Nearly three years post-Katrina, levels of anxiety and depression remain high among its victims. Post-traumatic stress levels have not decreased in the New Orleans metro area and have actually doubled on the Gulf Coast, according to the Harvard-based Hurricane Katrina Community Advisory Group study published in the January issue of Molecular Psychiatry (Vol. 13, No. 1).

The survey of 815 survivors 20 months after Katrina is a follow-up to the initial, baseline assessment taken over a period five to eight months after the storm. The results indicate the incidence of serious mental illness and suicidal ideation have also increased, say researchers.

These patterns are not what the team expected, says sociologist Ronald Kessler, PhD, a health-care policy professor at Harvard Medical School and the study's principal investigator. Although it is normal to find higher levels of trauma in the wake of a disaster, the baseline study found a doubling in anxiety mood disorders when compared with results from the National Co-morbidity Survey Replication taken three years earlier. When the follow-up study showed no reduction in levels of trauma--and in some cases an increase--it was an extraordinary finding, says Kessler.

"In the United States, the richest country in the world--we have no precedent for this," he says.

Previous research by Kessler and others has found that after most natural disasters, trauma initially rises but goes down steadily over time. A study of Florida victims of Hurricane Andrew in 1992, led by psychologist Fran H. Norris, PhD, found a slight increase in trauma levels over time, but nothing as high as the levels after Katrina. It will take years to tease out all the factors that made this disaster so much more devastating for people, but experts point to such problems as the lack of a solid infrastructure before the storm, the scope of the physical damage, the continuing economic hardship and the slow pace of recovery. For the area's mental health providers, however, one overarching theme is all too evident: In many ways, the devastation and displacement have never ended.

The big uneasy

In New Orleans, residents will tell you that the city's infrastructure was substandard before Katrina, but its culture was second to none. Since Katrina, a way of life has been shattered. Extended families continue to be scattered, and many historic neighborhoods are gone or virtually deserted.

Local psychologist Joy Osofsky, PhD, professor of pediatrics and psychiatry at the Louisiana State University (LSU) Health Sciences Center, says her center has screened over 12,000 children for mental health problems since Katrina and continues to see distress levels that track with the Kessler study.

"One of the reasons that we are seeing a persistence of symptoms longer than described in other post-disaster studies is because of the extent of the devastation that took place," says internist and pediatrician Benjamin Springgate, MD, MPH, co-chair of REACH-NOLA, a community-based partnership dedicated to improving health and access to quality health care. "There are tens of thousands of houses that have not been touched [rebuilt or torn down], and people are living in trailers on their property. It's an ongoing reminder of trauma."

Natural coping mechanisms such as relying on support from family and friends are difficult because people's social networks have been fragmented, adds Springgate.

"Many people in New Orleans had never left the neighborhoods they were born in," he says. "Now the people you knew are dispersed and maybe your neighborhood doesn't even exist anymore."

Options for seeking professional help with the lingering trauma are also extremely limited due to the loss of major facilities that were destroyed by the storm and have been slow to rebuild or not rebuilt at all and the number of mental health providers who left because of the loss of their homes, practices or both.

"A disaster exposes all the fault lines that were in a city before the disaster took place," says child psychiatrist Elmore Rigamer, MD, the medical director of Catholic Charities Archdiocese New Orleans. "We already had problems with the mental health-care system. We didn't have good outpatient care and then comes the storm."

Most devastating was the loss of Charity Hospital, which provided most of the city's emergency psychiatric services, says psychologist Anthony Speier, PhD, director of disaster mental health operations for the Louisiana Department of Health and Hospitals. Charity had 96 in-patient psychiatric beds and a crisis-intervention center, which served 6,000 people a year, Speier says.

The city has also lost many of its mental health providers, he adds. It's difficult to get precise numbers, but Speier says that at one point after the storm, they had fewer than 20 psychiatrists in the city and have had a hard time recruiting replacements. And psychologists' numbers dropped 35 percent from 2005 to 2007, according to an article in the February Professional Psychology: Research and Practice (Vol. 39, No. 1).

Swept away

Mississippi has fared somewhat better. It hasn't lost as many mental health providers and most hospitals remain open. However, many psychologists lost their homes, and in some cases, their practices and they continue to struggle, says Angela O. Herzog, PhD, incoming president of the Mississippi Psychological Association (MPA). As a result, mental health services are hard to come by for residents of the rural coast area where roads and entire towns were wiped away by Katrina's force.

Residents have been facing long-term displacement and a slow recovery, says Jeffrey Bennett, the director of the Gulf Coast Mental Health Center, the region's principal provider of public mental health care.

"About a half a mile in from the coast is being rebuilt, but the coast, with its hotels and tourist attractions, is just gone."

Cramped conditions caused by living in trailers, or staying with relatives who don't really have the room have also been major sources of stress, he says.

As Monitor went to press, the Centers for Disease Control and Prevention was recommending the immediate evacuation of the more than 10,000 people still living in FEMA trailers. Tests have revealed toxic levels of formaldehyde, and FEMA promised to speed up the relocation of residents to hotels and motels until they can find more permanent housing. Bennett isn't sure where that housing is going to come from.

"We have a lot of people who lived in subsidized housing before Katrina, and it is just not coming back."

The continuing trauma is taking its toll: Mental health facilities along the Gulf have seen an increase in substance abuse cases, says Bennett.

To address the behavioral needs, William Martin, PhD, MPA's disaster-response coordinator, would like to help implement psychoeducational programs that focus on resiliency. Some programs in New Orleans, such as REACH-NOLA, are working with church and other community leaders to communicate that symptoms such as irritability, a general sense of malaise and "the blues" are normal reactions to the storm and that it might be helpful to talk to a pastor or a professional counselor. Springgate says they are starting to gain some traction. Martin has had less success with similar efforts in Mississippi.

Osofsky points to an expansion of LSU's outpatient Behavioral Sciences Center as cause for hope. Psychiatrist James Barbee, MD, the center's director, hopes that the increase in space will allow them to see approximately 30,000 patients a year--three times the number of cases they saw pre-Katrina.

In fact, the Louisiana Department of Health and Hospitals recently announced an initiative to improve mental health services in New Orleans. The plans include establishing community treatment teams that will provide social services, mental health and substance abuse treatment, and medication management. Mobile clinical teams of mental health and nursing practitioners will augment clinical services by offering treatment in community and school settings. The department is also seeking additional funding to establish a regional triage center where police and emergency-service personnel can take individuals in crisis to receive further care.

So what will future surveys show? Kessler and his team will be checking back in with the Katrina Community Advisory group this summer, as the region hits the three-year anniversary mark. He has no idea what he'll find.

"We're in uncharted territory here," he says. "That's why it's so important to continue studying this group."

Springgate sees lots of work ahead, but also some hope.

"We are going to continue to do our best--New Orleans is a resilient community," he notes. "I expect that this is going to be a generational challenge."