Psychiatry - July 2008 - (Page 37)

DISCUSSION The cases presented in this article raise several important issues regarding mental healthcare in New Orleans after Hurricane Katrina. The statistics cited in the case of Willie Lewis demonstrate that many emergency receiving sites did not anticipate the high level of preexisting psychiatric disorders that they found in evacuees. Whether it was the neighboring state of Texas or states farther away, such as Oklahoma and West Virginia, preexisting psychopathology was a common feature in evacuees who sought help immediately following Katrina. The fact that Louisiana’s evacuees had a high level of symptomatic psychiatric illness has been suggested to reflect deficits in mental healthcare existing long before Hurricane Katrina. A series of studies done by the Substance Abuse and Mental Health Services Administration in the year before hurricanes Katrina and Rita showed that Louisiana was in the group of states with the highest rate of serious mental illness50 and illicit drug use.51 Louisiana has also consistently received low ratings for its mental health services from the National Alliance on Mental Illness (NAMI), garnering grades such as ‘D’ on state report cards.52 Per NAMI’s report, these low grades reflect Louisiana’s lack of mental health infrastructure, lack of patient information access and portability, and low per capita mental health expenditure of $51.34. Compounding Louisiana’s challenges in mental healthcare is its high poverty rate at 19.6 percent, well above the United State’s average of 12.4 percent.53 Most studies of mental illness and poverty strongly correlate poverty as a risk factor for negative outcomes among the mentally ill.51 Further problems that Louisiana faced before the devastation of hurricanes Katrina and Rita also included its patchwork system of community mental health care centers and group homes that had been criticized as being riddled with incompetence and fraud.54–56 The state’s Office of Mental Health had TABLE 1. Mental healthcare problems in Louisiana prior to 2005 hurricanes Low per-capita spending on mental healthcare Little utilization of health information technologies/electronic medical records in mental healthcare High rates of illicit substance use in adults High rates of serious mental illness in adults High rate of household poverty Findings of widespread incompetence and fraud in community mental health system Recurrent monetary reductions in state’s mental health budget also endured deep budget cuts in preceding years, resulting in reductions in residential treatment, substance abuse treatment, and inpatient mental healthcare.57 In his testimony before the US Senate Governmental Affairs Subcommittee on Disaster Recovery, Louisiana’s Disaster Mental Health Operations Director Anthony Speier, testified that the rebuilding of Louisiana’s mental health system must correct inequities that existed prior to Hurricanes Katrina and Rita, as well as address pressing issues that have arisen since the storms.60 These preexisting mental health issues in Louisiana are summarized in Table 1. Another issue has frequently arisen in the discussion of the treatment of the seriously mentally ill after Katrina. Many mental health professionals found it impossible to receive funding for services through the main federal funding mechanism for mental health services after a disaster, the Robert T. Stafford Disaster Relief and Emergency Assistance Act (Stafford Act). Indeed, a recent report from the General Accounting Office has confirmed and documented the inflexibility of the Stafford Act.55 The Stafford Act restricts funding to short-term crisis counseling efforts designed to provide emotional support and mitigate additional stress after a disaster. The Stafford Act has no provision that allows it to fund services, such as psychiatric treatment or prescription drugs, should these services not be available after a disaster.56 Furthermore, funded crisis services rely on “paraprofessionals” who often have not had any formal training in mental healthcare, disaster management, or crisis counseling. Certainly, these crisis counseling services do have value. Louisiana’s program (Louisiana Spirit) has conducted over 2,500,000 contacts with hurricane survivors, reaching almost 250,000 people in the state.48 However, many other types of services for populations who were known to be vulnerable to stress due to their preexisting psychiatric issues were not funded because the services were determined to be a continuation of preestablished care and not simply “crisis counseling.” Other smaller federal funding sources are not under the same restriction as the Stafford Act. In the immediate aftermath of the storms, the Administrator of SAMHSA announced that part of its two-fold response plan was to “ensure that people impacted by the hurricanes who have serious mental illnesses and addictive disorders…continue to receive ongoing treatment for their chronic problems.”57 Indeed, SAMHSA even took steps to provide [JULY] Psychiatry 2008 37

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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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