Hurricane Katrina devastated the Gulf Coast last August, causing at least 1,300 deaths and billions of dollars in property damage, and there are concerns that the emotional and psychological toll could be enormous as well. The Substance Abuse and Mental Health Services Administration, for example, recently estimated that half a million people who were affected by the hurricane may need some form of mental health counseling.

What may set Katrina apart from other disasters that have occurred in the United States is not only the scale of destruction left behind but the length of time for which people have been affected and will continue to be affected. A number of research and volunteer projects are under way at universities along the Gulf Coast to assess the psychological impact of people in the region as well as to help residents cope. Some of the researchers involved with those projects shared their ongoing work, as well as their firsthand experiences and observations, in interviews with NeuroPsychiatry Reviews.

"What stands out for me the most is the complete and utter devastation of this area that you can’t put into words or pictures on TV," said Carl Weems, PhD, Assistant Professor of Psychology at the University of New Orleans. "You can drive from New Orleans to Biloxi, Mississippi, and for a hundred miles you will basically see nothing but flood-ravaged homes. On the coastline along Mississippi from the Rigolets, which is the coastline by New Orleans, to Gulfport and Biloxi, the houses are just completely and utterly wiped out." Dr. Weems was preparing to move into a house two blocks off the Gulf of Mexico in Long Beach, Mississippi, when Katrina struck, and upon returning he found "nothing left of it except the brick steps to the front porch and front door, and rubble that was my house in my neighbor’s yard, and my truck, with a house and yacht essentially on top of it, across the street in my neighbor’s front yard."

Trying to gauge the psychological effects of Katrina—along with Hurricane Rita, which hit much of the region less than a month afterward—may be difficult from a timing standpoint, because the exact impact date is less clearly defined, compared with other disasters such as the 9/11 terrorist attacks and Hurricane Andrew in 1992, according to Stacy Overstreet, PhD, Associate Professor of Psychology and Director of the School Psychology Training Program at Tulane University in New Orleans. "Most families for Hurricane Andrew stayed in Miami, and so the day the hurricane hit was the day of the impact, and 9/11 is a similar sort of phenomenon," she said. "In New Orleans, 80% of our population evacuated the city ahead of the storm. So when you are thinking about what to expect along this timeline, it’s hard to know when impact is. Was it the media exposure? Did they find out their pet died? Was it two months later when they came back to New Orleans for the first time and saw their house? It’s a really complicated picture of knowing when we are going to start seeing some of these issues arise."

TRAUMA AND PERCEPTION

Dr. Weems is leading a group of investigators who are conducting a cross-sectional study of children and adults who were living in the Gulf Coast region when the hurricane hit. Thus far, about 400 people (ages 12 to 86) have completed surveys regarding their levels of stress, experience of the hurricane, and other factors. Though all the data have yet to be compiled and analyzed, Dr. Weems has observed a few trends.

"We’ve gone to some Federal Emergency Management Agency [FEMA] sites and shelters and talked to people in our neighborhoods and some students at universities in Mississippi and New Orleans, and we’re finding that lots of people have experienced lots of different traumatic events," said Dr. Weems. "When we asked them, ‘What was your worst experience of the event?’ [the responses] were very wide-ranging—from ‘Swimming out of my attic window,’ to what I think is very interesting in terms of the media coverage, ‘Watching what is happening on TV and feeling how poorly New Orleans has been portrayed on TV.’ From the footage at the Superdome to the footage at the Convention Center, some people felt very badly about being from New Orleans because of the bad reputation that the media portrayed people who live in New Orleans as having."

Participants were also asked whether they felt discriminated against because of their background. "Interestingly, across ethnicities in Mississippi, we’ve gotten very few people saying that they felt discriminated against, regardless of what ethnicity they were," commented Dr. Weems. "In New Orleans, again across ethnicities, whether they were Caucasian or African-American, people said, ‘Yeah, I do feel like I was discriminated against, because I’m from New Orleans. Not because of my ethnic background, just because people from New Orleans aren’t to be trusted….’ The image that comes to my mind when I read these responses is the people looting and stealing while the city flooded."

Dr. Weems pointed out that a number of people who expressed this concern were among those who evacuated before the storm hit, and so instead of experiencing the storm directly when it hit, they watched TV coverage of it. "What’s going to be interesting is when we get these data compiled, to be able to look and see if people who felt [discriminated against], if they do have a lot of symptoms or similar level of symptoms as those who swam out of their attic window. The type of trauma that one experienced may not be all that important, but the way one interprets the experience that he or she did have is the big thing that I’m looking forward to trying to figure out."

So far, according to Dr. Weems, among respondents who have reported adverse symptoms at least "a little bit" or "some of the time," 25% were feeling worthless, 30% were having nightmares, 35% were hopeless about the future, 47% were feeling no interest in things, 47% were lonely, 50% were feeling blue, and 82% said that they became upset when they thought of what had happened. "Only 6% reported thoughts of ending their life, a much smaller but still troubling number," he said.

ANXIETY DISORDERS IN CHILDREN

Dr. Weems’ group is also conducting a longitudinal investigation of more than 200 youths ages 7 to 17. "We were poised to have cognitive, physiologic, and social risk factors or variables, and we were testing how they were related to the development of anxiety," he said. The researchers had completed one-year follow-up interviews in about 60 children, "and then the hurricane hit. So we’ve changed the focus now a little bit to how those variables interact with the experience of trauma to predict the development of problems more broadly in the wake of something like a natural disaster."

Armando A. Piña, PhD, Assistant Professor of Psychology at Arizona State University and coinvestigator of the child anxiety study, said that based on very preliminary data collected thus far, children have reported problems such as an inability to concentrate, worries, and difficulty sleeping, "which are symptoms that are typical to youths who have anxiety problems," he said. "If a significant group of kids is presenting with a new set of problems, because we are assessing the impact of the hurricane itself, we would be able to determine statistically whether their behavior problems are related to the experience of the hurricane, to all of the stress associated with this after the hurricane, the breakdown of social support, or any problems in their families that they might have experienced afterward," explained Dr. Piña.

The researchers are going to compare posttraumatic stress disorder (PTSD), anxiety, depression, and other behavioral symptoms, pre- and post-Katrina. They plan to follow up with all the families that they had assessed pre-Katrina, "but the challenge is finding them now," noted Dr. Weems. "To date we have found 78 families, and 58 (74%) have agreed to follow-up interviews, and about 40 have been completed."

Defining PTSD in children has always been particularly difficult, according to Dr. Weems. "It’s going to be a great opportunity to look at the development of this disorder in kids whom we have gotten basically prospective data on, which usually you can’t get, because the trauma happens, and you say, ‘Here is a group of people that may develop PTSD,’ but you don’t know what their symptoms and characteristics were like before the trauma," he said. "We have collected a number of pretrauma variables, and so we will have an idea of what they were like before the trauma and can determine if any of these personality variables predicts response to trauma.

"I think what this research may show us is what PTSD really is and which children have a propensity to develop symptoms. I hope the research can inform the DSM-IV so we are better able to identify those youth who experience a traumatic event and are going to have some of these symptoms immediately and then which are going to go away, and also identify those kids who really have longer-term problems, because it’s really the maintenance of these symptoms that constitutes the problem."

SCHOOL COUNSELING

Dr. Overstreet is currently counseling children in New Orleans at Lusher Charter School (kindergarten–12) and at St. Peter Claver, a parochial school (prekindergarten–8) in Treme, one of the oldest African-American neighborhoods in the United States. She said that so far, children are having nightmares and difficulty sleeping. "I think the hardest thing for them is dealing with the ongoing challenges of living in New Orleans right now," she commented. "Most of our kids are living in houses that are being renovated, or they are living with family or friends while their houses are being renovated. They are in different schools, they are with different people, their whole lives have changed. So a lot of the stress that is happening is from dealing with ongoing, day-to-day stress, as opposed to reliving their hurricane experiences."

Basically, two groups of children have emerged, she said. One consists of those who constantly talk about hurricane-related issues. "They are sort of retelling their story over and over again and perseverating on the stresses that they are dealing with day to day," said Dr. Overstreet. "I think that’s a warning sign for the development of PTSD." Then there are children who want to completely avoid all thoughts, feelings, and conversations about Katrina. "We’re actually kind of seeing a developmental difference. Our high school kids are tending to be the avoiders—‘I’m OK, I don’t want to talk about this, I’m tired of dealing with it’—and the younger kids are more likely to be talking about it all the time."

Dr. Overstreet is also helping to implement a curriculum that is focused on teaching general coping strategies to deal with stress as well as providing opportunities to process Katrina-specific experiences. "We’re hoping that we can do some preventive work to help kids deal with the ongoing stress that they are facing and also gain some coherence over the chaos that has been their lives lately," she said.

EVACUEES IN HOUSTON

Peter Norton, PhD, Assistant Professor of Psychology and Director of the Anxiety Disorder Clinic at the University of Houston, volunteered at a medical center set up at Houston’s Astrodome after evacuees were moved there from the Superdome in New Orleans, all of whom have since moved into other housing. In general, people were overwhelmed, he said. "That’s really the only word that I could use to adequately describe it. Every one of them looked like they had been through a nightmare that we couldn’t imagine…. Many of these people lost loved ones, lost their homes, lost everything."

Dr. Norton noted that evacuees in Houston were reluctant to approach the mental health area to speak with anyone. "They had too many other issues to try and deal with, keeping their family together, locating loved ones who were possibly on another bus or in a different area of the Astrodome," he said. "Also, to some extent, I think we are catching a bit of a cultural issue. Going to see psychologists or mental health professionals is a little less typical among African-Americans, which the evacuees, at least the ones at the Astrodome, predominately were. So [officials] took most of the mental health professionals and put us in other units."

Dr. Norton ended up assisting in a quarantine unit, where his role was to help counsel sick people who were told that they were going to be confined to one room for three or four days, which increased their anxiety about being separated from their family. "The common thread among evacuees was the fear of losing their family, after everything else they had lost," he said. "Because at that point, that’s pretty much all they had."

Dr. Norton believes that the psychological impact will lessen for most people in the coming months. "But for a small subset of people, you are going to see a lot of PTSD symptoms begin to emerge these days, where they are starting to have some bad dreams or nightmares about it," he said. "The first storm that hits [this coming year] is probably going to terrify some people."