Memories of Hurricane Katrina slow mental health recovery in New Orleans

From the Journal of the American Medical Association. The photo is from Unity of Greater New Orleans.

When Lucy Lexapro paraded through Mardi Gras, Ben Springgate, MD, MPH, knew something had changed.

Springgate, an assistant clinical professor of medicine at the Tulane University School of Medicine in New Orleans, had marshaled a citywide effort to help survivors cope with stress in the aftermath of Hurricane Katrina. Revelers dressed as antidepressants were more than a sign of blowing off steam during the city's annual gala.

"That helped to diminish the popular stigma about mental illness," he said.

When humor and hope were in short supply, the city showed its resiliency. But as New Orleans and the surrounding Gulf region commemorate 5 years since the deluge, recovery from the storm's mental health blows still is ongoing. Experts say survivors have higher-than-expected rates of stress-related mental health disorders, including depression and posttraumatic stress disorder (PTSD). And the new devastation of the BP Gulf Coast oil spill appears to be compounding that effect.

Ronald Kessler, PhD, professor of health care policy at Harvard Medical School in Boston, said Katrina survivors who were spared severe stress have not had persistent problems. But those who were hardest hit—for example, those who lost a loved one or a home—continue to struggle.

"We still find that they have elevations, and it's pretty substantial," said Kessler, who also directs the Hurricane Katrina Community Advisory Group, a panel of experts that is studying the storm's psychological impact on residents. He added that data being prepared for publication as this article went to press indicate that mental health problems in a cohort of children "stayed very high, more than double the rates among kids before the hurricane."

Kessler's previous work compared the hurricane's mental health impact on the New Orleans metropolitan area with that of storm-damaged regions in Louisiana outside the metro area and in Alabama and Mississippi. He and his colleagues reported that about 6 months after the hurricane, 49% of 594 residents interviewed in New Orleans met criteria from the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) for anxiety and mood disorders, compared with 26% of 449 residents in the other areas. PTSD prevalence was 30% in New Orleans, compared with 13% outside the metro area (Galea S et al. Arch Gen Psychiatry. 2007;64[12]:1427-1434).

Follow-up a year later produced some surprises. Even though mental health disorders generally subside after a disaster, the prevalence of PTSD, serious mental illness, suicidal ideation, and suicide plans increased significantly in the entire study area. But the increases in PTSD and serious mental illness were in populations outside of New Orleans, even though metro area residents coped with life-threatening floods from levee failures and had the highest initial rates of mental health disorders. Residents in all the regions studied reported significantly lower hurricane-related stress a year later, but the rate of decrease was smaller and the prevalence of stress was higher in New Orleans than in the surrounding areas (Kessler RC et al. Mol Psychiatry. 2008;13[4]:374-384).

The findings show that stress alone cannot explain the increased prevalence of PTSD and serious mental illness in regions outside of New Orleans. While the reasons for these patterns are not clear, Kessler said they persist.

"Hurricane Katrina [is] not your typical disaster," he said in an interview. "It wasn't like the tornado sweeps through and it's gone tomorrow, then you start cleaning up and 6 months later it's better. This just went on forever; there are still places that don't have electricity after all this time. It's just grinding people down."

Since 2006, researchers at the National Center for Disaster Preparedness at Columbia University's Mailman School of Public Health in New York City have followed up 1000 families affected by the hurricane. Nearly 2 years after the storm, families they studied had scores that were significantly lower than the US mean on the mental health component of the Medical Outcome Study SF 12 (Abramson D et al. Disaster Med Public Health Preparedness. 2008;2[2]:77-86).

Irwin Redlener, MD, the Center's director, also was preparing follow-up data at press time. Five years after the devastation, he said in an interview, "we're still seeing substantially higher rates of mental illness and emotional problems than we would ever expect."

The Kaiser Family Foundation publishes updates on New Orleans' recovery trends (http://www.kff.org/katrina). The Foundation's new 5-year data show that a vast majority (80%) of residents in Orleans Parish say their mental health needs currently are well met. The data, based on 1528 randomly chosen adults interviewed earlier this year, also show that 16% said a health professional had ever told them they had a serious mental illness compared with 5% interviewed in Orleans Parish in 2006. This year, 16% said they had taken a prescription medication for a mental health–related condition in the past 6 months compared with 8% in 2006. About two-thirds have rated their own mental health as excellent or very good: 66% this year compared with 69% in 2006.

Some of the Kaiser data reflect what addiction specialist Ken Roy, MD, sees in clinical practice at Addiction Recovery Resources Inc, in Metairie, La, a treatment facility where he is medical director. "On a daily basis I see people who have had depression for years now and finally are coming to seek help," he said.

"When I see a patient today, I ask them, ‘Tell me your Katrina story,’" he said. "In every patient . . . it's always huge; it's always part of the stress that is associated with their present condition."

Now, the BP oil spill has compounded or reactivated traumatic stress that, for many, began with Katrina. "We're seeing people talking about increases in anger and increases in anxiety," said Howard Osofsky, MD, PhD, the Kathleen and John Bricker Chair and professor of psychiatry at the Louisiana State University (LSU) School of Medicine in New Orleans. "We have people call us [who] had posttraumatic stress disorder or symptoms" after the hurricane, "and they improved so much. But now it's like the lid has come off again."

From April 20, when the Deepwater Horizon drilling rig exploded, through the first week of July, Catholic Charities Archdiocese of New Orleans assisted 14 000 area residents at 5 community centers it operates in and around New Orleans. Catholic Charities provides assistance with housing, food, health care, and other concerns. Medical Director Elmore Rigamer, MD, said about 3000 who came for help received mental health counseling, including 50 who needed psychiatric care.

"The spill is a continuous onslaught of insults," he said.

Even as hurricane recovery continues, health professionals and government officials say long-needed investments in mental and behavioral health services now are being made in New Orleans and the rest of the state.

"The health care system in our region has responded dramatically and made significant progress in trying to get its hands around the population's mental health issues," said Springgate, also director of health for the RAND Gulf States Policy Institute.

With RAND, Tulane, and a number of community and faith-based organizations, Springgate cofounded and is president of REACH NOLA, an initiative that developed new strategies to deliver evidence-based mental health care in post-Katrina New Orleans. "We have had a wide range of investment of time, energy, and money into building a higher quality and more accessible care system for mental illness," he said.

REACH NOLA operates on a team-based approach. Support from the Robert Wood Johnson Foundation and the American Red Cross enabled the participating partners to hire and train psychiatrists, social workers, counselors, and community outreach workers to provide mental health services. Based on team care models developed at RAND, the University of California at Los Angeles, and the University of Washington, REACH NOLA also trained primary care professionals, case managers, psychologists, and social workers to work together to make cognitive behavioral therapy available in their communities.

For example, residents who came to meetings of neighborhood associations and churches talked about their struggles in coping with storm-related losses. Springgate said some worried about being viewed as "crazy" and had no idea how to access the services they needed. Bureaucratic barriers only exacerbated stress and anxiety. "There was a huge amount of anger and frustration that came from the failures of government on the federal, state, and city levels," said Rigamer of Catholic Charities, a REACH NOLA partner. Springgate said community health workers who were trained to offer education and outreach, screening, referral to a clinical organization, or peer-to-peer support were dispatched to neighborhood associations and churches to help guide residents into care.

To date, said Springgate, "We worked with more than 70 nonprofit and safety net organizations, we trained more than 400 of their providers . . . we delivered 110 000 services, and we have residual capacity now that enables us to look forward."

A couple of months before Katrina struck, the State of Louisiana developed plans to restructure its mental health care delivery system with an emphasis on community-based care. "That document guided how we rebuilt the infrastructure," said Anthony Speier, PhD, deputy assistant secretary of the Louisiana Office of Mental Health, who headed the state's federally funded crisis counseling program created in response to Katrina. Experts in New Orleans said early on that a goal was to spread safety net health services throughout the city rather than keeping them clustered in the downtown area.

The state has since invested millions in developing a new community-based system for mental health services. For example, the Metropolitan Human Services District in New Orleans now uses mobile vans to deliver services to residents who lack transportation. Previously, Speier said, outreach clinics came to neighborhoods perhaps on a monthly basis. Tulane psychiatrist Daniel Winstead, MD, said District officials set up a centralized call system with human personnel, not automated systems, to make it easier for residents to schedule appointments or call for emergency help. Tulane and LSU also have been involved in setting up medical homes, many with a mental health component that helps some patients avoid a trip to the emergency department.

In fact, said Speier, a measure of progress is a reduction in visits to the Mental Health Emergency Department Extension at the LSU Interim Hospital in New Orleans. "There was an overreliance on the emergency department as the only way to get immediate psychiatric assistance," he said. "We are not perfect in addressing those needs, but we have made a big dent."