Psychiatry - July 2008 - (Page 34)

The issues raised in this article are ones faced by other municipalities in the United States. Hurricane Katrina has certainly exacerbated these issues, but other municipalities are facing similar problems. It is my hope that by discussing these issues we can help build stronger mental health services for all whom we serve. CASE 1—THE PLIGHT OF THE RETURNING MENTALLY ILL Much of the published literature about psychiatric issues from Hurricane Katrina has focused on the development of acute or posttraumatic stress symptoms in evacuees who witnessed traumatic events in their homes and evacuation centers. However, some of these studies have also demonstrated the barriers faced by the chronically mentally ill evacuees who left New Orleans like most others. Gavagan and colleagues4 found a high number of evacuees at the Houston Astrodome with preexisting psychiatric diagnoses that would lead to serious problems if left untreated. Russell-Rodriguez and colleagues5 found that 14 percent of evacuees treated at an evacuation center in Oklahoma had preexisting mental illness that required medications pre-hurricane that also pre-disposed them to experience posttraumatic stress disorder (PTSD). North and colleagues6 found high rates of pre-evacuation diagnosis of bipolar mood disorder (7.2%) and schizophrenia (16.3%)— along with urgent requests to refill medications used to treat these diagnoses—in several hundred adults surveyed at the Dallas Convention Center. Other published reports7 also found frequent mental health complaints among evacuees, but these reports did not differentiate preexisting symptoms from those that developed due to the trauma of the storm. As residents began to return to New Orleans in the late fall and winter of 2005, mental health services did not follow their return. One often-cited report by Weisler8 found that 22 psychiatrists remained 34 Psychiatry 2008 [JULY] in New Orleans from a pre-storm total of 196. The State of Louisiana Department of Health and Hospitals found only 42 of 208 psychiatrists practicing in the greater New Orleans area.9 The same state report found that mental health beds had dropped from 487 beds pre-storm to 190 beds—with many of those beds already filled by institutionalized mentally ill patients. By one accounting, there were only 17 mental health beds in New Orleans for acute mental health issues a year after Katrina’s landfall.10 It was in this setting that Willie Lewis and his family returned to New Orleans. On March 31, 2007, Mr. Lewis was brought to a hospital in New Orleans by police officers. The police had been called to transport Lewis, who had a long-standing diagnosis of paranoid schizophrenia, because he had been refusing to take his psychiatric medications and had been threatening his mother.11 According to police reports, Mr. Lewis declined treatment at the hospital and left—reportedly without a physician evaluation. Less then 10 minutes after arriving back at home, Mr. Lewis repeatedly stabbed his 77year-old mother in the driveway of their home in the Uptown section of New Orleans. Mr. Lewis was then arrested and is now being held in Orleans Parish Prison on charges of attempted second degree murder.12 This incident prompted widespread publicity about violence being committed by the chronically mentally ill in New Orleans. Mayor C. Ray Nagin released a letter that he urgently sent to then Governor Kathleen Blanco demanding that at least 100 mental health beds be opened in New Orleans.13 Police also complained that they were spending enormous amounts of time “babysitting” the chronically mentally ill and were transporting 185 to 200 mental health patients every month to hospitals—a sharp increase from pre-Katrina levels. It was also publicized that hospitals were trying to curtail police from bringing the mentally ill to their emergency rooms (ERs) for evaluation and treatment. Police reported being berated by nurses at hospitals, who were urging them to take psychiatric patients elsewhere. One reported example claimed that police were met by hospital staffers on the ER ramp hoping to turn away patients before they set foot inside the hospital’s grounds and become that hospital’s responsibility.9 Supporting law enforcement’s accusation was the fact that many area hospitals had closed their psychiatric wards after the storm. Therefore, the mentally ill needing hospitalization often had to be transported to psychiatric facilities in Baton Rouge, Alexandria, and Shreveport, Louisiana.14 With the addition of these mentally ill patients “parked” in their ERs, uncompensated care at New Orleans area hospitals sky-rocketed after Hurricane Katrina. One hospital reported that uncompensated care increased by more than 140 percent—from $17 million prior to Katrina to $41 million after Katrina, with 90 percent of the uncompensated care coming from its ER.15 Five hospitals reported an aggregate loss of $135 million in uncompensated care after Katrina. A major issue that prevented area hospitals from reopening their psychiatric wards was that there was no solution in sight for funding uncompensated inpatient mental healthcare. Reopening psychiatric beds would likely have increased area hospitals’ problems with uncompensated care, even though it would have alleviated the situation in their ERs. In fact, it is only relatively recently that the state of Louisiana has proposed financing mechanisms of reducing the burden of uncompensated care for hospitals in New Orleans that are caring for the mentally ill.16 Because of the lack of mental health facilities in which to place the chronically mentally ill, Orleans Parish Prison has become the largest psychiatric center in New Orleans.17 It is at that facility where Willie Lewis remains and is presumably finally receiving psychiatric care.

Table of Contents Feed for the Digital Edition of Psychiatry - July 2008

Psychiatry - July 2008 Editor's Message Editorial Advisory Board Contents PsychRx Letters to the Editor Reliability of Diagnoses: Do Psychiatrists Use Structured Interviews In Real Clinical Settings? Trend Watch: Use of Atypical Antipsychotics in the Elderly Review: The Struggle for Mental Healthcare in New Orleans-One Case at a Time Psychotherapy Rounds: Psychotherapeutic and Adjuntive Pharmacologic Approaches to Treating Posttraumatic Stress Disorder Original Research: Baseline Dissociation and Prospective Success in Special Forces Assessment and Selection Commentary: Performance-Enhancing Drugs: Where Should the Line Be Drawn and By Whom? Commentary: Psychiatric Diagnosis and the Pathlogist's View of Schizophrenia Journal Watch Classified Advertising Information for Authors

Psychiatry - July 2008

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