– Every other month, Tanya Nelson travels 32 miles from the heart of Appalachia’s coal country for an appointment with the nearest psychiatrist. But the commute, which should take less than an hour through winding mountain roads, consumes her entire day.

Nelson, 29, needs treatment for bipolar disorder, depression and anxiety. She doesn’t drive, so she must use a van service to keep appointments. It makes numerous stops along the highway, picking up other travelers, and usually doesn’t return to her home in New Richmond, W.Va., until day’s end.

Patricia Hagerman, 63, of nearby War, W.Va., has relied on her sister for the past 11 years to drive her an hour each way to the nearest psychiatrist — in Princeton, W.Va. She makes the trip once every two months for depression and anxiety treatment. “I don’t want to go,” she said, “But I do go. [Seeing the psychiatrist is] worth the trip.”

Getting mental health services here is fraught with challenges. But the need is great. There are no psychiatrists in Wyoming County. A handful of small, general medical practices and a few behavioral health specialists handle services for the 21,763 residents. Patients’ issues — ranging from depression, anxiety, addiction and other mental health concerns — are aggravated by the local economic downturn.

Dr. Joanna Bailey, who practices family medicine here and treats patients covered by Medicaid, said the lack of mental health care access puts her patients at a disadvantage. “As a family doctor, I’m doing way more psychiatry than I am comfortable with,” Bailey said.

She sends patients who need specialized help to the closest psychiatrist in Beckley, W.Va. It can take a month to get an appointment.

Bailey practices in both Wyoming and McDowell counties — Appalachian areas once fueled by a booming coal industry. Today, much of the local economy relies on tourists coming to use the area’s ATV trails. Infrastructure has been neglected. Shops have been abandoned.

Medicaid enrollment is 35 percent in Wyoming County and 48 percent in McDowell County, the advocacy group West Virginians for Affordable Health Care said.

She said that about 30 percent of her caseload is treatment for mental health issues.

The coal industry, which was once king in this region, has been declining for years. “So, we’ve lost a lot of people, and that’s depressing,” Bailey said. “We haven’t had growth, and a lot of people are unemployed right now. That’s traumatic to families.”

When parents with mental health disorders go untreated, a “vicious cycle” is set in motion, she said. “Those children grow up with the same mental health issues because they’ve watched the same unhealthy relationships their whole life. It’s just a cycle of abuse and trauma.”

Joy Butcher-Winfree works with Bailey as the sole clinical psychologist within their practice. She usually handles about nine behavioral health cases each day.

“I only have so much time and only so much energy,” Butcher-Winfree said. “It’s very overwhelming most all the time. … If someone is in a crisis, they need more than that 15-, 30- or 45-minute slot.”

One resource for patients is the Southern Highlands Community Mental Health Center, which also accepts Medicaid patients. The Wyoming County location serves about 400 people, according to clinic administrator Rebecca Marsh. It offers therapy sessions, counseling, group support meetings and community engagement programs. Yet Marsh said she has trouble hiring employees.

“It’s difficult for folks from surrounding areas to drive to this area to provide the services,” Marsh said.

Study after study shows health markers in Appalachia lagging. In August, an analysis in the journal Health Affairs found a widening gap comparing health indicators such as infant mortality and life expectancy in Appalachia with the rest of the country.

Also in August, research released by the Appalachian Regional Commission highlighted the area’s high mortality rates in seven of the nation’s leading causes of death — including suicide. It also showed the region has fewer health care professionals compared with the rest of the country, specifically mental health care providers.

The lack of sufficient mental health care access contributes to other health issues, such as chronic pain and substance abuse, Bailey said.

She said some cases make her nervous about whether she can provide sufficient care. One is depression in adolescents. She prescribed one patient the antidepressant Prozac but fears that a bad reaction to the drug led the teen to attempt suicide.

Since that episode, “it makes me more nervous,” she said. “But at this point, I’m a month out of being able to get people in [to see a psychiatrist], unless I’m sending somebody to the hospital.”