Rural California. The good life. Far from urban sprawl, it offers open spaces, traditional values, small town friendships…
… and rising suicide rates.
Recent state data illuminates a surprising trend: suicide rates are 80% higher in rural counties than within their urban counterparts.
Perhaps most shocking is the demographic largely responsible for this difference: older adults over 50. Far from the bucolic life imagined by many nearing or in retirement, aging in rural settings is increasingly being linked to social isolation, depression and suicide.
“Across the board, seniors do not usually go looking for mental health services,” says Viviana Criado, executive director of the California Elder Mental Health and Aging Coalition. “And small counties don’t have the resources to provide age-specific care.”
Behavioral health outreach was given a shot in the arm after the 2004 passage of California’s Mental Health Services Act (MHSA), or Proposition 63. Afterwards, community forums were held to address county mental health concerns.
In its wake, a handful have responded with a creative solution: mobile mental health.
The outreach typically takes two forms: trained professionals or volunteer peer counselors, often seniors. In either case, the goal is the same: go to the older adult.
The stakes are high for both the elderly and the state.
Because behavioral health woes are closely tied with physical ills, mental health interventions can keep older adults – including those low-income elders on Medi-Cal – out of both hospitals and expensive nursing homes.
Sutter and Yuba counties have formed a unique bi-county collaboration targeting older adults over 60 called BEST — the Bi-County Elder Services Team.
Yet delivering mobile mental health there hasn’t always been easy.
Once, 20% of BEST’s mental health care was offered off-site — typically at client homes. After the financial services collapse of 2008, however, BEST lost all four of its part-time staff — peer mentors and case managers — so that percentage has dwindled to just 5%.
“I’m mobile, but not as mobile as I used to be,” says BEST team lead Charles Benson, who treated 70 clients in 2014, mostly at a twice-weekly county clinic. “Now it’s just me.”
The mantra for isolated older adults is the same everywhere: get connected.
“For the most part, it’s hooking them up with (community) support or natural support — family, friends, some sort of social network,” says Benson. “Socialization.”
Access to behavioral health care in rural areas is often a huge challenge. Many rural counties have limited resources over vast geographies where seniors may lack transportation, or are simply too sick to travel.
Optimistically, Kern County features a growing MHSA-spawned outreach program that targets prevention and early detection: the Volunteer Senior Outreach Program, or VSOP.
Often provided referrals by Adult Protective Services, older adults are first visited at home by a county social worker or therapist. As long as the elder isn’t suicidal, they’re turned over to one of 19 trained volunteers ranging in age from 23 to 90 who use the Healthy IDEAS self-management model for treating depression.
Again, the response to social isolation is straightforward.
Just getting the person out to enjoy things,” says Jeremy Oliver, who heads Kern County’s department of Aging and Adult Services. These activities may include bingo, gardening, reading or attending a movie. Last fiscal year the program served 289 older adults.
While VSOP (called SAGE in Bakersfield) covers half of Kern County, Oliver says the goal is to continue expanding it county-wide.
Late life depression is a growing scourge; as many as 10% of older adults who visit their primary care physician are diagnosed with severe depression.
The death of a spouse can produce a cascading series of behavioral events that may include financial woes and substance abuse — either alcohol or prescription opioids used for chronic pain. Add poor physical health and limited access to mental health services and the results can literally become deadly. Suicide rates are highest among white older adult males – likely compounded by the greater availability of firearms.
Latinos elders are often doubly stigmatized when it comes to mental health issues. Besides the societal stigma faced by many older adults, Latino culture typically reinforces this stigma.
In response, Monterey County’s Alliance on Aging has trained its first set of senior peer counselors to help Latino seniors, many of whom have worked as farm workers.
While San Diego County is not considered rural, it has several mobile mental health teams that blanket the county to reach isolated elders where they live.
“They’re the hidden population,” says Jennifer Hurlow-Paonessa, head of the geriatrics program at the Neighborhood House Association in San Diego, home to one of the outreach teams. “That’s what’s nice about mobile outreach.”
Hurlow-Paonessa emphasizes the critical link between physical and mental health.
“What we find with older populations is that they have co-occurring conditions,” she says. “Not just behavioral but physical.”
Of six outreach regions — a collaboration between the county’s behavior health division and Aging and Independence Services — some use a tag team approach with a therapist or social worker for behavioral health and a registered nurse with a psychiatric background to address physical health needs. Its 11 outreach workers assisted over 2,500 clients in the last fiscal year.
What would happen in San Diego without the mobile teams?
They would become more and more socially isolated and not get the physical and mental health care they need,” she says. “(Many clients have) refused to go to the doctor in a long team.”
One excellent — and hugely untapped — resource is the Oakland-based Senior Center Without Walls, which offers a wide variety of classes by phone to California residents 60 and over: gratitude, games, travel, support groups, and health and wellness.
“It’s fundamental purpose and reason for being is to connect people to one another,” says director Amber Carroll. “I can’t understand why every health care system isn’t banging on my door.”
In the future, look for mobile mental health to gain popularity as California’s population ages – one in five residents by 2030, or a whopping 8.4 million older adults.
“There’s going to be an ongoing need for this,” says Benson. “It’s not just the mental health community, but the healthcare community. They’re going to see an increasing number of patients with mental health problems.”
Hurlow-Paonessa puts the outreach in acutely human terms.
“They have so many losses they’re dealing with,” she says. “We go out there and give them hope.”