Hogg Foundation for Mental Health

Assessing the Mental Health Needs of Texas' Hurricane Survivors

March 1, 2006

As part of the foundation's continuing efforts to monitor and evaluate Hurricane Katrina and Rita's survivors' needs for mental health assistance, staff recently held a meeting with a national expert in disaster-related trauma and a local mental health expert to better understand how the mental health needs of survivors may translate into increased service demand for Texas in the coming months.

Since hurricanes Katrina and Rita, Texas foundations and state and local governments have attempted to determine the scope of mental health problems in the evacuated population. Anecdotal reports indicate that the use of services by evacuees has been minimal and within the service capacity of existing agencies. However, some organizations have reported that 20 to 25 percent of the evacuated population is likely to develop mild to moderate mental health problems within five to six months of the disasters, which suggests the possibility of an increasing demand for mental health services in the near future.

To assess these predictions and their implications for the state, Dr. Fran Norris, research professor in the Department of Psychiatry at Dartmouth Medical School and a psychologist with the National Center for Post-traumatic Stress Disorder, and Dr. John Burruss, assistant professor in the Department of Psychiatry and Behavioral Science at Baylor College of Medicine, were asked to participate in a telephone discussion with Ms. Heidi McConnell, advisor to Governor Rick Perry, and with Hogg Foundation representatives Dr. King Davis, Ms. Carolyn Young, and Dr. Laurie Alexander.

According to Dr. Norris, a leading expert in the study of natural disasters, research indicates that a significant proportion of disaster survivors experience mental health problems.

Overall, the literature suggests that 25 to 30 percent of survivors from areas hardest hit by disasters are likely to show signs of Post Traumatic Stress Disorder (PTSD) or related psychiatric disorders. However, when looking at an entire population of disaster survivors, with varying levels of exposure to the disaster, 5 to 10 percent is a better estimate of the numbers of people likely to develop PTSD or related disorders.

Norris indicated that there is rarely a surge in demand for mental health services following a natural disaster. Of all survivors experiencing PTSD and related symptoms, only 7 percent will seek care from traditional mental health settings immediately following the disaster.

Findings from the National Comorbidity Study indicate that 80 percent of people with PTSD eventually seek mental health treatment; however, the median delay from trauma to treatment is 10 years. In the initial period following a disaster, help seeking is more likely to be through primary care providers rather than through specialty mental health providers and organizations.

There are a number of known risk factors for developing mental health problems following a natural disaster, said Norris. Children are particularly vulnerable to mental health problems following a disaster of the magnitude of Hurricanes Katrina and Rita. Displacement from the community is another important risk factor and particularly relevant to the Katrina and Rita survivors. Many of the other risk factors for developing PTSD are the same as for mental illness in general, including prior mental health problems, poverty, and ethnic/racial minority status.

Prior research on disasters has demonstrated that ethnic minorities are particularly vulnerable to developing PTSD and related problems. In Norris' study of Hurricane Andrew, she found large differences in rates of mental health problems across ethnic/racial groups. Spanish-preferring Latinos had the highest rates of mental health problems, followed by African Americans. English-preferring Latinos had approximately the same rates as non-Hispanic Whites.

Norris noted that level of exposure to the trauma partially explained these differences; however, they were primarily due to differences across groups in treatment preference, loss of control (including a sense of fatalism), discomfort in working with professionals of different ethnic/racial backgrounds, and distrust of mental health providers.

Norris indicated that Katrina and Rita evacuees with mental health problems will likely be reluctant to seek help from the established health and mental health system despite the availability of highly effective treatments for PTSD and related disorders. Stigma and distrust are important barriers to their help seeking. The cultural histories and experiences of many of the evacuees act as impediments to their accessing mental health care in Texas, thus increasing their risk of developing more serious problems in future months and years.

Untreated PTSD may lead over time to physical health problems, increases in marital strife, domestic violence, lower family well-being, lower overall functioning, lost work days, and school adjustment problems in children. The limited research available indicates that the cost of untreated PTSD for society is significant.

Norris provided foundation staff with a bibliography of relevant research articles, which will be posted on the foundation's website.

Two studies are currently underway to assess the health and mental health status and needs of Katrina and Rita survivors. McConnell reported that one conducted by the Gallup organization focuses specifically on Texas survivors and will be completed in March 2006.

Norris stated that a study by Dr. Ronald Kessler, Professor of Health Care Policy at Harvard Medical School and Principal Investigator of the National Comorbidity Study, will utilize a national sample of evacuees.

Awareness of the ethnic and cultural differences in hurricane survivors' help-seeking patterns and their multiple risk factors have guided the development of Project Resiliency in Houston, which was recently proposed by Dr. Burruss and colleagues in conjunction with the local mental health authority, behavioral health provider network, and city health department.

The plan focuses on outreach to survivors in a variety of settings, including apartment complexes and schools.

In their work, Dr. Burruss' group is grappling with various issues in establishing a "second- tier" system of services in which evacuees have access to services that many Texans do not. Those issues include the length of time such services can be offered, sources of funding over time, the impact on citizens who are not evacuees (but who have equally pressing mental health needs), and the burden on the service community.

Looking to the future, the group agreed that the best strategies at present are the following:

Share the discussion from this meeting and available research literature on disasters with other foundations, governmental bodies, and provider organizations;
Assess the findings from the two research projects currently underway;
Encourage Houston's Project Resiliency and track its results over the next months;
Assess the involvement of Gulf region foundations in mental health-related projects for evacuees; and
Convene the discussion