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 programs.

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 city.

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 high.

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>.▪