Too few psychiatrists and mental health professionals and too little
sustainable funding continue to present barriers to care for children four
years after Hurricane Katrina washed over New Orleans, even as Louisiana
health officials close down the city's only remaining public inpatient
psychiatric hospital in a budget-cutting move.
Collectively, the events reflect the still-unsettled state of New Orleans'
mental health services.
"New Orleans is in an unprecedented mental health crisis," said
Mordecai Potash, M.D., an associate professor of clinical psychiatry in the
Department of Psychiatry and Neurology at Tulane University. "Seventy
percent of the population has returned to the city, but we have only 50
percent of the inpatient beds that we had before the storm."
Studies from the Kaiser Family Foundation and Harvard University have shown
increases both in severe mental illness that was not present before Katrina
and in psychiatric problems exacerbated by the storm and its aftermath, said
Potash in an interview.
The status of federally funded children's mental health services in the
city and in surrounding Jefferson, Orleans, Plaquemines, and St. Bernard
parishes was detailed in a report from the U.S. Government Accountability
Office (GAO) released in July.
Before Katrina, uninsured children and children from low-income families
depended largely on Charity and University hospitals for health care,
including mental health services. Charity Hospital has been closed since the
hurricane. University has reopened but lacks the combined former capacity of
the two hospitals. As a result, much health care has shifted to
community-based mental health centers or school-based health centers that
provide some mental health services. Two regional human services districts
covering the area also offer some services to children. All of these services
are at or near their capacity, said Potash.
Numerous federal agencies and programs provide support for mental health
services in the region. Medicaid and the State Children's Health Insurance
Program together cover 110,000 children in the area, and the Substance Abuse
and Mental Health Services Administration funds a number of other
The GAO survey of 18 government, social service, educational, and health
care organizations in the area found that they had problems recruiting and
retaining child psychiatrists, psychologists, and nurses. These difficulties
have grown worse since the storm because many providers who left the area did
not return. While from 2004 to 2006 the number of psychiatrists in the nation
increased by 3 percent, the number in New Orleans decreased by 21 percent.
The local organizations also pointed out to the GAO the need for reliable
funding streams and better reimbursement for services, especially for those
rendered outside traditional clinic settings. Some federal programs have
provided financial incentives for professionals to work in the New Orleans
area, but many were temporary and are due to end this year or in 2010.
Poor public transportation, the loss of personal automobiles in the flood,
competing family priorities (like housing problems and unemployment), and
stigma about accepting mental health services also create barriers for
families seeking help.
Those issues are addressed to some degree by the re-establishment of
school-based health centers, said the report. Seven centers existed before
Katrina but closed because of storm damage. However, there are now nine, and
four more are planned. Locating health centers on school campuses eases
transportation problems, and students from other schools can be driven to the
centers if needed. Parents don't need to take off work to get their children
to appointments, and including mental health services in these centers reduces
stigma by masking the type of care a child receives.
Local health officials told the GAO investigators that they could not place
a clinic in every school but would develop a system with hubs that would serve
10 feeder schools.
Limited referral services, including beds at local inpatient psychiatric
hospitals, was another barrier cited by the GAO. That factor is now
complicated by the closure in August of the New Orleans Adolescent Hospital
(NOAH). Gov. Bobby Jindal's (R) February budget proposed closing the hospital,
moving some patients across Lake Pontchartrain to the Southeast Louisiana
Hospital in Mandeville, and expanding community-based services in the
The hospital served only young people before Katrina, but housed some
adults after the storm.
Maintaining the status quo at NOAH in the face of budget shortfalls would
call for significant cuts in existing services, according to a statement by
Alan Levine, M.H.S., M.B.A., secretary of the state's Department of Health and
Hospitals, justifying the decision. The state's plan shifts funds to expand
local clinics, outreach teams, and other community-based systems of care and
would also provide transportation to Mandeville for hospitalized patients'
families, he said.
NOAH's vulnerability probably arose because it was to be reopened in stages
after Katrina, said Potash. Not enough beds were put back into service to
bring the per-bed cost down to expected levels, so the per-bed cost remained
Families of NOAH patients have filed suit to block the move, but the case
won't be heard for several months.
"Both sides are genuinely concerned with the mental health of New
Orleans' citizens, but they have different views on meeting those needs even
with the financial constraints of the recession," said Potash, who
favors keeping NOAH open. "But I haven't heard any clinical arguments
for closing NOAH, only financial ones."
Some psychiatric beds remain in the city, primarily at the LSU Interim
Hospital at DePaul, formerly operated by Tulane University.
Whether anyone can make a success of expanded community-based treatment is
open to question, given the past failures of such ideals in the United States,
said Potash. "To do it right, you would need a period of overlap with
both in- and outpatient services, see if the outpatient services succeed, then
phase out the inpatient services," he said.
That test won't be carried out in New Orleans, since NOAH has closed, but
the outcomes will be watched closely.
"Barriers to Mental Health Services for Children Persist in
Greater New Orleans, Although Federal Grants Are Helping to Address
Them" is posted at<www.gao.gov/new.items/d09563.pdf>.▪