These results should be interpreted with the following four sets of limitations in mind. First, the survey excluded people unreachable by telephone, leading to under-representation of the most disadvantaged and possibly most severely ill. Systematic survey non-response (i.e., people with mental disorders having a higher survey refusal rate than those without disorders) or systematic non-reporting (i.e., recall failure, conscious non-reporting, or error in the diagnostic evaluation) are also possible. Prior studies suggest that these lead to underreporting of traumatic events as well as mental disorders from traumatic experiences, and therefore underestimation of unmet need for treatment (20
Second, psychopathology was not assessed using structured diagnostic instruments but by chronic condition checklists and a screening scale. For the K-6 scale, good concordance with clinical interviews has been consistently documented both in our small reappraisal of Katrina survivors as well as earlier methodological studies (12
); however, it should be kept in mind that individual-level imprecision regarding diagnoses may have been increased because of the use of such measures.
Third, corroborating data on treatments are lacking, raising the possibility that the self-reported information on service use is to some extent biased. Some investigators have found that self-reports of treatments may over-estimate service use in administrative records, especially regarding the frequency of visits (22
). Finally, the survey's cross-sectional nature prevents us from concluding that the observed correlates and reasons are causally related to mental health service use.
With these limitations in mind, these results reveal that two forms of unmet need for treatment were very common among Katrina survivors with mental disorders: disruption of existing treatments among people with prior needs as well as failure to initiate treatments among those with new needs. Over 1/5 (21.3%) of respondents reported having an active mental disorder in the 12 months before the hurricane, a somewhat higher estimate than previously reported for mental disorder rates in the two Census Divisions subsequently affected by Katrina (8
). Among those with pre-existing disorders, over 1/5 experienced disruptions in their care after the hurricane including roughly equal proportions that received fewer and that received no mental health services post-Katrina. Among respondents without disorders in the year before the hurricane, 18.6% developed new onset disorders and this percentage was significantly higher in metropolitan New Orleans than in other affected areas. Only 1/5 of these new onset cases received any treatment during the post-hurricane period. The limited data available on mental health service use after disasters corroborate our findings. Among evacuees living in Louisiana FEMA shelters, parents reported difficulties maintaining and initiating mental health treatments both for themselves and their children with mental health needs (24
). Even after disasters not marked by large-scale displacement or destruction, many with mental health needs experience difficulty accessing or continuing in care (25
Our findings of frequent disruption in existing treatments and widespread failure to initiate new ones may not be surprising, given the already high background levels of undertreatment in the U.S. (30
) and the fact that Katrina struck people who before the hurricane were among the poorest and largely racial or ethnic minority residents. However these results may not be unique to Katrina survivors and could generalize to the likely populations that would be adversely impacted by future catastrophes. Those with lesser means and minorities have been shown to be at higher risks of psychological harm from disasters, even though they unfortunately possess fewer resources and supports to cope with the hardships from such catastrophes (31
Furthermore, following the disaster there was widespread loss of mental health care facilities, treatments, and personnel, as well as the employment, financial resources, and insurance to pay for care (9
). These losses were greatest in New Orleans perhaps explaining why reductions in existing treatments were more common there than in other affected areas. Such losses in infrastructure, personnel, and financial means to pay for treatments are reflected in the finding that lack of enabling factors was given by the vast majority of existing cases as the reason for their disrupted treatments. Mental disorders are also often associated with low perceived needs for treatments, high levels of stigma, and even avoidance of mental health care for fear of re-experiencing painful memories (11
). These attitudinal barriers appear to explain why many new-onset cases, did not seek any treatments after Katrina.
The negative consequences of both forms of unmet need for treatment are uncertain. Katrina survivors with mental disorders could conceivably have had their symptoms quickly dissipate, both without treatment and without long-term consequences. However earlier studies have shown that most cases of post-traumatic stress disorder (PTSD) have durations greater than one year (37
), with more than 1/3 failing to recover after many years and times to remission being nearly twice as long among those untreated versus treated (20
). Dysfunction, development of comorbidity, and suicidality have been associated with even subthreshold PTSD symptoms (20
The services that Katrina survivors did receive is likely to reflect both what was available as well as patients' preferences. Most used the general medical sector for mental health care, emphasizing the importance of training and supporting primary care personnel to deliver quality mental health treatments in disaster settings. One means to do so might be to increase the co-management of cases by general medical and mental health specialty personnel, a practice that was exceedingly rare among Katrina survivors. While psychiatrists saw only a small proportion of cases overall, they had provided treatment to nearly half of those with pre-hurricane needs experiencing disruptions in care; such findings may indicate a particular role for the psychiatry sector in ensuring treatment continuity during disasters. Pharmacotherapy was the most commonly used modality of treatment for emotional problems, suggesting that current initiatives, most importantly the Strategic National Stockpile of emergency medications, include frequently used psychotropic classes (40
). Use of psychological counseling was much less common, despite some prior research showing that this modality may be preferable to pharmacotherapy in largely underserved minority populations (41
). Psychiatrists were more likely to deliver some form of counseling, suggesting they might be used to increase use of psychotherapies in future disasters.
The correlates of initiating and continuing in mental health treatments are consistent with prior research in both the general U.S. population as well as the few studies of disaster survivors (30
). The lower rates of initiating mental health treatments among racial and ethnic minorities post-Katrina is concerning and suggests that their greater financial barriers and prior experiences or expectations of poor care due to prejudice may continue to operate and discourage help-seeking during disasters (43
). That having insurance is associated with starting treatments is also worrisome, given that 20% of the non-elderly in Louisiana and Mississippi were uninsured before Katrina and this proportion swelled after the disaster due to job losses (26
). The greater likelihood of treatment disruption among the young may be due to their greater dependence on others to obtain and remain in treatments—a dependence that can grow in the chaotic aftermath of disasters (25
). Those with lower incomes may not have the financial means to pay for treatments, leading them to cut back or drop out (29
Hurricane Katrina has shown that complex humanitarian disasters—acute situations affecting large populations caused by multiple factors such as shortages of basic necessities and population displacement that result in significant morbidity and mortality—can exact a heavy toll on those with mental disorders (47
). Many in this vulnerable population dependent upon mental health care will have their treatments disrupted; likewise, many with new-onset disorders will fail to start treatment. Given this reality, what can be done in the U.S. during a complex humanitarian disaster to deal with the financial, structural, and attitudinal barriers to mental health care and ensure the initiation and continued use of treatments? Our ability to make specific recommendations is limited by the absence of a systematic analysis of the health care delivery systems that were available to Katrina survivors. However at a minimum, informational resources could be posted by the CDC, SAMHSA, and other organizations to alert disaster survivors with mental health care needs to what, how, and where treatments can be obtained (48
). Emergency insurance programs, such as Medicaid waivers enacted after the World Trade Center disaster and by 17 states for Katrina survivors, also appear to be necessary to help low-income survivors and those without insurance coverage to pay for services (44
). Regardless of the ultimate strategies chosen, they will need to address the knowledge and attitudinal barriers among survivors that afflict programs in which services are only passively made available (46
). Active screening and aggressive outreach interventions already developed to enhance treatments in primary care could be explored for use in disaster settings (50
). Multiple potential responses may be necessary to ensure the health of the many vulnerable and underserved survivors with mental illness.