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Jennifer Krajewski knows just how hard mental health care in rural Nebraska can be to come by.
Krajewski is a North Platte area suicide prevention advocate. She said it’s painfully obvious how few hospitals there are in the western half of the state compared to the Lincoln and Omaha areas.
“Out here, we don't have five different hospitals,” Krajewski said. “We have one, and it may take two hours to get to that one hospital.”
Lincoln County, home to North Platte, has 54 mental health providers for its 35,000 people, or 1.5 providers per 1,000 county residents. In Lancaster County, by contrast, that rate is 2.3 per 1,000. And North Platte is not the worst county in the state — 29 of them have 0 providers.
While preventing suicide does not only come down to providing mental health care access, Krajewski and others believe it plays a vital role. Like many industries, mental health access is a story of labor shortages. Only five counties in Nebraska are not designated as having a mental health care provider shortage, according to the University of Nebraska Medical Center.
“There's a shortage even in the best of areas,” said Marley Doyle, director of UNMC’s Behavioral Health Education Center. “And then there's an extreme shortage in areas that are geographically more remote from the eastern side of Nebraska.”
Krajewski got passionate about suicide prevention because of first hand experience.
In 1998, her brother died by suicide. He had what we now know as PTSD, she said. He was a rural firefighter and paramedic in western Kansas. Over time, the job took its toll on him.
After reading his journals, “we learned that he was suffering from visual and auditory hallucinations,” Krajewski said.
At the time, she was studying sociology in college. Because of that, she took his suicide personally. “How am I supposed to do this line of work if I didn't even recognize it in my own brother?” she asked herself at the time. The death sent her into a tailspin, she said.
A year later, she attempted to take her own life.
Through the help of a family friend who happened to be a counselor, she got the support she needed to get healthy again.
Now, Krajewski makes it her life work to prevent suicide. She does that helping out three different organizations – as the founder of the North Platte Suicide Prevention Colation; coordinator for the Southwest Nebraska LOSS Team; and as a board member for Nebraska’s chapter of the American Foundation for Suicide Prevention.
If you, or someone you know, is having thoughts of self-harm or suicide call or text 988 to speak to someone who can help
Building a workforce
Like many professional industries right now, the workforce shortage is a key problem for mental health care access.
“It is hard to get people to come out here, whether you're talking to professionals, mental health, doctors, lawyers, whatever,” Krajewski said.
Nebraska is not alone, according to UNMC’s Doyle. Like the rest of the country, Nebraska is seeing higher rates of depression and anxiety following the pandemic, Doyle said.
UNMC’s Behavioral Health Education Center detailed the needs of the industry, and much more, in a lengthy report last year. Some key findings:
- Of Nebraska’s 93 counties, 88 are designated as having a shortage of mental health providers.
- 29 counties have no behavioral health provider of any kind.
- However, from 2010 to 2020, the number of psychiatrists increased by 32% and the number of psychologists and mental health therapists by 39%
In those counties short on providers, Nebraskans may be forced to see a primary care physician for mental health treatments. For the most part, regular doctors are familiar with behavioral health, Doyle said. However, if a Nebraskan needs more mental health help – like therapy or an in-person meeting with a psychologist – those seeking care may be waiting a long time.
“We're finding more and more that by the time that people are potentially able to get in to see their counselor, it's too late,” Krajewski said. “When you're in crisis, you need to be able to see someone now – not in two months.”
Part of BHECN’s mission includes finding ways to fill in those gaps. With satellite offices on the campuses of the University of Nebraska at Kearney and Chadron State, the researchers formed a better picture of the differences between meeting the needs of different parts of the state, Doyle said.
Right now, BHECN is focusing efforts to provide opportunities for students – and potentially one day mental health care providers – in their neck of the woods, Doyle said.
“The more opportunities students have to train and stay in Nebraska, the more likely they are to stay,” she said. “From a concrete level, we really do try to find as many training opportunities for students in the state of Nebraska with the hopes that it will increase the likelihood that they'll stay.”
Another factor that prevents people from getting help manifests in the long-standing stigma surrounding mental health, Krajewski said.
“People still think if you talk about it then somehow it's going to happen to you,” she said.
Breaking through as a non-family member in Krajewski’s line of work can be tough. She said she understands why.
“Out here, we rely so much on our families and just doing it ourselves because we have to,” she said. “When you're out on a farm 30 miles from town, you kind of have to make do with what you have.”
Slowly, rural Nebraska is making progress. But in broader terms of suicide prevention, Krajewski thinks Lincoln and Omaha are five to 10 years ahead of rural western Nebraska.
Overall, the pandemic helped some skeptics realize their mental health does matter. But the stigma will still be tough to overcome because the best solution isn’t a quick one: talking one on one, Krajewski said.
Servicers working hard to meet demand
Nebraska’s suicide rate is a little better than its peers in the Midwest and Rockies, but not good enough for Sheri Dawson, the director of the Division of Behavioral Health Services.
The division at Nebraska’s Department of Health and Human Services plays a key role in suicide prevention and mental health care access. In part, it provides funding for Nebraskans who are Medicaid eligible.
The department wrote the previous statewide suicide prevention plan that had been in effect from 2016 to 2020. For the next plan, Dawson has some big picture goals.
She said she wants to make sure more Nebraskans are prepared to help one another.
“Many people could probably give you signs of a heart attack,” Dawson said. “How many Nebraskans can identify early signs of mental illness or someone that might be experiencing suicide distress or crisis?”
She’d like to integrate physical and mental health care services. For example, when someone attends an appointment with their primary care physician, Dawson would like their mental health to also be evaluated at the same time.
“We want people to get the same type of care that you can for physical health care,” Dawson said.
Growing telehealth options will be a key for the future of healthcare – but also a great way to reach rural Nebraska with mental health care services, Dawson said.
And finally, DHHS would like to keep improving the state’s 988 program, which is nearly two months old.
In the first month, the new suicide prevention hotline came in 6% above its first goal, according to Michelle Nunemaker, the state’s 988 planner at DHHS.
Crisis counselors at the Boys Town call center determined 24 of more than 1,500 first month’s callers needed a behavioral health team to respond, but only five people consented to talking to the team in-person.
Nunemaker said Boys Town will offer a phone or telehealth option in the hope that more of those callers will take the offer.
“We can still get them connected with services and supports in their time of need, but also doing it in such a way that they would feel comfortable and would be more open and receptive to supports,” Nunemaker said.
With the help of the Kim Foundation, the University of Nebraska Public Policy Center and the state’s suicide prevention coalition, Dawson hopes DHHS will publish the updated statewide suicide prevention plan later this fall.
The Midwest Newsroom's Daniel Wheaton contributed reporting and data analysis to this story.