    [Senate Hearing 110-481]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 110-481

                      POST-CATASTROPHE CRISIS: ADDRESSING
                          THE DRAMATIC NEED AND SCANT
                       AVAILABILITY OF MENTAL HEALTH CARE
                               IN THE GULF COAST

    =======================================================================

                                    HEARING

                                   before the

                    AD HOC SUBCOMMITTEE ON DISASTER RECOVERY

                                     of the

                                  COMMITTEE ON
                             HOMELAND SECURITY AND
                              GOVERNMENTAL AFFAIRS
                              UNITED STATES SENATE

                           ONE HUNDRED TENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                OCTOBER 31, 2007

                                   __________

           Available via http://www.gpoaccess.gov/congress/index.html

           Printed for the use of the Committee on Homeland Security
                            and Governmental Affairs

                                   __________

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            COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

                   JOSEPH I. LIEBERMAN, Connecticut, Chairman
    CARL LEVIN, Michigan                 SUSAN M. COLLINS, Maine
    DANIEL K. AKAKA, Hawaii              TED STEVENS, Alaska
    THOMAS R. CARPER, Delaware           GEORGE V. VOINOVICH, Ohio
    MARK L. PRYOR, Arkansas              NORM COLEMAN, Minnesota
    MARY L. LANDRIEU, Louisiana          TOM COBURN, Oklahoma
    BARACK OBAMA, Illinois               PETE V. DOMENICI, New Mexico
    CLAIRE McCASKILL, Missouri           JOHN WARNER, Virginia
    JON TESTER, Montana                  JOHN E. SUNUNU, New Hampshire

                      Michael L. Alexander, Staff Director
         Brandon L. Milhorn, Minority Staff Director and Chief Counsel
                      Trina Driessnack Tyrer, Chief Clerk

                    AD HOC SUBCOMMITTEE ON DISASTER RECOVERY

                     MARY L. LANDRIEU, Louisiana, Chairman
    THOMAS R. CARPER, Delaware           TED STEVENS, Alaska
    MARK L. PRYOR, Arkansas              PETE V. DOMENICI, New Mexico

                         Donny Williams, Staff Director
                     Aprille Raabe, Minority Staff Director
                            Amanda Fox, Chief Clerk

                                C O N T E N T S

                                     ------
    Opening statements:
                                                                       Page
        Senator Landrieu.............................................     1
        Senator Stevens..............................................    10

                                   WITNESSES
                          Wednesday, October 31, 2007

    A. Kathryn Power, M.Ed., Director, Center for Mental Health
      Services, Substance Abuse and Mental Health Services
      Administration, U.S. Department of Health and Human Services...    10
    Anthony H. Speier, Ph.D., Director, Disaster Mental Health
      Operations, Office of Mental Health, Louisiana Department of
      Health and Hospitals...........................................    18
    Jan M. Kasofsky, Ph.D., Executive Director, Capital Area Human
      Services District, Baton Rouge, Louisiana......................    20
    Kevin U. Stephens, Sr., M.D., J.D., Director, New Orleans Health
      Department.....................................................    22
    Ronald C. Kessler, Ph.D., Professor of Healthcare Policy, Harvard
      Medical School, and Principal Investigator of the Hurricane
      Katrina Community Advisory Group...............................    29
    Howard J. Osofsky, M.D., Ph.D., Kathleen and John Bricker Chair
      of Psychiatry, Department of Psychiatry, Louisiana State
      University Health Sciences Center..............................    31
    Mark H. Townsend, M.D., DFAPA, Professor and Vice Chairman for
      General Psychiatry, Director of Psychiatry, Medical Center of
      Louisiana at New Orleans.......................................    33

                         Alphabetical List of Witnesses

    Kasofsky, Jan M., Ph.D.:
        Testimony....................................................    20
        Prepared statement...........................................    71
    Kessler, Ronald C.:
        Testimony....................................................    29
        Prepared statement with an attachment........................   100
    Osofsky, Howard J., M.D., Ph.D.:
        Testimony....................................................    31
        Prepared statement...........................................   113
    Power, A. Kathryn, M.Ed.:
        Testimony....................................................    10
        Prepared statement with attachments..........................    41
    Speier, Anthony H., Ph.D.:
        Testimony....................................................    18
        Prepared statement...........................................    58
    Stephens, Kevin U. Sr., M.D., J.D.:
        Testimony....................................................    22
        Prepared statement with attachments..........................    93
    Townsend, Mark H., M.D., DFAPA:
        Testimony....................................................    33
        Prepared statement...........................................   117

                                    APPENDIX

    ``Trends in mental illness and suicidality after Hurricane
      Katrina,'' September 2007, by Ronald C. Kessler, Sandro Galea,
      Michael J. Gruber, Nancy A. Sampson, Robert J. Ursano, and
      Simon Wessely..................................................   120
    Michael A. Zieman, FACHE, Administrator of Memorial Behavioral
      Health, Memorial Hospital at Gulfport, Mississippi, prepared
      statement......................................................   152
    Lafayette Parish School System, prepared statement...............   155
    East Baton Rouge Parish Schools, Baton Rouge, LA, prepared
      statement......................................................   156
    Monroe City School District, Monroe, LA, prepared statement......   157
    World Health Organization, December 2006, Bulletin...............   159
    ``The Louisiana Model for a Local System of Care,'' report from
      the Capital Area Human Services District.......................   169
    Chart entitled ``Mental Health Resources in New Orleans,''
      submitted for the Record by Senator Landrieu...................   175
    Chart entitled ``SAMHSA Funding to Gulf Coast in Fiscal Year
      2006,'' submitted for the Record by Senator Landrieu...........   176

                      POST-CATASTROPHE CRISIS: ADDRESSING
                          THE DRAMATIC NEED AND SCANT
                       AVAILABILITY OF MENTAL HEALTH CARE
                               IN THE GULF COAST

                                  ----------

                          WEDNESDAY, OCTOBER 31, 2007

                                         U.S. Senate,
                     Ad Hoc Subcommittee on Disaster Recovery
                          of the Committee on Homeland Security
                                            and Governmental Affairs,
                                                        Washington, DC.
        The Subcommittee met, pursuant to notice, at 2:35 p.m., in
    Room SD-342, Dirksen Senate Office Building, Hon. Mary
    Landrieu, Chairman of the Subcommittee, presiding.
        Present: Senators Landrieu and Stevens.

                 OPENING STATEMENT OF SENATOR LANDRIEU

        Senator Landrieu. Good afternoon. The Subcommittee on
    Disaster Recovery will come to order.
        When I became Chairman of the Subcommittee on Disaster
    Recovery at the beginning of this year, I promised that this
    Subcommittee would work to create the most effective disaster
    response and recovery system possible, streamlining current
    processes, designing brand-new tools, where necessary,
    promoting better coordination between government at all levels,
    the private sector, and the nonprofit community, particularly
    as it relates to dealing with catastrophic disasters.
        With the help of my Ranking Member, Ted Stevens, this
    Subcommittee has held five hearings since its inception in
    March 2007. Our first hearing was basically an overhead
    snapshot of the current situation, urgent steps toward fixing
    the recovery process led off by testimony from GAO. The second
    was a hearing entitled ``Beyond Trailers: Creating a More
    Flexible, Efficient, and Cost-Effective Federal Disaster
    Housing Program,'' examining a more efficient, cost-effective
    way to handle the Federal disaster housing program. Our third
    hearing was ``Repairing the Road Home Program,'' trying to help
    literally hundreds of thousands of homeowners and renters get
    back to their communities and their neighborhoods. Our fourth
    was a hearing on problems with FEMA's public assistance program
    entitled ``FEMA's Project Work Sheets: Removing the Most
    Obvious Obstacles to Our Recovery.'' And, last, just less than
    a month ago, I had the privilege of hosting a field hearing in
    Anchorage, Alaska with Senator Stevens actually looking at a
    pending disaster of coastal erosion on the northwestern shore
    of Alaska at a small fishing village, Shishmaref, where the
    impacts of coastal erosion were clear and dramatic.
        Through these hearings, we have been able to create a
    narrative that tells a story that I think is very compelling
    and one that this country needs to hear and absorb, and that is
    that our country's disaster response mechanism lacks the muscle
    and the flexibility necessary to prevent and ward off disasters
    as well as to facilitate the long-term recovery of impacted
    communities, particularly from catastrophic disasters.
        Only last week, we saw the heroic efforts of first
    responders in California as they battled the massive fires that
    destroyed over 500,000 acres. The dramatic images of this fire,
    as well as this morning's 5.2 magnitude earthquake in the Bay
    Area, reminds us that disasters can and will strike anywhere,
    that no place in the United States is immune.
        The Federal Government appears to have applied some of the
    lessons learned from the 2005 hurricane and subsequent levee
    failures. However, we have to understand that putting out those
    fires, as horrible as they are, and which tragically claimed
    1,676 homes, 250 businesses, and it took 16 lives, which is
    horrific to even think about those numbers, but the comparison,
    if you will, to Hurricanes Katrina and Rita that destroyed
    266,000 homes, 18,000 businesses, and killed nearly 1,700
    people, is what this Subcommittee has focused a good bit of its
    time and attention on.
        The common thread, however, between these two events,
    despite their difference in their magnitude, is the fact that
    survivors of these fires and the survivors of the floods are
    both suffering right now from severe emotional and mental
    impacts. These impacts will be long lasting for California
    survivors, and they are long lasting for the survivors along
    the Gulf Coast.
        Many of you who watched the coverage of the wildfires saw
    reports of distress, nightmares, and emotional disturbances in
    evacuees as they camped out in shelters awaiting news on the
    status of their homes and their loved ones. Unfortunately for
    them, I know that this is only the beginning. Even 2 years
    after our terrible 2005 hurricane season, hurricane survivors
    along the Gulf Coast continue to suffer emotionally as they
    ride out the slow recovery process.
        For Hurricanes Katrina and Rita survivors from all walks of
    life, the stress from the storm and rebuilding has hit a high
    level that can only be described as a crisis. The loss of
    homes, jobs, and loved ones, together with the separation of
    family and the slow, painful pace of recovery has left, I
    think, emotional scars.
        The mental health situation has emerged as one of the most
    critical issues facing our recovery, and that is the focus of
    the hearing today. From our police force, our firefighters, and
    other first responders, who themselves were victims, to our
    young children, to the elderly, from everyday men and women
    trying to provide for their families, the mental health crisis
    in the Gulf Coast has left no segment of society untouched.
        Between May 2005 and February 2006, 668 first responders
    were surveyed by the LSU Health Sciences Center: 19 percent of
    police officers exhibited symptoms consistent with post-
    traumatic stress disorders (PTSD); 26 percent exhibited
    symptoms of major depression; 1 in 5 said their alcohol
    consumption had increased. A survey of 2,757 children returning
    to New Orleans within a year of Hurricane Katrina found that 20
    percent had been touched by a hurricane-related death or
    injury; 33 percent had been temporarily separated from parents
    or guardians; 1,638 school children grades 4 through 12 were
    also surveyed by LSU; 54 percent met criteria for PTSD or
    depression. During the same period of time, 31 percent of
    children preschool to age 5 demonstrated symptoms meeting
    criteria for mental health referrals.
        We always have a challenge in our community for mental
    health. There never seems to be enough resources or enough
    services. But the situation along the Gulf Coast and the
    potential long-term impacts of the fires in California warrant
    some attention and our focus today.
        The city of New Orleans currently has just five active
    emergency rooms. As of August 2006, only 77 out of 460 pre-
    Hurricane Katrina beds, inpatient psychiatric beds, are
    available in New Orleans. This has forced hospitals to turn
    away even suicidal patients. Recent surveys have found that
    only 140 out of 617 primary care physicians have returned. An
    American Psychiatric Association survey found that 22 of 196
    psychiatrists--only 22--are still practicing in New Orleans.
        Now, when I say New Orleans, I mean the regions: St.
    Bernard, parts of St. Tammany, Jefferson, and Orleans Parishes.
    We still have major destruction in Cameron on the western side
    of our State, and along the Mississippi Gulf Coast, the
    communities of Waveland and Biloxi and other places--Pass
    Christian, MIssissippi--are still very significantly impacted.
        [The prepared statement of Senator Landrieu follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Senator Landrieu. So I thank Senator Stevens for joining
    me. He has been a real champion in this effort. I would like
    now to ask for his opening statement, and then when he finishs,
    I will be introducing our first witness.
        We do have three panels, but we intend to move this hearing
    quickly, and we do anticipate other Members showing up, and
    when they do, they will be recognized and their statements
    submitted for the record. Senator Stevens.

                  OPENING STATEMENT OF SENATOR STEVENS

        Senator Stevens. Well, thank you very much, Madam Chairman.
    I do not have an opening statement. I look forward to hearing
    the statements of the witnesses. We have a conference on
    defense at 3:30 p.m., so I will have to leave at that time.
    That is why I would just as soon move long.
        Thank you very much.
        Senator Landrieu. Thank you, Senator Stevens.
        Our first witness will be Kathryn Power, Director of the
    Center for Mental Health Services, Substance Abuse and Mental
    Health Services Administration (SAMHSA). Prior to her
    appointment, she served for over 10 years as the Director of
    the Rhode Island Department for Mental Health, Retardation, and
    Hospitals. She has also served in the capacity as community
    health director there.
        Ms. Power, you have a tremendous amount of responsibility
    and authority over this Federal program, and we thank you for
    being here today and look forward to your testimony.

     TESTIMONY OF A. KATHRYN POWER, M.ED.,\1\ DIRECTOR, CENTER FOR
       MENTAL HEALTH SERVICES, SUBSTANCE ABUSE AND MENTAL HEALTH
     SERVICES ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND HUMAN
                                SERVICES

        Ms. Power. Thank you very much, Madam Chairman and Members
    of the Subcommittee. I am really appreciative of the honor to
    appear before you today, and I thank you for the opportunity.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Ms. Power with attachments appears in
    the Appendix on page 41.
    ---------------------------------------------------------------------------
        I am going to be brief in my oral response to the questions
    that you had asked me to address, and I would ask that you make
    the full test of my remarks a part of the hearing record.
        As a mental health professional, I have a special lifelong
    interest in trauma responsive care. As I started my career as a
    rape crisis counselor, I learned about the powerful effects of
    trauma--how trauma could psychologically devastate a person,
    how the damage from trauma could spill into a person's entire
    social network, including partners, family, friends, and
    children. But it does not take an expert in trauma or mental
    health care to know that times of crisis leave indelible marks
    etched on our psyches, we need only to look inward. I also
    learned that healing and recovery are possible and do take
    time.
        Some 50 years ago, I still remember Hurricane Hazel, a
    deadly and tremendous storm of enormous power that made an
    enduring impression on my young mind.
        I remember the nuclear accident on Three Mile Island on the
    Susquehanna River in Pennsylvania. I lived a mere 8 miles away
    from that accident with my two sons and husband.
        And I remember the night of the Station Night Club fire in
    West Warwick, Rhode Island, in which 100 people lost their
    lives, and at that time I was the State Mental Health and
    Substance Abuse Authority. Today, 4 years later, the community
    and the State are still recovering.
        I am forever changed by these events. I am sure that each
    of you has had significant similar transforming experiences.
    Some events propel us forward; others test our mettle.
    Hurricane Katrina did both. While challenges remain, I am
    convinced that already Hurricane Katrina has taught community,
    State, and national citizens and leaders ways in which to
    effect fundamental change in how we understand and approach
    disaster preparedness and response, particularly in behavioral
    health, and above all, for the most vulnerable victims of these
    events.
        Effective disaster preparedness and response are an
    essential part of SAMHSA's public health mission in building
    resilience and facilitating recovery. That is why, in September
    2005, SAMHSA focused all of its resources to assist the
    affected communities along the Gulf Coast deliver an effective
    behavioral health response. That is why today we are still
    responding to the behavioral health needs and outcomes for
    those still struggling to heal and to recover.
        Based on our research early on, we estimated that over
    500,000 women, men, and children might be in need of crisis
    assistance. Our understanding of the risk and protective
    factors mandated that our work at that time proceeded along two
    courses that were parallel that emphasized the principles of
    collaborating with the local and State authorities. The first
    path was to lower the psychological distress and build
    resilience for those otherwise healthy individuals for whom the
    disaster might have increased their risk of behavioral health
    problems; and, second, ensuring continuity of care for those
    individuals who had mental and substance abuse disorders
    already.
        SAMHSA alone has provided more than $170 million in mental
    health and substance abuse funding, including $64 million in
    2007. Those funds are also in addition to the Crisis Counseling
    Program, which is funded by FEMA and administered by SAMHSA, as
    well as the SAMHSA staff costs that were associated with the
    mobilization of over 900 Federal and civilian staff that
    provided mental health disaster services in the region. They
    include discretionary and block grant mental health and
    substance abuse treatment and prevention funds.
        While much physical and emotional rebuilding remains to be
    accomplished, the work that SAMHSA undertook in collaboration
    with Federal, State, and local officials in the affected Gulf
    Coast regions stand as a testimony of what can be done and what
    can be done well to help rebuild the emotional health and well-
    being of a proud population. The process and outcomes of our
    work to reach out to people through the Crisis Counseling
    Program, whether to assure them that their feelings were normal
    and healthy or to urge them toward further evaluation and
    treatment, were the subject of and intensive cross-site
    evaluation in July 2007. And, Madam Chairman, that is one of
    the studies and objective evaluations that you had asked me to
    bring, and I brought a copy of that with me today.
        While we could say that our work is complete and life in
    the Gulf Coast today approximates what it was in the days
    before Hurricane Katrina and her sister hurricanes, we cannot
    say that. However, it is not for want of effort on the part of
    SAMHSA and on the part of HHS and on the part of the
    Administration. The work of building resilience and
    facilitating recovery begins with individuals in families, in
    neighborhoods, and in communities themselves. What SAMHSA can
    do best is to provide state-of-the-art tools, state-of-the-art
    resources to our colleagues on the ground, and I believe that
    is precisely what we have done over the many months since
    Hurricane Katrina.
        Today, I believe that the resources and the knowledge are,
    in fact, placed squarely in the hands of the States, to use as
    they determine to the best interest of the behavioral health of
    the women, men, and children throughout the Gulf Region, and
    all of those who have been affected. In just these past 3
    weeks, SAMHSA has offered to continue to work with leaders of
    the Gulf State Region to bring greater transparency to the
    process through which resources can be best allocated to meet
    the behavioral health needs of Hurricane Katrina survivors.
        I would be very pleased to answer any questions you may
    have, and thank you again for the opportunity to speak before
    you.
        Senator Landrieu. Thank you.
        Let me begin by commenting that clearly your background
    more than adequately prepares you for the job that you are
    doing now, and I appreciate the sincerity with which you are
    approaching it. One of my questions has to do, though, with the
    law that seems to restrict some funding or most of the funding
    of FEMA going to crisis counseling as opposed to treatment.
        Could you comment about whether you agree with the status
    of the law? If not, have you recommended a change? And how does
    that narrow interpretation affect you from actually delivering
    treatment? Because I understand that the crisis counseling is
    actually limited to five visits only and no real treatment in
    terms of mental health needs.
        Ms. Power. Thank you for the question, Senator. I think it
    is a very important one, and I think that we need to focus on
    the Crisis Counseling Program (CCP), which really was
    originally entitled the Crisis Counseling, Training, and
    Assistance Program when it was started 30 years ago. And I
    think that even if we just talk about the semantics of that,
    the origination of the program was basically designed to really
    be short-term interventions. It was not intended from its
    origin to be long-term mental health treatment.
        One of the things that we have found over the past several
    years, particularly in working with the Gulf States, is that
    the component parts of the Crisis Counseling, Training, and
    Assistance Program are sometimes hard to understand, and we
    need to explain a little bit more clearly what the particular
    programs are under the CCP.
        So under one program of the CCP, which is the Immediate
    Services Program, that is the program that is available for a
    60-day period that is really designed to hopefully support
    public education efforts after disasters about behavioral
    health reactions, and really the phenomena--and, actually, the
    upside of what has occurred post-Hurricane Katrina is that for
    the first time--and I think your Subcommittee is evidence of
    this. For the first time, people are really paying attention to
    mental health and substance abuse issues in a disaster. And I
    really do think that that is such an important step in the
    right direction from a public health perspective.
        The other part of the Counseling Program is the longer-term
    program, which is 9 months, and that program is really
    designed, again, for public education campaigns, for short-term
    interventions, for hotline services, and for individual crisis
    counseling in the outreach to homes.
        What we did do in this particular iteration is that we did
    create, working with FEMA and working with both Louisiana and
    Mississippi, another classification of service called
    Specialized Crisis Counseling Services. And that was, frankly,
    Senator, the first time that they were able to take the Crisis
    Counseling Program and say, wait a minute, we think that there
    might be another level of need that needs to be reviewed; and
    if the State can justify the need in catastrophic disasters,
    there was a specialized crisis counseling service that was
    provided.
        Senator Landrieu. Do you know how much money was allocated?
    Because I see here that the total amount awarded to the
    immediate crisis counseling--I think this is just Louisiana
    numbers--was $20 million.
        Ms. Power. In the Immediate Services Program?
        Senator Landrieu. In the Immediate Services Program for
    declared parishes. Then it looks like there is about $1.2
    million for undeclared parishes.
        Ms. Power. OK.
        Senator Landrieu. Do you know how much of that money was
    carved out for actual treatment the way you have just
    described?
        Ms. Power. Well, I think your question actually talked
    about the fact that there are longer-term treatment needs that
    are not necessarily being met by the Crisis Counseling Program.
        Senator Landrieu. Correct.
        Ms. Power. And I think that is true because the Crisis
    Counseling Program was really expected to meet short-term
    interventions. The individuals from the State I am sure can
    verify this. The longer-term treatment was really, I think,
    identified as being supported through the social services block
    grant dollars that Louisiana received. So that was what I
    understand were the plans to use those funds for.
        Senator Landrieu. Correct, and we received, according to
    this, $64 million. But my point is since you have testified
    that it came to your attention, or the administrator's, that
    perhaps the crisis case program that was crafted 30 years ago
    was missing maybe an important third level of treatment, say
    again what you all did.
        Ms. Power. What we did was we had conversations with FEMA
    and with both the State, both Louisiana and Mississippi, and
    developed what we called an expanded service through
    Specialized Crisis Counseling Services, and that was basically
    intended to try to address some of the needs that you had
    articulated around substance abuse screening and referral,
    suicide risk assessment and intervention, teaching stress
    management techniques and coping techniques and the
    prioritization and triaging of particular anxiety symptoms,
    assisting with the coordination of care, and doing focused
    interventions with a licensed mental health professional and
    resource coordinator.
        So that was the expanded Specialized Service Counseling,
    and both Louisiana and Mississippi took advantage of that.
        Senator Landrieu. Great. And, again, I am trying to get to
    what percentage of the allocation was directed to that new
    approach, generally.
        Ms. Power. We will have to get that for you.
        Senator Landrieu. If you could get that for me, because I
    appreciate the movement to be flexible and try to respond to
    the situation, and I think for the record it would be important
    to know what resources followed that action, because it brings
    me to--and then I will turn it over to my colleague for any
    questions. And this is a small program, but it is somewhat
    indicative. And, again, this is not to be overly critical of
    you personally or your department, but recently, as you know, I
    had to, with the help of my colleagues, reinstate funding for a
    $400,000 grant that was one of the few operational grants in
    the entire Gulf Coast, very small amount of money but
    significant to us, $400,000, that was actually eliminated this
    year in the SAMHSA budget. And I had to, with the help of the
    other Members of the Senate, reinstate that last week in an
    appropriations process.
        So it leads me to believe that while your testimony seems
    to be that you are all leaning forward, evidently there is some
    part of the agency that is cutting back funding when another
    part of the agency is trying to support additional funding.
    Now, we fixed that, and I thank the Senators for stepping up.
    But I cannot keep fixing every $400,000, $300,000, and $200,000
    grant. We have got to see some real action, I think, within the
    Department to make changes that are necessary and recommend
    things to us for improvement.
        Senator Stevens.
        Senator Stevens. Thank you.
        Ms. Power, if you think about the national scene with the
    hurricanes in the Southeast, violent storms in the West, the
    fires in California, and floods up in New England, isn't it
    true that there is this problem of adjustment throughout the
    country today, notwithstanding on top of that we have two wars
    going on? How do you allocate your resources under those
    circumstances?
        Ms. Power. Well, Senator, we have certainly through our
    discretionary grant portfolio and through those programs
    particularly focused on systems of care for children,
    particularly focused on the child trauma network, as the
    Senator had mentioned, and we have a fairly wide portfolio of
    discretionary programs that we know we will hear from and
    receive applications from those areas that have been affected
    by these disasters.
        We have seen the effects of the expansion of the Garrett
    Lee Smith suicide program take effect and take root within
    college campuses. We have seen expansion of the National
    Suicide Hotline, which we actually have created another hotline
    for purposes of response. So we try to use our discretionary
    program, even though it is not huge, we try to make sure that
    discretionary program can appropriately respond to the mental
    health and substance abuse needs of populations. It is very
    huge, and particularly because you as leaders in the Senate and
    in the House are saying mental health is really important, the
    emotional lives of people is very important, and it is finally
    being given the same level of attention as physical health
    care. We applaud that and think that is wonderful. And as
    people become more attuned to and understand what psychological
    first aid is, what resiliency factors work well for people, we
    hope that education and training and awareness are going to go
    a long way for people to be able to understand what they can do
    for their own mental health in terms of traumatic reactions,
    what they can do to support their families and themselves in
    ways we have learned from September 11, 2001. We are learning
    from Hurricanes Katrina, Rita, and Wilma. We are learning from
    each disaster what are some of those risk and protective
    factors that we need to educate people more about so that, in
    fact, people can be armed with much stronger personal tools and
    techniques to be able to handle what is really quite
    unrelenting pressure. With one crisis after another, the
    environment in which we live, with the status of life today, it
    has been very difficult to try to react.
        So we try to use our discretionary portfolio, and we are
    also trying to get information out about how do you assess your
    own mental health, what is good psychological first aid, what
    are good tools and techniques that you need to have as an
    individual. Nobody ever taught us that when we were growing up,
    and we are finally learning that is an important part of our
    educational system and an important part of our family-
    strengthening system.
        Senator Stevens. Well, my comment would be that I am from
    the generation where we did not have that luxury, but beyond
    that, it does seem to me that we are not doing enough in our
    educational process. You just said we used to learn it at home,
    and if we are not going to learn it at home, we have got to
    learn it in school. What are we doing about putting us into the
    educational system and dealing with prevention rather than
    reaction?
        Ms. Power. One of the things that I did, Senator, in my
    life is that I taught elementary school. I taught fifth and
    sixth grade, and then I taught high school math for several
    years. And as a parent and as a teacher, I have always believed
    that we have not necessarily used our schools and the
    opportunities in our schools to build mental toughness and
    mental competency. And so we have adopted an emotional
    competency agenda using work that is well researched in terms
    of bringing emotional competency skills into the classroom and
    helping students build their sense of mastery in terms of their
    own emotions. And we have some selected programs that we use
    with our Safe Schools Healthy Students grantees that we work
    with, with the Department of Education. We have anti-bullying
    programs. We have a number of focused school mental health
    programs that really do reflect and, I think, show an
    appropriate way to encourage our teachers, our family members,
    and our students to become much more knowledgeable about their
    own competency and their own emotional level of mastery for the
    way they are, the way they think, the way they behave, and the
    way they function. And I think that there is very powerful work
    going on in our schools that are selected sites to teach us
    more about how do we get better at that and how can we push
    that out further and make not just centers of excellence but
    have it across the United States in all of our school systems.
        Senator Stevens. Thank you very much.
        Senator Landrieu. Thank you.
        I would like to follow that up now because my question
    would be specific. As you know, we lost--probably close to 50
    schools were destroyed just in Orleans Parish, another 7 in St.
    Bernard, and any number of schools throughout the Gulf Coast,
    elementary and high schools were destroyed, and that whole
    system is being rebuilt and revamped.
        Does SAMHSA right now have any current initiatives with the
    school boards or parishes or counties along the Gulf Coast, any
    extra support that you all are doing directly, not through
    social service block grants, to help with mental health
    counseling in the schools? And if so, where? And if not, why
    not? Is it a lack of resources?
        Ms. Power. I am not familiar, Senator, with anything
    specific. I will go back and offer you my review of, if we have
    any specific grantees that may be receiving some of our
    prevention and school mental health promotion grants, and I
    will take a look at that and make sure that you have that
    information. I did not look at that portfolio before I came
    today. I apologize.
        Senator Landrieu. If you could get that information to us.
        Ms. Power. Absolutely.
        Senator Landrieu. Because this is a real need in our
    schools. The schools have become a potential stabilizing force
    in the community.
        Ms. Power. Absolutely.
        Senator Landrieu. Stabilizing to the children that have no
    home, no church, no playground, no neighborhood, and
    stabilizing to the parents who can put their children in school
    during the day and manage to either gut their home, rebuild
    their home, or go back to work, or all of the above. And
    schools are becoming in this recovery the sort of necessary and
    essential anchor.
        Now, hospitals are anchors, too, and churches are anchors,
    and synagogues, but schools, I am observing as a leader in this
    community, are becoming sort of the central anchor. And it
    seems to me that would be a good place of delivery to help and
    counsel children who can be identified by their teachers and
    administrators, and also a place where parents can be receiving
    information about the state of their own mental health and
    strategies or coping mechanisms as you have suggested. So I
    would like you to look into that.
        Just two more questions, and then we will move to the
    second panel. According to my records, in 1995 and again in
    2002, the FEMA Inspector General recommended that FEMA and
    SAMHSA should collaborate to evaluate the overall effectiveness
    of this Crisis Counseling Program that you have described and
    we have talked about. Do you know if there has been an official
    ongoing collaborative, either then or now, between FEMA and
    SAMHSA to see if this program could be restructured to meet
    some of the needs that we have identified in your testimony?
        Ms. Power. I came to SAMHSA in 2003, Senator, and since I
    have been there, we clearly have an ongoing cooperative
    coordination arrangement with FEMA on a regular basis to talk
    about the Crisis Counseling Program. We did have--and this is
    the other piece that I brought--a final evaluation, outside
    external evaluation on the Crisis Counseling Program done in
    July 2007. So that I am delivering to you today so that you can
    see that this is a formal evaluation of the Crisis Counseling
    Program.
        In that evaluation, they have made very specific
    recommendations for FEMA and SAMHSA to sit down and have a
    conversation about what is the next evolution on this program,
    and, in fact, we are starting those discussions and have had
    those discussions and are going to continue those discussions.
    And as a matter of fact, in preparation for today's hearing, I
    talked to the mental health commissioners and substance abuse
    directors of the Gulf Coast States and said give me your ideas
    about where we need to go, because we have this set of
    recommendations, and we will be sitting down with FEMA and
    having those conversations.
        Senator Landrieu. OK. Thank you for your time and your
    attention, and we will accept that report, and it is something
    that our Subcommittee is going to spend some time focusing on
    because we think the need is real, it is severe, and it needs
    to be addressed.
        Ms. Power. Thank you, Senator. I really wanted to just add
    one other item which I did not get a chance to speak about some
    of the other things that we have been working on. But I will
    tell you that just recently we learned that the State of
    Louisiana had spoken with the Department of Health and Human
    Services about the need that they had relative to the shortages
    of mental health professionals in the area, particularly in the
    areas that you described, and that the shortages in those
    mental health professionals were really a very significant
    barriers to utilizing the existing resources that were
    available for delivering care. And I wanted to just report--
    which I think is good news--that the Department has offered to
    assign Commission Corps officers who have mental health
    expertise to fill vacancies in the State and local clinics
    until full-time staff can be recruited in the areas. And we are
    really excited about the opportunity to be able to have the
    Department in discussions with the State Health Department on
    the feasibility of that, and I think that is really a wonderful
    step in the right direction.
        Senator Landrieu. Well, I appreciate that, and I hope that
    your remarks will be noted in this Subcommittee, but also when
    monies are not expended, which sometimes happens in many of our
    accounts, despite the ongoing efforts for recovery, sometimes
    in most instances it is because of the shortage of personnel or
    the complete destruction of the facilities that would normally
    absorb the funding. And the Gulf Coast should not be penalized
    for that, but the programs should be made more flexible so that
    those resources can be used more slowly over time as our
    personnel come back.
        Thank you so much.
        Ms. Power. Thank you very much, Senator.
        Senator Landrieu. If our second panel would come forward, I
    will do your introductions as you take your seats. Our first
    witness will be Dr. Anthony Speier. He is the Director of
    Disaster Mental Health Operations for the Louisiana Office of
    Mental Health. Prior to Hurricane Katrina, Dr. Speier served as
    Director of the Division of Program Development and
    Implementation for the Louisiana Office of Mental Health. He
    served as Chair of Adult Services and brings many years of
    experience to his job.
        Jan Kasofsky, our second witness, is Executive Director of
    Capital Area Human Services, and let me thank her for her great
    work. Many of the citizens of Orleans and St. Bernard fled to
    the Capital Area, and her agency has done just a heroic job to
    literally provide service and care for hundreds of thousand of
    citizens as they fled to higher ground. She has any number of
    experiences that give her the ability to do the job that she is
    doing now.
        Dr. Kevin Stephens, good to see you again. He is currently
    the Director of the City of New Orleans Health Department. He
    serves on the clinical faculty of Xavier University, Dillard
    University, the LSU Medical School, and Tulane Medical School.
    It should be noted that Dr. Stephens stayed at Charity Hospital
    through the disaster, was there during and immediately
    afterwards, and has been helping to lead the redevelopment of
    our health care system in the region.
        So I hope that you all will limit, of course, your remarks
    to--I think we have 5 minutes each, and then we will open it up
    for questions, and we will start with you, Dr. Speier.

     TESTIMONY OF ANTHONY H. SPEIER, PH.D.,\1\ DIRECTOR, DISASTER
     MENTAL HEALTH OPERATIONS, OFFICE OF MENTAL HEALTH, LOUISIANA
                   DEPARTMENT OF HEALTH AND HOSPITALS

        Mr. Speier. Thank you, Madam Chairman, Senator Stevens, and
    Members of the Subcommittee. I would like to spend a few
    moments giving a little history about the mental health system
    in Louisiana prior to Hurricane Katrina.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Mr. Speier appears in the Appendix on
    page 58.
    ---------------------------------------------------------------------------
        Governor Kathleen Blanco and Senator John Breaux initiated
    a health reform movement in Louisiana in 2004, of which mental
    health reform was a major component. The storm came, challenged
    us in many ways, but that process has moved forward. And we now
    operate under a strategic plan for access to mental health
    care, which is the State's plan to organize services, and it
    goes beyond just what the Office of Mental Health provides. It
    refers to services that occur throughout both the public and
    private sector.
        The basic principles of that plan is the use of evidence-
    based practices, providing effective services for people of all
    ages, provide accessible crisis services, provide combined
    access to primary and mental health care, and provide
    individualized supports for persons with serious and persistent
    mental illness and people with serious emotional disturbance.
        There is a very real crisis in Louisiana and the Gulf
    Coast, as you both have mentioned. The mental health needs, as
    we have seen them in people with serious and persistent mental
    illness, are tremendous and have gotten only worse from the
    storm. When you look at the general population, there have been
    recent studies by both the Kaiser Family Foundation, by the
    Louisiana Public Health Institute, and by Dr. Kessler's group.
    They have indicated over and over how people can access health
    care, people can access mental health care; the hospitals that
    they were used to going to no longer exist. There is even
    better evidence that people who have a more compromised
    situation, people who have less resources available to them,
    have a harder time accessing health care. This is true for
    older adults, middle-aged people, and, most profoundly, our
    children.
        Since September 2005, I have directed the Crisis Counseling
    Program, what we call ``Louisiana Spirit,'' and what we have
    seen in that program is that we have people who never before
    would have used mental health services are now desperately in
    need of them. Just to give you all a few numbers that represent
    the scope of work we have done, since September 2005, we have
    made over 2.6 million contacts with people throughout the
    State. Of those, we have made contacts with people in southwest
    Louisiana and southeast Louisiana. We have provided over
    400,000 more in-depth counseling sessions to a little over
    239,000 individuals, of which 100,000 of those individuals are
    in the greater New Orleans area. And what we are finding is
    those numbers are not decreasing at this point in time. Recent
    numbers from our crisis lines show a doubling of numbers since
    August and September over June and July, and we think the
    anniversary issues and the prolonged rate of recovery have had
    a major impact on people and still has that impact.
        You mentioned the Specialized Crisis Counseling Program,
    which is one of the very positive things that we have been able
    to accomplish with FEMA and SAMHSA, and in our program,
    specialized crisis counselors are providing services to people
    who are experiencing suicidal ideation, who are experiencing
    senses of hopelessness and helplessness.
        We find from our people that they are experiencing fear.
    They are fearful for their children. They are fearful and
    anxious about the next storm and living in a trailer. People
    are sad, and when they get home, they find that they all of a
    sudden experience loss and grief. So they get their home built,
    and then that rush is gone, and all of a sudden the losses are
    tremendous that they experience, and they need to be able to
    deal and treat the grief they are experiencing.
        In Louisiana today, instead of things resolving themselves,
    we still have over 40,000 people in trailers, which we estimate
    between 200,000 and 250,000 people are still in a displaced
    status, both in Louisiana and in our neighboring States. People
    who are still struggling with the early stages of disaster
    recovery, which usually take place in the first 9 months after
    a disaster--or 6 months after a disaster, and we have
    experienced that with a number of storms. This storm is not
    stopping.
        Senator Landrieu. Could you try to wrap up in the next 30
    seconds?
        Mr. Speier. I will. The points I would like to make about
    what we need to do: We need to meet the survivor needs. We need
    a process of providing quick referral and treatment for trauma,
    anxiety, and depression. We need to assist people with profound
    feelings of loss and grief; ensure rapid response to
    psychiatric emergencies; provide commitment to group
    interventions to help survivors re-establish security in their
    lives.
        And what we need to do for future disasters is to provide a
    national strategy where we do psychological first aid; we build
    a mobile volunteer professional corps of mental health
    professionals; we institute mitigation programs where we can
    plan for disasters. Right now we are not able to plan for a
    disaster through the FEMA process if it is a mental health
    issue. We need opportunities to have continuity of operations
    plans, and we need to be able to have 5-year cycles of funding
    that are flexible and allow us to move the dollars as we so
    need so that we meet the needs of the people rather than the
    needs of the Federal regulations. Thank you.
        Senator Landrieu. Thank you very much. Dr. Kasofsky.

      TESTIMONY OF JAN M. KASOFSKY, PH.D.,\1\ EXECUTIVE DIRECTOR,
      CAPITAL AREA HUMAN SERVICES DISTRICT, BATON ROUGE, LOUISIANA

        Ms. Kasofsky. Madam Chairman and Members of the
    Subcommittee, thank you for the opportunity to testify about
    the mental and physical health needs and disaster response in
    the greater Baton Rouge area. I am Dr. Jan Kasofsky, Executive
    Director of Capital Area Human Services District, the publicly
    funded mental health authority in the Baton Rouge area. The
    impact of Hurricane Katrina far exceeds the geographic
    destruction in New Orleans. As you have already mentioned, over
    350,000 New Orleanians initially evacuated to the Baton Rouge
    area, and the efforts by the provider community led the
    groundwork for a best practice approach for normalizing access
    to ongoing care.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Ms. Kasofsky appears in the Appendix
    on page 71.
    ---------------------------------------------------------------------------
        Between 30,000 and 40,000 evacuees remain, some having
    chosen to stay, while others are using it as a staging point to
    return to their city. There is no question that the rate of
    disabilities and homelessness in this population, particularly
    mental illness, is much higher than in the typical population
    and is reflected in the volume and acuity data in this region.
        The public adult mental health clinics currently have a 65-
    percent increase in new clients, more patients in crisis, and a
    10- to 12-week wait to see a psychiatrist. The wait time for
    children is now 6 to 10 weeks. Although the mental health
    clinics have added social workers and streamlined intake
    processes, we cannot meet the capacity expansion demands to see
    and retain patients without adding psychiatrists. Although we
    have the funding, we have not been able to recruit needed
    psychiatrists. It is essential that the recruitment incentives
    for physicians in the greater New Orleans area be available to
    the greater Baton Rouge area to support capacity expansion.
        The local private and public emergency departments have a
    sustained 30-percent increase in behavioral health crisis,
    totaling over 720 individuals per month, with all of these
    individuals needing hospitalization. The large number of people
    using the emergency departments is a clear indication of
    increased trauma, the loss of public and private beds from the
    greater New Orleans area, and a massively overwhelmed local
    public outpatient clinic system. Clearly, increasing clinic
    capacity will greatly assist the emergency departments.
        A specialized psychiatric emergency department is being
    established locally as one of nine components of a crisis
    system. Services there will include administering medication,
    counseling, referrals, and linkage to ongoing appropriate and
    alternative services. This modular unit is being developed
    while we await receipt of the funds into our budget.
        Homelessness is now stable at a 15-percent increase, with
    80 percent noting their disability as mental illness and
    addictive disorders and 37 percent noting that they came to the
    area due to Hurricane Katrina. With 876 FEMA trailers still
    occupied, though scheduled for de-commissioning soon, and
    additional families still receiving rental subsidies for market
    housing, it is anticipated that, given their income levels,
    many will enter the homeless population once subsidies end.
    There must be acknowledgment of the levels of ongoing need by
    the evacuees for accessible, affordable housing, especially for
    those with disabilities.
        Capital Area is newly contracting for housing and treatment
    for individuals with addictive disorders and mental illness to
    serve 120 individuals annually. Within the region, an
    additional 50 to 75 transitional housing beds are under
    construction, and permanent supportive housing has increased by
    31 beds. There are an additional 162 units currently under
    construction or in the development phase.
        While primary care needs are being met, access to public
    specialty clinics is extremely limited. There is an average 17-
    week wait for life-sustaining treatments needed from
    cardiology, pulmonology, endocrinology, and other clinics.
    Access is limited by funding for additional medical
    specialists.
        I will briefly identify five recommended changes to the
    Federal disaster response which hindered or complicated our
    local response and recovery efforts.
        One, psychiatric medicines, methadone, and pain management
    medicines are crucial and must be included in the Federal
    formulary in a disaster.
        Two, a building from which to deliver care at congregate
    settings is required for providers to deliver confidential
    care, provide privacy, and be sheltered from the weather.
        Three, FEMA must establish transportation to nearby service
    delivery facilities from the non-commercial congregate sites to
    avoid dependency on mobile teams.
        Four, the Spirit teams must be able to make direct
    referrals for people experiencing trauma and in need of an
    immediate intervention to ensure service access. The Stafford
    Act must allow this during the immediate disaster response.
        Five, in a disaster, the locally delegated authority must
    be allowed to lead one unified approach as identified by the
    National Incident Management System.
        In conclusion, I want to thank this Subcommittee for its
    attention to our needs and its financial assistance on behalf
    of the greater Baton Rouge area evacuee and provider community.
    In this continuing crisis, we still have ongoing recovery
    needs, especially for psychiatrists and medical specialists to
    expand capacity and for accessible and affordable housing.
    Thank you.
        Senator Landrieu. Thank you very much, Doctor. Dr.
    Stephens.

     TESTIMONY OF KEVIN U. STEPHENS, SR., M.D., J.D.,\1\ DIRECTOR,
                     NEW ORLEANS HEALTH DEPARTMENT

        Dr. Stephens. Good afternoon, Chairman Mary Landrieu and
    Ranking Member Ted Stevens, distinguished guests, all of you
    who are present here. I am Dr. Kevin Stephens, Director of the
    New Orleans Health Department, a city that contributes greatly
    to our culture and commerce in this country, and it is a city,
    however, that is still facing a crisis in the availability of
    mental health care after the worst natural and manmade
    catastrophic disaster that occurred in the United States.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Dr. Stephens with attachments appears
    in the Appendix on page 93.
    ---------------------------------------------------------------------------
        Thank you for providing this opportunity to share with the
    Subcommittee the urgent mental health care needs of our
    community, and we appreciate your continued concern about our
    progress in rebuilding the mental health system.
        Hurricane Katrina devastated our infrastructure, flooding
    seven of the nine hospitals and many other medical facilities.
    And so what I want to do, I want to focus on three things,
    three critical problems: One, the lack of an adequate number of
    available psychiatric hospital beds for citizens in our region;
    two, the ongoing challenge of recruiting and retaining mental
    health professionals, as we heard earlier in this hearing; and,
    three, the criminalization of mental health patients that
    system gaps are causing. I will outline what existed before
    Hurricane Katrina, what is currently available, and, finally,
    what we have to do to adequately serve our citizens.
        Prior to Hurricane Katrina, we had over 350 public and
    private psychiatric beds available in New Orleans, and that
    included 152 beds at the Medical Center of Louisiana, 30 at New
    Orleans Adolescent Hospital, and others at DePaul and the VA.
        The beds at Charity were critical because they served our
    large population of uninsured and underinsured citizens, and
    that facility included 92 inpatient beds, as well as 20 dual
    diagnosis beds for those with psychiatric and substance abuse
    problems, and a critically important 40-person capacity Crisis
    Intervention Unit. This specialized unit allowed for
    individuals in psychiatric crisis to be observed for evaluation
    in a safe place. The Charity CIU served as the single point of
    entry or central triage station. First responders were able to
    transfer care of mental health patients to a designated area
    for medical clearance and psychiatric evaluation, which was
    done within one hour. The proximity to the emergency department
    provided the seamless and critical medical clearance for
    patients to be moved to the CIU for evaluation, treatment, and
    release or admission, depending upon their illness. The CIU
    also accepted referrals from other facilities which depended on
    Charity to appropriately triage the patients.
        Currently, there is less than half the number of public and
    private mental health beds in the city as we had prior to
    Hurricane Katrina. This is a particularly acute problem since
    public hospital beds are unavailable to the uninsured. Of the
    two Medical Center of Louisiana campuses--University and
    Charity--only University Hospital has reopened. It provides
    emergency department services and has 10 beds in a temporary
    mental health emergency room extension (MHERE) unit. University
    Hospital also has approximately a 20-bed detox unit, and the
    State has opened approximately 52 beds at the New Orleans
    Adolescent Hospital and the DePaul sites, with plans to
    increase the number by the end of this year.
        Thanks to the perseverance of Congress on Hurricane
    Katrina-related health issues and the recent hearing, Secretary
    Leavitt gave the area $100 million for primary and mental
    health. We think that these are critical dollars for the area,
    but it is too early for us to determine their impact on mental
    health because we just got these funds several weeks ago.
    However, these funds will not increase the number of inpatient
    psychiatric beds.
        We are also very grateful to the Medical Center of New
    Orleans because--at Charity, because they have expanded and
    responded to the need. However, because of a steady stream of
    people returning home and new people coming to the area, there
    is an increasing prevalence of mental illness since the storm.
        Recent reports, as you will hear later, have said that the
    prevalence of serious mental illness has pretty much doubled
    from pre-Hurricane Katrina. In fact, our EMS department
    averages one call per day of suicide attempt, bizarre behavior,
    or actual suicide. We average 190 police calls per month from
    our 911 call log for serious mental illness and threats of
    suicide.
        The city has three things I will just briefly say: One, the
    lack of a CIU in the area. However, the MHERE at University
    Hospital does not accept referrals from other hospitals; it
    does not serve as a single point of entry for mental health,
    but does provide some services, but we are in need of more. If
    you look in the presentation here, you can see that the ER time
    for the EMS is very prolonged. Our police department has troops
    that go and wait in the emergency room to get services because
    the emergency departments are really clogged up with mental
    health patients.
        A centrally located CIU is also important, and I just want
    to get to the shortage of personnel. We are working with the
    Acting Surgeon General to temporarily help us shore up our
    mental health professionals.
        Last, we have to create a system that does not criminalize
    the mentally ill who go into jail due to lack of services.
        The Stafford Act does provide some resources for crisis
    counseling after major disasters. However, the act does not
    provide for psychiatric services or funding for prescriptions.
        The lack of portability of Medicaid from State to State
    also must be addressed to improve access to health and mental
    health care following a disaster. States should be required to
    give full faith and credit to the evacuating State's Medicaid
    program for the time of the declared emergency. This is
    critical for mental health patients, especially now as we go
    through the next hurricane season and so forth, especially when
    you evacuate to other States, you have to have your insurance,
    or else you have no insurance, and then you are back in the
    problem again. And these people have mental illnesses. That
    makes it more difficult for them to navigate. So this
    portability of Medicaid from State to State, especially during
    a declared emergency, is really something that we think is
    critical.
        I would just like to thank you for this opportunity to
    speak on our mental health status and as well as your
    commitment to New Orleans. And though we face a historic
    crisis, we are hopeful that with your assistance we can solve
    the remaining problems and build a better and stronger
    community for everyone. Thank you.
        Senator Landrieu. Thank you very much.
        I have asked my staff to walk over to the charts here
    because I think it is an important place to start the questions
    for this panel.
        This is a chart of mental health resources in New Orleans
    before Hurricane Katrina and after Hurricane Katrina,\1\ and I
    want to say again that if time would have allowed, we could
    have had the same testimony for every parish and county that is
    affected. Please do not take that this hearing is just about
    New Orleans. It is an attempt to show the needs in the region
    as well as what I have started to refer to as the ``host
    communities,'' led primarily by Baton Rouge, but Hammond has
    been another host community; Lafayette, Louisiana, has been a
    host community; Alexandria, Louisiana; Shreveport; where people
    are still displaced in other places, and I am sure this is the
    same for Mississippi. The people of the Gulf Coast just did not
    disappear. They have gone somewhere else, either to north
    Mississippi or central Mississippi or to Alabama, until they
    can get back to their homes.
    ---------------------------------------------------------------------------
        \1\ The chart submitted by Senator Landrieu appears in the Appendix
    on page 175.
    ---------------------------------------------------------------------------
        So this is a crisis that is going on throughout the whole
    Gulf Coast, but these are just some numbers. If you can see the
    psychiatric beds in New Orleans, there were 350. Now there are
    77. In the greater New Orleans area, it was 668 and now it is
    289. Physicians in New Orleans, 617; now 140. Psychiatrists in
    New Orleans, 196; today it is 22. Doctors participating in
    Medicaid was 400; today it is 100. And this Subcommittee
    intends to give the statistics for all the parishes and
    counties for the record. None will be as dramatic as this, but
    I would say that they are all going to have a significant
    reduction of beds, facilities, and professionals needed to
    solve this problem. And we intend to not just continue to talk
    about this, but to come up with solutions. And the Federal
    Government has an obligation, in my view, to be part of the
    solution, but we are not the only entity responsible, and that
    leads me to the questions to you, Dr. Speier, for the State of
    Louisiana.
        I understand the legislature--and I am not sure if it was
    last year or the year before--recently cut funding to your
    office by 23 percent. Is that true? If not, was there any
    decrease at all in funding? Was there an increase? And can you
    explain your budget situation right now from the State level to
    your office?
        Mr. Speier. I am not aware of the 23-percent decrease. I am
    primarily with the Crisis Counseling Program, so I have been
    involved in that, Senator, and cannot really speak to that
    shortfall. I can speak to that we have received an increase
    this year in our budget funding, annualizing many of the funds
    that were provided through the social services block grant,
    programs the legislature did not have any idea that money would
    continue. They had reviewed our mental health activities and
    made strategic investments out of that many. Rather than that
    block grant money just coming in and going out, it laid the
    foundation for the State to then come in and build sustainable
    programs. And so this year, we have received I know at least
    $13 million towards those programs.
        Senator Landrieu. Because you are saying the Federal
    Government--if I can interpret what you are saying--allowed the
    State to keep its social service block grant funding and not
    have to return it at the end of the year, which is customary.
    It allowed them time to build a basis of services. I do not
    want to put words in your mouth, but is that what you are
    testifying to?
        Mr. Speier. The social services block grant money was one
    year----
        Senator Landrieu. They were one time, but they are allowed
    to be kept, as I recall----
        Mr. Speier. Correct.
        Senator Landrieu. Didn't we extend the deadline?
        Mr. Speier. Yes, and they extended the deadline, but it was
    late in the extension of that deadline. And so we still have
    those social service block grant monies, and the State used its
    own resources to expand mental health services during this
    fiscal year.
        Senator Landrieu. Because it is very important as we try to
    marshal better, more streamlined, more effective, more muscular
    Federal response, that the Federal Government believes that the
    States and the local governments are doing their fair share as
    well in terms of finding solutions.
        What is the State's most pressing mental health need? I
    know you listed several, but if you had to say what is on the
    top of your list from your perspective, what would it be?
        Mr. Speier. The State's most pressing mental health need is
    human resources and the resources necessary to deal with the
    hurricane recovery population. The resources that come into the
    State now through Federal funds for--non-disaster Federal funds
    and State funds are targeting people with serious and
    persistent mental illness, people with serious emotional
    disturbance. Those are the primary populations, and the
    populations mandated by the State.
        The new population which has emerged and continues to
    manifest itself in more significant ways is the hurricane
    recovery population. The people who are worn out and are
    becoming now symptomatic in significant ways, we do not have
    the treatment dollars to address this population nor the
    workforce. We have experienced a 23-percent shrinkage in the
    mental health professional workforce, as your graphs indicate.
    It is what we have experienced all over the State, having to
    close admissions for the first time in clinics in north
    Louisiana because of the loss of workforce.
        So what we need, in my opinion, is incentives that the
    Federal Government could help us establish to retain and
    recruit a workforce and long-term funding for programs like the
    Crisis Counseling Program that included--and include a flexible
    use of the funds with treatment dollars so we can address
    issues of trauma and clinical depression.
        Senator Landrieu. I will just summarize the first part of
    it because this is very interesting to me. In a catastrophic
    disaster, or even a large-scale disaster, you are paralleling
    your efforts to the population that had mental illness before,
    and the current situation has exacerbated it, making their
    treatment options more difficult, their places of service
    sometimes destroyed, whole new systems have to be set up. But
    what you are also saying is there is an emerging population of
    people who were very healthy or relatively healthy mentally
    before that are now showing symptoms of mental illness that
    basically have no structure within the current framework to
    basically be treated or dealt with.
        Mr. Speier. That is absolutely correct.
        Senator Landrieu. All right. Doctor, why don't you go ahead
    and just take that question from your perspective, what would
    be--and your testimony was excellent, and, again, let me thank
    the Capital Area for everything that you all did to help, and
    continue to do. And we, I believe--I have said this many times.
    The Federal response has been not what it needs to be to our
    host communities across the board, and we are continuing to
    work on that.
        But what would you say from your perspective is the most
    immediate and the need of higher priority from your view?
        Ms. Kasofsky. Well, I think the point you just summarized
    that Dr. Speier said is very crucial. We are seeing more people
    who are traumatized who actually do meet the State's criteria
    for mental illness, and so I have been completely surprised
    about the number of people that call for our services that
    actually do meet the serious and persistent now. And so we have
    to increase our capacity for those folks because they are so
    unstable.
        However, as you said, there is another population, there
    has always been another population, that have very few options
    of where they could go. It was typically other not-for-profits
    that had set themselves up to see folks who are experiencing
    mental health issues but hopefully never needing the services
    that the government would provide for a serious mental illness.
    That population was not served well prior to Hurricane Katrina
    because there are just not enough providers that were offering
    it. And now at this point we really do need to see that those
    folks are seen so that they can get some services so that they
    do not ever meet our criteria.
        However, as I mentioned in my testimony, my clinics are
    having a sustained increase of 65 percent of people meeting our
    criteria, people are waiting much longer than they have ever
    waited before between treatments, and we did see a lot of our
    local population actually drop out of treatment during the
    height of the disaster when we had to see the new folks who had
    escaped harm in New Orleans. And so we know that the frequency
    by which we need to see them is not where it should be because
    we do not have enough physicians or psychiatrists, to see them.
        So although I think it is huge that we address the crisis
    needs that Dr. Stephens is talking about and the needs of
    people that meet the criteria in my clinic, we cannot just
    focus on crisis. If we only put our resources in crisis, that
    is all we will ever be able to support. And so we need to look
    at the other interventions for people who are experiencing
    mental health needs who are not seriously mentally ill, have
    their interventions in a timely way. We need to meet the needs
    of people that are chronic and seriously mentally ill. They
    have to be able to have access to doctors, their medicine, and
    the other needs for wrap-around service. And I include
    homelessness. Housing is so critical. It is just not possible,
    it is not feasible to stabilize people when they are half-
    living on the street or in a car.
        So I would say from my perspective that timely
    interventions for people in need who do not meet our criteria,
    the interventions for people that do meet our criteria so that
    they can be seen in a timely way, attain and be maintained in
    stability, and also have housing so that they can get on with
    their lives.
        Senator Landrieu. Let me ask you this, and if it is in your
    testimony, forgive me, but what are the costs associated with
    what you could identify as sort of the typical case of a
    middle-class family who was not mentally--or person who was not
    mentally ill before but who shows fairly severe signs of stress
    associated with either the loss of home, community, etc., what
    would be the--and assuming that the health insurance that they
    still have--which is a big assumption, but assuming they have
    it, does not cover mental illness because most do not--and the
    Federal Government has yet to mandate that, although we are
    very close to doing so, as you know. What would the average
    cost be for a person to receive either treatment or medicine,
    to move them from this point to a healthier situation? I know
    this is a broad question, so all of you could answer generally
    what you think the cost might be to an individual.
        Ms. Kasofsky. I am going to need to claim incompetence in
    that area because the people that come to see us, they are not
    typically middle-class people because of their disabilities.
    And so we do see really only the people that are seriously and
    chronically mentally ill.
        Senator Landrieu. Dr. Stephens, would you know what the
    cost would be to a family that is not covered by a government
    program?
        Dr. Stephens. I do not know, but what we can do after this
    hearing, we can go back and I can compile that and give you
    something other than just off the top of my head, something
    that is based on some real numbers, and get it back to you.
        Senator Landrieu. That would be very helpful. Dr. Speier.
        Mr. Speier. And we have the same situation where we have
    the Medicaid dollars; we know what people spend in that arena.
    We do not have a private sector number. One of the limitations
    is the kinds of services that are available and accessible to
    people, especially people who are not in the Medicaid system.
        Senator Landrieu. Well, it brings me to a point that has
    been a pattern or a common thread through all of these hearings
    as I have observed and tried to help with this recovery, is the
    point that in a normal situation you have a population that is
    either disabled, elderly, very poor, sick, homeless, that are
    covered by government programs, and it is, of course, their
    income limits that are sometimes very low. In other words, you
    can get your services if your income is below $10,000 a year or
    $15,000 a year. But if you think about the hundreds of
    thousands of people that were affected who were generally
    healthy, single earners, or double-earner families, who now
    find themselves homeless, without a neighborhood, were healthy
    before and working before but are unable because of the
    catastrophe. If we do not increase the income limits, this
    whole group is basically without an ability to finance their
    own mental health and physical health recovery. And it is
    something that I think the Federal Government is having a very
    difficult time understanding about this population of recovery
    population. It is not only your typical poor people who have
    limited resources that are struggling desperately under the
    circumstances, but it is a whole new population of middle-
    income families who are otherwise generally healthy,
    financially, emotionally, etc., that without a change in the
    Federal programs are basically left without virtually any
    assistance or aid. And that is what is happening along the Gulf
    Coast.
        We are having a hard time explaining to the Federal
    Government that while we understand we want to and will
    continue to commit our first to the poorest first, and the
    sickest--and we will always have to do that just because of the
    moral obligation--that there is still this huge population when
    you look at the mental health--in particular the mental health
    needs, but it is not only limited to mental health.
        Dr. Stephens.
        Dr. Stephens. Thank you, Senator. I will look at that, and
    perhaps even another graph that you could look at is the
    mortality rate. It was reported by the AMA in the journal
    Disaster Medicine that for the first 6 months in 2006, we had a
    47-percent increase in the mortality rate in New Orleans. And,
    in fact, if you look at the mortality rate of New Orleans and
    compare it to the rest of the country, before Hurricane Katrina
    we were elevated. So this is 47 percent on top of that. And
    part of it is the mental illness and so forth that we see, and
    that is something that I think we definitely need to look at
    and address also.
        Senator Landrieu. And, Dr. Stephens, this will be the last
    question of this panel and we will move to the third, but could
    you comment briefly? We have had hearings and it has been the
    focus of attention about the criminal justice situation, the
    rising murder rate, the challenges to the criminal justice
    system. Just today the district attorney of New Orleans stepped
    aside and a new district attorney has taken over to try to
    stabilize the situation. But is there a nexus potentially
    between lack of mental health services and a rising crime rate?
    Do you have any studies that would suggest that or any data,
    either today you can give that testimony or submit it later, or
    any comments about from your perspective if there is any
    relationship there?
        Dr. Stephens. Well, thank you again very much. No doubt,
    like in the past 6 months, we average 500 hours in transporting
    patients to institutions. The police in July logged 534 hours
    at the emergency room for our EMS. Our EMS director said we
    waste basically a million hours in personnel costs and unbilled
    revenue over the last 6 months because of waiting.
        And so when you go to the prison system, they have the
    largest psychiatric hospital, if you will, in our city, which I
    think is a shame that the largest psychiatric care that you can
    get is a 60-bed unit at the prison. We have 15 female and 45
    male. And I talked to Dr. Gore, the prison medical director,
    and he said he was having the same challenges. He has one full-
    time psychiatrist and one part-time psychiatrist and 60
    patients, and these are critically ill. And then what happens
    is their patients either are sent back into the community or
    they are discharged from home or they are discharged from
    prison without places to go, and so they end up either getting
    hurt or hurting someone else and contributing to the crime
    problem and recidivism and so forth. It is just problematic.
        Senator Landrieu. OK. Thank you very much. It has been an
    excellent panel. I appreciate it.
        They have just called a vote at 3:45, so I am going to
    recess for 10 minutes, and we will resume the third panel
    probably right at 4 o'clock. Thank you so much.
        The Subcommittee will stand in recess.
        [Recess.]
        Senator Landrieu. Our hearing will resume. Let me begin by
    introducing our third panel, if you all will have a seat.
        Our first witness on our last panel is Dr. Ronald Kessler,
    a Professor of Health Care Policy at Harvard Medical School and
    Director of the World Health Organization's World Mental Health
    Survey Initiative. He directs the Hurricane Katrina Community
    Advisory Group. Thank you, Dr. Kessler, for joining us and for
    all the things that Harvard University across the board has
    done to help us. We are really grateful for your support, and
    the many of universities in the country that have stepped
    forward to help.
        Dr. Howard Osofsky is Chairman and professor and head of
    the Department of Psychiatry at LSU. He has been in the
    forefront of this recovery effort and a long-time champion of
    people with mental illness and mental challenges, adults as
    well as children. He is a Psychiatric Association member,
    American Psychiatric Association member and American College of
    Psychiatric Fellow. We thank you very much for your help and
    support.
        And then Mark Townsend is a professor of psychiatry and
    Vice Chairman for General Psychiatry at LSU Health Sciences
    Center in New Orleans. He has extensive experience in community
    psychiatry, having served as medical director of the LSU
    Partial Hospitalization Program and is an assertive and active
    member in community team treatment.
        So I thank you very much, all of you, and we will start
    with you, Dr. Kessler.

        TESTIMONY OF RONALD C. KESSLER, PH.D.,\1\ PROFESSOR OF
       HEALTHCARE POLICY, HARVARD MEDICAL SCHOOL, AND PRINCIPAL
     INVESTIGATOR OF THE HURRICANE KATRINA COMMUNITY ADVISORY GROUP

        Mr. Kessler. Thank you, Madam Chairman and Members of the
    Subcommittee. As you mentioned, I am the Principal Investigator
    of the Hurricane Katrina Community Advisory Group, and this is
    a group of about 1,000 people that we assembled shortly after
    the hurricane. It is representative of all those who were pre-
    hurricane residents of the areas affected by the hurricane who
    we asked to allow us to follow over time in a series of surveys
    to track the mental health and well-being of people in the
    population. This is a series of studies funded by the National
    Institute of Mental Health, FEMA, and by the Assistant
    Secretary for Planning and Evaluation at HHS.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Mr. Kessler appears in the Appendix
    on page 100.
    ---------------------------------------------------------------------------
        In our baseline survey, we found that about 14 percent of
    people who were residents of the hurricane-affected area met
    criteria for SAMHSA's definition of a serious mental illness;
    another 21 percent met criteria for some other mental disorder
    according to the standard DSM categories, and this is roughly
    twice as high as what we find in typical general population
    surveys.
        We also found, though, that unlike typical general
    population surveys where we find that women have higher rates
    than men, poor people higher rates than rich people and old
    people higher rates than young people, the changes in the
    prevalence associated with the hurricane were largely unrelated
    to socio-demographics. This was, for better or worse, an equal
    opportunity disaster that affected broad segments of the
    population, irrespective of their prior vulnerabilities.
        We also found something very encouraging and intriguing,
    and that is despite the high rates of anxiety and depression
    and PTSD in the population, very small proportions of the
    people in this population reported having suicidal ideation,
    plans, or suicide attempts in the first months after the
    disaster. As a matter of fact, we found that these things were
    vanishingly small in the first few months, and what seemed to
    be happening was that in questioning more depth about this,
    despite the fact that many people were understandably anxious
    and worried about the future, they were sad and depressed about
    their losses, there was a sense of strength and optimism in the
    population that was quite remarkable. Many people, as a matter
    of fact, the majority of the population said they felt that
    they were stronger because they had lived through this and they
    survived. They had a sense of greater meaning and purpose in
    their life. They felt more religious. They felt more connected
    to their fellow citizens. So that strength was something that
    seemed to be buffering people from the worst excesses of this
    emotional crisis.
        Now, this kind of positive effect has been found in the
    past. However, we know that this kind of psychological
    adrenaline goes away in about a year. Fortunately, in most
    disasters the crisis period also goes away in a year.
    Construction efforts are made and so forth. That has not been
    the case here. And as a result, when we looked at our follow-up
    survey, the first survey that was about a year later, close to
    2 years after the hurricane, rather than the typical pattern
    one finds where prevalence goes down, we found either
    stabilization of the prevalence, no decrease at all in the New
    Orleans metro area, and an actual increase in the prevalence of
    serious emotional problems in the areas outside the New Orleans
    metro area--Alabama, Mississippi, the other parts of
    Louisiana--and suicidality, a dramatic increase across the
    board in the New Orleans metro area as well as in the rest of
    the hurricane area. About half the people who were affected
    emotionally in a really clinically significant way have been in
    some kind of treatment. Most of that treatment has been
    medications, not psychotherapy. Most of it has been delivered
    by primary care physicians. Most of the psychiatrists that have
    been involved in this effort--as you mentioned already, there
    is a smaller number--they have been focused on the people who
    had pre-existing mental disorders, that severe, persistent
    population. The nuanced cases that we have already talked
    about, the people who are doing well--and these are new cases--
    they are mostly being seen by primary care doctors and being
    given pills without any psychotherapy.
        This is a problem, and as many speakers have said already,
    in a situation of this sort when you have a lot more need and
    lower resources, we are in a tough situation. There is a need
    to expand services. But at the same time, I want to emphasize
    that it is also important to realize that no matter what the
    expansion of services, it is unlikely to be adequate for the
    need. And so in addition to just expanding services, we have to
    think creatively about how to make those services as cost-
    effective and stretch as far as they can. There are some
    interesting models that are out there: Commission Corps we just
    heard about from Kathryn Power, but also there is
    telepsychiatry, collaborative care models where psychiatrists
    part-time consult with primary care physicians to expand their
    services, patient program matching things. And these are things
    that it seems to me we have to encourage work to be done on in
    the future.
        Thank you.
        Senator Landrieu. Thank you, and I am going to be getting
    back to that final point in my line of questioning, because I
    think that is really key to helping to solve the crisis that we
    are in, and I thank you.
        Dr. Osofsky.

       TESTIMONY OF HOWARD J. OSOFSKY, M.D., PH.D.\1\ CHAIRMAN,
      DEPARTMENT OF PSYCHIATRY, LOUISIANA STATE UNIVERSITY HEALTH
                            SCIENCES CENTER

        Dr. Osofsky. Senator Landrieu, Members of the Subcommittee,
    thank you very much for asking me to testify today. This
    testimony is not about pointing fingers; rather, it is about
    the real problems of real children and adolescents in the
    greater New Orleans area.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Dr. Osofsky appears in the Appendix
    on page 113.
    ---------------------------------------------------------------------------
        I want to focus on the dilemma that these children and
    adolescents face in having their mental health service needs
    met. The resources and funding provided do not adequately
    address the mental health treatment service needs of the tens
    of thousands of children traumatized by Hurricane Katrina and
    further traumatized by the continuing stresses due to the slow
    recovery.
        The Stafford Disaster Relief Act Crisis Counseling Program,
    including the Specialized Crisis Counseling Program, while
    helpful, prohibits mental health diagnosis and treatment.
    Children and adolescents, while resilient and pleased to be
    back home, are in desperate need of proven outreach clinical
    evaluation and treatment services. Collaborative efforts of
    LSUHSC trauma trained mental health professionals and returning
    school districts have demonstrated the importance of
    integrating mental health services in school and preschool
    settings to provide support and needed therapeutic help in a
    destigmatized manner.
        The devastation to children and families resulting from the
    displacement and significant losses of all that was familiar as
    a result of Hurricane Katrina provides a unique perspective on
    the effects of this disaster. Our data gathered since the storm
    demonstrates the widespread nature of this disaster which
    personally affected the majority of children assessed. In
    addition to the data we submitted, during the second year after
    Hurricane Katrina, the 2006-2007 school year, well over half of
    the 7,000 children assessed in the most heavily devastated
    Orleans, Plaquemines, and St. Bernard parishes had still not
    returned to their pre-storm homes. Over 40 percent still met
    the cut-off for mental health referral indicating the chronic
    effect of this disaster on children and adolescents. We
    currently are receiving many and increasing numbers of
    referrals and requests for mental health evaluation and
    services from school personnel and parents. The students
    referred are having severe school difficulties--academic,
    behavioral, emotional, and risk-taking. The scientific
    consensus is that we cannot leave these cries for help
    unanswered. Without adequate mental health services, we can
    count on these children having increased incidences of post-
    traumatic stress disorder and depression and decreased ability
    to meet their potential. We strongly believe, and available
    evidence has proven, that these negative outcomes can be
    prevented if adequate mental health evaluation, diagnosis, and
    services can be provided.
        Some lessons we have learned:
        One, it is perfectly clear that we need a better national
    plan for children and families following disasters that can be
    funded at the Federal level and implemented and channeled at
    the local level.
        Two, the Stafford Disaster Relief Act should be revised to
    allow for needed mental health evaluation and treatment
    services.
        Three, mental health services after a major disaster need
    to be funded on a long term basis not only to address current
    problems, but to prevent serious mental health and behavioral
    sequelae.
        Four, if volunteers are to be used effectively, they need
    to be trained in trauma-focused services for children before
    being deployed.
        Five, mental health services have been and should be
    increasingly provided in child- and family-friendly settings
    such as schools and preschools.
        In closing, we very much appreciate your efforts to help
    these children and families. We beseech you that if there are
    resources and discretionary funds available from FEMA and
    SAMHSA, these funds should be provided immediately for
    evidence-based mental health services for these struggling
    children, adolescents, and families who so desperately need
    them. It is clear that this funding is needed now to prevent
    irreparable damage to children traumatized by Hurricane
    Katrina. Your leadership has made and can make all the
    difference.
        Thank you for your attention to this important matter, and
    I will be glad to provide either more data or clinical
    vignettes to demonstrate what we are discussing.
        Senator Landrieu. Thank you very much. Dr. Townsend.

     TESTIMONY OF MARK H. TOWNSEND, M.D., DFAPA,\1\ PROFESSOR AND
     VICE CHAIRMAN FOR GENERAL PSYCHIATRY, DIRECTOR OF PSYCHIATRY,
               MEDICAL CENTER OF LOUISIANA AT NEW ORLEANS

        Dr. Townsend. Thank you, Senator Landrieu and Members of
    the Subcommittee, for letting me testify to you about our
    achievements and challenges. Since July of this year, I have
    been the Director of Psychiatry for the Medical Center of
    Louisiana at New Orleans, which is a part of the LSU Hospitals
    Health Care Services Division. Our medical center consists of
    the newly renovated LSU interim hospital as well as
    comprehensive and specialty clinics throughout the region. Our
    department is composed of faculty mainly from the psychiatry
    departments of LSU, chaired by Dr. Howard Osofsky, and also
    from Tulane University. We have been given the mandate to
    provide psychiatric treatment to a city that, as you know, has
    survived many other traumas, only to be in part irreparably
    flooded in August 2005.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Dr. Townsend appears in the Appendix
    on page 117.
    ---------------------------------------------------------------------------
        One such flooded place was Charity Hospital, which is where
    I worked, which was second oldest continually operating public
    hospital in the United States, which is now closed. Charity
    Hospital at one time had 2,500 beds. At the time of the storm,
    psychiatry staffed 92 of them. Although with relatively fewer
    beds, Charity's emergency department experienced an enormous
    volume. We handled about 600 psychiatric emergencies a month.
    Most of those were treated successfully and returned to the
    community within 24 hours, and that was in our crisis
    intervention unit.
        Of course, because of that I am keenly and personally aware
    of what we have lost at Charity, and I am happy to be able to
    work with the LSU Hospitals administration to preserve what I
    think were the best aspects of treatment at Charity while we
    all transition to a new and more flexible system of care. We
    have to be flexible because we have lost much of the bricks and
    mortar that housed the previous system. And we have to take new
    approaches because patients are best treated and stabilized in
    the community. They have to not present to emergency
    departments and have to not be admitted to hospitals. I also
    think we must identify at-risk youth, as has been already said,
    to prevent those with psychiatric illness from being identified
    and literally treated as criminals. If arrested, we must divert
    these people from prison and address their psychiatric medical
    illness.
        Two years after Hurricane Katrina devastated the city,
    Charity Hospital and its 92 psychiatric beds remain closed. The
    medical center now directs medical and surgical treatment from
    its smaller, sister--University Hospital. Comprehensive
    psychiatric services have been planned for LSU's new teaching
    hospital, but that will be 5 years down the line. Today, the
    region lacks most of its pre-storm inpatient psych beds, even
    though its people have not only largely returned, but also have
    demonstrated persistently elevated rates of mental illness. And
    as you have shown there, New Orleans had more than 300 licensed
    beds prior to the storm.
        However, progress is being made. In September of this year,
    the LSU interim hospital opened new psychiatric inpatient units
    uptown New Orleans at DePaul Hospital in a leased building.
    DePaul hospital had served the region for about 100 years by
    providing a full range of psychiatric services for adults and
    children. And LSU Hospitals hopes to open approximately 40 beds
    on that site, which is an extremely positive development but,
    still, the city has less than a third of its former inpatient
    beds.
        I also want to say that LSU is also addressing other
    important needs. The LSU interim hospital has created an
    emergency room. It is called an emergency room extension that
    is handling 200 psychiatric patients a month. We have also
    opened 20 medical detox beds, and I have to say the LSU
    psychiatry outpatient clinics, which were largely staffed by
    members of the LSU psychiatry faculty, opened very early, way
    back in October 2005. But recent grants, including the much
    needed primary care access and stabilization grant, have
    allowed LSU to expand its office space and also its culturally
    sensitive programs for patients of all ages.
        Both LSU and Tulane medical schools have demonstrated
    tremendous resiliency to be able to be present in New Orleans
    today. And LSU Hospitals' medical centers are more than able to
    provide top-quality psychiatric education. But as we discussed
    already today, the region itself continues to lack key pieces
    of public health infrastructure. I am going to summarize what I
    think those would be.
        These next steps are very complex. Charity's CIU, which Dr.
    Stephens referenced, was able to treat people so efficiently,
    600 people a month, because it was well staffed and the
    community had sufficient inpatient, respite, step-down, and
    group home beds. More mental health professionals, not just
    psychiatrists, which we have spoken about today, but others--
    psychologists, social workers, rehabilitation counselors,
    recreation therapists--all need to be lured back into the area
    to resume clinical practice if we are to open these hospitals
    and these facilities. And community services must be increased
    so that crises can be defused, where they should be, within the
    neighborhoods and not within emergency rooms. And, finally,
    criminal justice diversion programs have to be developed for
    individuals with psychiatric illness whose behavioral symptoms
    have led to arrest. They must be diverted from our jails.
        Senator Landrieu, I want to express my sincere thanks to
    you for allowing me to speak about our progress and our
    challenges, and I am grateful for the assistance that you have
    already provided, and I look forward to assisting you in the
    work yet to come.
        Senator Landrieu. Thank you all very much for your
    testimony.
        Let me begin, Dr. Kessler, with you, where you ended your
    opening remarks. Could you give three or four specific
    recommendations, which I think are included in your statement,
    about new strategies, kind of more effective approaches?
    Because you hit the nail on the head when you said that there
    is basically not enough money in the bank to cover the needs
    that have been expressed and described here.
        Assuming, however, that we can identify some additional
    resources, it is going to take a combination of some additional
    resources and some change of strategy or innovations or new
    tools or methods or approaches.
        Could you comment from your view, having conducted this
    fairly large study, on what some of those effective approaches
    might be?
        Mr. Kessler. Sure. Well, the study itself does not tell us
    anything about effective strategies, but we know from past
    experience that emergency psychiatric medicine has been an area
    where we have lagged in our development of effective strategies
    because emergency situations are emergencies, and we jump in
    and do the best we can. As you probably know, for many years
    debriefing was this method that was considered to be the first
    thing to do where paraprofessionals would go and talk to people
    about their experiences and let them work them out and so
    forth. We now know on the basis of just recent controlled
    studies that not only does debriefing not work, it actually
    hurts people.
        Now the development of psychological first aid just in the
    past few years has been shown to be a much more effective
    strategy. The problem is we do not have a lot of things in our
    bag of tricks that we know to be effective things that work
    specifically in crisis situations. And in this particular
    crisis, we do not have anything that we can pull out right now
    and say it works.
        However, during a crisis of this sort is exactly the time
    where some limited amount of incremental resources should be
    devoted to trying new things, to think about the next crisis
    down the line. It is a hard thing to do when we are in the
    middle of this emergency, but as you mentioned at the onset,
    disasters are becoming increasingly common in America, $50
    billion a year of infrastructure damaged, on average, each year
    for the past decade in the United States. The number of people
    in the aging population who are moving to coastal areas where
    they are subject to these things is increasing. This is not
    just a one-time thing. This is an opportunity to learn
    something about how we can do better during the next disaster
    and the next after that.
        So I hope that in the midst of jumping in and trying to
    plug our hole in the dike at this particular time, we divert
    some resources to thinking creatively about things that we do
    not yet know whether they work but there is potential. I
    mentioned telepsychiatry, which is something that is a
    development in rural areas in America, but is something that
    has a potential here. We know that telephonic cognitive
    behavioral therapy has now been shown to work almost as well as
    face-to-face cognitive behavioral therapy, and there are a lot
    of people that could profit from that.
        Senator Landrieu. Interpreting that to mean counseling over
    telephone?
        Mr. Kessler. Yes, counseling over the telephone. And there
    is good evidence now that this is quite effective, and one of
    the resources that we have in crisis situations is that there
    are many people around the country who are willing to help.
    They do not have any structure to do that. There are
    psychiatrists, social workers, clinical psychologists all
    around America who would be willing to donate 2 hours a week if
    we had a system that would allow them to do that. We know that
    on September 11, 2001 the problem was that there was an
    inundation of an army of people who wanted to help, but there
    was no mechanism to get the help to the people. If we could
    devote some resources to coordination of allowing the resources
    that are potentially available to get to people, there is one
    good one.
        A second one that is of great value is something called
    collaborative care models where psychiatrists do not work with
    patients but work with primary care doctors, so each doctor--
    one psychiatrist is connected to 10 primary care doctors, so
    when the primary care doctor finds a patient that has an
    emotional problem that is well beyond the skill level of the
    primary care doctor, they have one psychiatrist who they talk
    to 3 days a week, and it extends those rare resources in ways
    that could be useful.
        These are just two examples. I do not know if they are the
    best, but the idea is----
        Senator Landrieu. No, I think they are excellent, and I
    would really urge you--and I know your time is very valuable
    and limited. But any other ideas like that that you could
    present in writing or in conversations with the staff to this
    Subcommittee would be appreciated.
        Mr. Kessler. Sure.
        Senator Landrieu. Because we intend to make some of these
    strong recommendations for the future, and I particularly am
    interested in your noting that a larger and larger segment of
    the population is moving towards the coast, not in every case
    but I think the details would suggest that these are retired--
    in some instances, retired elderly, and hurricanes and other
    disasters have a disproportionate effect on older people, as I
    have just observed from our limited background in this. But I
    think this is a very important issue for our country, the aging
    of the population, the increased incidence of major disasters,
    particularly this hurricane-prone region of the Gulf Coast,
    Florida, and the East Coast.
        The other point I wanted you to just--and I want to be
    clear that I heard this correctly. You said that your study so
    far has indicated that some of the initial counseling was not
    only not helpful but it was potentially harmful. Could you go
    over that one more time?
        Mr. Kessler. There is something called ``psychological
    debriefing,'' which was popular for many years among
    paraprofessionals, and Dr. Osofsky can tell you more details
    about it. But it was essentially the idea of telling people
    about your trauma, reliving it, getting it out of your system,
    and sort of catharsis. And that was something that was a
    commonly done thing. It was sort of the norm in the field of
    disaster medicine. We move in and we have all these essentially
    lay people debrief trauma victims.
        Senator Landrieu. And let people tell their story so they
    will feel better.
        Mr. Kessler. And there have now been some studies that have
    shown that it does not work. As a matter of fact, not only
    doesn't it work, but since they do it in groups, what it really
    does is it retraumatizes so everybody hears everybody else's
    story and they go away feeling worse.
        Because we were in the midst of doing all these--running
    around and doing this stuff in crises, nobody took a step back
    and said let's systematically see whether that works or not. So
    taking a step back and sort of thinking carefully about what
    works and what does not has the potential to leverage our
    limited resources by getting us to invest more in the things
    that do work rather than the things that do not work. And right
    now we are in a knowledge deficit situation. We have a lot of
    good psychotherapies that we know that work in general, but
    what works particularly for particular people in these
    situations we do not know. So there is a lot that we need to
    discover about what is most cost-effective in these kinds of
    populations that could help us leverage those rare resources in
    ways that we cannot.
        Senator Landrieu. And, finally, has anyone from any Federal
    agency approached you with a plan to do exactly as you have
    outlined, trying to invest some research dollars and trying to
    find out what works?
        Mr. Kessler. No, they have not, but there are these
    interesting things, and Project Liberty, for example, where, as
    you probably know, there was a hotline set up to refer people
    who called for help to professionals who volunteered to provide
    free help, over 400,000 people were referred to psychotherapy
    in New York. Not a single piece of information was collected on
    whether any of those people went, whether the psychotherapy
    worked, what kind of psychotherapy they got. But there is an
    opportunity to set up systems of this sort that with just a
    little bit extra data collection we could see what things
    worked and what did not, what worked for what kinds of people.
    Instead of referring somebody just to the psychotherapist who
    is closest to you, maybe we will discover that women profit
    more from interpersonal and men from cognitive behavioral
    therapy, and there should be more matching of people to places.
        A one-percent increment in the investment of resources and
    thinking that through could have a dramatic multiplier effect
    in the effectiveness of what we can do.
        Senator Landrieu. And the cost savings.
        Dr. Osofsky, do you currently know of any program that is
    reaching specifically out to teachers or to educators as they
    come back to the community to stand up their schools, any
    particular programs that are helping them to then be able to
    help the children or the parents that they come into contact
    with? Because that would seem to me to be one effective
    strategy. Is there anything that you are aware of currently
    that is being funded in either Louisiana, Mississippi, or the
    Gulf Coast area?
        Dr. Osofsky. If I could just take one moment to comment on
    the points Dr. Kessler was making.
        Senator Landrieu. Go ahead.
        Dr. Osofsky. We have been working with Dr. Speier on the
    idea of training even within the Crisis Counseling Program,
    within the Specialized Services Program, to train the
    counselors in what we call learning collaboratives about mental
    health approaches that can be of help, so that not only within
    the limits of the program, the effectiveness they can do, but
    also they then can go back into their communities and have
    other positions, the additional skill sets that they will have.
    And we are also working with the States on the telemedicine
    program, especially in the child and adolescent area, but in
    psychiatry to help expand services to other parts of the State.
    But I think these are crucial.
        I do want to let you know that we have actually been
    screening--at the schools' request--teachers and to try and
    provide additional services for them, because we are dealing
    with individuals who themselves are very traumatized, who need
    to deal with the traumatized children and adolescents, and then
    at the end of the day also have to deal with their own issues
    that they are going through. And this comes up over and over
    again.
        What I think would also be effective--and we actually find
    there is great acceptance of it, and we do training for
    teachers about red flags and how to look for things and how to
    respond in classrooms, but also to extend this further, I find
    the pediatricians, primary care doctors, nurse practitioners
    would be very responsive to this type of approach in a way
    where--for example, we have seen so many youngsters come in who
    are on large amounts of medication that are inappropriate, or
    some who need medication or they need other types of treatment.
    But we see this with adults, too, and the issue of trying to
    look at the impact of trauma itself and how to differentiate
    and how to respond, how to recognize when there will be
    problems and how to best intervene. And I really do think this
    could be a very positive thing that could come out of all of
    the collective experience and not only help in our State but
    help in the country as well.
        Senator Landrieu. OK. Our time is limited, so I just have
    one more question for you, Dr. Townsend. Given the statistics
    of the lack of professionals that are back serving--and I
    realize the problem is broader of the solutions than just
    recruiting, but it has been mentioned by several members of
    this panel today. What is LSU either doing or recommending, or
    Tulane, for that matter, what could the State be doing, or the
    Federal Government, to help you recruit the professionals you
    need to help re-staff, if you will, the mental health network?
        Dr. Townsend. I think there are two parts to that. Looking
    ahead, unfortunately, all of us seem to be talking about the
    next disaster where we can collect data, which, of course,
    there will be one. If there was a way beforehand to stabilize
    the workforce, just basic profession-specific counseling,
    psychiatrist to psychiatrist, psychologist to psychologist, to
    buy books for people to replace their offices, would have, I
    think, kept some people from leaving the area. But now there is
    discipline-specific money that needs to be available. I
    understand there was nursing money that has now run out. There
    was money to attract physicians. In my opinion, that is not
    nearly enough. And the group of people that seems to be
    preventing us from opening that next wave of hospital beds is
    not nurses; it is licensed clinical social workers.
        So we have to come up with a way of having meaningful--and
    I guess even though it seems like a lot of money, for some
    reason it is not meaningful enough to attract people to south
    Louisiana--meaningful amounts of money targeted in ways that
    get people to come down. I am very appreciative and I like the
    idea of this mobilization corps, but those people will have
    places where they definitely can be used and definitely where
    it is not appropriate because of the lack of continuity of
    care. And, of course, we need people who are going to invest in
    living in south Louisiana or south Mississippi and other places
    for several years to come.
        Senator Landrieu. Do we know what the current recruitment
    either bonus is--what is it for nurses or medical
    professionals? Do we know?
        We will get the information, but I think the Federal
    Government has initiated a small program for recruiting for
    health care professionals, and I will look into it and get it
    put into the record. I do not know if any----
        Dr. Osofsky. We do have that. The one piece is--we have
    actually been very fortunate in retaining professionals and
    recruiting. It is not just having the bonuses to perhaps have
    people come, but the funding so that we can guarantee their
    salaries because I do find people who are very willing to come
    here and want to participate and hopefully to live and stay
    here.
        Senator Landrieu. This would be a good point to end the
    panel. Part of it is not only just recruiting the professionals
    to either stay or come back, incentives to stay or come back,
    but it is also then leveraging, as Dr. Kessler said, the
    nonprofit sector, the volunteer sector, to enhance the capacity
    to deliver services at a fraction of a cost, as opposed to just
    thinking about one-to-one counseling, doctors, social workers,
    etc.
        So these are some very excellent ideas. I thank you all
    very much for being a part of the panel today. We have gone
    over time, but it has been, I think, a very interesting and
    worthwhile discussion, so we look forward to visiting with you
    all and keeping up as we develop better strategies to deal with
    the ongoing crisis in the Gulf Coast and prepare better in the
    future.
        Thank you, and the hearing will come to an end.
        [Whereupon, at 4:56 p.m., the Subcommittee was adjourned.]

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