As Hurricane Katrina altered the geography of New Orleans and other parts of Louisiana and Mississippi, it also led to turmoil and changes in the mental health systems in the region, a process still in flux.

Some of those changes were forced by the physical destruction of major mental health facilities like the Veterans Affairs Hospital and the monumental Charity Hospital in New Orleans and other clinical sites.

In addition, the 2007 election of Republican Gov. Bobby Jindal in Louisiana led to changes in how the state government funded and organized mental health services.

Immediately after hurricanes Katrina and Rita in 2005, the federal Substance Abuse and Mental Health Services Administration (SAMHSA), in cooperation with APA, organized efforts to send psychiatrists and other mental health workers to the Gulf region.

However, that emergency role was out of character for the agency, said Linda Ligenza, M.S.W., L.C.S.W., public health advisor at SAMHSA.

"SAMHSA monitored crisis-counseling grants from FEMA [the Federal Emergency Management Agency] and continues to provide training and technical assistance, but we are not a service-delivery organization," said Ligenza in an interview.

Those crisis-counseling grants ended in May 2007 in Mississippi and in June 2009 in Louisiana. Hurricane Gustav in 2008 triggered new grants to Louisiana that ended in January 2010, she said.

On the local level, the state-run Louisiana Spirit Recovery program was funded by FEMA and provided 678,000 crisis-counseling sessions and over 3 million outreach contacts offering support and information on resources before closing in December 2009.

In general, the mental health system before Katrina was fragmented, too often using costly levels of care and achieving less-than-optimal outcomes, said Craig Coenson, M.D., medical director of the Metropolitan Human Services District, which covers New Orleans and several surrounding parishes (counties).

Health officials looked at the post-Katrina moment as an opportunity to build a coordinated system with better access by shifting to a community clinic—based model, he said.

Administrative changes in the Metropolitan Human Services District have brought "a fresh set of eyes for public services" after several years of controversy, said Coenson, who arrived 18 months ago from Minnesota. "We're trying to achieve efficiencies and reallocate money to direct services and housing. We also want to better integrate medical and behavioral health services and work more closely with federally qualified health centers."

Assertive community treatment teams and forensic teams expanded intensive and supportive care for chronically mentally ill individuals. Peer-support services have increased, and one-time grants paid for a mobile mental health for rural areas in the region, he said.

One controversial decision was the closure of the New Orleans Adolescent Hospital (NOAH) last year (Psychiatric News, September 18, 2009). Inpatients were transferred to Southeast Louisiana State Hospital at Mandeville, 45 minutes away across Lake Pontchartrain.

The state provides transportation for families to visit patients, but time and distance can still be a hardship for some, so patients get less family support, said Howard Osofsky, M.D., Ph.D., a professor and chair of psychiatry at Louisiana State University (LSU) School of Medicine in New Orleans.

Children's Hospital, across Henry Clay Street from NOAH, allots 24 inpatient behavioral health beds for adolescents and another five for children, said Osofsky. Children's loses "money on those beds, but it has been remarkably cooperative."

NOAH was providing much uncompensated care after the storm, said Richard Dalton, M.D., medical director of the state's Office of Mental Health and a professor of psychiatry at Tulane University. "We moved outpatient services to two clinics, one on the east bank of the river and one on the west bank."

The department also added multisystem therapy for in-home services for 100 high-need adolescents in the district.

"We think more children and adolescent issues are being addressed now than prior to the storm," said Dalton.

However, there have been repeated complaints about the lack of public psychiatric beds in the city. The VA opened satellite clinics in the New Orleans area, but it has no inpatient beds, and a new hospital is three to five years in the future.

Some beds are available at private or university hospitals. LSU maintains 38 beds at the DePaul Hospital, uptown, but Osofsky said these are almost always full. Bottlenecks occur at both ends of the inpatient stay. There are too few beds in which to place patients stabilized in area emergency rooms. Then, when patients are ready for discharge, the limited number of group homes and paucity of other community services for the "walking mental health wounded" create other problems.

Tulane University's hospital has no inpatient psychiatric beds, said Mordecai Potash, M.D., an associate professor of clinical psychiatry. Tulane briefly opened an acute psychiatric unit but closed it in December 2008 after just seven months when the university decided it was costing too much to operate.

Katrina wasn't the only storm to hit the Gulf region, and New Orleans wasn't the only city affected. The area around Baton Rouge turned into a de facto way station for many New Orleanians displaced by Katrina. The Capitol Area Human Services District was finally managing to fill its social-service needs when Baton Rouge was clobbered by Hurricane Gustav in 2008. The district had to shuffle 168 administrative and clinical employees to other spaces for a year.

Help was slow in coming, said agency executive director Jan Kasofsky, Ph.D., in an interview. "The Federal Emergency Management Agency takes so long to reimburse that repair expenses had to come out of our budgets."

Today, the district's client load is 57 percent higher than in summer 2005, Gerald Heinz, M.D., the district's medical director, told Psychiatric News. The recession also contributed to increases in clinic admissions as people lost their health insurance. At the same time, budget cuts have lopped $3 million from the district's operating budget.

Yet another new stream of patients in the district was triggered by the state's decision to close intermediate-care inpatient beds and use the funds to provide more community care.

However, the shift to community-based care has not gone smoothly.

"The governor's plan was to cut back on inpatient services and put the money into outpatient services, but no new money has been put into outpatient mental health services," said Harold Ginzburg, M.D., M.P.H., J.D., a psychiatrist in private practice in Metairie, La., and a clinical professor in the Department of Psychiatry and Neurology at Tulane University's Health Sciences Center.

The move from inpatient to outpatient care was driven less by Katrina than by philosophical and budget reasons and would have occurred anyway, said Potash. The lag in the shift of funding into the community is probably to be expected, he believes.

The state may also move to privatize services, Kasofsky said. "We don't know if our employees will choose to work with private contractors."

Potash is worried the move to private contractors will lead to a lowering of the quality of care to save money.

Both regions have had difficulty attracting and retaining psychiatrists since the storms. Moreover, there are no local residency training programs in Baton Rouge. (There are training programs in New Orleans, at LSU and Tulane.)

Many psychiatrists and other mental health professionals left New Orleans after Katrina, either because their homes or workplaces had been destroyed or because most of their patients were unable to return to the city.

"We can't lose sight of the burden on mental health workers," said Coenson. "There is a lot of burnout, anxiety, depression, and anger among them, too."

"Some professionals have returned," said Osofsky, but obstacles remain. "I have had inquiries from psychiatrists around the country but budgetary constraints limit hiring."

Nevertheless, time and therapy are having an effect on patients. Hurricane Katrina still comes up as an issue among his patients today, said Potash.

"But most have made long strides toward recovery and putting Katrina behind them," he said. "It didn't happen as quickly as they wanted because many ran into roadblocks that were not fair, but eventually their situations worked out."

(Several sessions on the mental health aftereffects of Hurricane Katrina will be presented at APA's annual meeting in New Orleans, May 22-26.)