Pam Kiser, 57, of Lafayette,thought she was fine.

The medication pre-scribed by Kiser’s psychia-trist to combat bipolar disor-

der was working in 2004. So she cut herprescription in half and eventuallystopped taking it completely.

“I thought, ‘I’m doing good,’ ” Kisersaid. “So I quit. I thought I was cured.”

She wasn’t.After she stopped, Kiser had a

psychotic episode. She heard voices.She saw things that weren’t there. Shecouldn’t even walk out the front door ofher home.

When she reached out to resume herappointments with her psychiatrist,she was told the wait time could be upto three months.

“When you’re in a crisis, for some-one with a mental illness, it’s like a per-son going through a heart attack,” Kis-er said. “You need help now because

the longer a heart attack goes, themore damage your heart has. ... It tookmonths to be able to get the help I need-ed.”

Experiences like hers aren’t rare inGreater Lafayette. In Tippecanoe andsurrounding counties, there is just onepsychiatrist for every 57,585 resi-dents, according to the federal HealthResources and Services

Dire shortage of area psychiatrists leaves patients waiting months for helpBY MIKEL LIVINGSTON | MLIVINGSTON@JCONLINE.COM INSIDE

Stigma: “I know people who desperatelyneed treatment. They’re hurting really badly,but ... they’re afraid to step out.” A4

AT JCONLINEVideo: Advocates talk about theirexperience with the mental health

system, including what patients experiencewhile waiting months at a time for anappointment or medication. Click on this story.

7

See BREAKDOWN, Page A4 JEFFREY MORRIS / GANNETT MEDIA ILLUSTRATION

Purdue University’s growing inter-national student population will re-ceive more English language supportbecause President Mitch Daniels hasapproved more than $2 million infunding for a two-year pilot program.

The funding comes after a faculty-led push. Many of Purdue’s interna-tional students are uncomfortablespeaking English and with Americanculture despite passing English profi-ciency tests and being admitted to the

university. About 20 percent of Pur-due students come from outside theU.S.

“We want these students to be suc-cessful,” said Frank Dooley, associatevice provost for undergraduate aca-demic affairs. “If you feel more com-fortable, you’re going to do better inclass. If we bring these students tocampus and they’re not successful,what are we doing?”

Purdue has supported internationalstudents in a variety of ways, but Doo-ley said the pilot program will coordi-nate and expand those efforts, begin-ning in the fall semester.

“The biggest difference is all of

Easing foreign students onto campusPurdue program to help inlearning English, US culture

By Hayleigh Colombohcolombo@jconline.com

See PURDUE, Page A9

An increase in the number ofinternational students at PurdueUniversity has lead to the creation of apilot programs to get students morecomfortable with English and Americanculture. FILE PHOTO/JOURNAL & COURIER

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‘I’m stuck’

Doug Fletcher, 56, has given up on theGreater Lafayette mental health sys-tem. Fletcher has been diagnosed withschizophrenia, and after working witheight psychiatrists who gave him ninedifferent diagnoses since 1985, he saidhe’s sworn off psychiatric care.

Fletcher was fired from his job in2002 due to, he said, side effects from hismedication that impaired his memoryand ability to concentrate. As a result,Fletcher no longer has insurance, mean-ing his only option for psychiatric care isthe part-time psychiatrist who spendssix to eight hours each week seeing pa-tients at Riggs Community HealthCenter.

But after that doctor started him onnew medication, Fletcher said he beganhearing voices speaking on either side ofhim. He’d heard voices a handful oftimes in the past, but never two at once.That’s when, Fletcher said, he knew themedicine wasn’t working.

So he stopped taking it. He now self-medicates. He said he drinks smallamounts of alcohol and eats spicy foods,both of which release beta-endorphinsthat Fletcher said help calm him.

“At my income level, he’s the only guyin town I can see, and since he’s alreadygiven me ineffective medication … I’mstuck,” Fletcher said. “They tried theirmedication and it didn’t work, so I’msticking with mine.”

For those like Fletcher, without insur-ance, private mental care is rarely an op-tion. Prompted by low insurance reim-bursements, just 55 percent of privatepsychiatrists accept insured patients,compared with 89 percent of other doc-tors, according to a 2013 study publishedin JAMA Psychiatry. That leaves mostpatients with steep out-of-pocket ex-penses.

A 2011report from the U.S. SubstanceAbuse and Mental Health ServicesAdministration showed that 45.6 millionAmerican adults suffered from a mentalillness that year. Of the 62 percent whodid not receive treatment, 50 percent —more than 14 million people — said it wasbecause they could not afford it.

“The challenge is that the benefits theinsurance companies allocate for psy-chiatry are sometimes discriminatoryagainst mental health,” said Dr. Nizar

Administration. That ratio is five timesworse than what’s recommended by thefederal Centers for Medicare and Medi-caid Services: at least one psychiatristfor every 10,000 people.

Meanwhile, an estimated one in fourAmerican adults will suffer from a diag-nosable mental disorder in a given year,according to the National Institute ofMental Health. In the nine-county Tippe-canoe shortage area, that translates tomore than 66,000 potential patients eachyear. And one-fourth of those, or an esti-mated 16,500 adults, will be classified ashaving a serious mental illness.

“The system is just broken,” said Kis-er, now an advocate for the National Alli-ance on Mental Illness.

“I worry because without treatment Idon’t know where I would be. I’m afraidfor my children and I’m afraid for mygrandchildren, about what would hap-pen to them if treatment has to stop be-cause of insurance or money or the lackof doctors.”

Not everyone in need of mental healthservices requires the treatment of a psy-chiatrist. Help can be sought from othermental health professionals, such aspsychologists, but those positions alsoare declining. According to the Health

Resources and Services Administration,55 percent of the nation’s 3,100 countieshave no psychiatrists, psychologists orsocial workers. And unlike psychia-trists, psychologists in all but two statesare prohibited from prescribing psycho-tropic medicine.

The mental health landscape facingHoosiers is grim.

Insurance companies provide low re-imbursement rates for psychiatrists, soa private psychiatrist stands to makemore money by refusing to accept in-sured patients. Meanwhile, the publicnetwork of clinics and hospitals increas-ingly relies on costly temporary psychi-atrists and other stopgap measures tofill the growing void left by the diminish-ing number of psychiatrists.

Further fueling the shortage of psy-chiatrists: More than 25 percent of psy-chiatrists are poised to retire in the nextdecade, and fewer Indiana medical stu-dents are entering the profession to taketheir place. The population is increasing,and the Affordable Care Act makesmore people eligible for mental healthservices. Some fear that the Americanmental health system is on a collisioncourse.

“It’s definitely a crisis situation inTippecanoe County and in Indiana,” saidJennifer Flora, executive director ofMental Health America of Tippecanoe.“The whole mental health system rightnow is in jeopardy.”

El-Khalili, a psychiatrist who owns Al-pine Clinic in Lafayette and is medicaldirector at the Sycamore Springs addic-tion treatment center. “Sometimes pa-tients, unfortunately, have to pay a high-er co-payment to get services.”

Patients who can afford the co-paysstill face long wait times. New patientsoften must meet at least once with a ther-apist or case manager before being re-ferred to a psychiatrist who can pre-scribe medication.

Kurt Harker, 53, is a West Lafayetteresident with bipolar disorder who for30 years has benefited from seeing apsychiatrist. Harker said quick help iscrucial for someone having a psychoticepisode.

“A person who’s in psychosis, which Ihave been — if you treat that personquickly and get them out of psychosis,they will recover a whole lot better thanif they are in that for an extended periodof time,” Harker said. “It just burnsthese pathways and images and thingsinto your brain cells, and then it’s somuch harder to treat it. Time is of the es-sence, especially if you’re in crisis.”

Long wait times is a common com-plaint heard at Mental Health Americaand the Lafayette Crisis Center’s24-hour crisis hotline.

“The doctors here are booked up,”said Jane McCann, executive director ofthe crisis center. “It’s also a problem forpeople new to the area that can’t havetheir prescriptions refilled. Their illnessdeteriorates while they’re waiting.”

About six months ago, a local mentalhealth provider called Flora at MentalHealth America, wanting to know if theexecutive director could refer one of the

BREAKDOWNContinued from Page A1

DESIGNATION POPULATION TO POPULATION PSYCHIATRIST RATIO HPSA SCORE*1. 138,674 35,557:1 162. 221,687 N/A 163. 310,957 57,585:1 154. 31,271 12,027:1 155. 78,651 N/A 146. 157,678 N/A 127. 108,606 49,366:1 118. 115,825 37,363:1 109. 108,928 0:1 6

*Health Professional Shortage Area score: The HRSA rates mental health shortage areas on a zero to 25-point scale with 25 being the most severe shortage.

SOURCES: Health Resources and Services Administration, U.S. Census Data THOMAS MAXFIELD/JOURNAL & COURIER

There are nine mental health provider shortage areas in Indiana, according to the Health Resources and Services Administration. Overall, Tippecanoe and surrounding counties tie for second most severe shortage of psychiatrists in the state.

SHORTAGE OF PSYCHIATRISTS

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Since he cannot find effective localpsychiatric treatment, Doug Fletcherself-medicates for his schizophrenia.

LOCAL RESOURCESMental Health America ofTippecanoe: 765-742-1800; www.mhalafayette.org; mha@mhalafayette.orgNational Alliance on Mental Illness— West Central Indiana: 765-423-6939; www.nami-wci.org; info@nami-wci.org

FIGHTING STIGMA• Use respectful language. Put theperson before the illness; use phrasessuch as “a person with schizophrenia.”Never use terms such crazy, lunatic,psycho or retarded, and correct peoplewho do so.• Provide professional develop-ment opportunities for staff re-garding diversity, mental healthissues, and fostering an inclusivework environment. Include mentalillness in discussions about acceptanceof diversity, just as you would discusscultural diversity, religious beliefs,physical disability and sexual orienta-tion.• Become an advocate. Createawareness by writing letters to news-papers and lawmakers. Speak out andchallenge stereotypes portrayed in themedia. Take it upon yourself to informyour community about the truth ofmental illness.

Source: National Alliance on Mental Illness

STIGMA OFTENDETERS THOSEWHO NEED HELP

Three decades ago, West Lafayetteresident Kurt Harker didn’t want any-one to know he had been diagnosed witha mental illness.

Harker has been diagnosed with bipo-lar disorder. But like many who experi-ence a mental illness, he feared stigmaand discrimination.

“I didn’t want anyone to know I tookmedicine of this nature,” Harker said.“So I hid it in my apartment or at work. IfI ever had to call a psychiatrist, I wouldgo somewhere far from the office. Ev-erything was hidden from everybody.”

These days, Harker is open about hisillness. He’s now a mental health advo-cate, involved with Mental Health Amer-ica and the National Alliance on MentalIllness, fighting the stigma that persistsaround mental illness.

“I know people who desperately needtreatment,” Harker said. “They’re hurt-ing really badly, but due to the stigma,they’re afraid to step out. They’re afraidto even go see a counselor.”

One in four Americans will experi-ence a mental illness this year. Stigmaassociated with those illnesses will deterhalf from seeking treatment, accordingto the National Alliance on Mental Ill-ness.

MHA and NAMI are two agenciesworking nationwide and locally to equip

the public with the resources they needto deal with mental illness.

“We need the public to understand it isa biological disorder, just like arthritisand diabetes,” said Pattie Wollenburg,executive director of NAMI of West Cen-tral Indiana. “It’s biological and it’s noth-ing to hide. It needs to be talked about,needs to be addressed. It’s not curable,but it’s treatable.”

But medicine isn’t a cure-all, Harkersaid.

“What really happens is, you take themedicine and what it does is get you to apoint where you can deal with the prob-lems you already have,” Harker said.“Medicine isn’t a magical cure for the is-sues I have to deal with in my life.”

Pam Kiser, another mental health ad-vocate, has been diagnosed with bipolardisorder. When she stopped taking her

medication in 2004, she spiraled into amanic episode.

Kiser began wasting money. She liedto her husband that she was using it forhouse payments, but instead spent it onfrivolous purchases.

“I didn’t need the stuff,” Kiser said.“It made no sense. It’s just the urge tospend the money. If I didn’t have themoney to spend, I’d get angry and I’d getdestructive.”

As a result, the couple lost their home,which had been three-quarters of theway paid off.

Now, back on medication and doingwell, Kiser works for NAMI. She speaksopenly about her experience and is usingit to help others in the same position inwhich she once found herself.

“It makes what I went through wellworth it,” Kiser said.

Kurt Harker of West Lafayette talks about his history of mental illness. He is on medication for bipolar disorder. PHOTOS BY JOHN TERHUNE/JOURNAL & COURIER

By Mikel Livingstonmlivingston@jconline.com

A4 Sunday, April 13, 2014 www.jconline.com • Journal & Courier

MENTAL HEALTH SYSTEM BREAKDOWN

www.jconline.com • Journal & Courier Sunday, April 13, 2014 A5

provider’s patients to a psychiatrist.Flora was confused because the pro-

vider was one of a handful of local agen-cies that employ psychiatrists in La-fayette. We would refer them to you, Flo-ra told the provider.

Not an option, the provider replied,because the wait time would be too long.

“When they are in need of that medi-cation, they sometimes initially believethey can just call someone and get an ap-pointment with a psychiatrist and get an-other prescription,” Flora said. “Itdoesn’t work like that.”

Instead, those patients can seek tem-porary sources of medication — such asthrough emergency rooms. Sometimesthey run into brushes with law enforce-ment.

Sgt. John Yestrebsky of the LafayettePolice Department is coordinator of theLPD Crisis Intervention Team. A nation-al curriculum gives officers an annual 40hours of training on how to deal withmental health issues.

But the training, offered by LPD andother local law enforcement depart-ments, is a temporary resource, Yes-trebsky said, and police can run intoproblems when trying to put a 24-hourpsychiatric hold on someone, only to findthat not enough psychiatrists or beds areavailable to accommodate that person.

“Oftentimes when the family doesn’tknow what to do, they call us,” Yestrebs-ky said. “The CIT program is great to putthat Band-Aid on it, to help de-escalatesomeone in a crisis. But where do you gofrom there if you don’t have the profes-sional resource that a psychiatrist is?”

An evolving profession

Area hospitals and clinics have at-tempted to adapt and meet the growingdemand for mental health services witha decreasing supply of psychiatrists.

Prompted by the shortage, WabashValley Alliance is in a “continual recruit-ment phase,” said Tom Gilliom, chief op-erating officer. Wabash Valley Allianceemploys two full-time and one part-timepsychiatrist and provides one full-timepsychiatrist to serve River BendHospital.

The alliance has contracts with sever-al recruiting firms and constantly up-dates job postings online in an effort toattract psychiatrists.

“The people that are applying arequalified people, but they are clinicalnurse specialists or advanced practicenurses,” Gilliom said. “It’s been monthssince we had anyone who was a psychia-trist submit a request for information tofind out anything about us. And it’s prob-ably been since last July since we actu-ally had an interview with a psychia-trist.”

As a result, the group currently hassix temporary psychiatrists filling in forpositions that should be permanent.Those doctors work on short-term con-tracts and typically commute from otherareas of the state or country. Gilliom esti-mates each temporary doctor costsabout 2.5 times that of a permanent

psychiatrist.“We don’t just pay their hourly rate,”

Gilliom said. “We have to pay their hous-ing. We have to pay their transportationand expenses. One gentleman lives in Ar-izona, so we pay for his flight back andforth and have a room at a local hotel, andhe also rents a car. So we have to paythose things in addition to his salary.”

Those short-term doctors result in in-consistent care and a revolving door thatinhibits patients from establishing trustand rapport with their physician.

“I had a doctor flat-out tell me, ‘I don’tfeel comfortable changing your medsbecause I don’t know if I will be here nextmonth to see how you’re doing,’ ” Kisersaid.

Wabash Valley, along with IU Healthand St. Elizabeth Health networks, hasembraced telepsychiatry, which typical-ly takes the form of a patient and psychi-atrist using Internet video services, suchas Skype, to bridge long distances.

“The local physician is here withthem, so it’s like a three-way conversa-tion,” said Patricia Hoyer, a nurse practi-tioner for IU Health Arnett. “The psychi-atrist can also talk to the physician hereas well as talking directly to the patient.It gives you all the visual cues as well asthe verbal cues (you’d get) over thephone.”

Health care providers are increasing-ly reliant on advanced practice nurses tofill the gap left by psychiatrists. Thosenurses can obtain the ability to prescribemedications, just like a psychiatrist,through advanced training.

But the Indiana Administrative Codehinders that process by requiring thenurses to enter into a “collaborativeagreement” with a supervising psychia-

trist. That doctor then oversees thenurse by auditing 5 percent of the nurse’scaseload each month.

With the psychiatrist also responsiblefor his own crowded caseload, there is alimit to how many nurses a psychiatristcan supervise. That means as the num-ber of psychiatrists dwindles, so too doesthe number of nurses eligible to pre-scribe medication in the place of psychi-atrists.

“Indiana is one of three or four statesthat still requires that collaborativeagreement,” Gilliom said. “The otherstates, because of some of these very is-sues, have done away with that becausethey don’t have the psychiatrists tomatch the nurses up with.”

The shortage has prompted reneweddiscussion at the Indiana UniversitySchool of Medicine, Indiana’s only inter-nal supply of new psychiatrists.

Fewer IU students are entering thefield of psychiatry. Historically, about 2percent of IU medical students enterthat branch of medicine, said Dr. ThomasMcAllister, chairman of the school’s de-partment of psychiatry. That’s about 2percent below the national norm formedical schools.

Getting those students to remain inIndiana is difficult. Of the 59 studentswho graduated on to residencies in psy-chiatry from the school since 2004, only23 accepted residencies in Indiana; therest went out of state.

“This is nationally, not just an IU prob-lem,” McAllister said. “There’s a lot oftalk and debate in the field about wheth-er we need to rethink instruction that isgiven in the first couple of years stu-dents are in the classroom. Maybe ex-pose them to some of the more interest-ing and exciting aspects, get them out ofthe classroom and into the clinical a littlebit earlier.”

Psychiatry can be a hard sell to med-ical students, said Dr. Christopher Cobb,the only full-time psychiatrist employedby St. Elizabeth Health.

In other fields of medicine, “you’vegot very clear objective data that willshow you what’s going on,” Cobb said.“Psychiatry is the one specialty thatdoesn’t have any of that. I liken psychia-try right now to maybe what being a fam-ily doctor was like 100 or 150 years ago. ...Psychiatry can be a tough sell becauseyou’ve got to be comfortable in essential-ly letting go of all this technology we use

in medicine — because most of it doesn’tserve you. Psychiatry takes a specialperson to be able to be in tune with that(patient).”

Student loan debt also is a factor. Theaverage medical student graduates withnearly $170,000 in loan debt, according tothe American Medical Association.That’s up 52 percent from a decade ago.

Because psychiatrists, unlike mostdoctors, are required to bill based on theamount of time they see a patient, thatpsychiatrist ends up making less moneyfrom fewer patients during the samework period as another doctor. Knowingthat they can make more money in otherfields of medicine — psychiatrists areroutinely ranked at or near the bottom onthe physician salary scale — few medicalstudents pursue a career in psychiatry.

“With the increasing debt load stu-dents are shouldering coming out ofmedical school, the question is whetherthere is an economic disincentive,”McAllister said.

Harker said the lack of student inter-est is discouraging.

“It’s really sad because they knowthey can make more money in otherparts of medicine, and yet the one part ofthe body that’s the most complex andstands to gain the most benefit frommore research, from more education,from having brighter psychiatrists, isyour brain,” Harker said.

“There are so many good things aheadin the field of psychiatry that you wantthese students to be the brightest stu-dents, but you lose them due to money.”

Developing a dialogue

McAllister suggests an in-depth stra-tegic planning process involving all men-tal health stakeholders to guide Indiana’smental health system into the future.

“We need to think through how wescale up psychiatric services so the peo-ple who need the care get it,” McAllistersaid. “We can address the leak here andthe leak there and patch it up, but itwould be really helpful to develop a dia-logue about who are the stakeholdersand how are we going to think about deli-vering mental health services.”

Advocates say they’d like to see moreincentives for students entering the pro-fession and higher base salaries for psy-chiatrists.

Dr. Jerry Sheward, medical directorand vice president of Aspire Indiana, astatewide behavioral health system, hasstudied Indiana’s shortage. He sees afield that will continue evolving.

That means more telepsychiatry.More reliance on temporary doctors andadvanced nurses with prescription-writ-ing authority. And more psychiatriststaking a back-seat consulting role as oth-er physicians — such as primary caredoctors — incorporate mental health intotheir practices.

“There will still be a small number ofpsychiatrists that will be able to set up ...and see a few very affluent people prettyaggressively,” Sheward said. “But as faras dealing with the public health needs ofthe state of Indiana, that model’s not go-ing to cut it.”

MEDICAL STUDENTS PSYCHIATRY PSYCHIATRY RESIDENCIESGRADUATION YEAR IN RESIDENCY RESIDENCIES IN INDIANA2013 295 6 12012 283 8 22011 298 2 12010 263 6 22009 263 11 32008 257 1 12007 268 9 42006 257 7 32005 258 4 32004 253 5 3Total 2695 59 23

FEW MEDICAL STUDENTS CHOOSE PSYCHIATRYThe shortage of psychiatrists, particularly in Indiana, is reflected in the small number of Indiana University medical school students who secure residencies in psychiatry after graduation.

SOURCE: IU School of Medicine THOMAS MAXFIELD/JOURNAL & COURIER

Continued from Page A4

Pam Kiser has had several psychotic breaks,but is on medication for bipolar disorder.

MENTAL HEALTH SYSTEM BREAKDOWN