- The Washington Times - Wednesday, August 5, 2009

Last of three parts.

NEW ORLEANS

The debate raging over how to alleviate New Orleans’ burgeoning mental health crisis pits two very different solutions from two strong-willed politicians against each other: Mayor C. Ray Nagin wants more beds immediately to treat patients in hospitals, while Louisiana Gov. Bobby Jindal’s administration is pressing for more outpatient treatment.

The planned closing Sept. 1 of the New Orleans Adolescent Hospital - the city’s lone public hospital with a dedicated mental health ward - has created a flash point. And neither side is sparing words.

The metal bars and barbed-wire fences associated with older mental institutions like NOAH represent “not a system [but] a failure,” said Alan Levine, secretary of Louisiana’s Department of Health and Hospitals. “It’s a dinosaur, a relic of what mental health systems looked like 20 years ago.”

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But opponents of the closing say that the city already is desperately short of facilities for its neediest patients and that plans to shift the patients to a hospital in Mandeville, La., will unnecessarily isolate them from friends and family.

Even now, “police are sitting in hospitals waiting for patients to be offloaded. We are in a crisis now. We need relief,” said Dr. Jullette M. Saussy, director of the city’s Emergency Medical Services (EMS). “In the face of all this, they are closing NOAH.”

Earlier in this series, The Washington Times documented an explosion in mental health problems after Hurricane Katrina, which swept away many residents’ homes, social networks and loved ones when it battered New Orleans in September 2005.

A study by the World Health Organization, which surveyed residents in the same areas of Louisiana, Alabama and Mississippi both before and six months after Katrina, found that the ratio of residents with some degree of mental illness had risen from 15.8 percent to 31.2 percent.

At the same time, New Orleans saw its ability to deal with mental illness sharply diminished, with the number of inpatient beds for the mentally ill reduced from 400 at 10 hospitals four years ago to just 170 beds at seven hospitals today.

Now NOAH, the only remaining public hospital in the area with beds for mental patients (it has 35), is to close on Sept. 1 and be integrated with Southeast Louisiana Hospital, a mental institution 40 miles away on the other side of Lake Pontchartrain.

Mr. Levine said the $14 million that Louisiana will save with the move will be used to improve much-needed outpatient services.

“You don’t prevent people from committing crimes by building more jails,” he said. “Similarly, you don’t prevent people from having mental problems by building more beds; all it is doing is cycling people in and out of beds. What solves the problem is expanding more resources in the community.”

But some independent psychologists contacted by The Washington Times said that even with a smaller population that it had before Katrina - now about 300,000 - New Orleans is going to need all the facilities it can provide, both inpatient and outpatient.

“The mental health needs of a city having undergone the issues New Orleans did have increased, not decreased,” said Dr. Rodney Lowman, a distinguished professor at Alliant International University in San Diego.

“A declining population does not offset the very large increase in mental health needs of a devastated city that is far from over its crisis. It is difficult to imagine that the current number of mental health services are sufficient,” Dr. Lowman said.

“Mental health services of all kinds are needed to address the huge number of mental health conditions - both obvious and hidden - that accompany a crisis of the type that city experienced.”

Defenders of NOAH are pinning their hopes on a lawsuit filed July 10 on behalf of a NOAH patient and an employee against Mr. Jindal, Mr. Levine and other state officials. The venue for the lawsuit, which seeks to stop the consolidation with Southeast Louisiana Hospital, recently was moved from Orleans Parish to the state capital, Baton Rouge.

The closing of NOAH “violates the ‘enumerated rights’ of the mentally ill under Louisiana law and places thousands of family members and other innocent citizens at risk for grave physical harm and even death,” the lawsuit argues.

“Without judicial intervention, mentally ill patients will become a real and immediate danger to themselves and the community-at-large,” it adds. “The harm will be irreparable, but it is preventable.”

Arguing against the merger with Southeast Louisiana Hospital, the lawsuit cites one incident in which a New Orleans resident died after jumping out of an ambulance during the drive across the Lake Pontchartrain causeway to Mandeville.

Different lessons drawn

There is another reason New Orleanians are leery of Southeast hospital: It once housed Bernell Johnson, one of the city’s most notorious killers.

Johnson, described by relatives as a paranoid schizophrenic, had just been released from Southeast when, on Jan. 28, 2008, he was approached on a New Orleans street by Nicola Cotton, a female police officer half his size who thought Johnson fit the description of a wanted rape suspect.

Suddenly agitated, Johnson turned violently on the 24-year-old officer. He seized her baton and used it to beat her during a prolonged struggle, then got her handgun and shot her with it, emptying the chamber into her lifeless body. Officer Cotton was two-months pregnant.

After the shooting, Johnson remained at the scene, and gave up the gun without a struggle when Officer Cottons fellow officers arrived.

“He stayed by her body because his paranoia was over,” said Dr. Kevin U. Stephens, the New Orleans director of health. “A normal person would not have stayed by a shot police officer.”

Both sides of the NOAH debate identify the death of Officer Cotton as the turning point for mental health awareness in New Orleans, but they are drawing different lessons from the incident.

Mr. Levine said he had been in his Baton Rouge-based job for less than a week when the shooting occurred.

“I got an e-mail from the public health director in New Orleans, who said [Officer Cotton] was murdered by a gentleman who had just been discharged a day before, or a couple of days before, from one of our mental health institutes. So, welcome to Louisiana; this is your problem,” Mr. Levine said.

“It used to be [mental health patients] were institutionalized, stabilized and released into the same community where they came from without having any support - an endless cycle of not solving the problem.

“This is the landscape I walked into,” Mr. Levine said.

After the shooting, Mr. Levine said, he spent the next two weeks in New Orleans trying “to understand the failures.”

“In New Orleans and Louisiana, but certainly in New Orleans, there is a heavy reliance on inpatient mental health services,” he said. “There were no community-based services for someone like the man who killed Nicole. He was in and out of institutions.”

Mr. Levine said the tragedy shows the need for more outpatient services to make sure the mentally ill receive regular attention, take their medication and are reintegrated into the community.

Innovative therapies

He pointed in particular to the development of innovative outpatient services that, he said, will reduce the city’s dependence on hospital beds.

In-home therapy - in which counselors deal with patients along with their families in a home environment - reportedly had an 80 percent success rate in keeping adolescents and young adults with severe behavioral problems in school and out of institutions.

Another program known as Assertive Community Treatment - in which doctors and social workers team up to provide psychiatric treatment, rehabilitation and support - has reduced hospital days by 58 percent to 85 percent, jail days by 83 percent and homelessness by 37 percent, Mr. Levine said.

One of the more creative projects is the peer-to-peer program operated out of the city’s Metropolitan Human Services District.

Former drug addicts and those who suffer from mild forms of mental illness serve as volunteers to canvas mental health clinics, offering assistance to patients suffering from similar maladies.

Chris English, a former crack cocaine user, is a trained peer-to-peer specialist who has gone to unusual lengths to help the mentally ill and drug addicts find a place to live by filling out laborious paperwork and authenticating their needs.

“If someone tells us they are sleeping on a rooftop, we have to go to the rooftop to make sure,” said Mr. English, who has his own history of rooftop living.

He was locked inside the New Orleans city jail when Hurricane Katrina hit, trapped for two days without food or any sight of a guard. He and 20 other men eventually broke through the ceiling, using bed rails to bash the cinder blocks, and made their way to the relative safety of the roof; there they awaited rescue along with another 80 prisoners who had reached the roof by other means.

“I am someone [the patients] can relate to,” Mr. English said.

Clear need seen

Other community leaders, however, see the Johnson case as proof of the city’s need for sufficient inpatient facilities so that potentially dangerous patients are not released prematurely onto the streets.

This year to date, the city’s coroner has ordered 250 people placed under protective custody for emergency psychiatric evaluation in a hospital, and the police department is transporting, on average, 200 mental health patients per month to hospital emergency rooms, said Mr. Nagin, who would like to see improvements in both inpatient and outpatient care.

“There is a clear need in our city for long-term and short-term mental health services,” Mr. Nagin told The Washington Times. “Many people in crisis in our community will require a period of hospitalization in facilities that best practices dictate should be accessible to their families for support.”

The mayor pointed out that many of the city’s residents with mental issues “were further impacted by the physical destruction and emotional trauma of Hurricane Katrina. Our focus is on the health and well-being of our citizens in crisis, and the closure of NOAH is a negative impact on their lives.”

Dr. David F. Duncan, president of Duncan and Associates and former chairman of the Mental Health Section of the American Public Health Association, comes down somewhere between Mr. Nagin and Mr. Levine. Institutions are not a thing of the past, he said, but their role will diminish as alternative forms of outpatient care are developed.

“A hospital distant from a city is a poor substitute for one in the city,” Dr. Duncan said. “If all else were equal, it would make far better sense to close a rural hospital and expand an urban one.”

The New Orleans Adolescent Hospital, despite its name, accepts adult as well as adolescent patients, but Dr. Duncan said its focus on younger patients makes it a poor choice to serve as New Orleans’ only public mental hospital.

“Adolescents are far less likely to need inpatient care and far more likely to be harmed by it,” he said.

That’s the message Mr. Levine wants to drive home to the people of Louisiana.

“I want to get to a place where we are not institutionalizing children. The best place for them is the home and community-based settings,” Mr. Levine said. “The point is you treat them in their setting. You can put a child in an institution and then send them back where they came from, having not solved their problem.”

Amanda Carpenter contributed to this report.

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