Multidisciplinary, Collaborative Programs Key to Overcoming MH, SUD Challenges in Appalachia

Alexandria Widener, M.A., L.C.M.H.A., presented a case study during an Annual Meeting session on Tuesday about an 18-year-old girl who was caught by police smoking marijuana and possessing illicit prescription drugs near school property.

The case study described what should have happened to the girl. She should have been connected with mental health and substance use disorder (SUD) support. Resources should have been offered to her family, who was struggling with poverty and substance misuse. But the case study also described what actually happened: The girl was suspended, faced legal challenges, and had charges on her record even 10 years later.

The story represented was, in fact, Widener’s personal experience. She developed depression at an early age and began to self-harm in middle school. “I quickly traded my knife for a pill and soon became another statistic,” she said. She was surrounded by friends and family who were also “prisoners to pills.” She grew up in Washington County, Va., a county within the Appalachian region, which has been devastated by the opioid pandemic.

The session in which Widener participated outlined the ongoing multidisciplinary collaborations that are addressing mental health and SUD needs in central Appalachia. To put into context what is happening in Appalachia, the session’s chair, Larry Merkel Jr., M.D., Ph.D., outlined the region’s history. He described how the need for fuel and raw materials during the industrial expansion in the United States resulted in the exploitation of the Appalachian region for coal and timber. He touched on the Coal Wars, which lasted from 1890 to 1930; the displacement of around 2,000 people when Shenandoah National Park was created; and the sterilization of over 7,000 people in Virginia as part of the Eugenics movement. Merkel is a professor and director of outreach in the University of Virginia’s Department of Psychiatry and Neurobehavioral Sciences.

Merkel and the other presenters spoke about some of the struggles in Appalachia, such as poverty, unemployment, and the loss of skilled young people who are leaving the area. The quality of health care is low, and the levels of chronic diseases are high, Merkel said—a situation that was only worsened by the COVID-19 pandemic.

Nicky Fadley, M.P.P., described the work that her organization, Strength in Peers, conducts in counties in Virginia’s Shenandoah Valley. The peer-run organization offers support for those struggling with trauma, substance use, mental health, homelessness, and reentry from incarceration. Fadley, who is the organization’s founder and executive director, explained that peer recovery specialists use their personal experiences to develop relationships with individuals who struggle with distrust of the behavioral health system and help them engage in treatment and social services. They provide support to individuals where they are, offering to visit people in their homes, on their porches, or in public places.

Further, Strength in Peers has a side-by-side recovery program in which individuals are connected with peer recovery specialists, case managers, counselors via tele-counseling provided by the Harrisonburg Center for Relational Health, and psychiatrists via telepsychiatry provided by the University of Virginia Department of Psychiatry. Fadley outlined the benefits of partnering with peer-run organizations for peer recovery services because of the support they can provide peer recovery specialists to avoid peer drift and burnout. (Peer drift occurs when peer support specialists do not feel comfortable in their recovery-oriented role, and they begin to shift to a more medical treatment role.)

During his presentation, Sy Atezaz Saeed, M.D., M.S., F.A.C.Psych., pointed to the impact that a shortage of mental health professionals, especially psychiatrists, has had on patients in emergency departments (EDs) in rural areas like Appalachia. Patients often find themselves boarded in the ED, waiting hours or even days to receive care for their mental illness.

“A growing body of literature now suggests that the use of telepsychiatry to provide mental health care has the potential to mitigate the workforce shortage that directly affects access to care, especially in remote and underserved areas,” said Saeed, who is the executive director of the North Carolina Statewide Telepsychiatry Program (NC-STeP).

NC-STeP’s goal is to ensure that anyone who enters a North Carolina ED receives timely, evidence-based psychiatric treatment via telepsychiatry. The program launched in October 2013, and as of the end of 2022, it had provided 57,052 telepsychiatry consultations, with over 8,500 involuntary hospitalizations being overturned and an associated savings of more than $50 million. Based on its success, the North Carolina legislature expanded the program beyond EDs and into community-based settings using a collaborative care model.

Widener highlighted how opioid use in Appalachia is a means of staunching pain, both physical and mental. Though she has not used opioids in nearly 11 years, she does not yet have a happy ending, she said. Fentanyl has consumed Appalachia, and her parents and nephew have experienced multiple fentanyl overdoses, requiring Narcan to save their lives.

“Hear me closely: My family is composed of hurting people who are desperately seeking relief that isn’t afforded to them in other ways,” she said. She detailed the difficulties she and her mother have had in connecting her mother to treatment. “Even in my own situation, it took years to get the help that I needed,” she continued. “I got a criminal record before I got help. This is why a multidisciplinary partnership is so essential to ending the opioid epidemic.” The challenges are daunting, she said, but with collaboration, they can be overcome. ■