Another Breakdown in New Orleans

For decades, everybody in New Orleans knew the drill, from police and emergency medical responders to the patients who managed to get there on their own. In a mental health emergency, the destination of choice was the 24-hour crisis intervention unit at Charity Hospital in downtown New Orleans, where a team of specialists could quickly evaluate patients who were a potential danger to themselves or others, stabilize those that could be medicated and referred to one of the city's outpatient clinics and admit the hardest cases to the hospital's psychiatric ward, where the 96 beds were fully occupied most of the time. All you had to do was mention the third floor at Charity, and most everyone knew what you were talking about.

But Charity — as it is still popularly known, even though the name changed to Louisiana State University Medical Center years ago — remains shuttered nearly two years after Hurricane Katrina, and is likely to remain that way. And with a handful of local emergency rooms forced to pick up the slack, Charity's closure is putting a great deal of stress on an already overtaxed health care system. Hospital staff more accustomed to treating cuts and chest pains are dealing with severely mentally ill patients and hard-core substance abuse cases. A limited number of ER beds, needed for heart patients and diabetic emergencies, are filled with psychiatric patients who have nowhere else to go. And police and ambulance drivers are being tied up by long waits at emergency units, depriving the city of essential crime fighters and first responders.

Terry Ebbert, the director of New Orleans' Office of Homeland Security and Emergency Preparedness, calls it nothing less than "a crisis in emergency mental health care." In March, Ebbert says, emergency medical service teams logged more than 300 hours in wait time at local emergency rooms, waiting for space to open up for people needing psychiatric care. The New Orleans Police Department, stretched perilously thin since the storm, had 207 cases in the same period where cops waited up to three hours with patients picked up for mental health disorders, or had to drive miles to a suburban ER that could admit them. In many cases, police are bypassing hospitals altogether and taking detainees to jail — an often harrowing destination for the mentally ill, but a place where they can at least receive treatment for the immediate crisis. "That's the Dark Ages," Ebbert says. "That's how we did this in the 1200s. We need to treat these people with the quality care that they deserve."

The city's entire health care system, of course, was thrown into turmoil by Katrina. But psychiatric services have been perhaps the slowest to recover. Seven regional state-run outpatient clinics are operating, with limited services, but of the 200-plus psychiatric beds that existed in the city prior to Katrina, only 20 are in service at the moment. The number of psychiatrists and psychologists has dwindled and, despite a federally funded recruitment program, hospitals report difficulty finding doctors and nurses who specialize in mental health. All this at a time when, mental health experts say, the actual number of people needing such services has increased, even as the city's population remains diminished by half.

The crisis prompted Mayor Ray Nagin this week to issue an impassioned plea to Louisiana's Governor, Kathleen Babineaux Blanco, for a centrally located crisis intervention unit, either in a reopened third floor at Charity or in a designated section of University Hospital, an L.S.U. medical school affiliate that houses the city's only trauma center and where, on one recent night, 18 of the emergency department's 23 beds were occupied by mental health patients. "These patients are still getting their medical evaluations in a routine emergency department. But then they are left there," says Cathi Fontenot, the hospital's medical director. "Emergency departments are not quiet areas of relaxation, especially in a trauma center like ours, where we have gunshot wounds and ambulances and patients being wheeled in and out. It is not a great environment to try to de-escalate mental health patients, as you might expect."

There are some promising signs. The state could provide funding for another 20 psych beds this summer, says Jerome Gibbs, executive director of the Metropolitan Human Services District, which oversees state-run mental health programs in the New Orleans area. University Hospital plans to have a mobile crisis unit operating on a site adjacent to the hospital by June, and is in negotiations with a closed mental health center uptown, where the hospital hopes to lease enough space to open 33 psychiatric beds. But staffing is still a huge challenge, Fontenot says. There are fewer resources available to follow patients once they leave the emergency room, fewer people to track them and ensure that they receive proper medication. And the aftershocks of Katrina are still reverberating.

"People are truly wearing down," says Howard Osofsky, chair of the psychiatry department at L.S.U. Health Sciences Center. "I don't want to underplay people's resilience, people's determination, how hard our community is trying. But if I go into a reception, I will have business leaders, I will have prominent members of the community come up to me and say, 'I have been so depressed. I just don't know if I can take it any more.'"

Gibbs has also seen a significant increase in the number of people presenting symptoms of depression, along with higher than normal rates of suicidal thoughts, substance abuse and domestic violence. The symptoms "have begun within the last couple of months to manifest themselves," he says. "But I think we still have a significant wave to occur. What we probably have now is a large number of people who possibly did not need mental health services before the storm, but with all the events associated with the storm — the loss of homes, the loss of family members, the loss of community — it takes its toll on people."