Rural–urban disparities in access to interventional psychiatry treatments among U.S. Department of Veterans Affairs patients

Abstract: While tele-mental health has improved access to standard medication management and psychotherapy for rural veterans, implementation of interventional psychiatry treatments will require in-person care, potentially leading to the exacerbation of rural–urban disparities in access to mental health care. We studied the availability of interventional psychiatry treatments, delivered clinically or in the context of a research trial, to rural and urban veterans. We used the U.S. Department of Veterans Affairs electronic medical record data to measure the use of electroconvulsive therapy, magnetic seizure therapy, repetitive transcranial magnetic stimulation (rTMS), vagus nerve stimulation, deep brain stimulation, ketamine (infusion or nasal spray), stellate ganglion block, and medication-assisted psychotherapy (AP) protocols, including 3,4-methylenedioxy-methamphetamine-AP and psilocybin-AP, as appropriate, for U.S. Department of Veterans Affairs patients with major depressive disorder and posttraumatic stress disorder from 2017 through 2024. We compared treatment use in rural and micropolitan locations to use in urban locations. Few patients received any interventional psychiatry treatment across strata. The most common modalities were rTMS, electroconvulsive therapy, stellate ganglion block, deep brain stimulation, and ketamine. The numbers receiving magnetic seizure therapy, vagus nerve stimulation, 3,4-methylenedioxy-methamphetamine-AP, and psilocybin-AP were too small to report in the micropolitan or rural cells. Micropolitan and rural patients had lower odds of receiving rTMS, electroconvulsive therapy, stellate ganglion block, deep brain stimulation, and ketamine than urban patients. The largest disparities were for rTMS and ketamine. There appear to be rural–urban disparities in the emerging field of interventional psychiatry, and the disparities are most pronounced for treatments that require repeated in-person visits, such as rTMS and ketamine.