Bloomberg Businessweek


In all of eastern Montana, the state with America’s highest suicide rate, there’s exactly one practitioner. Rural America has a mental health care crisis
Big Sky just outside Glendive, Mont.

1 THE MENTAL HEALTH UNIT INSIDE THE Glendive Medical Center is dark, and when Jaime Shanks declares that a light switch surely must be around here somewhere, a faint echo chases the words down an empty hall.

“Here it is,” she says. The lobby flickers into clear view. “As you can see, everything is state-of-the-art, and it’s just a gorgeous facility.” She approaches a window and motions to the greenery beyond. “And isn’t this beautiful? A little courtyard you can look out on.” She admires it for a moment. “They didn’t want an atmosphere that felt too institutionalized. The colors all around, if you notice, are very warm.”

Behind a nurses’ station, a dry-erase board says that today is March 30. It’s actually late June. For three months the unit has been dormant, lights out. Shutdowns are hardly unusual; sometimes they last years. Since its grand opening in 2002, this unit—the only place in eastern Montana where a person with a mental health emergency can be admitted for inpatient care—has languished in a state of desertion more often than not.

The problem isn’t a lack of demand; Montana is cursed with the highest suicide rate in the nation, and it’s higher in this predominantly rural part of the state than in any other region. During the rare times when the unit is up and running, the supply of incoming patients is predictably, and sometimes frantically, consistent. The problem here is staffing. Administrators can’t find anyone to run the place.

Last fall, after years of fruitless recruiting drives and ad placements, the center finally snagged a recently graduated psychiatrist to oversee the unit. This spring, not long after the local newspaper celebrated her arrival, she quit. “I think maybe it was just a little too much for someone without experience to take on, and I don’t blame her,” says Shanks, who as marketing director is part of the recruitment team. “There’s such a huge need out here, and I can see the burnout in mental health providers that comes out of that.”

In much of America, and especially in places like Glendive, mental health care is a profession defined by severe imbalances. Overall demand for psychiatric services has never been higher, yet the number of providers has been falling since the 1960s. Psychiatrists are generally paid less than other medical doctors, they’re reimbursed by insurance companies at lower rates for many of the same services, and they absorb more mental stress than practitioners in most specialties. There’s been a slight uptick in psychiatric residencies in the past five years, but more psychiatrists are leaving the profession than entering it, and about 60% are over the age of 55, according to the Association of American Medical Colleges.

This is coming to a head at a terrible time. Suicide rates across all demographics in the U.S. are rising dramatically. Since 1999 the overall national rate has jumped 33%, and the spike has been especially sharp in rural counties—52% compared to about 15% in urban areas. Rural Americans are twice

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