The digital divide in access to broadband internet and mental healthcare

Telemedicine has been championed as an innovative solution to improve access to mental healthcare in communities with reduced mental healthcare resources. However, whether these communities have the necessary broadband infrastructure to access the full functionalities of telemedicine has not been well studied.¹⁴ In this study corresponding broadband access with mental healthcare access in 3,138 US counties, we found that US counties with reduced broadband access have lower average densities of mental healthcare physicians, non-physician mental health practitioners, inpatient psychiatric and substance abuse treatment facilities, and outpatient facilities. These differences were found to be statistically significant. Moreover, counties with reduced broadband access are at a far greater risk of having no providers of each service in the region, particularly mental health physicians, non-physician mental health practitioners, psychiatric and substance abuse hospitals, and outpatient treatment facilities. These findings underscore that, while telemedicine may mitigate many key barriers to in-person mental healthcare, lack of broadband access may present an additional barrier to care for individuals already living in medically under-resourced communities. In a secondary analysis, we found that broadband access tends to be lower in areas that are rural and/or have high poverty rates.

Our findings corroborate previous studies that illustrate the manifold sociodemographic disparities in access to broadband internet. For example, several studies suggested that rural areas with larger Black and American Indian/Alaska Native populations, lower educational attainment, and higher poverty rates tend to have less broadband access.¹⁵ These results also support several previous studies that have found substantial shortages in mental healthcare professionals occurring disproportionately in rural areas.¹⁶ In addition, this study expands on the literature by directly corresponding broadband access with access to mental healthcare services at each level from diagnosis to treatment—including physicians and non-physician mental health professionals, psychiatric hospitals, inpatient and outpatient treatment facilities, and pharmacies and drugstores.

The clear association of broadband access with mental healthcare access, urbanization level, and poverty rate characterized here raises the question of whether under-resourced areas simply have lower demand for these services. However, previous studies have established that mental healthcare needs are similar in rural and urban areas. One study found mental illness incidence rates to be 17.3% in large metropolitan counties and 18.3% overall in non-metropolitan counties. The study also found rates of serious adult mental illness to range from 3.8% in large metropolitan counties to 4.7% in non-metropolitan counties.¹⁶ Furthermore, suicide rates in the most rural communities have been found to be nearly twice those of their urban counterparts.¹⁷ Poverty has also been linked to a higher mental illness incidence. In fact, one study found that children in the poorest households have a threefold increase in the risk of having a mental illness compared with children in the wealthiest households.^18,19 Thus, our study and previous studies highlight a clear maldistribution of both in-person and virtual mental healthcare resources.

Disparities in access to mental healthcare resources are particularly pronounced for outpatient care. In fact, counties with reduced broadband access are nearly three times more likely to have no outpatient treatment facilities, which typically offer services such as mental illness screening, outpatient counseling, substance abuse services, and trauma services accessible from the patient’s home.²⁰ This is particularly concerning since outpatient care plays a uniquely important role in providing early mental health screening, diagnoses, and interventions due to the speed, reduced costs, and increased convenience of outpatient care. Moreover, given that many psychiatrists choose to go into outpatient services, the lack of outpatient treatment facilities may exacerbate barriers faced by rural populations in accessing mental healthcare services and prescriptions.

This issue is exacerbated by the striking disparities in access to pharmacies and drugstores in communities with reduced broadband access: counties with reduced broadband access are over five times more likely to have no pharmacies and drugstores. Thus, if broadband internet—and by extension telehealth—is not readily accessible in areas with limited outpatient services and medication access, the risk of treatment delay and serious mental illness increases dramatically.²¹ Indeed, rural communities demonstrate an increased prevalence of specialized, serious, and persistent mental illnesses, including psychological distress, adolescent major depressive episodes, and suicide compared with their urban counterparts.²² Moreover, the increased prevalence of serious mental illness in rural areas may also contribute to rural–urban disparities in the criminalization of mental health disorders.²³ Together, these findings highlight a clear need for increased and immediate access to specialized mental healthcare services in rural communities.

While we have presented a clear need for the expansion of broadband access in medically under-resourced communities, there remain many challenges in expanding both telehealth infrastructure (in the form of broadband internet) and in-person mental healthcare resources in these areas. Of particular importance, because rural businesses and homes are located far apart from one another, installing fiber-optic cables across many miles for a small number of paying customers presents internet service providers with the challenge of geographical barriers and a limited profit margin.²⁴ Economic barriers also prevent the expansion of healthcare facilities in rural areas.

Given the negative mental health consequences of limited access to broadband in areas with limited mental healthcare resources for screening, diagnosis, and treatment, it is imperative to develop solutions that enable more equitable access to broadband internet and telehealth in medically under-resourced communities.²⁵ One of the first steps that can be taken by policymakers is increased investment in broadband internet infrastructure in rural and low-income communities—including urban communities with high poverty rates—through programs such as the Broadband Infrastructure Finance and Innovation Act in the United States. In recent decades, broadband internet access has become a super-determinant of health, linking individuals to vital resources such as education, health information, food, employment, and health professionals.⁹

Another potential solution may be to invest resources into training a variety of mental healthcare personnel to be deployed in rural settings, including physicians, non-physician mental health practitioners, physician assistants, and social workers. Ideally, these professionals would be deployed in outpatient settings, where screening, prevention, and diagnosis are emphasized. Mobile phone-based technology may also serve as a key tool in improving access to mental healthcare in rural communities. An additional approach to address the issue of broadband internet and telehealth access in rural communities is integrated and collaborative care models. These models of healthcare emphasize blending mental healthcare with general medicine services and uniquely position primary care physicians and mental health professionals receiving such training to mitigate both the physical and mental health burden experienced by rural communities.^26,27 Mobile phone-based technology may also serve as a key tool in improving access to mental healthcare in rural communities. An estimated 86% of individuals with serious mental illness use a mobile phone; therefore, this technology may be harnessed in the development of mobile interventions that remotely screen for mental illness.²⁸ Finally, we recommend that federal and state governments provide financial assistance for initiatives that draw more physicians toward rural communities.

This study contains a few key limitations. First, the FCC broadband data used considers only the percentage of households that lack access to broadband data; therefore, the percentage of households with access to broadband outside the household in facilities such as schools, public libraries, or workplaces remains unclear and requires further study. However, utilizing a broadband source outside the home may present barriers such as transportation costs and lack of convenience; thus, accessibility to broadband internet at the household level is still relevant. A second limitation is that the most recent FCC broadband dataset used was published in 2020, before the massive expansion of broadband internet access in response to the COVID-19 pandemic. A third limitation is that the county demographic data from the American Community Survey, mental healthcare access data from the National Neighborhood Data Archive dataset, and broadband access data from the FCC were obtained from different years as each data source was last updated at a different time. Finally, as this analysis is associative rather than causative, this study cannot establish a cause-and-effect relationship between broadband access and mental healthcare access, although this would be a goal for future experiments.

In conclusion, this study presents one of the first formal analyses corresponding broadband internet access to mental healthcare resources at each level of care—from screening to treatment—across the United States. We found that US counties with reduced broadband access have reduced access to all six mental health services analyzed in this study, particularly mental health physicians, non-physician mental health practitioners, inpatient psychiatric and substance abuse hospitals, and outpatient facilities.