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As the conversation and stigma surrounding mental health continue to evolve, access to care, or lack thereof, remains a barrier, even in the presence of heightened public awareness and empathy.

“We need kind of both,” Dr. Marley Doyle said. “We need an increase in mental health awareness. But then we also need an increase in access to care. Because if you don’t have both, then it’s not going to really improve things.”

Doyle, a psychiatrist serving as director of the Behavioral Health Education Center of Nebraska, said the shortage of mental health services is still particularly glaring in rural areas due in part to the location of programs.

“Part of the reason is that a lot of the training programs, like the majority, right, are in Omaha and Lincoln,” she said. “And so people come to school, and then they find jobs, and then they don’t leave.”

Population and funding disparities certainly play a role in the shortage. But Joseph Evans, doctor of psychology and professor emeritus at the University of Nebraska Medical Center, said there’s a stark difference in the ratio of providers to citizens in Omaha and Lincoln compared to the rest of the state.

“The average for psychiatrists is 14 per 100,000 [people],” he said. “Nebraska’s, in urban areas, is like 12, so it’s pretty close. But if you take a look at rural areas, it’s down to less than two. So it’s like two per 100,000 people, and there’s only 11 counties in the entire state that have psychiatrists, out of 93.”

The numbers for licensed mental health practitioners are better, though still not ideal. There are slightly over 48 per 100,000 people in urban Nebraska, and approximately 19 in rural areas.

The Nebraska legislature has taken steps toward addressing the need for additional resources throughout the state, according to Evans. The BHECN received a grant of over $25 million, which Evans said has, in turn, been distributed primarily into rural practices. The Nebraska Medical Association also received funding from the American Rescue Plan Act with the goal of placing more behavioral health providers in rural Nebraska.

Some concrete developments have also helped alleviate the lack of mental health resources in parts of Nebraska. One such development is telehealth.

“The infrastructure that was related to telehealth was about hard line connections from point A to point B,” Sarah King, doctor of clinical psychology, said. “So the idea was that you would go to your community hospital or your community clinic, which would have a hard wire from that clinic to, you know, this place in Lincoln or this place in Omaha. And that’s truthfully how the infrastructure was set up.”

Today, telehealth often involves phone and video chats, which folks can do from the comfort of their home. Virtual healthcare has both benefits and drawbacks. King, president of the Nebraska Psychological Association, emphasized the anytime, anyplace model as a significant positive.

“This allows people to not have to drive two or three hours to gain access to services,” she said. “Even people who live locally, like in Lincoln or Omaha or a larger city, they don’t have to take nearly as much time off of work or off of school.”

On the flip side, telehealth is not the be-all-end-all solution, as widespread technology access, comfort levels, costs, and insurance coverage remain obstacles to virtual care. Its suitability also depends on the patient’s condition.

“It’s good for more mild to moderate psychiatric illness,” Doyle said. “But for people with severe mental illness, telehealth isn’t the standard of care.”

Evans added that there is still value in seeing healthcare providers face-to-face, especially when dealing with children and family issues.

“Part of dealing with kids is working with their parents,” he said. “So you really need to be able to demonstrate and show them how to, for example, manage some behavior problems with their kids, as opposed to just trying to do it over the internet.”

Another emerging development is incorporating mental and behavioral healthcare into primary care. A one-stop shop, if you will, wherein patients can have their physical and mental needs met in one visit.

“Almost everybody, at least one time during the year, goes to see their primary care physician,” Evans said. “So it’s an ideal time to kind of capture that audience and find out if there are problems that can be dealt with before they become, you know, major issues.”

Evans spent 34 years as director of psychology at UNMC’s Munroe-Meyer Institute, which focuses on disabilities and special healthcare needs. During his time, integrated behavioral and primary care was an area of focus.

“We’d actually developed or supported 42 integrated clinics across the state of Nebraska,” he said. “Twenty-four were in rural areas. Eighteen were in the Omaha [and] Lincoln areas. So I think that’s been one of our big contributions.”

Many primary care providers now give mental health questionnaires to their patients during visits, according to King. Some even have psychologists on hand to provide brief, immediate care. However, primary caregivers are already overextended and integrated care can add to that.

“Our medical system as a whole is kind of overwhelmed,” King said. “It’s good to do some screening and provide those services really anywhere you can help people, and yet, it’s not necessarily an option to just put more on our primary care system.”

Despite the positive trends, mental health awareness and access still have their pitfalls. Doyle said that awareness of one’s mental health alone is just the first step toward caring for it.

“A mental barrier still exists,” she said. “You can be aware of mental health, but then taking the step and getting treatment is a different thing.”

Both King and Doyle further noted that many providers in Nebraska, especially those offering psychiatric and psychological evaluations, currently have waiting periods of six months or longer, which only discourages patients from seeking treatment.

The good news is that applicants to behavioral healthcare programs are reaching record-highs, according to Doyle. The bad news: there aren’t enough providers and supervisors to meet the demands.

“There still is quite a bit of a bottleneck,” Doyle said. “Because, you know, we can’t admit all these students that are interested because we don’t have enough faculty to train them.”

Looking to the future, Evans said people have started to realize that mental health services are needed on a continuum, ranging from anxiety symptoms to full-blown psychosis.

“One of the things that we really are focusing on is more of the front end,” he said. “The idea being that we will focus more on prevention and early intervention, as opposed to putting money back into the system that looks at the rear end, where people have to be hospitalized, or have to go through detox programs or addiction programs.”

Telehealth, integrated behavioral and primary care, and early intervention all serve to alleviate the striking shortage of mental health providers, especially in rural areas. The ultimate aim, though, is to solve the root of the problem: long travel distances to receive care.

“My goal would be to have nobody have to drive more than 50 miles to get services,” Evans said. “And that ain’t happening right now. That’s still a good, I think, goal overall.”