An investigation into the prevalence and perceptions of mental health disorders in Appalachian West Virginia

Abstract

Introduction

Appalachian West Virginia’s population is disproportionately afflicted by mental illness, with Logan County having the highest depression rates in the United States. To further understand the mental health situation in Appalachian West Virginia, this research study aims to evaluate the prevalence and perceptions of mental health disorders among patients of Coalfield Health Center.

Methods

An online survey was administered to patients at Coalfield Health Center containing 25 questions categorized into three parts: demographic, beliefs/perceptions about behavioral health, and behavioral healthcare access.

Findings

The data demonstrated that 37% of participants had received a mental illness diagnosis and 82% knew someone with a mental illness. Nearly 10% of participants denied having reliable transportation or health insurance coverage. Patients reported lacking mental health knowledge and a majority indicated a need for mental health education.

Conclusions

The data affirm a high prevalence of mental illness in Logan County, with barriers to care including a negative community perception, low socioeconomic status, lack of access to resources, and low health literacy.

Introduction

Appalachia, spanning parts of 13 states in the eastern United States, is renowned for its rugged terrain, rich cultural heritage, and tight-knit communities. However, alongside its natural beauty, the region grapples with significant socioeconomic and health care challenges that profoundly impact its residents’ health and well-being [8, 14]. Among these challenges, the prevalence and perceptions of mental health disorders stand as crucial areas of concern, particularly within underserved communities [1].

Socioeconomic disparities in Appalachia are stark, with a substantial portion of the population experiencing poverty rates well above the national average. According to recent data from the Appalachian Regional Commission, the median household income in the Appalachian region ($56,780), is notably lower than the national median of $69,021 [2, 4]. The Appalachian Regional Commission classifies counties into five economic status designations: distressed (lowest 10%), at-risk (lowest 25%), transitional (middle 50%), competitive (top 25%), and attainment (top 10%). For fiscal year 2023, there were 82 distressed, 109 at-risk, 218 transitional, 10 competitive, and only 4 attainment counties in the Appalachian region [1, 4]. This region also has lower rates of post-secondary education compared to the national average, which has multifactorial yet objectively deleterious effects on health outcomes [1, 19]. Additionally, food insecurity and a lack of affordable nutritious diets facilitated by both geographical accessibility and low-income status are apparent and are known to mediate worse health outcomes [5]. One health outcome associated with food insecurity is mental health. Appalachia has a 20.8% higher rate of food insecurity than the US average of 12.3%, which studies have shown to be a significant risk factor for the development of depression and anxiety [23].

Located in Chapmanville, a small town nestled in the heart of West Virginia’s Appalachian Mountains, Coalfield Health Center plays a pivotal role in providing primary and preventive healthcare services [6]. Coalfield Health Center serves as a critical lifeline for the Logan County community, which has been shaped by a history of coal mining and economic challenges [6, 24]. West Virginia has the highest age-standardized prevalence of depression at 27.5%, and residents of Logan County have the highest prevalence of any county in the US at 31.9% [15]. Furthermore, eight of the ten counties with the highest prevalence of depression in the US are in West Virginia, with five located near Logan County in the southwestern part of the state (Fig. 1) [15].

Fig. 1.

West Virginia is home to 8 of the 10 counties with the highest prevalence of depression in the US. These 8 counties are Fayette, Lincoln, Logan, McDowell, Mingo, Webster, Wirt, and Wyoming. Figure created with Adobe Illustrator

The Coalfield Health Center clinic, a nonprofit organization, has a mission that extends beyond mere healthcare provision; it embodies a commitment to holistic well-being and community resilience [6]. The clinic’s services encompass a wide range of healthcare needs, including increasing access to mental health screenings, which is unique in an area so afflicted by economic depression and historically inadequate mental health access [6, 14]. The clinic strives to create a culture of mental health inclusivity that is vital for rural Appalachian communities. It serves an economically and medically diverse patient population, many of whom face significant barriers to accessing healthcare due to geographic isolation, limited transportation options, and financial constraints. These challenges are compounded by the region’s history of economic instability and limited employment opportunities, which contribute to higher rates of poverty and healthcare disparities [14]. Despite these obstacles, Coalfield Health Center remains a beacon of resources for Chapmanville and surrounding areas.

To further understand the mental health situation in Appalachian West Virginia, this research study aims to evaluate the prevalence and perceptions of mental health disorders among patients of Coalfield Health Center. By focusing on Chapmanville and its neighboring communities, this analysis seeks to illuminate the intersection of socioeconomic factors, health care access, and mental health outcomes within rural Appalachia. Through a comprehensive survey administered at Coalfield Health Center, this study captures the valuable insights of the area’s residents regarding demographic trends, beliefs about mental health, and the barriers to accessibility to behavioral health services. The findings of this study are poised to improve mental health literacy, reduce stigma, and enhance access to mental health services in rural Appalachia. By amplifying the perspectives and experiences of Chapmanville residents, this research strives to catalyze positive change that promotes mental well-being and strengthens community resilience in the face of persistent socioeconomic challenges.

Methods

An online survey was developed using Qualtrics (Seattle, WA) and administered to patients at Coalfield Health Center. All survey procedures were approved by Institutional Review Board protocol 5376 (FW00003332) at Eastern Kentucky University and all methods were carried out in accordance with relevant guidelines and regulations. After patients were roomed and before the medial provider attended to the patient, the online survey was administered through a tablet that was provided by Coalfield Health Center. Prior to beginning the survey, all patients provided informed consent including acknowledgment of voluntary (non-compensated) consent to participate and published, along with, being informed of the intent of the survey, the methodology, and that participation was anonymous. The survey was conducted at the adult clinic and 18yrs and older was a requirement of patient participation. The respondents were selected through convenience sampling based on patient availability at Coalfield Health. Since, recruited patients were selected based on access and availability at the center, determining a response rate or sample size would not provide an accurate valuation due to the method of population sampling. Data was collected at Coalfield Health Center from May 1, 2023, to August 1, 2023. Data will be made available upon a reasonable request to the corresponding author, Lindsay.Cormier@uky.edu.

The patient survey contained 25 questions and took approximately 15 min to complete. The survey was categorized into three main parts: demographic and prevalence questions, beliefs/perceptions about behavioral health issues, and questions pertaining to behavioral health care access. The survey was provided to the patients in a single questionnaire format with each of the questions delivered in a multiple-choice design and survey format, design and questions were adopted and adjusted from previous surveys [7, 9, 18]. The demographic questions (10 total) investigated place of origin, Appalachian classification, sex at birth, annual income, and educational levels. The beliefs/perceptions about behavioral health questions (11 total) were used to capture attitudes, knowledge, stigma, and understanding related to mental health and behavioral disorders. The questions pertaining to behavioral health care access (4 total) aimed to measure various aspects of individuals’ experiences, barriers, and facilitators related to accessing mental health services. The online survey text and behavioral questions developed through Qualtrics are included as Appendix 1. The data was analyzed in aggregate using Qualtrics and GraphPad Prism software. One-way ANOVA and t-tests were utilized to compare the average response rates.

Results

Demographics and prevalence

In total, 153 patients responded to the survey: all were considered Appalachian, 92 were female, 60 were male, and one chose not to disclose their sex. Demographically, 100% of the respondents classified themselves as white, and the largest age group was 18–29 years old that was seen in the center. In addition, a large percentage of households reported an annual income between $51,000 and $100,000. Moreover, a total of 85% reported obtaining an education of high school and above, of which 46% reported obtaining an education beyond high school (Table 1). Demographic information obtained from the survey reflect West Virgina state demographic information in which racial and ethnic composition is 92.8% with a medium household income of $57,917 and an education rate of high school or higher of 88.6% (United States Census Bureau).

Table 1.

Sample demographic information including Age, Annual Income and Education

Age		Annual Income		Education
Age Range	Count (%)	Income (× 1000)	Count (%)	Highest Level	Count (%)
18–29	47 (31%)	Under $20	29 (19%)	Less than HS	23 (15%)
30–39	27 (18%)	$21–$25	15 (10%)	HS	59 (39%)
40–49	26 (17%)	$26–$50	29 (19%)	Beyond HS	71 (46%)
50–59	31 (20%)	$51–$100	54 (36%)
60–69	12 (8%)	Over $100	23 (16%)
70 or older	10 (6%)

Regarding the prevalence of mental health disorders in the region, over a quarter of the patients (37%) responded that they had been diagnosed with a mental illness (Fig. 2a) and 61% indicated that someone in their immediate social circle (family members and friends) had been diagnosed with a mental illness (Fig. 2b). A total of 82% of the patients indicated that they knew someone in their community with a mental illness. Further, 41% affirm that they know 1–5 community members with a mental illness, 18% know 6–10 community members, and 22% know more than 10 community members with a mental illness (Fig. 2c). A greater percentage of patients reported knowing 1–5 community members with a mental illness compared to the other categories (Fig. 2c).

Fig. 2.

Assessment of the prevalence of individuals diagnosed with mental health issues. a Percent of patients had been diagnosed with a mental illness; b Percent of patients indicated that they have family members and friends who have been diagnosed with a mental illness; c Percent of known community members with a mental illness. n = 153; **p < 0.01; ***p ≤ 0.001; t-test and one-way ANOVA. Figure created with GraphPad Prism Software

Accessibility

The majority of patients (91%) affirmed that they had reliable access to transportation to and from the clinic, leaving 9% of families that denied having reliable transportation. The number of miles traveled by patients to arrive at the clinic is as follows: 0–10 miles (41%), 10–20 miles (37%), 20–30 miles (12%), 30–60 miles (8%), and more than 60 miles (2%). These numbers are roughly equivalent to the number of miles needed to travel to the nearest behavioral health service provider. Approximately nine out of ten patients (91%) stated they had some form of health insurance, while nearly one-tenth (9%) stated they had no health insurance.

Perspectives

When assessing patient exposure to local mental health resources, 61% of participants responded that they were aware of mental health resources in their community, whereas 39% were not (Fig. 3a).

Fig. 3.

Awareness of behavioral health services and assessment of patient’s mental health ratings. a Percent of patients indicated they were aware of behavioral health services; b Patient indicated rating of their own mental health. n = 153; **p < 0.01; t-test and one-way ANOVA. Figure created with GraphPad Prism Software

When assessing patient perspectives on their own mental health, 36% strongly agree that they understand their mental health, while 40% agree, 15% neither agree nor disagree, 7% disagree, and 2% strongly disagree. Furthermore, 46% indicated that they would rate their mental health above average, 21% indicated an excellent rating and 25% indicated a somewhat good rating (Fig. 3b). Additionally, 27% indicated that they would rate themselves having below average mental health, 13% rated their mental health as somewhat poor and 14% rated their mental health as poor. While there was no significant difference between the categories of ratings, the below average ratings represent a subset of patients that could benefit from mental health mediation.

When patients were questioned about their mental health knowledge, 34% suggested their knowledge was above average, 48% said it was average, and 18% said it was below average (Fig. 4a). This data shows a significant increase in patient mental health knowledge in both categories compared to the below-average group (p < 0.05 and p < 0.0001). Patients derived their knowledge about mental health from personal experiences, relationships with a mentally ill person, career experiences, educational experiences, news/media, and personal interest. A majority (55%) of patients affirm that personal experience is an important source of their knowledge. Importantly, 95% of patients indicated that they wanted more mental health education (Fig. 4b).

Fig. 4.

Patient perception of mental health knowledge and the desire for enhanced education. a Patent knowledge about mental health; b Percent of patients indicating they wanted more mental health education. n = 153; *p < 0.05, ****p < 0.0001; t-test and one-way ANOVA. Figure created with GraphPad Prism Software

The final survey set attempted to gauge patient beliefs on causes of and the public’s view of mental health. Of the respondents, 82% felt there was a negative stigma or perception towards mental health (Fig. 5a) and a significant percentage (95%, p < 0.001) indicated that the general public needed mental health education (Fig. 5b). Patients believe that causes of mental illness include family/relationship problems, stress, drinking/drugs, physical illness, death/loss, adverse childhood abuse/events, genetics, and environment. Most (91%) believe that stress contributes to mental illness development, 86% say adverse childhood events contribute, and 85% say death/loss contributes. Interestingly, 61% of patients believe that people can be born with mental illnesses, 11% believe they cannot, and 28% were unsure.

Fig. 5.

The perception around mental health and the need for general public education. a Percent of patients that believe there is a negative stigma toward mental health; b Percent of patients that feel the general public needs mental health education. n = 153; ****p < 0.0001; t-test. Figure created with GraphPad Prism Software

Discussion

Health disparities such as diabetes, obesity, hypertension, and cancer have been well tracked and found to have high incidences in Appalachian states such as West Virginia, leading to poor health outcomes for its residents [13]. The rates of depression among residents of West Virginia have been previously reported as higher than the rest of the nation [15, 16]. Although it has been estimated that 50% of Americans will exhibit symptoms of a mental illness within their lifetimes, our study indicated that 37% of patients reported ever being diagnosed with a mental illness [17] (Fig. 2a). Additionally, significant percentage (61%) of the patients reported knowing a friend or family member diagnosed with mental illness (Fig. 2b) and an even greater number knew of a community member that were diagnosed (Fig. 2c). Further, 27% reported having below average mental health. Several barriers that may contribute to poor mental health diagnoses and poor levels of access can be identified from the results of this study.

Perhaps the largest barrier to recognizing, reporting, and treating mental illness in Appalachian West Virginia is the systemic economic landscape of the state. Previous studies have demonstrated that socioeconomic status has a large impact on mental health within the Appalachian population, with lower status residents having the highest proportion of mental health issues [16]. Economic stagnation and decline in West Virginia have created a low density of hospitals and mental healthcare infrastructure, making it difficult for West Virginians to access general health care—let alone mental health services [8, 12]. This may be a factor contributing to the 39% of our sample which reported that they are unaware of available mental health resources (Fig. 3a). Subsequently, 54% of the patient population indicated that their mental health was “average” to “poor” (Fig. 3b). Collectively, this indicates that there is a grave need in the West Virginia population to improve access to mental health resources and information.

A second barrier for mental health care attainment is negative cultural perception [21]. Our data demonstrated that 82% of patients believed there was a negative perception toward mental health disorders (Fig. 5a). Other studies show that in rural populations, individuals with mental health disorders reported not receiving encouragement or motivation from family and friends to seek health services [11]. The lack of community and family support for receiving mental health care shows a need for a cultural adjustment toward positive affirmation regarding mental health. In particular, Appalachian women have acknowledged the negative stigma associated with depression and have been found to have a disproportionately higher rate of attempting to coping independently with mental health and not obtaining mental health services [21]. This has been attributed to cultural norms and perceptions set upon Appalachian women of being able to endure hardships and doing so under spiritual norms [21]. Similarly, over 90% of our patients agreed that stress contributes to mental illness. Part of this cultural emphasis on self-reliance and resistance to participation in mental health treatment may also stem from a fear that costs will worsen their families’ already precarious economic outlook [11, 21]. When considered together, these cultural beliefs could lead to a decrease in seeking health care services and a hesitation to discuss mental health socially [21].

The low quality of education and educational resources in West Virginia leads to lower health literacy for West Virginians, which may result in lack of recognition or knowledge of next steps [25]. Lower health literacy is a significant contributor to lower quality of life as well as unfavorable health outcomes [13, 20]. Our study found that 66% of our patients indicated that they had average to below average knowledge of mental health (Fig. 4a) and 95% of the patients indicated that they wanted mental illness education for the general public (Fig. 4b). Our patients stated that they derived their knowledge about mental health largely from personal experience, but fewer cited educational experiences as a significant contributor. This shows the dire need to increase mental health literacy and available resources for mental health education within the Appalachian community. Other studies found that even the lack of health insurance literacy made it more difficult for West Virginians to navigate the complexities of funding their mental health care [10]. Factors such as a lack of understanding of the healthcare system, insurance policies, and knowledge of constant changes to insurance have also been found to lead to decreased health insurance literacy [10].

Final barriers include access to both transportation and health insurance [3]. Transportation barriers to health care have been found to enhance health disparities and isolation of central Appalachian patients, leading patients to rely on emergency department services or hospitalization [3]. Additionally, a lack of transportation has been found to be associated with poorer management of chronic illness due to missed appointments, delayed care and medication use [22]. Transportation is a critical barrier–both feasibly and financially–to obtaining health care interventions in rural Chapmanville, West Virginia, with 10% of patients lacking reliable transportation services and 24% of patients traveling more than 20 miles to the nearest facility. To address this issue, Coalfield Health Center partnered with TriRiver Transit to provide low-cost transportation for low-income patients across Logan, Lincoln, Boone, and Mingo counties. The transportation initiative is particularly crucial for the behavioral health services they introduced in August 2022, which require consistent follow-up. From a healthcare provider’s perspective, the transportation partnership reduces missed appointments and improves continuity of care. Observational data and direct communication indicate that since the transportation initiative began, patient adherence to appointments has increased, leading to better health outcomes. Furthermore, although only 10% of the patients in this study indicated that they did not have insurance, Coalfield Health Center states that 55% of their patient population is collectively on Medicare and Medicaid. One study found that Medicaid beneficiaries eligible for non-cost transportation often would pay out of pocket for transportation to office visits [3]. With a patient base largely reliant on these government resources, Coalfield Health Center serves as a critical safety net in these underserved counties.

Limitations. The data collected and interpreted from this study is based on self-reported patient and healthcare provider perspectives. These are viewpoints subject to social suitability and response bias due to individual ideologies and perspectives. In addition, the data was collected (intentionally) at a single healthcare provider facility, enabling localized cultural biases. Additionally, the population demographics was limited by racial and ethical diversity and consisted of a larger number of younger respondents.

Conclusion

Patients in the Appalachian region of West Virginia are disproportionately affected by mental health disorders. This study strived to gather important information regarding mental illness prevalence, cultural beliefs toward mental health, and barriers to receiving health care for mental illness. Overall, our data affirms a high prevalence of mental illness in Appalachian West Virginia, with barriers to care including a negative community perception, low socioeconomic status, lack of access to resources, and low health literacy. Transportation and access to health insurance may also contribute, although these barriers are somewhat mitigated by local transportation initiatives and state insurance programs. These identified beliefs and barriers should be thoughtfully considered when creating targeted interventions aimed at improving mental health care in West Virginia. Ultimately, initiatives should strive to bolster the existing efforts of mental healthcare facilities, while providing resources for community access to and education regarding mental health care.

Appendix: patient survey

Demographics

1. Do you consider yourself from Appalachia?

Yes.

No.

2. If yes to the question above, what county do you reside in?

3. What is your current household income?

Under $20,000.

Between $20,000 and $25,000.

Between $26,000 and $50,000.

Between $51,000 and $100,000.

Over $100,000.

4. What is the highest level of education you have completed?

Less than a high school degree.

High school diploma or GED.

Education beyond high school.

5. What is your current age?

18–29.

30–39

40–49

50–59

60–69

50 or older.

6. Which sex were you assigned at birth?

Female.

Male.

Intersex.

Other.

I’d rather not disclose.

7. What is your ethnicity?

White.

Black or African American.

Hispanic or Latino.

Asian or Asian American.

American Indian or Alaska Native.

Native Hawaiian or other Pacific Islander.

Other.

8. Do you have health insurance?

Yes.

No.

9. Have you ever been diagnosed with a mental illness?

Yes.

No.

10. Has a family member or close friend of yours ever been diagnosed with a mental illness?

Yes.

No.

Accessibility

11. Do you have access to transportation to clinical facilities?

Yes.

No.

12. How many miles did you travel to get here?

0–10.

10–20

20–30

30–60

More than 60.

13. Are you aware of behavioral or mental health services in your surrounding area?

Yes.

No.

14. If yes to the question above, how many miles away is/are the services?

0–10.

10–20

20–30

30–60

More than 60.

Perspective

15. How many people in your community do you know that is affected by mental illness?

0.

1–5

5–10

More than 10.

16. I have an understanding of my mental health.

Strongly agree.

Agree.

Neither agree nor disagree.

Disagree.

Strongly disagree.

17. I view mental health as important as physical health.

Strongly agree.

Agree.

Neither agree nor disagree.

Disagree.

Strongly disagree.

18. Overall, how would you rate your mental health?

Excellent.

Somewhat good.

Average.

Somewhat poor.

Poor.

19. How knowledgeable do you consider yourself to be about the importance of mental health?

Above average.

Average.

Below average.

20. In your opinion, do you think people can be born with mental illnesses?

Yes.

No.

Not sure.

21. In your opinion, which of the following is/are not an example(s) of a mental illness? (check all that apply)

Posttraumatic Stress Disorder.

Insomnia.

Phobias.

Obsessive–Compulsive Disorder.

Anorexia Nervosa/Bulimia Nervosa.

Autism.

Anxiety.

Bipolar Disorder.

Depression.

Schizophrenia.

22. What is/are the source(s) of your knowledge about mental illness? (check all that apply)

Personal experience.

Relationship with a mentally ill person.

Career-related experience.

Educational experience.

News/media (TV news, radio news, and newspapers/magazine articles).

Personal interest in learning about the mentally ill.

23. In your opinion, what causes mental illness? (check all that apply)

Family/relationship problems.

Depression.

Stress.

Drinking/drugs.

Physical illness.

Death or loss.

Bad childhood or abuse.

Genetics.

Environment.

24. Do you believe the general public needs to be educated about mental illness?

Yes.

No.

25. Do you believe a negative stigma surrounds mental illnesses in Appalachian areas?

Yes.

No.

Author contributions

T.D., J.D., A.H., and L.C. wrote the main manuscript. Figure 1 was prepared by L.R. and N.V. and all remaining figures and tables were prepared by T.D., J.D., L.R., N.V., and L.C. All authors were invovled in data analysis and reviewed the manuscript.

Funding

The authors did not receive support from any organization for the submitted work.

Data availability

Data will be made available upon a reasonable request to the corresponding author, Lindsay.Cormier@uky.edu.

Declarations

Ethics approval and consent to participate

Research procedures were approved by Institutional Review Board at Eastern Kentucky University, protocol 5376 (FW00003332). Subsequently, all methods were carried out in accordance with relevant guidelines and regulations.

Competing interests

The authors declare no competing interests.