'Legacy of Katrina' Report Details Impact of Stalled Recovery on Mental Health Status of Children

/PRNewswire/ -- Five years ago Hurricane Katrina and the flooding of New Orleans caused the evacuation of 1.5 million Gulf Coast residents. After a year, 500,000 people remained displaced, many residing in highly transitional shelters, including the notorious FEMA trailer parks. Now at the five-year mark, substantial consequences from this prolonged displacement have resulted in widespread mental health issues in children living in the region, according to a new study by the National Center for Disaster Preparedness (NCDP) at Columbia University's Mailman School of Public Health and a related white paper from the Children's Health Fund (CHF). Together, these documents indicate that although considerable progress has been made in rebuilding the local economy and infrastructure, there is still an alarming level of psychological distress and housing instability. Investigators believe that housing and community instability and the uncertainty of recovery undermine family resilience and the emotional health of children. These factors characterize what researchers are calling a failed recovery for the Gulf region's most vulnerable population: economically disadvantaged children whose families remain displaced.

The CHF report, "Legacy of Katrina: The Impact of a Flawed Recovery on Vulnerable Children of the Gulf Coast," expands upon on a study by NCDP researchers, who have followed a cohort of more than 1,000 families affected by Katrina and the ensuing disruption. According to the Gulf Coast Child & Family Health Study, funded by the Children's Health Fund and published in the current issue of American Medical Association's Journal of Disaster Management and Public Health Preparedness, the widespread mental health problems still experienced by Gulf Coast children serve as a barometer for the failed recovery of their families and their communities. Over one-third of the children in displaced families have been clinically diagnosed with at least one mental health problem since Katrina -- with behavioral and conduct disorders the most common of these problems. Yet fewer than 50% of parents seeking needed mental health counseling for their children were able to access professional services. Furthermore, nearly half of the households in the study were still living in unstable conditions and, five years later, 60% of respondents still report their situation as being unstable or worse than it was before Katrina.

"This study points to a major crisis facing the children of the post-Katrina Gulf Region," says Irwin Redlener, M.D., director of the National Center for Disaster Preparedness at Columbia's Mailman School of Public Health and president of the Children's Health Fund. "From the perspective of the Gulf's most vulnerable children and families, the recovery from Katrina and the flooding of New Orleans has been a dismal failure."

"Previous studies have demonstrated a significant increase in the prevalence of anxiety, depression, and post-traumatic stress disorder, following Hurricane Katrina, as well as a rise in violence and suicide," said Italo Subbarao D.O., MBA, deputy editor of AMA's Disaster Medicine and Public Health Preparedness Journal. "This study adds further credence to widely accepted views that adults and children affected by catastrophic emergencies can experience up to a 40% increase in mental and behavioral illness."

According to David M. Abramson, Ph.D., MPH, director of research at the NCDP and senior author of the study which looked at the roles of parents and communities in children's recovery, "Children are completely dependent upon others in their lives to provide the security and stability that will help them recover. This suggests that the many support systems in children's lives - their parents, their communities, and their schools - are not yet functioning properly. The slow recovery of children's mental health in Gulf Coast populations is a bellwether indicator of how well the region is recovering."

Additional key findings:

-- Even as long as four and a half years after the event, about 45% of
parents report that their children are experiencing emotional or
psychological problems that they hadn't experienced prior to Katrina.

-- Children post-Katrina are 4.5 times more likely to have serious
emotional disturbance than pre-Katrina. For the purposes of this
study, such disturbances were defined as emotional issues,
hyperactivity, conduct and problems relating to peers.

-- Nearly half of people who had been displaced for over a year by
Katrina are still living in unstable conditions.


The study findings are supported by clinical data from the Children's Health Fund, which provides mobile clinics that travel to underserved areas in the Gulf Coast to provide care for families and children. In the period of June 2009 through June 2010, despite improvement in housing conditions in Louisiana, psychiatric, developmental or learning-related disorders in children were diagnosed as frequently as respiratory illness. And in New Orleans alone, approximately 30,000 school children were not able to return to public school. However, data also shows that children who were relocated sooner did better in school than students with longer periods of displacement and those who were enrolled in higher performing schools did the best, thus highlighting the importance of social systems in a child's post-disaster recovery.

Both the study and the clinical reports from the Children's Health Fund's Gulf Coast pediatric programs paint a clear picture of how insufficient government response and recovery efforts continue to take a toll on children's welfare, especially those who are the most underserved. Dr. Redlener, a pediatrician and professor at Columbia University's Mailman School of Public Health, outlined a number of implications for policymakers and others: "Affected families need urgent assistance to return to a state of 'normalcy' characterized by safe communities and stable housing. Nearly two out of three children affected by Katrina continue to experience serious mental and behavioral problems or the stress of unstable housing or both, with children living in poverty over two times as susceptible to serious emotional disorders. We believe that this represents at least 20,000 children affected by Katrina--and perhaps considerably more. Immediate action needs to be taken to increase mental health services in the region."

Dr. Redlener continues, "And it's not just clinical services that are needed by these marginalized families. Every effort must be made to rapidly bring back a 'state of normalcy', that is, stable safe housing for every family in communities with appropriate access to essential services and economic stability."

The Gulf Coast Child & Family Health Study has collected mental health data in the Gulf Coast since January 2006 and covers a random sample of 1,079 households in Louisiana and Mississippi, including 427 children. Face-to-face interviews were conducted by trained interviewers, and the key outcome variable was Serious Emotional Disturbance, based upon the Strengths and Difficulties Questionnaire (SDQ), a widely validated diagnostic screener. The data were collected in four waves over the course of four years with the majority of data for this analysis drawn from the fourth round of data, collected through March 2010.

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Obama Administration issues rules requiring parity in treatment of mental, substance use disorders

/PRNewswire/ -- The U.S. Departments of Labor, Health and Human Services (HHS), and the Treasury today jointly issued new rules providing parity for consumers enrolled in group health plans who need treatment for mental health or substance use disorders.

"Today's rules will bring needed relief to families faced with meeting the cost of obtaining mental health and substance abuse services," said U.S. Secretary of Labor Hilda L. Solis. "The benefits will give these Americans access to greatly needed medical treatment, which will better allow them to participate fully in society. That is not just sound policy, it's the right thing to do."

"The rules we are issuing today will, for the first time, help assure that those diagnosed with these debilitating and sometimes life-threatening disorders will not suffer needless or arbitrary limits on their care," said Secretary of Health and Human Services Kathleen Sebelius. "I applaud the longstanding and bipartisan effort that made these important new protections possible."

"Workers covered by group health plans who need mental health and substance abuse care deserve fair treatment," said Deputy Treasury Secretary Neal Wolin. "These rules expand on existing protections to ensure that people don't face unnecessary barriers to the treatment they need."

The new rules prohibit group health insurance plans -- typically offered by employers -- from restricting access to care by limiting benefits and requiring higher patient costs than those that apply to general medical or surgical benefits. The rules implement the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).

MHPAEA greatly expands on an earlier law, the Mental Health Parity Act of 1996, which required parity only in aggregate lifetime and annual dollar limits between the categories of benefits and did not extend to substance use disorder benefits.

The new law requires that any group health plan that includes mental health and substance use disorder benefits along with standard medical and surgical coverage must treat them equally in terms of out-of-pocket costs, benefit limits and practices such as prior authorization and utilization review. These practices must be based on the same level of scientific evidence used by the insurer for medical and surgical benefits. For example, a plan may not apply separate deductibles for treatment related to mental health or substance use disorders and medical or surgical benefits. They must be calculated as one limit. MHPAEA applies to employers with 50 or more workers whose group health plans choose to offer mental health or substance use disorder benefits. The new rules are effective for plan years beginning on or after July 1, 2010.

The Wellstone-Domenici Act is named for two dominant figures in the quest for equal treatment of benefits. The late Sen. Paul Wellstone, D-Minn., who was a vocal advocate for parity throughout his Senate career, sponsored the ultimately successful full parity act. He was joined by former Sen. Pete Domenici, R-N.M., who first introduced legislation to require parity in 1992. Champions of the legislation also included the bipartisan team of Rep. Patrick Kennedy, D-R.I., and former Rep. Jim Ramstad, R-Minn.

The issue of parity dates back more than 40 years to President John F. Kennedy, and also was supported by President Clinton and the late Sen. Edward Kennedy.

The interim final rules released today were developed based on the departments' review of more than 400 public comments on how the parity rule should be written. Comments on the interim final rules are still being solicited. Sections where further comments are being specifically sought include so-called "non quantitative" treatment limits such as those that pertain to the scope and duration of covered benefits, how covered drugs are determined (formularies) and the coverage of step-therapies. Comments are also being specifically requested on the regulation's section on "scope of benefits" or continuum of care.

Comments on the interim final regulation are due 90 days after the publication date. Comments may be emailed to the federal rulemaking portal at http://www.regulations.gov/. Comments directed to HHS should include the file code CMS-4140-IFC. Comments to the Department of Labor should be identified by RIN 1210-AB30. Comments to the Treasury's Internal Revenue Service should be identified by REG-120692-09. Comments may be sent to any of the three departments and will be shared with the other departments. Please do not submit duplicates.

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Care Management Improves Physical Health of Patients with Mental Illness

Connecting mental health patients with care managers responsible for coordinating their health care significantly improves their overall health and wellbeing, according to a study by Emory University public health researchers.

The study, the first of its kind, tested a population-based medical care management intervention aimed at improving medical care in community mental health settings. Recent studies show that people with severe mental illness die 25 years younger than the general population largely due to medical causes such as heart attacks.

"There is a growing concern about the epidemic of premature morbidity and mortality among persons with serious mental illnesses," says lead study author Benjamin Druss, MD, MPH, professor of health policy and management and the Rosalynn Carter Chair in Mental Health at Emory's Rollins School of Public Health. "This model provides one of the first evidence-based approaches for addressing that problem by helping patients access high-quality medical care."

A total of 407 people with severe mental illness at an urban community mental health center were randomly assigned to either the medical care management intervention or usual care. The patients were all ages 18 and older, considered economically disadvantaged, and experienced serious and persistent mental illness.

For individuals in the intervention group, care managers provided communication and advocacy with medical providers, health education and support in overcoming system-level fragmentation and barriers to primary medical care. Patients in the usual care group were given a list with contact information for local primary care medical clinics and were permitted to obtain any type of medical care or other medical services without the assistance of a care manager.

At a 12-month follow-up evaluation, researchers found that medical care management was associated with significant improvements in the quality and outcomes of primary care. The intervention group received an average of 58.7 percent of recommended preventive services compared with a rate of 21.8 percent in the usual care group.

In addition, patients in the intervention group received a significantly higher proportion of evidence-based services for cardiometabolic conditions (34.9 percent versus 27.7 percent) and were more likely to have a primary care provider (71.2 percent versus 51.9 percent). The group showed significant improvement in mental health functioning, and at one-year follow-up, had a substantially lower risk for heart disease than those in the usual care group.

These findings suggest that care management is a promising approach for improving quality and outcomes of medical care for patients with serious mental illnesses, says Druss.

The study titled, "A randomized trial of medical care management for community mental health settings: The Primary Care Access, Referral, and Evaluation (PCARE) study," was published in the Dec. 15 online edition of The American Journal of Psychiatry. It was funded by a grant from the National Institute of Mental Health of the National Institutes of Health.

In addition to Druss, study authors were: Silke Von Esenwein, PhD, director of research projects, Kimberly Rask, MD, PhD, associate professor of health policy and management, and Liping Zhao, MSPH, senior biostatistician, of the Rollins School of Public Health; and Michael Compton, MD, MPH, assistant professor of psychiatry and Ruth Parker, MD, professor of medicine, of the Emory School of Medicine.

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Blue Cross Blue Shield of Georgia Is Skimping on Mental Health Care, Says Georgia Psychological Association

/PRNewswire / -- Late in 2007, Blue Cross Blue Shield of Georgia (BCBSGa) announced that it was cutting its hourly therapy reimbursement rate for clinical psychologists by approximately 19%. This new rate is about the same as you pay your auto mechanic or home handyman per hour.

However, unlike your mechanic, BCBSGa wants to pay licensed psychologists about half of what they were paid 10 years ago by BCBSGa. In 1998 clinical psychologists were reimbursed by BCBSGa nearly one and a half times today's rate for the same therapy hour. Accounting for inflation, today's rate should be nearly double in 2007 dollars (US Bureau of Labor Statistics based on the Consumer Price Index). Unlike medical doctors and dentists, psychologists see only one patient per hour.

As a result, GPA is hearing from its members that more and more licensed psychologists, especially the most experienced, are finding they can no longer see patients insured with BCBSGa insurance because they cannot run a practice, much less make a living, on what BCBSGa, one of Georgia's largest insurers, is willing to reimburse psychologists

Effective treatment requires highly specialized training and experience. Clinical psychologists licensed in the state of Georgia have either a Ph.D. or a Psy.D. including a bachelor's degree, 4-6 years post-graduate work, plus 1 year supervised internship, and at least one year post-doctoral supervision by a licensed psychologist.

"Research has shown again and again that there is a connection between good physical health and good mental health," said Georgia Psychological Association past-president, Dr. Joni Prince. "And taking a pill alone is not usually the most effective way of improving mental health; psychotropic drugs work better when used in conjunction with psychotherapy," she continued.

But clinical psychologists feel pressured to defend themselves if they see their BCBSGa patients for more than the "licensure type average" of 6.0 sessions, even though BCBSGa offers its PPO customers 50 therapy sessions per calendar year. Major depression, can affect almost 9% of the American population (Mann, New England Journal of Medicine, 10/27/05), and is a leading cause of lost productivity and time off from work. "It seems that Blue Cross is basing treatment decisions on statistics rather than clinical information," Prince said.

What else should you know?

In addition to psychotherapy, psychologists are the only mental health professionals who are qualified to administer, score, and interpret psychological testing instruments, including psycho-educational testing (for IQs, learning disabilities, etc.) and neuropsychological testing, among others.

Yet BCBSGa routinely denies coverage to its customers for psychological evaluations. Evaluations and accompanying clinical interviews are the first step in either diagnosing or ruling out learning disabilities, ADHD, Depression, Anxiety, Bi-polar disorder and other psychopathology. Nearly half (45%) of those with any mental disorder meet criteria for two or more disorders (National Institute of Mental Health press release related to a study published in September 2006 issue of the American Journal of Psychiatry).

Without proper evaluation, mental disorders will go undiagnosed and therefore, untreated. For instance, among adults who have an anxiety disorder about half had symptoms of some type of diagnosable mental illness by age 15, an NIMH-funded study showed. The results emphasize the importance of early diagnosis and treatment of anxiety disorders (NIMH Science Update 2/7/07). "In spite of these studies, many of which are publicized, patients are neglecting their mental health in part due to poor coverage and limited access to quality mental health care," Dr. Prince continued.

Once your child is diagnosed, for example, with Autism or Asperger's, his or her treatment may not be covered by BCBSGa, depending on the type of policy. This flies in the face of Georgia Law, which considers both Autism and Asperger's to be neurological conditions, all of which are mandated by law to be covered equally by insurers (GA Code 33-24-59.10).

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Study Focuses on Teens at Risk for Psychosis

Emory University in Atlanta is playing a key role in the largest, most comprehensive study ever funded by the National Institute of Mental Health (NIMH) of adolescents and young adults at risk for developing a psychotic disorder. The five-year, $25-million study joins the resources of Emory and seven other major research universities, with the goal of identifying more precise predictors for psychosis, and a better understanding of the neural mechanisms involved.

"This is a critical, watershed study," said Elaine Walker, Samuel Candler Dobbs Professor of Psychology and Neuroscience at Emory. "To date, no one has systematically studied brain development, patterns of electrical brain activity and changes in gene expression in youth at risk for psychosis."

Schizophrenia, the most extreme psychosis, affects about 1 percent of the population and can have devastating consequences. Most people diagnosed with schizophrenia are unable to hold a job or live independently for most of their lives. They often suffer from homelessness, major depression and anxiety disorders.

"Because schizophrenia is severely debilitating, usually chronic and very costly, preventing its onset has become a major area of emphasis of the NIMH," said Walker, who has studied the origins and precursors of psychosis for 30 years.

Early Diagnosis Critical for Teens

The typical onset of schizophrenia and other psychotic disorders is about 21 years of age, with warning signs beginning, on average, around age 17. Studies have shown that about 30 to 40 percent of prodromal teenagers – those showing warning signs – will develop schizophrenia or another psychotic disorder. About 25 percent of the prodromal teens continue to experience mild symptoms without getting worse, while the remaining 35 percent get better as they enter adulthood.

"We are hoping to get to the point where we can identify people who will cross the threshold into psychosis with 85 to 95 percent accuracy, instead of 30 to 40 percent," Walker said. "Evidence has been accumulating that, not only are there brain abnormalities in people with psychotic disorders, the brain abnormalities get worse the longer the patient goes untreated."

While anti-psychotic drugs can be effective, they also have serious side effects, so physicians are hesitant to recommend them until someone enters the clinical stages of psychosis.

Stress Hormones May Hold Key for Treatment

Walker recently completed a study that tracked changes in the stress hormone cortisol over several years in prodromal teenagers. The results found much sharper increases in cortisol levels in the participants who were eventually diagnosed with a psychosis. "This suggests that youth who are vulnerable to psychosis may be especially sensitive to elevations in cortisol selection," Walker said.

One hypothesis of the NIMH study is that changes in stress hormones that occur in at-risk adolescents are influencing gene expression in the brain. "All neurons in the brain have receptors for hormones and research on animals has shown that cortisol can change how these neurons function," Walker said. "If our theory is right, and we can identify what's going on with this process, it's possible that we could eventually modify cortisol secretion in a way that buffers teenagers against its effects, and gets them through this critical risk period."

Each of the eight institutions involved in the NIMH study will recruit 100 prodomal teenagers and 50 controls to participate in the project. Participants will undergo regular diagnostic interviews, measurements of their cortisol levels, magnetic resonance imaging (MRI) to observe physical development of their brains, and electroencephalography (EEG) to measure neural electrical activity. In addition, the researchers will regularly collect and compare genetic data of the participants.

Researchers are now undergoing training in the study protocol, to ensure data standardization. In January, recruitment for participants will begin. In addition to Emory, the institutions involved are: Harvard, Yale, UCLA, UC-San Diego, Einstein Medical College and the University of Calgary.

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Cognitive Behavioral Therapy Effective for Treating Trauma Symptoms in Children and Teens

Individual and group cognitive behavioral therapy is effective in reducing depressive disorders, anxiety, post traumatic stress disorder or other trauma symptoms in children and teenagers, according to an extensive review of dozens of studies conducted by the Task Force on Community Preventive Services, an independent group of scientists partially funded by the federal government.

However, many clinicians are using other types of therapy, such as art, play or drug therapy, which are not proven to be effective. The findings are published in the September issue of the American Journal of Preventive Medicine.

Cognitive therapy focuses on a person′s thoughts and beliefs, and how they influence mood and actions, and aims to change a person′s distorted thinking patterns. Behavioral therapy focuses on actions and aims to change unhealthy behavior patterns.

Mental Health organizations have estimated that more than 75 percent of U.S. mental health professionals who treat children and teens with post traumatic stress disorder are using therapies that are not known to be effective.

“The good news is there is substantial research showing the effectiveness of group or individual cognitive behavioral therapy in treating children and teens experiencing the psychological effects of trauma. We hope these findings will encourage clinicians to use the therapies that are shown to be effective,” said Robert Hahn, Ph.D., MPH, coordinating scientist at the Centers for Disease Control and Prevention’s Community Guide Branch and an author of the Task Force report.

In addition to individual and group cognitive therapy, the Task Force evaluated other interventions including art therapy, play therapy, drug therapy, and psychological debriefing, but could not find sufficient scientific evidence to support their use. The Task Force recommends that more research be done on other forms of therapy to determine whether or not they might be effective.

“Childhood trauma is a widespread problem with both short- and long-term consequences. Many kids with symptoms of trauma go undiagnosed, which can lead to unhealthy behaviors in adulthood such as smoking and alcohol or drug abuse,” Hahn said. “Increased screening to identify trauma symptoms in children can help these kids get the therapy they need and lessen the likelihood they will engage in these risky health behaviors when they become adults.”


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America Supports You: Group Offers Free Mental Health Counseling

Mental Health practitioners nationwide are donating their time and services to provide free, confidential counseling to military people and their families.

"Combat affects everyone in one way or another," explained Dr. Barbara Romberg in an "ASY Live" interview on BlogTalkRadio. "Most people react when exposed to a situation where there are extreme or horrific events; it is a human reaction to abnormal situations."

ASY Live is part of the Defense Department's America Supports You program, which connects citizens and companies with servicemembers and their families serving at home and abroad.

Romberg, founder and president of "Give an Hour," said she started her nonprofit organization to educate servicemembers and their families about the seriousness of post-traumatic stress disorder and the importance of taking steps to combat it.

"When we set up the organization a few years ago, the concept was very simple, she said. "We asked mental health professionals across the country to give an hour of their time."

When one of the program's providers was asked why she joined, Romberg said, her answer was equally simple. "How could I not? It's so little that they are asking of me to give," the practitioner said.

Romberg said a broad spectrum of mental health practitioners participated in Give an Hour. "We have mental health professionals of all kinds -- psychologists, psychiatrists, social workers, licensed marriage and family counselors, substance abuse counselors and pastors," she explained. "One size doesn't fit all; people need different things."

Raising awareness about PTSD is as important to the group as providing help to people who need it, she said.

"We are really launching a public education campaign to make sure our entire country understands post-traumatic stress -- what it is and why it's so important to address," she said. "Post-traumatic stress is a condition that will affect most people."

Romberg said there are important signs that a family member can identify that may be an indication that professional help may be a necessary part of the recovery process.

"Anyone might be withdrawn or irritable for awhile, but if those symptoms persist past six or eight weeks, then you need to take action," she said. "If the family member seems to be uninterested in activities that they used to be interested in before, uninterested in relationships with spouses or children, or engaging in persistent drinking or substance abuse as a way of escaping, that's a warning sign," she explained.

Nightmares, anxiety attacks and rage can lead to very serious symptoms if left untreated, she added, "but it doesn't have to become a chronic mental illness at all."

For that reason, Romberg explained, it is important that family members work to recognize symptoms and seek counseling as quickly as possible. Most people want to feel as if they can handle these issues, she said. And in fact, they can, but sometimes they need assistance, she added. That's where Give an Hour comes in.

Give an Hour provides counseling not only for servicemembers, but also for affected family members, whom Romberg defines as "anyone who loves someone who is serving."

"When someone we love is deeply affected, the consequences are usually fairly far-reaching," she explained. "Spouses and children are, of course, an immediate concern, ... but grandparents, aunts and uncles are just as affected by this situation.

"If you, as a family member, feel like you have resources," she continued, "you can put together a plan and you have ... someone else to help you think through it, and eventually encourage [your] loved one to come with [you]."

It is also important, she noted, to keep a close eye on children.

"Spouses that are focused on their husband or wife, it might be really difficult to also be concerned with their children," she said. "We see things such as regression -- a young child that's maybe 3 was potty-trained and all of a sudden starts wetting the bed or isn't eating or sleeping well."

The services offered by Give an Hour are free and ongoing, and providers stay in the network a minimum of a year, Romberg said.

"If their provider has to leave, we provide a replacement," she noted. "They are never told, 'You've used up your services here.' By building such a hard network, it's not a hardship to give an hour. And [the practitioners] are happy and eager to give."

To receive support or to register to become part of this support network, people can visit the organization's Web site, www.giveanhour.org. People seeking help can search for the nearest participating provider by entering their ZIP code.

"It can be an educational conversation or it can be setting up an appointment to meet face to face," Romberg said. "If they don't know what type of assistance they need, they can also click on the 'Contact Us' button, ... and we will help locate a provider.

"It's all about partnering, networking, reaching out, connecting -- helping them to get what they need," she said.

By Jamie Findlater
Special to American Forces Press Service

Jamie Findlater, host of "ASY Live" on BlogTalkRadio, works in the New Media directorate of the Defense Media Activity.