US Counties Hit Hard by a Lack of Psychiatric Care


In 2020, US counties that were without psychiatric care or broadband coverage had significantly more drug overdose deaths and completed suicides compared to other counties, new research shows.


In the US, there is a severe lack of psychiatrists and access to mental health care. In 2019, 21.3 million US residents were without broadband access. These patients were forced either to use telephone consultation or to not use telehealth services at all, although use of telehealth during COVID-19 somewhat improved access to psychiatric care.

For the study, researchers gathered sociodemographic and other county-level information from the American Community Survey. They also used data on the psychiatrist workforce from the Health Resources and Services Administration (HRSA) Area Health Resources Files.

Information on broadband internet coverage came from the Federal Communications Commission, and measures of mental health outcomes were from the Centers for Disease Control and Prevention.


The study identified 596 counties (19% of all US counties) that were without psychiatrists and in which there was inadequate broadband coverage. The population represented 10.5 million residents.

Compared to other counties, those with lack of coverage were more likely to be rural (adjusted odds ratio [aOR], 3.05; 95% CI, 2.41 – 3.84), to have higher unemployment (aOR, 1.12; 95% CI, 1.02 – 1.24), and to have higher uninsurance rates (aOR, 1.03; 95% CI, 1.00 – 1.06). In those counties, there were also fewer residents with a bachelor’s degree (aOR, 0.92; 95% CI, 0.90 – 0.94) and fewer Hispanics (aOR 0.98; 95% CI, 0.97 – 0.99), although those counties were not designated by the HRSA as having a psychiatrist shortage. That designation brings additional funding for the recruitment of clinicians.

After adjusting for sociodemographic factors, counties without psychiatrists and broadband had significantly higher rates of adult depression, frequent mental distress, drug overdose mortality, and completed suicide compared to other counties.

Further analysis showed that the adjusted difference remained statistically significant for drug overdose mortality per 100,000 (9.2; 95% CI, 8.0 – 10.5, vs 5.2; 95% CI, 4.9 – 5.6; P < .001) and completed suicide (10.6; 95% CI, 8.9 – 12.3, vs 7.6; 95% CI, 7.0 – 8.2; P < .001), but not for the other two measures.


“Our finding suggests that lacking access to virtual and in-person psychiatric care continues to be a key factor associated with adverse outcomes,” the investigators write. They note that federal and state-level investments in broadband and the psychiatric workforce are needed.


The study was conducted by Tarun Ramesh, BS, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, and colleagues. It was published online as a research letter on September 24 in JAMA Network Open.


The investigators did not consider whether recent legislation, including the Consolidated Appropriations Act of 2021 and the American Rescue Plan, which expanded psychiatry residency slots and broadband infrastructure, reduces adverse outcomes, something the authors say future research should examine.


The study received support from the National Institutes of Health, including the National Institute on Minority Health and Health Disparities and the National Institute of Mental Health. The authors have disclosed no relevant financial relationships.

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