Hurricane Response Often Ignored Mentally Ill People

Persons with psychiatric disabilities must receive the same help as other people when disasters strike and should be included in every stage of emergency planning, according to a report from the National Council on Disability, a federal advisory group.

“We hope that the report will be read by anyone concerned with disaster relief and prevention,” Julie Carroll, J.D., senior attorney adviser for the council, told Psychiatric News.

That would include psychiatrists interested in disaster issues, said Arshad Husain, M.D., chair of APA's Committee on Psychiatric Dimensions of Disasters and director of the University of Missouri International Center for Psychosocial Trauma, in Columbia, Mo. He plans to send copies of the report to members of his committee, he said.

The report documented how Katrina and Rita caught so many agencies and organizations involved with disaster response off guard. It was based largely on media reports and firsthand accounts of persons with psychiatric disabilities derived from conference calls organized by the National Council on Disability, but did not involve any formal survey, said Carroll. The report said that relief organizations and governments at all levels mismanaged evacuations, discriminated against persons with psychiatric disabilities, and terminated recovery services prematurely.

The council used the term “people with psychiatric disabilities” to describe people who use or have used mental health or psychiatric services, including those in some phase of recovery prior to the hurricanes.

“People with disabilities were segregated from the general population in some shelters, while other shelters simply refused to let them enter,” according to the report.

Even before they reached shelters, some persons with psychiatric disabilities ran into problems. Residents of group homes or other psychiatric facilities were lost to emergency officials, who were unprepared for the special requirements needed to transport or relocate them. Some ended up in state parks or other refuges that were not set up to meet the needs of persons with psychiatric diagnoses. Still others were inappropriately institutionalized because they were stereotyped with the stigma of mental illness.

“Shelters were crowded, noisy, chaotic, confusing, and sometimes violent, all inadequate circumstances for a person with psychosis, anxiety, or depression,” said the report. “Many ended up living right outside the shelters, and services were not provided to people living outside the shelters.”

“Sad to say, people with mental illness are far down on the totem pole in the best of times, but they are even farther down in the worst of times,” said ron Honberg, J.D., legal director of the National Alliance on Mental Illness (NAMI). “Denying access to shelter to persons with psychiatric disabilities is almost like sentencing them to death.”

These inadequacies were visible right after Katrina, said Honberg. Two weeks after the storm, NAMI sent a letter to the acting director of the Federal Eergency Management Agency (FEMA) asking for expansion of the agency's crisis counseling program to include help for persons with serious mental illness, both preexisting and triggered by the hurricane.

The lack of preparation affected even the most routine aspects of evacuation. A police officer's knock on the door could be easily misinterpreted by a mentally ill person if it raised the image of an earlier involuntary commitment episode.

Longer-term relief measures raised new problems, said the report. FEMA forms or applications for housing were often difficult to fill out with assistance. Untrained FEMA representatives often denied housing to persons with psychiatric disabilities after incorrectly assessing their disabilities. FEMA or the Stafford Act may cover short-term mental health services but were not designed for people who might remain displaced for months or years.

“FEMA mental health resources were designed only for `normal reactions to abnormal situations,' but not for people with serious mental illnesses separated from their own services,” said Honberg.

In its report, the National Council on Disability urged a range of policy changes at all levels of government. Relief services like FEMA housing, HUD housing waivers, and Medicaid coverage should continue for at least two years after a disaster, argued the report. Medicaid mental health services should include conditions worsened by the disasters as well as caused by them. Federal agencies such as the departments of Homeland Security (the parent of FEMA) and Health and Human Services should adopt policies and regulations that reflect the requirements of the Americans With Disabilities Act and Section 504 of the Rehabilitation Act to provide relief services that don't discriminate against those with mental illness. State and local officials should rethink evacuation procedures, select one person to be responsible for disaster disability questions, and simplify procedures to allow out-of-state health professionals to work during an emergency. Trained peer advocates should be allowed to provide counseling under the Crisis Counseling Assistance and Training Program. The American Red Cross should train its personnel to better identify and work with people with psychiatric disabilities. Finally, the report urged that people with disabilities be included in planning for disasters and allowed to participate in relief and recovery efforts.

Thus far, many localities have been incorporating similar recommendations for handling people with disabilities, but not many have yet included people with psychiatric disabilities, said Carroll.

“All of us should have been better prepared,” said NAMI's Honberg. “Now we are less interested in making accusations and more interested in learning the lessons, correcting the problems, and making sure it doesn't happen again.”

“The report should be viewed as a beginning of a healthy dialogue,” said David Post, M.D., medical director of the Capital Area Human Services District in Baton Rouge, La., in an interview. “Certainly there are many lessons to be learned, especially that we all should be mindful of the specific needs of those with disability.”

“The Needs of People With Psychiatric Disabilities During and After Hurricanes Katrina and Rita” is posted at<www.ncd.gov/newsroom/publications/2006/peopleneeds.htm>.▪