Chad Reznicek knows all too well the stigma surrounding mental health in rural Colorado.

A behavioral health specialist with the Colorado AgrAbility Project, Reznicek noted that communities remain tightly knit in small towns, and it’s not uncommon for everyone to know each other’s business.

Residents, he said, are wary of seeking help precisely because they fear being judged, particularly when that judgment could potentially jeopardize entire livelihoods. 

“If me and my neighbor are both competing to lease a plot of land from another neighbor and that neighbor sees my truck in front of the clinic, then they might have to weigh out, ‘Well, Chad’s got too much going on. Maybe I’ll just sell to Bill instead,'” he said.

But it’s not just the stigma that acts as a barrier to access, a confluence of factors has made rural Colorado a “mental health desert.” 

There are fewer mental health facilities in rural Colorado, and it’s tougher to persuade a practitioner to give up the convenience of city living and move to a town far away.    

And while officials, experts and advocates have aggressively pushed to expand access to mental health services in rural areas, they all agreed that much work remains 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 to one for every 755 residents in urban areas.

One of the obvious reasons is the population weight across the state.  

Census data shows that rural Colorado has nearly 80% of the state’s land but only about 14% of its population.

Michelle Mills, CEO of Rural Health Center, explains that the challenge extends beyond recruiting mental health providers to rural areas. Finding housing for them is equally problematic, she said. 

“You have to have a place for people to live, even if you can find somebody to hire,” she said. “I think all of Colorado is a mental health desert, so if you’re having difficulty recruiting in an urban area, it’s twice as hard in a rural location.”

Adding to the complexity is the requirement that federally certified rural health clinics allocate no more than 49% of their services to mental health care to maintain proper certification. This limitation means that, even if these clinics could offer more, they would risk losing the critical benefits of certification, such as grant opportunities and regulatory flexibility.

In many rural parts of Colorado, it’s not uncommon to have to travel several miles to reach a neighbor’s house and even farther to access the nearest medical provider. Patients seeking mental health care in some regions may have to drive several towns away to reach a clinic, which can be impractical or even impossible for many.

The way experts put it, these factors have created a perfect storm — communities struggle with limited mental health services, exacerbated by the pervasive stigma surrounding mental illness.

The promise of telemedicine — if the Internet works 

Many have looked to technology to help the gap in rural areas.

Telemedicine, for example, has grown significantly since the COVID-19 pandemic, and it offers a promising option for patients in remote areas.

But it’s not a universal solution precisely because broadband access remains a a significant issue in rural Colorado, with more than a dozen counties reporting nearly a quarter of the population lacking at-home internet service.

Tackling the state’s internet connectivity issues became a priority for the state legislature this year, when policymakers established the Cell Phone Connectivity Interim Study Committee. The newly formed bipartisan committee, which held its first meeting in July, is focusing on addressing connection gaps in rural Colorado.

‘You just need help, and that needs to be OK’

Even if mental health care were readily available to every rural Colorado resident who needed it, advocates are skeptical that many would seek it.

Ashley House of the Colorado Farm Bureau Foundation attributes this reluctance to the “pull yourself up by the bootstraps” mentality in rural and agricultural communities.

“I think there’s a certain reticence in rural communities to reach out for help,” she said. “Sometimes, you just need help, and that needs to be OK.”

While conversations about mental health in rural communities have improved recently, House said it still has a long way to go.

One in five rural Coloradans reported experiencing depression, based on data from the Colorado Rural Health Center. House attributed this figure to the unique pressures of agricultural work, compounded by some level of isolation of rural living, as well as the financial strain and supply chain disruptions brought on by the pandemic.

The latter, she said, significantly affected many farmers’ mental health.

Experts: Help is available

Help is available for those who need it and are ready to seek treatment, experts and others emphasized.

Organizations, including the Colorado Department of Agriculture, Colorado State University Extension, Farm Bureau Foundation, and the Colorado Office of Behavioral Health, oversee a program that provides vouchers to agricultural workers and their families for six free telehealth therapy sessions.

Colorado is among 19 states with similar programs, and Reznicek reports that the state boasts one of the nation’s highest participation rates, having delivered more than 400 hours of therapy last year.

All therapists affiliated with the the Colorado Agricultural Addiction and Mental Health Program either have personal experience in agriculture or have received special training to understand the unique lifestyle of agricultural workers.

Reznicek said this tailored approach is essential for ensuring the program’s effectiveness.

“By the time someone is able to get to a therapist, there’s a lot of stigma,” he said. “So, we’ve been working to try to reduce that, but if someone does get to the point of meeting with the therapist and they have to spend the first two sessions helping someone understand what their life is about and why they can’t just take a vacation from these stressors, it’s a little bit harder of a sell.”

“So, we really try to prioritize the idea that if someone has the courage to reach out and ask for help, we want to ensure that they come back to the second session, and the best way to do that, we think, is to make sure that there’s a connection,” Reznicek said. 

Because the therapy sessions offered by Colorado Agricultural Addiction and Mental Health Program are virtual, patients don’t need to leave the farm for their appointment, and they can even meet with their provider during work hours.

“Oftentimes, farmers and ranchers are reluctant to leave the farm, and providers may not always have appointments when the sun goes down and they’re coming off the field,” House said. “Telemedicine offers more flexibility in that you don’t have to travel to meet with your provider.”

Virtual appointments also provide privacy for patients, which is essential to those afraid of being judged for seeking therapy.

“We knew that a big hallmark of the program had to be keeping peoples’ information private and to protect their identity as much as possible,” House added.

The Farm Bureau Foundation also launched the Neighbor Project initiative, which encourages Coloradans in rural areas to check in on their neighbors and provide them with postcards that include contact information for a crisis hotline and information about state programs.

Evidence has shown that peer-to-peer connections are among the most effective ways to address mental health.

“So, that’s something we’ve tried to bolster and elevate,” House said.

Growing optimism

Numerous legislative efforts at both the federal and state levels have sought to increase access to mental health care in rural communities.

The Rural Wellness Act, introduced by U.S. Reps. Yadira Caraveo of Colorado and Brad Finstad of Minnesota would reauthorize the USDA’s Distance Learning and Telemedicine Program, which provides grants to help rural communities implement technology projects, such as telemedicine treatment for substance use disorders.

In 2023, Colorado’s Michael Bennet, along with U.S. senators Tammy Baldwin of Wisconsin and Joni Ernst of Iowa, introduced the Farmers First Act, which aims to address the significant rates of suicide among agricultural workers, which are 3.5 times more than the general population.

The bill would increase funding for the USDA’s Farm and Ranch Stress Assistance Network, which connects agricultural workers to mental health programs and resources.

Both bills have been assigned to committees, but no further action has been taken.

At the state level, legislators have sought to address the mental health crisis affecting rural Coloradans.

In the 2024 session, Gov. Jared Polis signed Senate Bill 55 into law. The new legislation seeks to improve access to mental health care in rural areas by establishing an agricultural and rural community behavioral health program within the state’s Behavioral Health Administration.

The program will designate a liaison to facilitate collaboration between the Behavioral Health Administration, the Department of Agriculture, behavioral health care providers, rural community leaders, agricultural communities, and nonprofit organizations that serve those communities.

The bill also establishes a working group composed of agriculture and behavioral health experts tasked with developing best practices for delivering behavioral health care to agricultural workers and their families. Additionally, it creates a grant program for existing or new initiatives that address the causes of mental health issues in the farming industry or rural communities.

“This bill is really gonna move the needle,” Reznicek said.

Other strategies, notably broadband expansion, would also indirectly positively affect rural mental health care, experts said. 

“It may seem obvious through a few of these bills because they have mental health or behavioral health in the name, but there’s also community investment and a lot of good nonprofit work going on that is more tied to rural economic health, but the tertiary or secondary benefit of a lot of that investment money is going to be for rural communities,” House said.