise see over a monitor."
Supply and demand
The University of Iowa operates the only psychiatry program in the state. It graduates 10 psychiatrists a year, four of which have certifications so they can go into internal medicine or family medicine if they choose.
Tracy said the expense of the program, which includes residency, is the main reason the program is not larger.
So, experts are looking at ways that mental health services could be provided to people in rural areas without using psychiatrists.
Dr. Michael Flaum, director of the Iowa Consortium for Mental Health, said the psychiatry shortage isn't just an Iowa phenomena, it's nationwide.
He suspects that the day-to-day mental health work in rural communities will be handled by physician assistants or nurses who have a special certification in psychiatric service.
These professionals could work in consultation with psychiatrists - perhaps through teleconferencing - to help treat patients. He said that a program along these lines is under development in Keokuk, where a physician assistant is the primary contact for the area's mental health services.
Flaum said one of the issues that still needs work is how the consulting psychiatrists get paid. Right now, most doctors don't get paid for consulting with their colleagues, but they do get paid for seeing patients. That makes spending time with patients, instead of talking with peers, much more valuable.
Another issue is training for people who work in the rural areas. Dave said there are no greater or lesser incidents of specific mental health problems in rural dwellers than their urban counterparts.
Still, as the 2010 census showed, Iowa's rural residents generally are older than people in the rest of the state and at greater risk for mental disorders associated with old age, such as dementia. Therefore, professionals who practice in mental health would benefit from specializing in geriatric mental health.
"That's almost a fine point," Flaum said. "We're not even there. A specialty would be nice, but we need psychiatrists period."