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story.lead_photo.caption One way the Department of Mental Health has reached out to rural residents (to let them know about what resources are available) is through business cards left at markets, convenience stores, grain suppliers, barber shops and other sites. The back discusses recognition of risk factors and how to seek help. The cards are small and discreet.

People who live in rural communities oftentimes struggle to gain access to basic medical care, and receiving behavioral health care is much more challenging in rural areas.

Even if behavioral health care clinics were available — and in most rural Missouri communities, they aren't — residents would hesitate to visit them, worried about the stigma associated with mental health concerns.

Farming can be stressful, according to Susan and Ryan Butterfield, of Brookfield.

"It's put a lot of stress on me," Ryan said Friday. "It's kind of been a bad year. I had a stroke. After I had a stroke, I had a heart attack."

Ryan, 55, had the stroke in June. The heart attack followed shortly. Susan is 52. She has multiple sclerosis — a disease in which a person's body mistakenly attacks the protective coverings of nerve cells.

Susan took over daily operation of the small cattle farm the couple operates. Friends pitched in this summer to help bring in hay.

"There's a lot of stress that people don't understand," Ryan said. "My wife is taking care of everything for me. That is putting so much stress on her."

The stress caused Susan's condition to relapse this summer. She ended up having to be flown to Columbia for treatment.

"We're trying to cope with it," Ryan said. "It's been terrible — in the middle of me having all of these problems, I kind of threw her into relapse trying to take care of me."

Having a behavioral health clinic nearby, where the couple might have been able to address their stressors, might have helped, he said.

Ryan said he'd use behavioral health resources if they were available.

Most rural residents probably wouldn't, according to Dave Welschmeyer, a farmer in Martinsburg. And if they did use the resources, they'd keep it to themselves.

"That's a need that's pretty much hidden," Welschmeyer said. "There are a lot of peopleI probably know somebody who deals with that (behavioral health concerns), but they keep it hidden."

Karen Funkenbusch, a health and safety specialist with University of Missouri Extension, said a recently released report, "Growing stress on the farm: The expanding economic and mental health disparities in rural Missouri," is a much-needed step toward providing behavioral health services to rural Missourians — farmers, ranchers and other people living in small communities.

The report looked at factors that adversely affect rural Missourians — things like flooding, severe storms, commodities markets, international trade, isolation and access to services.

"That report tells us, in a nutshell: where are we today in Missouri, looking at mental health?" Funkenbusch said. "It doesn't matter what I tell you. What matters is what our farmers say. It tells the story of the mental anguish they deal with day in and day out."

The report was created through a collaboration between MU Extension, Missouri Hospital Association, Missouri Coalition for Community Behavioral Healthcare, Missouri Department of Mental Health and Missouri Farm Bureau. The intent was to elevate awareness of the economic challenges farmers face and the mental health outcomes rural Missourians obtain.

A number of unique stressors lead to the anguish farmers and ranchers experience, according to the report.

Those stressors range from weather to markets for their products to health.

People living in rural communities and on Missouri farms are aging more rapidly than in other communities — and their health care demands are increasing.

The average age of a Missouri farmer was 54 in 1997 and 58 in 2012, according to the Missouri Department of Agriculture. By 2017, the age was 58. Of the state's 100,000, only 636 were under 25 in 2017.

Now, according to the Missouri Farm Bureau, the average age is 59.3.

For a farmer — who's not likely to take the day off to drive two hours to see a physician, let alone a mental health care professional — physical and mental health issues may compound, Funkenbusch said.

She said a married full-time farmer who is in his 70s and lives in rural Northwest Missouri called her this past week. The man reached out because his wife was dealing with anxiety and depression. The farmer is sacrificing the time to care for his wife and drive her to Kansas City, where she can receive the treatment she needs, but the effort takes a toll.

"The reason he brought it up is his wife used to feed the cattle. His wife used to be engaged," Funkenbusch said. "She had surgery, and her health has declined. It has brought on more anxiety and stress. He has his own health problems he's trying to deal with."

The report gives stakeholders new teeth they can take to lawmakers when asking for help overcoming challenges in rural Missouri, Funkenbusch said.

Rhonda Perry, program director for the Missouri Rural Crisis Center, is also a livestock and grain farmer near Armstrong, north of Columbia. Perry and other members of MRCC visited Jefferson City last week as part of the organization's effort to lobby lawmakers to create policies that help farms remain "viable and sustainable and thriving."

Gathering the data and creating a report are the first steps in getting something done for rural communities, Perry said.

"The avenues for people to get to (behavioral health services) are not there. There isn't decent internet service," Perry said, "that allows people to easily be able to find services that are close to them and let them engage in a digital way."

Discreetly.

Perry said she wasn't speaking about any specific town, and her comment applies to all rural communities.

"I am saying something about the type of place where I live. Our town is 280 people. The county seat has 2,500 people," she said. "It's one of those places that is a small community. People know people's business."

They go to the same grocery stores, churches, gas stations and schools. Typically, a farmer goes to the same banker every year to ask for a farm operating loan — loans to family farmers that cover the costs of feed, seed, fertilizer, pesticides and other expenses.

Do farmers want their colleagues discussing where their pickup was parked?

"What people say and what people know about your operation — that matters," Perry said. "It's also your economic livelihood. It isn't just an issue of pride. There are big, real ramifications right now."

First, communities have to recognize the problems, she said.

Then, stakeholders must determine what services are necessary and how best to provide them.

Mat Reidhead, MHA vice president of research and analytics (and the primary author of "Growing stress on the farm") presented the report to the Mental Health Commission on Thursday.

The commission is made up of seven governor-appointed members who in turn are tasked with appointing the director of the DMH. The DMH tries to prevent mental and substance use disorders and developmental disabilities. It also treats and habilitates people with disorders and disabilities. DMH improves public understanding and attitudes about those with mental health conditions.

The report looks at economic and mental health disparities across the state for farmers — along the rural/urban divide, Reidhead said.

"Untreated mental illness is a growing health crisis across Missouri," he said. "And, because of issues related to culture, and stigma, and social determinants, and limited access to care, we're seeing adverse outcomes related to mental illness compound for rural populations."

But, for farmers and ranchers and commodities producers, the impact of the "toxic stress and depression" can be more severe because it's driven by conditions beyond their control.

"We wanted to call attention to the larger rural behavioral health crisis in Missouri by building this coalition of stakeholders in agricultural mental health and publish this report," Reidhead said.

The effort was also intended to highlight work DMH is doing across the state to "start to move the needle" in improving outcomes for rural residents' behavioral health issues.

Between 2003-17, almost 4,000 rural Missourians died by suicide. The Centers for Disease Control and Prevention show the rate of suicides for Missourians is 18 percent higher for those living in rural areas than for those living elsewhere.

The number of Missouri hospital emergency department visits in rural counties for mental health and substance use disorders grew by more than 14,000 per year from 2009-19. Rural Missourians made about 44,000 emergency department visits in 2019 for behavioral health issues.

"Our hospital emergency rooms are becoming the de facto care outlet for folks in mental health crisis," Reidhead said.

Stacey Williams, a DMH suicide prevention coordinator, followed Reidhead on Thursday, updating the commission on the agency's efforts to reduce suicidality in rural Missouri.

For a few years, the agency has operated a program called "Help Him Stay" to address the high number of suicides in middle-age men. (About 380 Missouri men ages 35-60 die by suicide each year.) The program may be found online at helphimstay.org.

Help Him Stay offers a confidential "lifeline" 24 hours a day, seven days a week at 1-800-273-8255. Staff working the lifeline can help callers through crises and put them in touch with nearby resources.

The program uses billboards, social media messaging and other resources to reach out to men in rural communities.

"(It's) just to encourage folks to reach out to talk to someone — to anyone," Williams said. "Talk to someone who can say, 'I have been through this and I reached out and that helped me — just talking about it.'"

The staff member may not necessarily encourage a hospital visit, but may inspire the caller to speak to someone close to them.

As the agency developed the campaign, it consulted a focus group of men.

"(The men in the group) said they wanted something that would be really easy to pick up in a local business," Williams said. "Something they could easily stick in their pocket or wallet — which wasn't a big flyer that was easy to see."

So the DMH developed business cards. DMH gives the cards in mass quantities to its 10 prevention centers — places like Community Partnership of the Ozarks in Springfield, FCC Behavioral Health in southern Missouri and Compass Health Network (with locations across Missouri, including Jefferson City, and others).

The prevention centers give the cards to community coalitions, which disperse them at convenience stores, feed lots, grain lots and other sites.

People seem to love them, Williams said.

"Suicidal thoughts are treatable," the card says on one side.

The other side says, "Suicide can be prevented. It means knowing what to do when you or someone you know is going through a difficult time. It means knowing how and where to get help. Help is available. For free, confidential assistance 24 hours a day/seven days a week, you can call the National Suicide Prevention Lifeline. The lifeline can help you get through an immediate crisis and put you in touch with resources in your community."

Both sides also contain the 800 number.

The organization is also training rural health providers in "Zero Suicide" approaches. It intends to expand the program and provide it for more primary care and hospital sites in rural communities, Williams said.

The report helps DMH identify where resources are needed, Director Mark Stringer said.

"The things we're doing in response (to the rural mental health crisis) meet challenges," Stringer said. "One of the biggest challenges we have is workforce. There are simply not enough mental health professionals."

With 57 of Missouri's 99 counties lacking any psychiatrists or psychologists, telehealth will be a big part of the solution — and already is in some locations, Stringer said. Telehealth allows health care providers in one location to serve patients in rural locations via the internet.

"It's telehealth, and it's the use of people who are in recovery themselves, who are reaching out to farmers and making those connections (that are going to provide better outcomes)," Stringer said.

DMH has to make every effort to reach people, he said.

"We're doing everything we can along those lines," he continued. "It just takes time. It takes persistence. It takes all the creative thinking we can muster to help find solutions."

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