New Orleans already is struggling with fewer than half of the inpatient beds for the mentally ill that it had before the 2005 hurricane - even as suicide rates and the number of people with mental health problems have doubled.
That shortage is about to become even more acute with the scheduled closing Sept. 1 of the New Orleans Adolescent Hospital (NOAH), the city's only public hospital still providing inpatient services for the mentally ill.
The closure, designed to trim $14 million from the state's 2010 budget, will leave New Orleans with 133 beds for mental health inpatient care and will make the city jail - with 60 of those beds - the city's largest psychiatric ward.
Before Katrina, "We had a functional system, not a Rolls-Royce, but we managed to treat patients," said Dr. Kevin U. Stephens, director of health for the city of New Orleans.
State funding for mental health services has risen steadily since the storm, from $37.4 million in 2006 to $74.4 million this year. Even so, Dr. Stephens said, "We have no real significant inpatient capability, and outpatient treatment is limited."
That shortage of facilities is felt most strongly by residents like Byron Turner, who four years after Katrina still is haunted by visions that eventually drove him to seek professional help.
"Life was real good for me before Katrina," he said. "I had no mental health issues ever in my life. I was never homeless. I had jobs. I had two automobiles before the storm."
Today, he is homeless and taking medication to reduce his bouts of anger. Sometimes he's angry about his situation, sometimes he just gets frustrated with himself. Sometimes, he's still angry over the hurricane.
"I still see the bodies. I still see the dead children. I still see the elderly people floatin' in the water. I still see the water," Mr. Turner said.
Overwhelmed public health agencies in New Orleans can only guess how many of the city's residents are, like Mr. Turner, still struggling to cope with the mental and emotional consequences of a maelstrom that swept away whole neighborhoods and stole away friends, relatives, homes and social networks - the glue that holds people's psyches together.
"We all kind of crazy after Katrina," drawled Judge Arthur L. Hunter, who presides over the city's mental health court, a special facility that has convened weekly since December 2003 and handles between 100 and 200 cases a year.
"Everyone suffers from post-traumatic stress disorder, whether their house flooded or not," the judge said.
Mental health is not easily measured, and attempts to quantify the explosion in mental health care needs after Katrina vary from agency to agency, but efforts have been made. One of the most comprehensive was by the World Health Organization, which surveyed about 1,000 Katrina-affected residents of Louisiana, Alabama and Mississippi some six months after the storm.
The Health Sciences Center at Louisiana State University produced similar findings in a 2007 report, which found that nearly 20 percent of the New Orleans population was suffering from serious mental illness. When the Federal Emergency Management Agency surveyed displaced families living in trailers and hotel rooms in Louisiana in February 2006, it found that 44 percent of the dwellers suffered from significant psychological distress.
'The walking wounded'
Equally telling are the suicide figures, which almost tripled in the year after Hurricane Katrina, according to the Metropolitan Human Services District (MHSD) and other mental health authorities. Dr. Jeffrey Rouse, the deputy New Orleans coroner dealing with psychiatric cases, was widely quoted in 2006 as saying the annual suicide rate had jumped from about nine people per 100,000 before the storm - slightly below the national average of 10 - to something over 26 per 100,000.
Altogether since 2006, reports show 101 suicides and 726 suicide attempts in a population that has ranged between 200,000 and 300,000. In the first five months of 2009 alone, 24 suicides and 82 attempts were reported - roughly double the national average.
They are "the walking wounded - untreated, they jump off bridges, they hang themselves, and they shoot themselves in the head," said Dr. Stephens, who has noted a spike in mental illness in his own office since the storm - including two suicides and other psychotic breakdowns.
"What we have is PTSD on steroids," the doctor said.
Recovery will require many years of sustained effort and commitment by public health officials and by the victims - people like Mr. Turner, who said he recognizes he is still in the first phase of dealing with his trauma.
"I'm still thinking at certain streets I might walk down, you know, I might think that I'm still, I'm swimming. I might think that I'm trying to get in a boat still," he said as he described his quest to get to a place where the word "normal" has some meaning again.
In the meantime, he must still walk those streets where the flooding was deepest - some where the water was 16 feet deep - and where memories come back with the greatest force.
"I actually saw my friend's grandmother's body floatin' in front of me. I'm like, lord, that's Miss Mary floatin' right there, and she's actually dead, stiff as a piece of plywood, you know.
"So, these things are real," Mr. Turner said.
City, state and federal agencies have pointed fingers at one another for four years, seeking to lay blame for the failure of the levees that allowed the flood waters to wash over the city. But as far as Dr. Stephens is concerned, that is no excuse for ignoring people like Mr. Turner.
"We as a society have to reach out and take care of them," he said. "Society needs to come in and be the safety net."
But the necessary health infrastructure no longer is there. Before Katrina, the city had 10 public and private hospitals with a total of more than 400 beds available for inpatient treatment of the mentally ill. Today, there are just seven hospitals, operating with fewer than 170 beds - a number that will be reduced further when NOAH closes.
Fight over NOAH
Mayor C. Ray Nagin protested the planned closing in an April 24 letter to Gov. Bobby Jindal, saying, "The City of New Orleans has faced a significant health care crisis since Hurricane Katrina. These changes would have the greatest negative impact on our poorest citizens who are frequently under insured or uninsured."
Mr. Nagin added that those poor residents "have few options for obtaining primary, emergency, or mental health services from other providers. Due to lack of insurance, they receive exorbitant bills they cannot afford if they do seek services in community hospitals."
State Rep. Neal Abramson, whose district includes New Orleans, mounted a last-ditch effort to keep the hospital open.
"For people who need the facility, they are looking at over an hour of travel, and most people don't have the means to get there," said Mr. Abramson.
For those who don't have cars, he said, the hospital might as well be moving to Arkansas.
Mr. Abramson succeeded in getting $14 million for NOAH funding added to the state's budget on June 25 - the same day Mr. Jindal vetoed a separate bill that had funding for the hospital.
"The only way that hospital will close is if the governor vetoes the money again," Mr. Abramson said at the time. And the governor did.
Mr. Jindal said in his veto statement that Mr. Abramson's plan would have required the money to be pulled from other health resources in the state, forcing "unacceptable cuts" in those resources. "NOAH operates at twice the daily cost as other state inpatient facilities," the statement added.
Mr. Jindal also argued that the Department of Health and Hospitals plan he backed required no reduction in outpatient or inpatient services for the region as a whole, and provided for community-based outpatient mental health services in New Orleans.
But the veto also means mentally ill patients who have relied on NOAH will have to find somewhere else to go for inpatient services.
"I've told people for so long, just don't come back [to New Orleans] right now," said Cecile Tebo, administrator of the New Orleans Police Department Crisis Unit that responds to 911 calls involving the mentally ill.
"Don't come back if you have any kind of special needs; this is not the place to be if you have elderly that are really sick, if you have children with special needs or people in the family with mental illness or mental retardation; this is just not a good place to be right now," said Mrs. Tebo, whose own staff of volunteers is just a little more than half the size it was before Katrina.
"Hopefully, I won't have to say that in like five years. I'll say, 'Come on in, we got it figured out.' "
In that respect, Mrs. Tebo has a great deal in common with mental health patients such as Mr. Turner, who also would like to say they have it figured out.
"No I'm not normal. I would love to be normal again," said the man who still sees bodies floating through the streets.
"I would love to get back to my life that I had before Katrina ... you know?"
Comparing the results to a pre-Katrina study in the same area, the WHO found that the number of residents with serious mental health problems had shot up from 6.1 percent to 11.3 percent, and the number with mild to moderate problems had risen from 9.7 percent to 19.9 percent.
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