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Take, for example, the case of Orleans Parish.  Katrina shrank and transformed a city of 444,515 people with a prevalence of serious mental illness of 6 percent (Kessler’s baseline) into a city of 191,139 with a 16 percent prevalence of serious mental illness (PopEst).  So although the population has been cut by over half, the population of those with one or more mental disabilities that impair normal function has grown from around 27,000 to 31,000. Using the conservative estimate that Katrina diminished the capacity of infrastructure and workforce by half, we can conclude that half of the system designed for 27,000, supplemented by Louisiana Spirit and various NGOs, remains to care for 31,000.

But this simple model of the mental health crisis is wildly utopian about how mental health needs are met within the American health care infrastructure. The reality is that due to stigma, a lack of insurance parity, ambiguity in psychiatric diagnostics, and even greater ambiguities in psychiatric epidemiology, the majority of those who qualify as mentally ill are not being treated. In June 2005, Ronald Kessler, the lead author of one aforementioned survey, published a study in the New England Journal of Medicine in which he compared the massive data sets of the National Comorbidity Survey conducted from 1990 to 1992 and its equally massive Replication Survey from 2001 to 2003. Kessler’s demonstrated that, even with dramatic increases in treatment, only 40 percent of those thought to have a serious mental illness received any treatment whatsoever between 2001 and 2003. Of those who did receive care, over half were treated by a general practitioner, meaning that they were only given drugs, not psychotherapy. What’s more, of those who did receive treatment, the majority were deemed to have absolutely no mental disorder (not even a mild or moderate one).

All of this should lead us to understand that mental illness in American has a loose and ill-defined correlation with treatment.  And so, when we assess the capacity of the post-Katrina system in New Orleans, we must understand that a labyrinth of mental health care access and use defined the volume of treatment within the pre-Katrina system as much as the sheer prevalence of mental illness did. The pre-storm mental health infrastructure, centered on Charity Hospital, serviced not the mentally ill of the city, but merely those who had come to rely on it to cope with their profound despair or instability. Because New Orleans possessed what Shartzer and Weaver describe as a “hospital-heavy” system, a disproportionate number of these patients were cared for in inpatient beds. However, thousands of other New Orleanians with similar conditions suffered in isolation from the system, either from preference or a lack of access.

If we are serious about caring for mental illness in post-Katrina crisis, we should look beyond the quality of the care that is being delivered within the struggling infrastructure. Fundamental questions must be asked about who is not seeking and receiving care. As mentioned above, epidemiologists believe that the prevalence of serious mental illness has doubled in the New Orleans region while the total population and infrastructure diminished proportionately to each other. Yet the New Orleans Police Department only receives 15 percent more mental health crisis calls per capita. The private hospitals in Jefferson Parish, which received much of the traffic from the closing of Charity Hospital, are overwhelmed, and yet they are still seeing fewer patients than they did before the storm. The storm has created an even wider gap between prevalence and treatment than normal. As swamped as the mental health system has been since the storm, it is not as swamped as it should be.

There are two explanations for the discrepancy between treatment and disease burden: one pessimistic and the other optimistic. The pessimistic account asserts that the storm and its complex aftermath have interfered with the attempts of the mentally ill to seek care.  Katrina disrupted the treatment routines, housing, transportation, and other sources of stability in the lives of patients who sought care before the storm. The same disruptions have made it difficult for residents who previously managed bouts of despair or psychosis with family support but who now need medical care to locate it in the barren post-storm psychiatric landscape.  These people may never fall apart so violently that they end in a police wagon, but their absence from health care utilization statistics represents their silent suffering.