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Psyched Out

After Katrina, New Orleans has more stressed-out people and fewer psychiatrists -- and (big surprise) federal emergency 'relief' doesn't cover most mentally ill patients.

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All Mary knew was that she wanted to be home. If she could somehow get back to her comfortable brick ranch house in her St. Bernard subdivision, where everyone knew everyone else, she would feel safe again. As she had done on so many other nights, she would walk into her bedroom, pull down the covers, climb into her warm, cozy bed and fall into a long, forgetful sleep.

The next day was Valentine's Day, so her dream seemed fitting. She needed to be home -- where her heart was.

When they found Mary, she was lying face down in a cold, moldy bed in her flooded-out home. She had made it back to her empty and now soulless neighborhood and gone into her house, which was still littered with her rotting possessions. Before she curled up on the bed, she swallowed more than 200 pills.

Mary's family had been searching for her for 13 hours when her nephew discovered her in the bedroom. Because it was so cold the night before -- Feb. 13, 2006 -- she had become hypothermic and the pills hadn't completely entered her bloodstream. She was alive, barely, and a St. Bernard paramedic picked her up and carried the now-blue Mary to the ambulance. Because there were and are no available hospitals in St. Bernard Parish, the paramedics drove Mary to Touro Infirmary in New Orleans, where hospital personnel stabilized her.

Mary (not her real name) is 37 years old and has bipolar disorder, which is characterized by periods of deep depression accompanied by manic episodes. She takes various prescription pills daily, but with so many drug interactions, there is a lot of room for error. A psychiatrist must monitor Mary's medications to ensure they're working effectively. When Katrina hit, Mary evacuated to Texas and lost touch with her psychiatrist. While the Red Cross was able to fill her prescriptions, the agency was unable to provide Mary a psychiatrist. She was on her own, and Mary doesn't always do well on her own.

She is now under the care of a psychiatrist, Dr. Erich Conrad, who sees her every two weeks. She's lucky -- unlike many chronically mentally ill patients living in the metro area, people "who have fallen through the cracks" as Conrad puts it. Not until they've endangered themselves or others and have been picked up by the police are they diagnosed and treated.

Even then, there's little room for the mentally ill in Orleans Parish these days. There are hardly any available beds, few psychiatrists, little staffing, and most times police have to drive patients across parish lines during an emergency.

The chronically mentally ill are not the only ones who are suffering from inadequate treatment opportunities. People who never had mental-health issues before Katrina are reaching out for help. With a higher percentage of the population requiring some mental health-care assistance, caseloads at open outpatient clinics have doubled, counselors are working 60 to 70 hours a week, and even some in the mental health-care field admit the quality of care is suffering.

New Orleans lost most of its psychiatrists to Katrina. According to an April 2006 report from the state Department of Health and Hospitals (DHH), only 22 psychiatrists, down from a pre-storm number of 196, were still working in New Orleans less than a year ago. Some of those who left were laid off by Louisiana State University's Health Sciences Center (LSUHSC), which staffed Charity Hospital. Dr. Howard Osofsky, chair of LSUHSC's department of psychiatry, says there was little the university could do about the situation.

"With the loss of federal funding, we couldn't meet base salaries. There was no choice. We could only preserve essential employees."

At the same time that LSUHSC was laying off people, the federal government was sending in mental-health workers. The Stafford Disaster Relief and Emergency Assistance Act provides funds during natural disasters, but in the case of mental-health care, the money can only be used for immediate crisis counseling and not for substance abuse, mental illness or any pre-existing mental-health condition. In other words, there were no additional funds for chronically mentally ill people evacuated to other cities. If they stayed behind or were lucky enough to make it back to the city, they could be doubly impacted by the storm: Their psychiatrist might no longer be in town, and federal emergency funding would not pay for their pre-existing conditions.

Osofsky says LSUHSC has been able to rehire some of its staff since the DHH report, which has not updated the April 2006 findings, but he adds that recruiting new psychiatrists is difficult. LSUHSC currently has 19 faculty psychiatrists who are back to their pre-Katrina number of medical residents in psychiatry. What the students don't have, however, is a main teaching hospital, which Charity provided. What the public no longer has is a good supply of in-patient psychiatric beds.

When Hurricane Katrina shut the doors at Charity Hospital, Orleans Parish lost nearly 100 psychiatric beds. Additionally, since the storm, six more hospitals closed or are no longer offering psychiatric beds. Orleans Parish now has only three hospitals -- New Orleans Adolescent Hospital, Community Care and Psychiatric Pavillion New Orleans -- offering in-patient psychiatric accommodations. And the latter has only geriatric psychiatric beds.

Among those hospitals, there are presently 82 psychiatric beds in Orleans Parish. Four beds are reserved for children, 10 for adolescents, 32 for adults, and 36 for people more than 60 years old. Before Hurricane Katrina, there were 422 psychiatric beds, with 214 beds reserved for adults. Even with the dramatic post-Katrina population drop, that's still more than an 80 percent decrease in psychiatric beds.

Charity's closure means more than just fewer psychiatric beds in Orleans Parish. Before the storm, New Orleans Police Department (NOPD) officers took people suspected of being mentally ill straight to Charity, which had an emergency room plus a Crisis Intervention Unit (CIU) with observational beds for 24-hour psychiatric evaluation. Dr. James Arey, a psychologist and commander of NOPD's crisis negotiation team, which oversees how NOPD handles psychiatric cases, says state law requires police to bring suspected mental patients to an emergency room in case the patient is actually physically ill. For instance, a diabetic with low blood sugar might display symptoms of mental illness.

"The big value was that we would bring them to Charity, where a nurse would screen them for physical illness," Arey says. "If they didn't have a physical ailment, they would go to the separate CIU room and up to the third floor for observation."

Within 24 hours, Charity's staff would know whether the person needed in-patient psychiatric services or could be referred to outpatient services. Osofsky says the system worked well, particularly if the mentally ill person had committed a crime.

"The safety valve was Charity Hospital," says Osofsky. "If there was any question in the police's mind, even after they got to central lockup, they could be diverted to Charity Hospital for evaluation. This doesn't exist anymore."

Arey says NOPD officers are trained to recognize chronically mentally ill people and the most effective ways to deal with them. Often, these people require structure and care, not a prison cell, and it is up to the police to get them to a hospital. When Charity Hospital was open, Arey says, officers were able to take a suspected mentally ill patient to the emergency room and leave the patient there knowing they would be stabilized. The process took about 15 minutes.

Today, when NOPD picks up someone officers suspect is mentally ill, they call ahead to an emergency room and let them know they're en route. Without Charity, Arey says, all local emergency rooms are in a seven-hospital rotation. Three of the hospitals -- Touro Infirmary, Tulane University Hospital, and University Hospital -- are in Orleans Parish while the other four -- Ochsner Medical Center, Ochsner Medical Center West Bank (former Meadowcrest Hospital), East Jefferson General Hospital and West Jefferson Medical Center -- are in Jefferson Parish. Sometimes officers have to drive more than half an hour just to get to the hospital. When they arrive, they don't usually receive a rousing welcome.

"About 100 percent of the hospitals say, 'Don't bring them here because it will be a 10-12 hour wait.' That's their way of not refusing the patient [legally they are required to accept any emergency patient], but they're trying to make us go someplace else," Arey says. "We take them there anyway."

Arey adds that even though private hospitals often don't want cops and their suspects in the first place, once they arrive, the hospitals want the cops to stay.

"They would like us to stay hours and hours, but we try to leave within an hour," Arey says. "Unfortunately, these hospitals haven't been able to ... increase their nursing staff, hospital police staff, and find secure places for these patients."

Before Katrina, NOPD averaged 330 psychiatric cases per month, Arey says. NOPD now fields around 180 of these calls per month. Even with the uncertainty surrounding current population figures (experts have pegged it at anywhere from 190,000 to 250,000), the number of cases per capita has increased -- perhaps only slightly, but possibly dramatically. Either way, police are spending much more time on each incident because of the drive time and having to stay longer at the hospitals.

Arey says the solution is opening a CIU in the LSU-operated University Hospital, which currently has no psychiatric in-patient beds. Arey says police could legally bring people they suspect are mentally ill to University Hospital because it recently opened an emergency room. Dr. Kathleen Crapanzano, director of Louisiana's Office of Mental Health, which oversees in-patient services across the state, agrees.

"When people come in, you want to make sure they're medically stable and cleared," Crapanzano says. "We've had talks with LSU to have it associated with University Hospital, and they've agreed to it."

That's news to Charles Zewe, vice president of communications and external affairs for LSU Healthcare Services Division, which supervises the state's public hospital system, including University Hospital. When contacted regarding University Hospital opening a CIU, Zewe said it was the first he had heard of it.

"If they have money for a CIU, that's wonderful," Zewe says.

LSU Healthcare Services Division plans to fill the gap left by Charity's closing by leasing part of the former DePaul Hospital from Children's Hospital, Zewe says. DePaul had in-patient psychiatric services prior to Hurricane Katrina -- but no emergency room. The new hospital would house 33 acute-care beds and 10 crisis-intervention beds, but without emergency room services there, police would still have to rely on the seven-hospital rotation to have arrested subjects evaluated.

"This doesn't help us at all," Arey says.

Zewe's answer is that the DePaul Hospital won't be opened until at least July and that adjustments can still be made.

"That's not a big deal," he says. "Everyone is pleased so far. We're confident we'll be able to work this out, but this is in the beginning stages."

After police escorting a mentally ill patient are able to leave a hospital emergency room, the patient becomes the hospital's responsibility. If the patient needs a psychiatric bed, the hospital must either provide one or find one somewhere in the state, which has far too few to go around. That means emergency room personnel often must make repeated calls seeking a bed for a psychiatric patient. Crapanzano says federal law mandates that if a hospital has an acute psychiatric bed open, the bed must be made available to any patient within the state.

"For acute beds, the need is immediate, so if we [Office of Mental Health] don't have a bed, the emergency rooms call the next place," Crapanzano says. "They might call us three days in a row until they find a bed."

When a bed is found, it could be in Mandeville, or it could be as far away as Alexandria. Availability, not proximity, is the relevant criterion, and Crapanzano says this process works both ways.

"We still get reports of people from Lake Charles, Lafayette and Alexandria ending up in psychiatric beds in the New Orleans area."

Transporting a psychiatric patient from an emergency room to an open bed hundreds of miles away is expensive, but the larger price comes at the expense of the patient's treatment plan. Osofsky says that when patients are transferred so far away, they lose their family connections.

"People need to be treated in their own community," Osofsky says. "It's especially critical for young people. You have to have the family working with them. If they're 100-to-150 miles away, the family won't be working with them, and the likelihood of relapse is considerably greater."

When Mary attempted suicide and was taken to Touro Infirmary, the hospital was able to give her a bed, but just until it located a psychiatric bed. Touro found a bed 10 days later, and Mary was transferred to a hospital in Crowley, 126 miles from her family's temporary home in Tickfaw. Mary doesn't remember much about the hospital except that "it was a bad experience and scary." She hardly saw her husband.

Crapanzano reports that the shortage of in-patient psychiatric beds isn't new to the state, but it is to New Orleans. She attributes much of the problem to insufficient staffing -- nurses, aides, doctors and social workers -- and the market forces relating to these positions. Sometimes, sincere efforts to solve the in-patient bed crisis can backfire.

"Social workers are a tremendous issue -- in-patient and outpatient. We got all this federal money from social services block grants to open up all of these crisis services across the state to try to decrease the need for beds," Crapanzano says. "We used that money to contract with local providers [in this case, Metropolitan Human Services District, which is in charge of the state's outpatient services in Orleans Parish] to get these services. Well, they can pay more than us ... so that's a prime job for social workers. There's just so many to go around."

Sometimes, patients have to work things out for themselves.

Mary realized she was becoming suicidal again in December. The stress of daily post-Katrina living was impossible, and her insurance company wasn't covering all of her medication. She knew she needed the intensive treatment that only in-patient services can provide, but she wanted to stay close to her husband -- and she didn't want to risk being sent to an unknown hospital. For three days, she continuously called local hospitals until she was able to arrange for a bed at River Oaks Hospital, a private psychiatric hospital in Harahan.

Michele Many, a licensed clinical social worker, is trying to keep people out of mental hospitals. As an instructor for LSUHSC's department of psychiatry's trauma team, she sees outpatients at New Orleans Adolescent Hospital and at other clinics as well. Even with all of her responsibilities, Many doesn't have an office and often finishes her 10- to 12-hour days writing her notes on her home computer. She almost lost her home office when the recent tornado hit her Uptown house, inflicting additional harm to her Katrina-damaged home.

"People say to me all the time 'you look so calm,'" says Many. "It's funny, but I don't always feel that way inside."

Many credits meditation techniques and the support of other trauma team members for her ability to maintain at least a superficial serenity. This must have served her well during the six months she lived on a cruise ship, where she also treated first responders residing there in the weeks immediately following Katrina. During this time, Many counseled numerous cops who said they never felt they needed counseling before the storm. Many says she's now hearing a similar refrain from the general public.

"We have a lot of people coming in who say they've never sought therapy before."

Most people now living in FEMA trailers never expected to be living in such tightly spaced quarters. Many say the trailers often cause previously minor inconveniences to escalate into major disturbances. "If there was prior marital discord, it's going through the roof because all of a sudden they're stuck in a trailer and can't get away from each other."

Adults aren't the only ones suffering in the cramped trailers. Osofsky says that recent surveys of area children indicate that 40 percent of fourth through 12th graders qualify for mental-health services. He adds that the cause of many of these issues is environmental.

"A significant percentage of kids are living without their parents or in crowded trailers," Osofsky says. "The noise levels there are so high, and they're hearing things they shouldn't hear, or seeing things they shouldn't see. These trailers weren't set up for good-size families."

So far, no study has definitively concluded that a greater percentage of the area's population is experiencing mental-health problems these days. But, says Osofsky, LSUHSC is working on such a report. The data so far indicates there is an increase. Osofsky says those preliminary results are not surprising.

"It's expectable, given the slowness of the recovery, the devastation and the economic situation," he says.

For Michele Many and the others on the LSU trauma team, the proof is in their caseload. Every social worker, psychologist and psychiatrist is taking on far more individual cases than they would have pre-Katrina, and often these additional patients are seen after the normal workday. These extra patients can include people who had a pre-existing condition prior to Hurricane Katrina, new clients and children.

For those who didn't have mental-health problems before the storm, the biggest complaint is depression. While each person has their own individual reasons for seeking therapy, Many says a majority share similar circumstances: loss of friends, family, the day-to-day frustrations of dealing with insurance companies, contractors and trying to find a home for the family. When these circumstances don't change or improve, the result can be depression.

"We're seeing an increase in depression and it's manifesting in family problems: child and parent, grandparent and parents, and parents with each other," Many observes. "One of the hallmark symptoms of depression is irritability and isolation. If you're living in a trailer, it's hard."

Another reason Many's caseload has increased is that the geographical area she covers has grown significantly. Before the storm, Many focused her efforts on Orleans Parish, but now she sees clients as far away as Laplace and St. Bernard. An associate of Many's used to make the trips to those suburban areas, but when she left for another position, that task fell to Many. She hopes at some point more social workers will be hired and she'll be able once again to concentrate on people in Orleans Parish.

As places like St. Bernard Parish repopulate, the demand for outpatient services grows accordingly. Family Services of Greater New Orleans operates an office in Chalmette and is seeing a steady flow of clients. Family Services accepts medical insurance but also bills on a sliding scale, depending on a client's financial situation. Ronald McClain, executive director of Family Services, says his organization's case-load has increased, particularly among those affected by domestic violence, depression, and general stress. Since the storm, McClain has been lucky to secure an additional 10 to 15 percent more staff.

Dr. Jerome Gibbs, the executive director of Metropolitan Human Services District (MHSD), which contracts with the state through the Office of Mental Health to provide public outpatient services, says that MHSD will soon have the same number of facilities as it did pre-Katrina -- although some of them will be housed in trailers. What he doesn't have is enough staff -- social workers, physicians, and psychologists. Gibbs adds that the loss of psychiatrists has caused many people who used to see private psychiatrists to rely on MHSD's doctors for medication now.

According to Gibbs, MHSD's purview has changed as well.

"Prior to the storm, we were confined to those only pronounced chronically mentally ill," Gibbs says. "Now we're seeing people who might have basic and first-time depression and anxiety disorders."

Gibbs agrees with Osofsky that a higher percentage of the population is experiencing problems. He believes that many people's problems were delayed, that the impact of the storm is only now hitting them. People in that situation often were so intent on getting settled again that they were able to ignore some of the obvious stressors. Now that they have their house back, there still are no neighbors, friends or community support. This forces them to confront their new and altered reality, which might require some outside assistance.

"What should be normal is not normal," Gibbs says.

The increased demand for MHSD's services is affecting the quality of care it can supply, Gibbs admits. Sometimes all MHSD can offer is medical services, writing prescriptions and checking medication levels, without talk therapy. The combination of medication and counseling does predict the best outcomes for patients requiring both types of treatment, but Gibbs admits that, sometimes, medical services are all that's available.

"It's more than nothing," Gibbs says, "but it doesn't meet the highest standard of care."

Restoring mental-health services in the city, outpatient and in-patient, is a tall order. Mental health-care workers are in short supply statewide, and New Orleans struggles to remain competitive in such a tight job market. That is particularly difficult when many of the local mental health-care jobs are state civil service positions that offer government wages. Worse yet, Osofsky says, some well-meaning short-term solutions may actually aggravate the situation.

"I'm very appreciative of some of the groups of volunteers, national experts that came in for limited amounts of time, but the real answer isn't there," Osofsky says. "The real answer is mental-health pros who will be here for the long run."

Osofsky says the area needs more long-term funding from the state's Healthcare Services Division, the Office of Mental Health, and more funds for the medical school so that, "as we recruit people, they'll be able to stay in New Orleans."

Long-term recruitment takes years, so other forms of assistance will be needed in the interim. More community out-patient centers, for example, would allow more people to get treatment before in-patient psychiatric care becomes necessary.

On the federal level, Osofsky says the Stafford Act should be amended to pay for ongoing clinical services, not just immediate crisis services.

Mary's situation is an example of how the Stafford Act can work against people with pre-existing, ongoing clinical needs. She is grateful she was able to secure an in-patient bed the last time she needed one, but she would like to avoid that in the future. Although she has had mental-health problems since she was 23 years old, she wasn't definitively diagnosed bi-polar until she was under the care of Dr. Conrad, a little more than two years ago. Conrad says that Mary's illness is difficult to manage, and her displacement probably contributed to her suicide attempt and her additional hospital stays. For someone who already has emotional issues, keeping it together during the struggling days of recovery has to be that much more difficult.

As she puffs on cigarette after cigarette, Mary explains that she's a nurse. She would like to go back to work so that she can return some of the kindness shown to her. She and her husband have started rebuilding their house, and they plan to move back within eight months. Mary knows it won't be easy, that for a while they might be the only ones living on their block, but she feels that home is where she needs to be.

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