[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.
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    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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