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Publication Briefs

Study Shows Veterans Living in Rural Settings Less Likely to Receive Psychotherapy than Veterans Living in Urban Settings


  • Analyzing VA data collected in FY 2004, the use of specialty mental health care was significantly and substantially lower for Veterans living in rural settings. Veterans living in urban settings were significantly more likely than rural Veterans to receive a specialty mental health visit (54% vs. 41%), any form of psychotherapy (24% vs. 17%), individual psychotherapy (20% vs. 15%), or group psychotherapy (8% vs. 3%) in the 12 months following their initial diagnosis of depression, anxiety, or PTSD.
  • Urban Veterans were about twice as likely as rural Veterans to receive four or more (9.46% vs. 5.08%) and eight or more (5.59% vs. 2.35%) psychotherapy sessions, even after controlling for travel distance and other demographic and clinical characteristics. This suggests that distance alone is insufficient to account for the differences observed.
  • Length of time between an initial diagnosis of depression, anxiety, or PTSD and receipt of psychotherapy services was longer for rural Veterans (mean = 102 days) compared to urban Veterans (mean = 99 days), but the difference was not clinically meaningful.
  • The authors suggest that focused efforts are needed to increase access to psychotherapy services provided to rural Veterans with mental health disorders.
  • It may be useful to examine recent VA data to assess whether VA’s emphasis on health care for rural Veterans is associated with improved measures of access and quality.

Findings from the nationally representative National Comorbidity Study indicate that individuals with mental health disorders who reside in rural settings are much less likely to report receiving any mental health treatment, particularly specialty mental health treatment. In recent years, VA has pursued the challenging goal of providing a full spectrum of mental health services for Veterans living in rural settings, yet little research has addressed their use of psychotherapy services. This retrospective study sought to determine whether differences exist between Veterans living in urban compared to rural settings, in regard to the initiation of psychotherapy, delay in the time of diagnosis to treatment, and dose of psychotherapy sessions. Using VA data, investigators analyzed information for 149,747 urban-dwelling Veterans and 65,044 rural-dwelling Veterans who had received a new diagnosis of depression, anxiety, or PTSD in a VA outpatient facility during FY04.


  • Data were collected prior to the introduction of VA’s initiative to improve rural mental healthcare, including mandating that each community-based outpatient clinic have specialty mental health service providers on staff.
  • Because the more stringent definition of rurality used in this study differs from the definition used by VA, “rural” Veterans in this study may be “more rural” and face greater barriers to care access than the overall VA-defined rural population.
  • This study relied on administrative data. As with any database study, there are questions about the reliability and validity of coding for conditions and procedures.

This study was partly funded by HSR&D, and Dr. Cully is supported by an HSR&D Career Development Award. Drs. Cully, Jameson, and Kunik are part of HSR&D’s Houston Center for Quality of Care & Utilization Studies. Dr. Fortney is part of HSR&D’s Center for Mental Healthcare and Outcomes Research in Little Rock, AR.

Cully J, Jameson J, Phillips L, Kunik M, and Fortney J. Use of psychotherapy for rural and urban Veterans. The Journal of Rural Health May 11, 2010;e-pub ahead of print.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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