Matt Vohl (left) meets with Rachel Steidl in the Student Activity Center on East Campus Mall in Madison, Wis., Jan. 27, 2012. Vohl and Steidl help lead the UW-Madison campus chapter of the National Alliance on Mental Illness. Lukas Keapproth/Wisconsin Center for Investigative Journalism

By Amy Karon, Kate Prengaman and Jenny Peek
Wisconsin Center for Investigative Journalism

A decade ago, Thomas Murphy was a college dropout who used alcohol and drugs to deal with undiagnosed depression. Now he’s back at the University of Wisconsin-Madison, where he co-leads a chapter of Active Minds, a national, student-run group promoting open conversations about mental illness.

Therapy made the difference for Murphy. But he can’t receive it at school. When he re-enrolled at UW-Madison and went to the counseling center, he walked out with no appointment and a list of referrals.

“They couldn’t help me because of my extensive history,” Murphy said. “So I go out and pay on my own for the services I need.”

Murphy’s story underscores a national dilemma: a surge in students seeking intensive counseling and psychiatric care, which college mental health centers often lack resources to provide. The problem has become even more urgent in the wake of mass shootings by troubled students at Virginia Tech and Northern Illinois universities.

In Wisconsin, understaffed counseling centers are prioritizing services for those with urgent needs, expanding group therapy options to reach more students, and referring patients off campus for long-term treatment. And students like Murphy are forming campus organizations to support peers and fight the stigma of mental illness.

A growing need

Step onto a U.S. college campus today and you’ll still find students rushing between classes or holding hands with first loves.

But 80 percent of college counseling center directors reported seeing more students in crisis during the past five years, according to a national survey in 2011. The same study found that students with severe psychological problems now account for nearly 40 percent of counseling center visits — more than double the proportion in 2000.

Last spring, 19 percent of college students surveyed by the American College Health Association said they’d been diagnosed with depression sometime in their lives, up from 12 percent a decade ago. Almost one in five students had seriously considered suicide.

These statistics aren’t all bad news, said psychologist Danielle Oakley, director of mental health services at UW-Madison, where counseling visits increased 10 percent last year alone. More people know about mental illness and are seeking help, and better psychiatric medications enable some to attend college who couldn’t have a generation ago.

But Oakley said the faltering economy is fueling worries about paying for school. Many students are stressed, overworked and sleep-deprived, which can cause mental health problems.

Though studies show people with serious mental illness usually aren’t violent, there have been tragic exceptions: In 2007 and 2008, troubled students shot themselves after killing 37 people and wounding dozens more at Virginia Tech and Northern Illinois universities.

Campuses across the country responded by revamping policies for handling disturbed students and staff. At UW campuses, threat assessment teams — whose members hail from deans’ offices, academic departments, campus police, and counseling centers — try to identify and help such people before they hurt themselves or others.

“If there is a silver lining in something like that happening, it’s put the spotlight on some needs on our campus,” said John Achter, counseling director at UW-Stout.

Still, most people with mental illness fly under the teams’ radar. And despite attempts to meet demand, Wisconsin students are being turned away — or told to wait weeks for care.

UW-Madison senior Rachel Steidl, Jan. 27, 2012. Lukas Keapproth/Wisconsin Center for Investigative Journalism

Long waits, but some improvements

UW-Madison senior Rachel Steidl was one such student. “I grew up really focused on helping other people,” she said. “When I had my own problems with depression, I didn’t feel like I had anyone to turn to. I was pretty lonely my freshman year.”

Steidl later saw a psychology intern at the campus counseling center. She learned to open up more and made friends. When she returned to the center this year, an intake provider saw her the same day to assess her needs.

That’s because at Oakley’s urging, UW-Madison began offering same-day assessments in early 2011.

“We don’t want any barriers to get to us,” Oakley said. “The day you decide that you want support, all you have to do is walk in.”

But what happened next frustrated Steidl. Because her immediate needs weren’t deemed urgent, she said, she was asked to wait three weeks for her next appointment.

“If my depression gets worse, it could escalate,” she said. “I want to avoid getting to the point where I have to call the crisis hot line.”

Most UW campuses use such triage systems to help students in crisis first. UW-Eau Claire student Anneliese Vaini, for example, was prescribed Paxil when she sought help for panic attacks in 2009. After she stopped eating and sleeping and went on a “financially disastrous” shopping spree, her campus counselor and psychiatrist correctly identified and treated her bipolar disorder — ending eight years of bouncing between clinicians who’d misdiagnosed her.

“They saved my life. Literally,” said Vaini, who now works as a pet groomer. “I wasn’t able to complete a degree, but they gave me a brighter future than education.”

But Steidl’s wait time is more typical. Last fall, UW-Madison students went an average of 14 days between their intake appointment and first regular counseling session, said Dr. Sarah Van Orman, health services director. Other UW campuses report similar waits.

Such delays stem partly from inadequate staffing. A UW System audit found that five years ago, only UW-Madison met the international standard of one mental health professional for every 1,000 to 1,500 students. The auditors recommended that over the short term, UW institutions aim to employ one mental health staffer for every 2,000 students.

But as of 2011, just eight of 13 campuses had achieved that ratio, an analysis by the Wisconsin Center for Investigative Journalism showed. Of those, only two schools — UW-Stevens Point and UW-Superior— met the international standard.

The average was about one mental health provider for every 2,027 students across the 13 campuses.

To improve counselors’ availability, UW-Madison wait-lists students for earlier sessions, offers daily drop-in groups and confidential consultations in several campus locations, and has more than 25 process and support groups to help students deal with issues ranging from low self-esteem, grief and social anxiety to graduating or coming out as a sexual minority.

None of these options was right for Steidl, though. She found a therapist in private practice.

Thomas Murphy’s face still bears scars from a violent mugging three years ago in the Dominican Republic. During his treatment for a resulting brain injury, he also got the counseling he needed for depression. Photo taken Jan. 23, 2012. Lukas Keapproth/Wisconsin Center for Investigative Journalism

Referred off campus, some never find help

It took a violent mugging in the Dominican Republic in 2008 for Thomas Murphy to finally face his depression. During rehabilitation for a brain injury, he also got the counseling he’d needed.

Milwaukee native Mary Martinco sought help sooner, seeing a therapist for depression for two years in high school. But transitioning to UW-Madison was painful.

“Freshman year I felt so alone, crying all the time,” recalled Martinco, now a junior.

Like Murphy, Martinco sought help at UW-Madison’s counseling services and left with a list of off-campus referrals. But in her case, they either weren’t a good match or didn’t take her insurance. In the end, it was her mother, not her school, who helped her find a therapist.

Most UW counseling centers limit students’ counseling sessions. UW-Madison students like Martinco, who need more than the 10 permitted each academic year, are often asked to go elsewhere from the beginning.

Oakley said that’s because making students change therapists disrupts their treatment. But a 2006 University of California-Davis study found that 42 percent of students referred off campus never connected with providers — usually because of financial concerns.

To address that problem and help prevent tragedies like those at Northern Illinois and Virginia Tech, UW System officials recommended in 2008 that campus providers follow up with high-risk students to help ensure they’re successfully referred.

A half-time case manager now fills this role at UW-Oshkosh. And in 2010, after Martinco’s failed referral experience, UW-Madison hired a full-time case manager who saw 300 students her first year— five times more than expected.

Still, lack of health insurance “poses great barriers” for students referred off campus, Van Orman said. She cited campus surveys that show 6 to 8 percent of students at UW-Madison are uninsured and another 30 to 40 percent have no coverage in the Madison area.

The case manager connects these students to agencies that charge a fraction of the going rate or to the student health insurance plan. She also helps students navigate deductibles and co-pays.

Some students struggle to pay for psychiatric prescriptions. Martinco saw peers risk going off medication when short on cash. She and Murphy said they knew students who self-medicated with alcohol or illegal drugs because they couldn’t afford mental health care.

“The self-medication issue is complex,” Oakley said. “For example, students who use substances such as alcohol to treat anxiety can end up with substance abuse problems in addition to their anxiety.”

Alcohol withdrawal symptoms can mimic anxiety, Oakley added, leading students to drink more or use stronger drugs. In the end, she said, money spent on drugs and alcohol, lost time at work, medical treatment for accidents and legal consequences can far outstrip medication costs.

UW-Madison senior Matt Vohl, Jan. 27, 2012. Lukas Keapproth/Wisconsin Center for Investigative Journalism

Student groups expand

Frustrated by her experiences on campus, Steidl joined fellow student Matt Vohl two years ago in reviving the campus chapter of the National Alliance on Mental Illness.

“We saw a lack of resources available for students with mental illness or even just mental health problems,” Vohl said. “We wanted to offer an alternative.”

Students responded en masse: More than 70 signed up at the campus organizational fair last September, Vohl said. A month later, they peppered Bascom Hill with signs.

“The best way to reduce the stigma is by educating people,” Vohl said. “We want to let people know that (mental illness) is not this inherent condition that makes people freaks, it’s not demonizing, it shouldn’t be taboo. It’s something that can affect anyone.”

Steidl and Vohl are working with the counseling center to train students to provide confidential, face-to-face support for peers who want to talk about everyday problems.

“You can go there and know that people kind of understand you at least,” said a member with obsessive-compulsive disorder who asked not to be named for privacy reasons. “You get to know their struggles every day, whatever they are, and to be there to be support for them and other people as well.”

Murphy and Martinco now run UW-Madison’s branch of Active Minds, which promotes mental health awareness. Five other Wisconsin campuses also have chapters. At UW-Parkside last semester, members practiced yoga, colored and made squeezable stress balls.

“Finally I feel able to talk about it, and I want to help others talk about it too,” Martinco said.

“I had this deeper, darker side that I never talked about,” Murphy agreed. “For me, communicating my emotions, my struggles, and my successes has been vital.”

Amy Karon is a reporter for the Wisconsin Center for Investigative Journalism. Kate Prengaman, Jenny Peek and Sam Zastrow contributed as students in a UW-Madison journalism class taught by Professor Deborah Blum, in collaboration with the nonprofit, nonpartisan Center (www.WisconsinWatch.org).

The Center also collaborates with Wisconsin Public Television, Wisconsin Public Radio and other news media. Works created, published, posted or disseminated by the Center do not necessarily reflect the views or opinions of UW-Madison or its affiliates.

About this story

Jenny Peek and Kate Prengaman reported this story with other journalism students in a UW-Madison class taught by Professor Deborah Blum, in collaboration with the nonprofit, nonpartisan Wisconsin Center for Investigative Journalism and the Investigative Journalism Education Consortium, which includes Midwestern university journalism professors and students working on news projects in the public interest. The Consortium is supported by a grant from the Robert R. McCormick Foundation. Read the IJEC consortium stories
Main story: Gaps persist in campus mental health services

Interactive map

Explore data on mental health services across the UW System

If you’re in crisis, call:
National Suicide Prevention Lifeline
1-800-273-TALK (8255)
TTY: 1-800-799-4TTY (4889)
Español: 1-888-628-9454

Veterans crisis line
1-800-273-TALK (8255): Press 1
Or text to 838255
Or chat confidentially on the crisis line website

UW-Madison’s 24-hour mental health crisis line: 608-265-5600

Campus resources

Interactive map with links and summaries of University of Wisconsin counseling centers.

UW-Madison chapter of the National Alliance on Mental Illness (NAMI)
uw.nami@gmail.com
608-268-6000

Active Minds
Chapters exist at Marquette University, UW-Madison, UW-Milwaukee, the Milwaukee School of Engineering, UW-Parkside and Carthage College.

Supporting Peers in Laidback Listening (SPILL)
Chapters exist at UW-La Crosse, UW-Madison and UW-Whitewater.

Off-campus organizations and links

National Institute of Mental Health

NAMI Wisconsin
608-68-6000
800-236-2988

Mental Health America of Wisconsin
Milwaukee office:
414-276-3122 or toll-free 866-948-6483
info@mhawisconsin.org
Madison office:
608-250-4368
shelgross@tds.net

Helping Others Prevent and Educate about Suicide (HOPES)
608-274-9686

Wisconsin Department of Health Services: mental health and substance abuse programs

Prior mental health coverage from the Wisconsin Center for Investigative Journalism

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Wisconsin mental health system braces for major cuts under Walker
A tribal tragedy: High Native American suicide rates persist
Wisconsin suicide toll rises, exceeds that of neighboring states

The Center also collaborates with Wisconsin Public Television, Wisconsin Public Radio and other news media. Works created, published, posted or disseminated by the Center do not necessarily reflect the views or opinions of UW-Madison or its affiliates.

By Sara Jerving

Wisconsin Center for Investigative Journalism

Not again.

That was the dread that hit 18-year-old Bianca Lewis when she learned she was pregnant with her second child, less than a year after her daughter was born.

The depression that had troubled the single mother during her first pregnancy intensified after the birth of her second child.

Lewis, of Sun Prairie, frequently cried.

She fell into fits of screaming rage.

She abused alcohol.

She even broke ceramic plates over the head of the father of her children.

More than 65 percent of depressed mothers don’t get adequate treatment for depression, according to a nationwide study released this fall by the UW-Madison School of Medicine and Public Health. The study of 2,130 women found that black, Hispanic and other minority mothers were among the least likely to be helped. Women with health insurance were more than three times as likely to receive adequate care compared to uninsured mothers, the study found.

“Expanding health insurance coverage to mothers with depression is a critical step in

helping them get the care they need,” said lead author Whitney Witt, assistant professor of population health sciences at UW-Madison.

Nationally, depression that develops during the pregnancy and up to a year after giving birth afflicts up to 15 percent of women, a condition that can cause long-lasting problems in children. Although women of all income levels and backgrounds can suffer from perinatal depression, for women living in poverty, it’s twice as likely to strike, according to the Wisconsin Association for Perinatal Care.

Solutions to the problem of perinatal depression in Wisconsin remain elusive.

Consider that:

• Few health care professionals specialize in perinatal depression, meaning not many women are screened for it, physicians may overlook depressive symptoms and there are few places for treatment if they’re diagnosed.

• Women living in poverty are especially vulnerable because they are often already under excessive stress.

• Some women may avoid treatment because of the stigma of feeling depressed at a time that’s supposed to be among the most joyful in their lives.

• Some who qualify for state-sponsored health insurance while pregnant may lose the coverage after the baby is born because of more-restrictive income requirements for women who aren’t pregnant.

Some symptoms of perinatal depression include feelings that persist for two or more weeks — being overwhelmed, a lack of energy, sleep disturbances, difficulty attaching to the child, loss of concentration and, in severe cases, a desire to hurt themselves or their baby. Postpartum depression can make a woman unable to pick up her child when it needs her or respond appropriately to other cues.

“The attachment that can very quickly rupture when a mother has postpartum depression is potentially devastating,” said Jenny Grether, program coordinator of the Early Childhood Initiative of Dane County, a local home visitation and employment program.

The majority of women suffering from perinatal depression will suffer in silence, and the harm to their children can be profound, experts say, including delays in the child’s cognitive and language development, behavioral problems or other psychological issues.

Mothers and children can also be at physical risk. The most extreme form of perinatal depression, perinatal psychosis, may cause a mother to hate her unborn baby or infant, have thoughts of suicide or of harming the child. While this type of perinatal depression is extremely rare, several cases have made national headlines. In 2008, Alisa Lorraine Evans of Milwaukee was found not guilty by reason of mental disease after she killed one of her twin infant sons and injured another after she was diagnosed with perinatal psychosis.

Insurance limits are tight

On top of the natural stress of being a new mother, poor women struggle, often alone, with how to feed their children, a lack of adequate transportation, child care, employment and health insurance.

The Early Childhood Initiative works in the low-income neighborhoods of Allied Drive, Russet Road and Wexford in Madison, as well as the town of Sun Prairie. Women who are pregnant or have a child under 1 year old can participate in the program.

While its main mission is help children and create self-sufficient families, the program has become one of the primary screening tools for perinatal depression in low-income areas of Dane County. The program finds that just over half of the new mothers and pregnant women screened in low-income areas of Dane County had depressive symptoms at levels warranting further evaluation.

For many low-income women, a lack of adequate health insurance remains a significant roadblock to getting help. For those who do have state-sponsored insurance, finding therapists who charge on a sliding scale, or who accept patients receiving Medicaid, is difficult, said Birdie Meyer, president of Postpartum Support International.

BadgerCare Plus, the state’s health insurance program for low-income residents, has a special eligibility standard for pregnant women, offering state-subsidized coverage, for example, to a family of four making up to $66,144 a year.

Following the birth, the mother will still be covered for at least 60 days and the child is still eligible for BadgerCare Plus, but the income eligibility for his or her mother tightens to $44,100 a year to qualify for BadgerCare Plus.

Sixty days after the birth, women who don’t meet the income-level requirements are dropped, according to the Wisconsin Department of Health Services. Some cases of postpartum depression don’t show up in the first two months, meaning a woman could be dropped from coverage before the condition is identified or treated.

“I am stable now”

For Bianca Lewis, the path toward wellness has been rough.

Lewis moved from Houston to Dane County to live with her baby’s father in 2006. But things didn’t work out, Lewis said, because he was involved with two other women, and he’d already fathered two children with one of the women. A few months after the birth of her first child, Lewis found herself alone with her baby daughter at a homeless shelter.

She’d just had her gall bladder removed and was preparing her seven-month-old daughter for surgery to repair a congenital defect when she found out she was pregnant again.

She felt miserable, overwhelmed — and depressed.

“So here I go all over again,” Lewis said. “Not knowing if he’s going to be there or not. And I’m going to be sitting here with two kids … “

Lewis got help from the Early Childhood Initiative, where she was referred by her landlord after her first child was born. She’s been seeing a therapist, has been on and off medication and has developed a support network to help her through episodes of depression. Throughout her apartment are handwritten reminders to “Take your meds!”

Since she qualified for state-subsidized health insurance and was connected to treatment by the Early Childhood Initiative, Lewis didn’t have to worry about access to care. Even without this stress, however, Lewis felt burdened with other problems that make it hard to cope with depression.

“Mentally, I am stable now, but I still have three bodies to worry about,” Lewis said. “I have to make sure that we have enough food at the house and that everyone gets to their doctors’ appointments … I just want everything to be like the classic normal family — have a perfect home, the kids can have a father-figure, a picket fence house, all of that.”

Access improves, yet stigma persists

Access to treatment for women in Wisconsin suffering from perinatal depression has improved over the past 10 years, said Ann Conway, executive director of the Wisconsin Association for Perinatal Care. Women and health care providers are more aware of the problem, which has boosted the number of women getting screened for perinatal depression. And a growing amount of research has focused on the effects maternal depression on infants, children and families, she said.

Still, many women with perinatal depression aren’t getting help, Conway said.

“Some of the things that have remained the same include the stigma associated with a mental illness; the fear of prescribing selected antidepressant medications for pregnant and breastfeeding women; and a lack of mental health providers, ” Conway said.

Jennifer Doering, assistant professor of nursing at the University of Wisconsin-Milwaukee, agreed a stigma persists.

“In society, there is the idea that you can’t be a good mom and have a mental disorder,” she said. ” The two, for whatever reason, wrongly seem to be on the opposite ends of the spectrum.”

The depression itself can be a significant barrier to getting help, Doering said.

“Simply making the phone call when you are depressed to seek help is, for many women, a severe and almost insurmountable burden, ” she said.

Should screening be required?

Rebecca Cohen, a mental health program analyst for the state Department of Health Services, believes all pregnant women and new mothers should be screened for depression. She said identifying women suffering from perinatal depression would help knock down some of the barriers to getting help. The Wisconsin Association for Perinatal Care recommends women be checked for depression twice during pregnancy and twice after the child is born, once at six weeks after birth and another time before the child is 1 year old.

Some states have passed legislation dealing with perinatal depression, including New Jersey, which requires health care providers to screen all new mothers for the condition. Earlier this year, a bill was introduced in the U.S. House of Representatives that would ensure new mothers are screened and treated for postpartum depression. The bill also calls for increased funding for research on postpartum depression.

Still, most women like Lewis who do find treatment do so by accident, said Lisa Hebgen, Wisconsin state co-coordinator of Postpartum Support International. She said there are few support groups in Wisconsin aimed at women with perinatal depression, who may feel alienated in regular new-mother groups.

Hebgen, who suffered from postpartum depression after the birth of her son, found Dane County had few health care providers versed in the problem. Nowhere in her birthing classes or doctor visits did she hear about perinatal depression. Hebgen said when she began experiencing symptoms of depression, her concerns were ignored.

Said Conway of the Wisconsin Association for Perinatal Care: “The most common lament we hear … is the lack of services for mental illness, especially for pregnant women with mental illness.”

The nonprofit Wisconsin Center for Investigative Journalism (www.WisconsinWatch.org) collaborates with its partners — Wisconsin Public Radio, Wisconsin Public Television and the UW-Madison School of Journalism & Mass Communication — and other news media. This report is part of All Together Now, a community-wide collaborative journalism project, with all coverage available at www.ATNMadison.org.

What is perinatal depression?

A majority of new mothers may experience the ‘baby blues’ where they feel tired, have no energy and are overwhelmed by both joyful and depressive emotions. The postpartum blues may last up to 10 days and normally go away naturally.

But symptoms of perinatal depression, which afflicts pregnant women or new mothers, are more serious and last longer than the ‘baby blues.’ Some of the symptoms include depressed mood, lack of interest in activities, an inability to sleep, decreased concentration, a lack of energy to respond to the baby’s needs, emotional detachment from the child, feelings of guilt about that detachment and thoughts of harming oneself or the child.

Researchers have long thought that perinatal depression is caused by hormonal imbalances. However, many recent studies have found that other risk factors may have a stronger impact on perinatal depression. Those include recent stressful events like a job loss, financial difficulty, relationship problems or divorce or a general lack of social support.

The Centers for Disease Control and Prevention has found that reports of postpartum depression are high among teenage mothers, victims of physical abuse, low-income patients, smokers and mothers with less than 12 years of education.

The most serious and rare form of perinatal depression is perinatal psychosis. Women with this disorder can have delusions, paranoia and hallucinations, including hearing voices and having thoughts of harming their babies or themselves. Women with these symptoms should seek medical help immediately.

Women with perinatal depression can experience anxiety disorders such as panic disorder or obsessive-compulsive disorder in addition to their depression. Postpartum obsessive-compulsive disorder can cause a mother to have persistent thoughts about harm to her baby, causing her to excessively protect her child.

Perinatal depression can last several months to a year or longer if left untreated. Extended maternal depression can damage a mother’s relationship with her child but also result in delays in the child’s cognitive and language development, behavioral problems and other psychological issues. Some of the treatment options include therapy and medication.

Key facts about perinatal depression

If you need help

• UW-Madison Postpartum Depression Treatment Program, 608-263-5000
• Postpartum Support International, Lisa Hebgen, Wisconsin state co-coordinator, 608-929-7629, http://postpartum.net/
• Maternal and Child Health Hotline in Wisconsin, 800-722-2295, www.mch-hotlines.org