By most measures Hurricane Katrina was one of the deadliest, costliest, and most devastating natural disasters in United States history. Nearly 90,000 miles of our nation’s Gulf Coast was affected by the storm in August 2005. Left in its wake was flooding and the destruction of countless homes, businesses, and much of the region’s other basic infrastructure (US House of Representatives 2006). However, Hurricane Katrina destroyed more than just the buildings and streets of communities: the catastrophe wreaked havoc on the mental health of many individuals in the path of the storm. It is a consistent research finding that high levels of depression and post traumatic stress disorder (PTSD) are present in populations affected by large natural disasters such as hurricanes (Norris et al. 2002). The extensive body of research on the mental health impact of Hurricane Katrina makes it clear that the 2005 storm is not an exception to this phenomenon.
Records were lost, clinics ruined, and personnel diminished. This leads to the big question on the minds of disaster mental health policy-makers: who pays to rebuild the mental health community?
The overall disaster response structure following Katrina has been heavily criticized because of its inadequacies, and the mental health community specifically has not been immune to these criticisms. This paper seeks to articulate some of these shortcomings in the response to the problem of disaster mental health and offer some policy lessons that may be learned from Katrina. First, the nature of the problems associated with disaster mental health and the unmet needs of those affected by Katrina will be discussed. This will be followed by a review of the empirical research on the prevalence of mental illness and the inadequacy of treatment following the storm. Potential policy alternatives – and the available research on the efficacy of such reforms – will then be examined, followed by concluding recommendations for future disasters. Although there may never be another event identical to Hurricane Katrina, the lessons it provides are essential to the improvement of disaster mental health response policy in the future.
NATURE OF THE PROBLEM
There are several important components to the policy problem of disaster mental health following hurricanes like Katrina. The first component is an obvious one: a widespread hurricane disaster creates widespread mental health needs. The greater the number of people affected by a single event, the greater amount of resources that are required to evaluate and treat adequately those afflicted with mental disorders. Compounding this is the finding that psychological problems following catastrophic disasters persist long past the crisis period when services are most available. Also, research suggests that disasters may begin a “spiral of losses,” where individuals with initial losses become more vulnerable to subsequent losses (Norris et al. 2002). PTSD, the most studied and reported disorder following disasters, is associated with dysfunction, development of comorbidity (the presence of two or more disorders simultaneously or sequentially), and suicidality – with even low levels of PTSD symptoms (Kessler et al. 1995). Thus, not only do disasters like Hurricane Katrina have a strong relationship with disorders, but such disorders also tend to persist and are associated with other serious mental health consequences.
The overwhelming nature of mental health problems following disasters leads to the second component in the policy problem: the insufficient or even lack of treatment for those who need it after times of crisis. Wang et al. (2008) suggest that there were two types of unmet treatment needs following Katrina: the disruption of care for those with preexisting disorders and the failure to initiate treatment for those experiencing new disorders as a result of the storm. The authors hypothesize that disruption of treatment may have been caused by competing financial obligations or the loss of care providers. For those with new disorders, failure to seek treatment could have been related to low perceived need for treatment, desire to avoid stigma, and fear of experiencing bad memories. Other research suggests that a lack of awareness of stress-related psychopathology and the availability of treatment options led to unmet treatment needs after Katrina (DeSalvo et al. 2008). Regardless, barriers – whether financial, structural, or attitudinal – served as an obstacle between victims and treatment, and it is these barriers that disaster mental health policy should seek to eliminate (Wang et al. 2007).
According to one study, an estimated 49.1% of [New Orleans residents] had a 30-day prevalence of any DSMIV anxiety-mood disorder, compared to the 26.4% of the remainder of the sample from surrounding areas.
A final related component of the policy problem involves the resources and funding necessary to meet the mental health needs of disaster victims. The destruction by Hurricane Katrina created an incredible logistical dilemma for the mental health community, as much of the infrastructure needed for treatment was inaccessible or unusable. Records were lost, clinics ruined, and personnel diminished. This leads to the big question on the minds of disaster mental health policy-makers: who pays to rebuild the mental health community? Many mental health professionals themselves left the region, and a large percentage have yet to return. This deficiency of professionals can be traced, in part, to the restrictions on paying local clinicians by the Robert T. Stafford Disaster Relief and Emergency Act, the main federal funding mechanism for post disaster mental health services (Lamberg 2008). Only short-term crisis counseling and support is paid for by the Stafford Act, leaving the bill for long-term treatment and medication with the patients, if they can even afford to continue treatment. The financial component of disaster mental health policy is one that cannot be ignored in the quest to generate better policies for the future.
These are the three central issues revolving around mental health that must be confronted following any large disaster such as Hurricane Katrina. In the United States, an intergovernmental disaster response structure is largely responsible for addressing these problems. This structure is, at its most fundamental level, a partnership between the levels of government. As the capacity of local governments to respond to a disaster is reached, the state governments may step in to meet demands. If this is not enough, the states can appeal to the national government for aid. During the aftermath of Katrina, localities like the city of New Orleans in states like Louisiana partnered with the national government, particularly the Federal Emergency Management Agency (FEMA) within the Department of Homeland Security (DHS), to form the backbone of the disaster response structure. The complexities of the intergovernmental disaster response structure, however, make it difficult for a short article to examine fully the many layers of systemic problems. The discussion here is more about how mental health is treated following disasters and who, at the ground level, is doing the treating rather than which governmental agency is overseeing it.1 What will be presented is merely a step in the direction of improved mental health disaster response. The problems outlined above are real, and it is the responsibility of some entity—be it the national government, the state and local governments, or nongovernmental actors—to better address these problems.
EVIDENCE: PREVALENCE, FREQUENCY, AND SEVERITY OF DISORDERS
Hurricane Katrina has served as the focus of much scholarly research in a varying array of fields, including public administration, urban affairs and planning, environmental studies, civil engineering, political science and others.2 Mental health researchers, too, have been studying the effects of the storm since its immediate aftermath. The levels of PTSD and other disorders following Katrina have been found to be consistent with, if not higher than, the levels of disorder following similar disasters. In fact, the doubling of the estimated prevalence of serious mental illness and mild-moderate mental illness following Hurricane Katrina is comparable to findings from other major disasters (Kessler et al. 2006). Since the bulk of the research on mental health outcomes after Katrina has examined the greater New Orleans metropolitan area, the scope of this paper will be similarly focused. Residents of the New Orleans area appear to have suffered an exceedingly higher level of disorder prevalence than normally seen following similar disasters. According to one study, an estimated 49.1% of these individuals had a 30-day prevalence of any DSM-IV anxiety-mood disorder3, compared to the 26.4% of the remainder of the sample from surrounding areas (Galea et al. 2007). The estimated levels of disorder in New Orleans were much higher than previous samples after comparable natural disasters, whereas the remainder of the sample was more consistent with the findings of previous studies.
Other characteristics of the storm make Hurricane Katrina a distinctive case study for mental health researchers and policymakers. The sociodemographic composition of the areas exposed to the storm’s rage – including large minority and lowincome populations – played a major role in the media coverage of the storm aftermath. Minority and low-income populations are known to be at an increased risk for distress and disorder following exposure to disasters (Coker et al. 2006). The limited resources after Katrina, combined with the characteristics of these disadvantaged groups, may have caused some individuals to be at extremely high risk for PTSD and other disorders (Ibid). However, the observation that exposure to hurricane-related stressors – loss of property, physical injury, etc. – was widespread and comparable across balanced sociodemographic subsamples indicates that the impact of the hurricane was not simply concentrated in any particular portion of the population (Galea et al. 2007). The hurricane struck blindly, exposing various segments of society to these stressors, with many contextual factors contributing to the severity of the mental health outcomes of individuals. Perhaps the most intriguing – and disconcerting – finding related to disorder prevalence is that post-Katrina mental disorder increased significantly during the two years following the disaster. This was an unexpected discovery, as other disaster studies show that prevalence declines following catastrophic events (Kessler et al. 2008).
It is clear that mental disorder was widespread in populations affected by Hurricane Katrina. But how well did the system deliver treatment? The research on this question is equally as clear: few Katrina survivors with mental disorders received adequate treatment. A study of perhaps the best sample of Katrina survivors done by Wang et al. (2007) found that 31% of respondents had evidence of a mood or anxiety disorder at the time of the interview conducted five to seven months after landfall. Of this subset, only 32% had used any mental health services since the disaster. 60% of those who had used services had already stopped using them. The general medical sector was primarily responsible for treatment, with pharmacotherapy the treatment of choice, and most treatments were of low intensity and frequency. A follow-up study by Wang et al. (2008) found that of the segment of the population that had used mental health services before Katrina, 22.9% saw a reduction or termination of treatment following the storm. Also found was that, of those with new-onset disorders after Katrina, only 18.5% received some form of treatment for emotional problems. It is a well-documented problem that not everyone who needed mental health treatment after Hurricane Katrina was receiving it.
The lack of available treatment options may be explained by a number of factors, most of them logistical and financial. As the storm displaced an estimated 2.5 million people, mental health professionals were displaced as well. In July 2005, shortly before the storm, 347 adult and child psychiatrists were practicing in the New Orleans metropolitan area. Nearly three years post-Katrina only 220 psychiatrists were practicing in the area, a mere 63% of the previous number (Lamberg 2008). During the immediate aftermath of the disaster, the Substance Abuse and Mental Health Services Administration (SAMHSA) funded the Katrina Assistance Project, which helped bring in more than 1,200 licensed mental health professionals to the areas most affected by the storm. However, the program ended on June 30, 2006, and most of the volunteers left the region soon after. The primary reason for the cessation of this mental health program and others was that federal funding through the Stafford Act of 1974 ended. The Act ensures funds for SAMHSA only for crisis management and not for continuing treatment (Weisler et al. 2006). Simply put, the emergency resources for Hurricane Katrina dried up, leaving a substantial void of mental health professionals that has yet to recover to pre-Katrina levels.
It has been demonstrated that brief, targeted, early interventions for disaster victims may be beneficial to a patient’s mental health concerning disorders like PTSD. Recognizing this, some propose to better educate disaster victims about mental health so that those who need treatment are better identified by friends and family.
Hurricane Katrina showed the world that there is plenty of room for improvement in disaster mental health policy in the United States. There are a plethora of problems that hurricane disasters pose in terms of mental health, and there are thus an equal number of areas to reform policy. Three central questions that disaster mental health policy revolves around include: How are we treating disaster victims with mental health problems? Who is doing the treatment? And how is the treatment being paid for? Many policy reforms addressing these questions have been proposed. Illustrative proposals for each question will be reviewed here.
The first policy area involves how treatment is delivered to victims of disasters like Hurricane Katrina. It is generally found that positive mental health outcomes are associated with early treatment interventions following disasters (Norris et al. 2002). Based on this idea comes the push for mental health education of at-risk populations immediately following disasters. Coker and colleagues (2006) described such efforts after survivors were evacuated from the Gulf Coast to the Houston, Texas area. A behavioral health triage program was developed to educate evacuees about PTSD and depression so that friends and families expressing such symptoms could be more easily recognized and referred to treatment. Educating the public about the consequences of disaster-related stress on one’s mental health may help ameliorate attitudinal barriers preventing individuals from getting treatment when it is needed. Others have proposed similar programs designed to help inform citizens of and seek treatment for common disaster mental health problems.
The second policy area asks: who is treating the mental health victims following disasters? As described above, Hurricane Katrina drove local mental health professionals from the affected area, many never to return. Thus, much of the burden for treatment was placed upon the shoulders of thousands of outside volunteers who descended upon the region only temporarily. Although these transplant volunteers appeared to be helpful in the recovery of the Gulf Coast, some researchers believe that a lack of local consciousness may have hindered care. Thus, there is a reform proposal for “culturally competent care,” where local professionals’ expertise in local language, socioeconomic class differences, and beliefs is employed to benefit treatment (Dass-Brailsford 2008). One study similarly proposed an increased hiring of minority professionals so that knowledge of discrimination, racism, and restricted access could improve treatment of minority victims of Katrina (Madrid and Grant 2008). Improved cultural consciousness of the population affected by disaster may help encourage the seeking of treatment and potentially improve the treatment itself. This goal could be achieved by both using local professionals and educating local volunteers about the region’s culture. As prominent Louisiana mental health official Harold Ginzburg explained in an interview, “Locals would have done a better job. We know our community resources, our culture, and our patients” (Lamberg 2008).
Finally, there is the financing component of disaster mental health, perhaps the most prominent question in the minds of policy makers. The primary federal funding mechanism for disaster response is the aforementioned Stafford Act. Many argue that a major shortcoming of the Stafford Act is that it stipulates that funds given to the states may only be used for crisis management. This has a tremendous affect on mental health treatment, as initial treatment for disaster victims is often cut short and money for continuing treatment is unavailable. Mental health programs that receive funding through the Stafford Act struggle to exist following the termination of federal dollars. That is why some propose extending funding from the Stafford Act to the states so that they can have the necessary financial flexibility to use funds for continuing treatment beyond the immediate crisis (Weisler et al. 2006). As financial barriers were a major reason why individuals did not seek treatment after Katrina, these scholars believe that this extended funding would allow many more people the access to the treatment they need.
EFFICACY OF ALTERNATIVES
It has been demonstrated that brief, targeted, early interventions for disaster victims may be beneficial to a patient’s mental health concerning disorders like PTSD (National Center for PTSD). Recognizing this, some propose to better educate disaster victims about mental health so that those who need treatment are better identified by friends and family. However, systematic studies on the education of victims on disaster mental health consequences and effects on delivery of treatment are lacking. There is some evidence of the success of this policy from the observations of Coker et al. (2006) following Hurricane Katrina in the Houston area, the place to which much of the displaced Gulf Coast population was evacuated. A mental health triage in Houston, in addition to helping treat disorders, was used to educate victims on identifying PTSD victims. Clients were identified faster and then were better linked to appropriate mental health specialists. This qualitative support helps to show how mental health education can benefit treatment following disasters like Hurricane Katrina. SAMHSA has also begun a hurricane mental health awareness campaign featuring public service announcements to generate attention to the issue (http://mentalhealth.samhsa.gov/disasterrelief/psa.aspx). However, it is unclear how effective the television and radio announcements will be in helping the problem of mental health in future disasters. Again, there is little systematic, quantitative evidence on this matter.
The benefits of using local professionals and expertise are twofold. First, evidence suggests that cultural consciousnessis beneficial to patients during treatment. Second, and more practically, encouraging local professionals to return to evacuated areas helps to revitalize the mental health community in the region and helps pave a better road to recovery.
For “culturally competent care” policy reforms, it too is difficult to quantify the consequence of cultural awareness on the efficacy of treatment. However, it is evident that many disaster mental health professionals and crisis management experts advocate a basic understanding of the local community. In one study of 46 international disaster experts, a clear consensus was found in favor of developing an understanding of the sociocultural contexts before commencement of intervention (Weiss et al. 2003). The recruitment of local relief workers and experts following disasters was recognized as valuable to disaster recovery. The experts also expressed concern for the lack of experience in local settings, and the complications it may have in restoring the viability of the local mental health institutions. The available qualitative evidence is very much in support of the cultural consciousness policy reform and the use of local expertise in disaster mental health relief.
Financial barriers served as obstacles to many people seeking mental health treatment after Katrina, and for those who did seek treatment, many stopped once treatment became unaffordable (Wang et al. 2008). Mental health treatment is a very expensive endeavor, especially for the many low-income victims affected by Katrina. It is a well-researched finding that some – though not all – disaster victims with PTSD symptoms benefit greatly from ongoing counseling and treatment (National Center for PTSD). Although it is impossible to test statistically the efficacy of expanded federal funding through the Stafford Act without actually implementing it, other evidence suggests that the effect on mental health treatment for victims would be favorable. Making long-term treatment affordable to populations affected by storms like Katrina allows those who do benefit from such treatment but could not otherwise afford it to undergo complete treatment regimens. This would help lead to more favorable mental health outcomes for the region overall.
In the realm of mental health policy, disaster mental health is a relatively new and rapidly evolving field. Each new unfortunate disaster sheds light on shortcomings of current disaster mental health policy, and the only real way to test new policy measures is to employ them in the field following disasters. In the aftermath of a catastrophe like Hurricane Katrina, it is tremendously difficult to study systematically the efficacy of such policy alternatives. Representative samples are difficult to obtain, variables are tough to measure accurately, and funding is not amply available. However, more research must be done. Studies that help identify those most vulnerable to mental health consequences following disasters would help guide professionals in determining who to target during treatment. Testing which methods of victim education on mental health are most effective could improve the timeliness of treatment after disasters. Research on how to get local mental health professionals to return to devastated regions and use their cultural expertise during treatment can show how to revitalize a deficit of professionals.
With that said, there is already enough evidence to implement or continue to implement the three specific policy proposals presented earlier. Each would be a cost-effective strategy to improve the current model of disaster mental health policy. Victim education to help friends and family identify at-risk individuals is a basic preventative measure that could spare many more negative outcomes in the long run. By being able to identify more quickly those with disaster-related symptoms, early intervention would reduce the effects of severe disorder prevalence in the population and reduce the stress on mental health resources in the future. The benefits of using local professionals and expertise are twofold. First, evidence suggests that cultural consciousness is beneficial to patients during treatment. Second, and more practically, encouraging local professionals to return to evacuated areas helps to revitalize the mental health community in the region and helps pave a better road to recovery. The extension of Stafford Act federal funding to continuing mental health treatment, although perhaps the most difficult policy change to impose of the three, is needed to help eliminate the financial barriers standing between victims and the adequate long-term treatment they need. After the immediate response to disasters like Katrina, the funding focus of the federal government is understandably rebuilding the physical infrastructure of the ravaged region. Not to be forgotten, however, is the psychological infrastructure that needs rebuilding as well. It is important for lawmakers to recognize that repairing the damaged psyche of a disaster-torn region is of great importance to that region’s recovery, and that investing in extended funding would provide significant, long-term public health benefits.
There is still much to be learned about mental health following disasters, and research must be continued to widen our understanding of the effects of events like Hurricane Katrina on a community’s mental well-being. The mental health problems associated with disasters are plenty and these are problems that must be tackled with informed public policy. Implementing wise policy measures like those proposed in this paper are solid steps in improving the response to mental health issues in the aftermath of disasters. Future disasters, although maybe not on Katrina’s scale, are inevitable. However, the shortcomings of the system exposed by the storm can be corrected so that the mental health needs of disaster victims in future events may be better served.
1 The focus on the federal Stafford Act (Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. §§ 5121-5206) is not meant as an advocacy for prolonged involvement of the national government post-disaster beyond the funding it provides. Strong arguments can be made in favor of state and local governments taking the lead in implementation of extended disaster relief. Large scale disasters like Katrina that affect many states inevitably require federal funds for the jurisdictions affected, though. Since the Stafford Act is the primary source of these funds, it makes for an easy target for reform in disaster response financing for the purposes of this article.
2 For a variety of perspectives see, for example, John C. Morris, “Whither FEMA? Hurricane Katrina and FEMA’s Response to the Gulf Coast,” Public Works Management & Policy 10 (2006): 284–294.; Saundra K. Schneider, “Administrative Breakdowns in the Governmental Response to Hurricane Katrina,” Public Administration Review 65 (2005): 515–516.; Louise K. Comfort, “ Cities at Risk: Hurricane Katrina and the Drowning of New Orleans,” Urban Affairs Review 41 (2006) 501-516.; Jeffrey Q. Chambers, Jeremy I. Fisher, Hongcheng Zeng, Elise L. Chapman, David B. Baker, and George C. Hurtt, “Hurricane Katrina’s Carbon Footprint on U.S. Gulf Coast Forests” Science 318 (2007)1107.; and Ian N. Robertson, H. Ronald Riggs, Solomon C. S. Yim, and Yin Lu Young, “Lessons from Hurricane Katrina Storm Surge on Bridges and Buildings” in Journal of Waterway, Port, Coastal, and Ocean Engineering 133 (2007) 463- 483.
3 The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSMIV) is the text containing all disorders recognized by the American Psychiatric Association (APA), and is the authority on disorders in the mental health field. Anxiety-mood disorders include PTSD, acute stress disorder, and other panic related syndromes (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000).
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