Frontier Psychiatry

In rural Montana, being pregnant in the winter is risky for many moms-to-be. They have to travel over 100 miles to visit the nearest healthcare provider to get prenatal care, braving heavy snow and temperatures far below zero. Rather than risk getting stuck or worse, they stay home.  Wouldn’t you? Today is National Rural Health Day.  This year, the Day is dedicated to advancing maternal health. Sadly, “maternity care deserts” in Rural America are actually widening as financially strapped hospitals close. In these areas, women are 2x as likely to die from childbirth-related complications compared to their counterparts in more densely populated communities. There are more than just nasty geographic barriers getting in the way of quality pre-natal care across Rural America. ** 1 **  There are higher uninsured rates in Rural America.  Medicaid expansion helped the people of participating states.  Georgia and Texas, two non-expansion states with large rural populations, have uninsured rates 2x higher than states with Medicaid expansion. ** 2 ** Over 140 rural hospitals have closed since 2010, pushing the number of health professional shortage areas higher.  66% of these shortage areas are in rural communities.  This means lower access to OB/GYN services and higher burden on health professionals who stay behind. ** 3 ** Telehealth is helping, but it’s not a perfect solution because 57% of Americans without broadband access live in rural areas.  Americans who can most benefit from digital services are often the very people who lack the necessary infrastructure. ** 4 ** People in Rural America are more likely to have lower incomes, be older, and have chronic health conditions.  These realities, combined with higher uninsured rates, have a devastating effect on morbidity and mortality rates. ** 5 ** There is more limited access to affordable prescription drugs.  Rural Americans are less likely to have access to Medicaid-contracted pharmacies and they are more likely to be enrolled in programs with poor pharmacy benefits. This post could go on and on, listing the factors contributing to the health inequities plaguing Rural Americans.  If you’re in a position to make a difference, please remember it’s National Rural Health Day. Consider this information beyond today as you think about how to make quality healthcare accessible to all Americans.

I moved from Connecticut to Montana in 2013. I can see why Rural America is feeling left behind. I've cared for thousands of patients since my arrival here. There are RURAL social determinants of health (SDOH) that drive health inequities. If you understand what's happening in Rural America, you might start to appreciate the forces influencing our national politics. 60% of American counties were counted as rural in 2020, accounting for a population of 46 million. Tomorrow is National Rural Health Day and this year's focus is on maternal health. Here are among the most powerful rural SDOH's that lead to higher mortality compared to urban and sub-urban communities: 1. Rural hospital closures. 2. Shortage of healthcare professionals. 3. Gaping healthcare deserts. 4. Higher uninsured rates. 5. Higher poverty rates. 6. More food insecurity. 7. More substance misuse. 8. Less physical activity. 9. Lower levels of education. 10. More social isolation. Beyond increased mortality rates, this hurts hope and limits possibilities for my neighbors.

There are so many approaches to mental health and primary care integration. I'm not convinced we know the best way forward. For the longest time we tried co-locating therapists in primary care clinics. Over time, the University of Washington published compelling research to support the collaborative care model (CCM). Thanks to powerful advocacy efforts, CMS even rolled out reimbursement codes to pay for CCM. I think its uptake has stalled, though. Primary care clinic staff already have enough to do and the reimbursement rates don't always cover the cost of CCM. There are also a lot of moving parts to deploying functional CCM - you're essentially building out a separate service line. More recently, Certified Behavioral Health Clinics (CCBHCs) have enjoyed growing popularity. This model involves integrating primary care into mental health settings. I wonder what the future of behavioral health and primary care integration will look like? Are the CCM and CCBHC models passing fads? Will one of them emerge as the answer? Do they represent scalable strategies that will help our primary care colleagues improve whole health outcomes? What's your take? A - "A new model will emerge. Neither CCM nor CCBHC is the answer." B - "CCM is the answer. It's here to stay." C - "CCBHCs represent the best approach to integration." D - "There is a better model you haven't mentioned." Give me your answer in the comments. I'd love your thoughts.

I'm not sure we have a mental health crisis anymore. Maybe this is just our new normal. I don't see anyone coming to the rescue in response to our worsening suicide rates. Where is the sense of urgency? Are we just numb to the regular diet of bad news related to the mental health of our fellow Americans? Our country's military Veterans are among the most impacted by our collective inaction. Today, over 20 Veterans will take their own lives. Right now, there are Veterans in your local emergency room seriously thinking about suicide. I think that bold and innovative mental health advocates and champions will ultimately save us. People who don't care about the friction and barriers built into our "system". We have thousands of people in positions of power with access to resources, but no sense of urgency. We have millions of people with a sense of urgency, but aren't in positions of power or lack resources. Let's support those people. If you know of someone who is doing something to improve mental health outcomes of our military Veterans, please give them a shout out in the comments. Or, you can DM me and I'll highlight their work.

Building functional teams in healthcare is hard. Building REMOTE functional teams in healthcare is even harder. 15 of our providers are spending a few days together IRL at a conference in Colorado Springs this week. This week is so precious for several reasons. Many of us are meeting one another in person for the first time. Nothing beats a hug. It turns out we like each other a lot even when we're not behind a webcam. We've been at this for about 5 years and we have a clinical team of about 30 employed providers. The investment to bring us all together this week has a huge ROI measured in improved morale and precious human connection. Remote work affords a lot of benefits. It makes the IRL meetings particularly special. These are the people in the picture...and, yes, I'm the obnoxious one on the floor. Reza Hosseini Ghomi, MD, MSE Claire Mastel, PA-C, CAQ-Psychiatry Melinda Truesdell, DNP, PMHNP-BC Joe Knoble, MD Nathan Bell Rachel Monahan, PA-C, CAQ-Psych Jonathan Brigham Swathi Krishna Asta Reindl, MSN, PMHNP Laura Adams Here's who's missing: Sarah Kerr Nicholas Meinhardt Matthew Thompson, MD, MPH, FASAM Megan Verlage

Suicide rates among US youth were trending downward in the late 1990's and early 2000's. Then in 2005, the FDA slapped a black box warning on antidepressants. The FDA claimed that antidepressants were likely associated with suicidal thoughts and behaviors in youth. The warning led to confusion and fear among patients and providers, compounding the pre-existing stigma surrounding mental health medications. According to last month's article in Health Affairs, the black-box warning caused more harm than good. It led to a reversal in the declining suicide rates among children and adolescents for one. Here are other ways that the warning hurt thousands of American youth in the years following the warning. Higher suicide-related events: 1. A 22% increase psychatric medication overdoses among adolescents and a 34% rise among young adults after the warning. 2. An estimated 2,500 additional youth completed suicide in the three years after the warning. 3. Suicide rates were declining in the late 1990's and early 2000's until the warning. Rates started to increase immediately after. There was a decrease in depression care: 1. Depression-related visits decreased nearly 50% among Medicaid patients aged 5-17 within three years after the warning. 2. The biggest drops occurred among primary care providers, the largest group of antidepressant prescribers. There was a reversal in antidepressant use: 1. Antidepressant prescriptions to patients under 18 decreased by nearly 50%. 2. Again, primary care providers (eg. pediatricians, family practice docs) were among the most likely to curb antidepressant prescribing to youth. Patients and families still ask me about the black-box warning, wondering if taking antidepressants will lead to suicide. Psychiatric medications aren't the answer to all mental health problems. But, for the sake of those who can benefit from the meds, let's not add to the stigma.

Gregory Kendall just got his job back at the Atlanta VA. He was fired last year after telling a local reporter that over 7,000 phone calls for mental health services went unanswered. In the dismissal letter, VA officials said he had "poor judgment" when he made the problems public. I think he showed remarkable courage and compassion for the Veterans who spent hours trying to get help. Two weeks ago Military(dot)com published another story alleging that VA staff have been deliberately canceling mental health appointments at the last minute. The practice was designed to obscure the fact that VA clinics didn't have enough staff to deliver much-needed mental health services. Officials were apparently trying to prevent more expensive referrals to community-based providers. A money-saving tactic. Some families have filed lawsuits against the VA, saying that the last-minute cancelations directly led to Veteran suicides. I can't believe that we're still reading stories like these. How is this happening? More than 20 Veterans kill themselves every day across the US. I'm grateful for the courage and advocacy demonstrated by Mr. Kendall and the heartbroken family members. Please share this post to amplify their voices.

Entrepreneurs are over 2x more likely to have dyslexia than the general population. About 35% of US entrepreneurs have dyslexia compared to a 15% rate among the general US population. While dyslexia is certainly a vulnerability in the classroom, affected people often develop traits that make them successful founders: 1. Delegation - they learned early how to surround themselves with people who helped them overcome known skill gaps. 2. Communication - they develop keen oral communication skills that help them articulate a vision with clarity and persuasion. 3. Team building - they prioritize personal connections and supportive environments. 4. Thinking differently - they are more comfortable challenging conventional wisdom and approaching problems from a different perspective. Less than 1% of US corporate managers had dyslexia. Here are examples of successful entrepreneurs with dyslexia: Richard Branson (Virgin) Charles Schwab Henry Ford Walt Disney Steve Jobs Tommy Hilfiger Ingvar Kamprad (Ikea) Paul Orfalea (Kinko's) Daymond John (FUBU) Barbara Corcoran This demonstrates the power of strength-based education and talent development. Imagine if school teachers had the time and resources to identify and build on students' strengths. Kids are expected to be successful in all subjects, while adults are allowed to specialize. Maybe we should rethink that approach?

Today, we celebrate the heart and soul of our clinical team—our amazing Medical Assistants! Your dedication, care, and hard work behind the scenes ensure our patients receive the best care possible. Thank you for being the backbone of our practice and for always going above and beyond! 💚 #MedicalAssistantAppreciation #ThankYouMAs #ourteamrocks #FrontierPsychiatry

We are looking to hire a passionate, mission-driven leader to be our SVP of Operations. Frontier Psychiatry is dedicated to lifting the mental wellbeing in rural communities. If you are an operations wizard and know how to scale the delivery of high quality psychiatric- and addiction treatment via telehealth, please DM me. We are in Montana, Idaho and Alaska with plans to reach many more rural communities in and around this region over the next 10 years.