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State of Mind 

A shortage of mental health professionals puts New Orleans' psychological recovery at risk.

There is no question of need," says Dr. Carl Weems, a professor in the University of New Orleans' Department of Psychology. "New Orleans has an epidemic of mental health-related problems."

Weems is not the only one who sees it that way. At a mental health forum last week, Research!America released results from a survey of more than 800 coastal Louisianans showing more than half of residents don't believe there are enough resources for mental health care in the region. And while state officials recently authorized much-needed funding to shore up New Orleans' resources for severely mentally ill patients and crisis care — partly a reaction to the January shooting of police officer Nicola Cotton by a suspect with reportedly severe paranoid schizophrenia — reports from local mental health professionals and outside studies indicate the city continues to suffer from a quieter, more expansive epidemic: post-Katrina depression and anxiety.

For these residents, who outwardly have a less debilitating mental illness, the city's shortage of mental health professionals, slow recovery and lack of resources have made it particularly difficult to find quality mental health care.

'The incidence of mental health problems in this population is higher than it would have been before Hurricane Katrina," says Dr. Howard Osofsky, chair of the Department of Psychiatry at Louisiana State University's Health Sciences Center.

Nationally, depression and anxiety disorders are among the most common mental illnesses, affecting 10 percent to 18 percent of Americans. According to Weems, the best studies estimate a full 25 percent to 40 percent of New Orleans residents are continuing to suffer anxiety and mood disorders related to Hurricane Katrina and the stresses involved in living in the city since the storm.

Psychologist Dr. Barry Schwartz likens patients whose mental illness was set off by the storm to breached levees. They might have had weaknesses and vulnerabilities before Katrina hit, but under normal conditions, they could have held together well enough to function as needed. Under extreme stress, however, "the weaknesses opened up," Schwartz says.

For many people with storm-related depression and anxiety, the initial trauma and continued burdens have laid bare those vulnerabilities and left them unable to cope like they once could. The depression and anxiety may not be conspicuously crippling, but it can contribute to a person's inability to function socially, with family or at work.

'Interference. It's our easy buzz word," Weems says, describing the subtler signs of storm-related depression and anxiety. Any changes in mood or stress that interfere with close relationships or keep a person from participating in activities that once were important to them can be a sign of a real problem.

For people who already suffered from depression or anxiety before the storm, it is likely their symptoms became worse afterward. The extra psychological strain can lead to physical pain in the form of headaches, irritable bowel syndrome, shoulder aches and difficulty sleeping.

In January, a published study by researchers from Harvard Medical School confirmed what many locals and mental health professionals already suspected: More than two years later, hurricane-related post-traumatic stress disorder (PTSD) and anxiety disorders continue to burden New Orleans residents. What was more surprising was that there appeared to be no significant decrease in Katrina-related mental illness in two years. Time has not been healing mental wounds.

Research from other disaster settings shows that the usual progression of event-related mental illness to eventual recovery has a trajectory of approximately three years. As New Orleans closes in on another anniversary of the storm, it is clear that the city's residents are taking longer to heal. Osofsky says he now is hearing projections of five to 10 years for those psychic wounds to heal.

Part of the problem is rooted in a severe shortage of professionals who normally would help patients recover. New Orleans has spent the last year-and-a-half designated as a federal Mental Health Care Health Professional Shortage Area. There just aren't enough qualified personnel to meet the massive need. For example, the Louisiana State Board of Medical Examiners has only 138 psychiatrists registered in the city. The national average for a population the size of New Orleans usually has three to four times that many.

Meanwhile, the people who are manning the city's delicate mental health structure continue to suffer what Osofsky calls "secondary traumatic stress," a combination of personal and professional stressors particular to people in mental health support positions. Not only are they dealing with their own problems of rebuilding, family separation and damaged social networks, but they are likely to stretch themselves thin by trying to treat as many patients as they can.

'We see compassioned people who are working and going through their own stress," says Osofsky. He says it is reflected in increased rates of sick leave — a classic indicator of unhealthy anxiety levels — among people who work in support positions at local hospitals and clinics.

'The quality of care is definitely decreased if, at the lower level, you don't have paraprofessionals," Weems says. Without a strong base of community supports, counselors and case managers, residents must seek mental health support from existing, overtaxed professionals. In practice, the crush of patients means less time to devote to evaluation and treatment and, as a result, a decreased quality of care.

This situation is especially relevant to local residents whose post-Katrina depression and anxiety are interfering with their lives but are not at crisis levels. The National Institute of Mental Health says for patients with "mild to moderate depression, psychotherapy may be the best treatment option." But those therapies can last about 20 weeks.

'One of the first things to keep in mind is how efficient and economical you can be in getting [patients] up to a point where they're coping," says Schwartz, who offers a variety of treatments to patients with depression and anxiety disorders. Exactly how long it takes for a patient to achieve a level of functionality where they are comfortable depends on the individual's illness and severity. A big problem surfaces when a shortage of time and personnel dissuades patients and doctors from exploring time-intensive routes of therapy that may have better long-term outcomes.

'Medicines are very expedient; cognitive behavioral therapy might take 10 weeks or 12 weeks," Weems says. Both routes can alleviate symptoms of depression and anxiety, but in the long run, he says, "The relapse rate once you stop taking medicine is much higher than cognitive behavioral therapy." That debate is one for residents who have the luxury of choice. Unfortunately, even patients who successfully navigate the fractured mental health system and receive initial treatment with one specialist may face difficulties finding another when they need them.

'That's a real challenge even with the people I know," Schwartz says of the referral process. For instance, a patient may be able to secure medication from a psychiatrist but will be on a waiting list for weeks to see a psychologist for cognitive therapy.

Schwartz knows how difficult it can be to wade through the system. Until 2005, he was a professor who had spent 25 years at the Tulane Health Sciences Center. His position was a casualty of cutbacks to keep the university solvent after the storm. "That left me with my own house destroyed, [and no longer] being a tenured professor," he says.

After he was laid off, Schwartz regrouped, and in the summer of 2006 opened a private practice where he now regularly witnesses the effects of the shortage of mental health professionals. "There are people that I'm not able to see when they call to be seen," he says. "I have to tell them I can put them on a list."

At press time, Schwartz had one open spot for a new patient, but he usually maintains a waiting list for new clients that is, on average, seven names long.

Osofsky and a team at LSU report similar experiences at the access-to-care clinic they opened in February, which serves both insured and uninsured patients. The team already has a waiting list, he says, but getting in for the first visit is only part of the challenge.

'Part of our problem is also the continuity in care," Osofsky says. Following a patient's treatment plan, coordinating between multiple doctors and completing counseling or therapy becomes infinitely more difficult when the whole structure is precarious.

The additional $26 million in funds that Gov. Bobby Jindal recently allocated for new mental health initiatives in New Orleans is intended to go toward increasing outpatient care for the city's mentally ill. This means expanding services like crisis care, case management and housing support, which are crucial resources for people suffering an acute mental health crisis or for patients who need significant social and medical support to stay independent. The average person who is depressed or suffering from post-Katrina anxiety or mood disorder, however, is still just below the cusp of qualifying for these services. That leaves a significant swath of New Orleans residents to cope with mental illness without stable access to care.

'That's real tough when there are people in a crisis but not in a crisis enough for hospitalization," Schwartz says. It's a self-perpetuating cycle: When resources are short, patients with mild to moderate mental illness get triaged out, but if they don't get treated, they're at risk of getting worse and becoming candidates for crisis care.

'The whole system of care isn't fully established," Osofsky says. "What we've been doing is establishing pieces of care."

Until the right people and structures are in place, the 25 percent to 40 percent of residents who are still suffering from Katrina-related depression and anxiety are at risk of falling through the cracks.

'The No. 1 thing is infrastructure," Weems says. "We're not reaching as many people as we should."

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