A few months ago, I took a tour of the physical destruction in New Orleans, but I ended up feeling more disturbed by the persistent sense of despair. Our driver and guide, Joe Gendusa, a 67-year-old native, zigzagged through the abandoned buildings, fighting off tears as he spoke. "My parents' graves were under seven feet of water," he said. "They never rebuilt the cemetery."
A nurse I spoke with later, Diane Graham, who has been treating patients in New Orleans since 1978, said there are thousands of people like Mr. Gendusa in the city, many of whom have sunk into clinical depression or worse, and yet the city lacks the services to handle their psychiatric needs.
New Orleans lost most of its mental health infrastructure in the storm, as clinics and hospitals were destroyed and health care professionals relocated. Pre-Katrina New Orleans had 225 working psychiatrists; according to the Orleans Parish Medical Society, 17 are left. Last fall, the Louisiana Department of Health and Human Services received $80 million in federal aid for behavioral health. But facilities have not been rebuilt, and basic services have not been restored. Instead, a mental health crisis has taken shape.
The state's Office of Mental Health was able to serve only about 40,000 people in all of Louisiana the year before Katrina. Immediately after the storm, health officials estimated that 250,000 people needed services in areas affected by the storm - a need that has not diminished. According to researchers at Louisiana State University, there has been a dramatic increase in depression, anxiety and post-traumatic stress. The Society for Research in Child Development found that 40 percent of children who have returned to school suffer such psychological problems as sadness, clinginess, difficulty concentrating, irritability and risk-taking behavior.
Yet the city's two major hospitals, at LSU and Tulane, lost their in-patient psych units in the storm. The facility run by LSU was destroyed. The DePaul Tulane Behavioral Health Center had a 110-bed psych hospital that was permanently damaged. So far, LSU has been able to reopen a 20-bed emergency psych unit (only five are in use, for detox), and it's slated to open a 33-bed acute adult unit. The Office of Mental Health reports that of 578 in-patient psych beds in New Orleans at the time of the storm, only 236 remain. The city's major remaining in-patient facility is the state-run New Orleans Adolescent Hospital, where Diane Graham works; its 45 beds now must be used for adults as well as children. One community facility, the Enhanced Health Treatment Center, has reopened in New Orleans East - without a penny in federal funding. In the suburbs, Jefferson Parish takes some overflow, but regional hospitals accept few patients, as they are pressed to meet local needs.
Dr. Jack Finn, president of the Metropolitan Hospital Council of New Orleans, says crime is on the rise in part because "there is nothing to do with psychotic patients except to give them a prescription and put them right back out on the streets." The state has funded a few ambulatory care clinics that provide psychiatric services, but they are not equipped for emergencies. Dr. Finn calls this "building the spokes of a wheel without the hub."
What has happened to all the federal money? Dr. Fred Cerise, Louisiana's secretary of health, says half of the $80 million is just now being distributed. The state used $55 million of these funds for mental health crisis services and $50 million from the Federal Emergency Management Agency to create Louisiana Spirit, which runs a crisis hot line and provides door-to-door services. Kathryn Power, mental health director for the U.S. Department of Health and Human Services, has praised the program, but Dr. Kathleen Crapanzano, a top Louisiana government health official, said it hasn't played a significant role. This year, HHS has granted Louisiana $50 million to attract health care workers, but many positions remain unfilled, largely because of the paucity of housing.
Two years after Hurricane Katrina, a state of psychiatric emergency persists. Federal, state and local health officials must come up with short-term interventions, including temporary facilities in the heart of the city. Concrete incentives, such as higher pay and upscale housing, should be used to attract mental health providers. Approval for hospital and clinic construction must be streamlined.
In May, New Orleans Mayor Ray Nagin finally wrote a letter to Gov. Kathleen Babineaux Blanco demanding that she "fix" the mental health crisis; Ms. Blanco responded with a list of public parties that share responsibility for the problem. She needs to be pressured to hold all of those parties accountable.
The American Psychiatric Association is hosting a conference in New Orleans in October whose theme is "RECOVERY: Patients, Families, Communities." Consciousness-raising is important, but it would be far more beneficial for the APA to pressure residency programs to send in rotating doctors.
A lack of proper psychiatric care interferes with all medical services. Patients under great stress are not only difficult to manage but also develop more physical illnesses. New Orleans' psyche has been badly damaged. Rebuilding it is one of the city's most important reconstruction projects.
Dr. Marc Siegel is a practicing internist, an associate professor of medicine and a fellow in the Master Scholars Society at the New York University School of Medicine.