Welcome, Introductions, and Charge to the Workshop

Wanda K. Jones, Dr.P.H., Deputy Assistant Secretary for Health, DHHS Office on Women’s Health, welcomed the meeting participants. She described their task as being to develop recommendations for concrete products and toolkits that could be developed from the Office of the Surgeon General to address key mental health issues affecting women and girls. Dr. Jones explained that each workgroup was comprised of a diverse range of participants (e.g., researchers, advocates, providers, consumers) to ensure that a full range of perspectives would be represented.

Rene Andersen, M.Ed., LCSW, Center on Women, Violence, and Trauma, described her personal and professional experiences with the effects of trauma, violence, and abuse on women and families. She told of her own experience of growing up in a family that appeared to be fun and loving on the outside (the “day stories”) but that hid an intergenerational cycle of abuse (the “night stories”) filled with cries of despair and terror. Ms. Andersen told how this history led to legacies of depression, addiction, posttraumatic stress, and a host of physical ailments in her life and those of her siblings. She told of being overmedicated and subject to many diagnoses and treatments – all of which overlooked this history of abuse for many years.

Ms. Andersen explained that the experience of trauma is central to the lives of many women and that emotional, physical, and sexual traumas are pervasive. She emphasized that violence is a social disease and not a personal issue. She also stressed the importance of helping the victims of trauma, violence, and abuse to understand that it need be neither unbearable forever nor passed from one generation to the next. Ms. Andersen offered herself as living proof that healing is possible. She noted that there are indeed many “rafts in the river” to offer help and support, including relationships with friends, service providers, recovery groups, and the like.

Everyone knows at least one woman who is a survivor of trauma, commented Ms. Andersen. She suggested that we must turn to women survivors as experts and truly listen to the stories they have to tell. She called for a fundamental shift in diagnosis and treatment founded on the belief that everyone can heal and that the question “What is wrong with you?” should be replaced with the question “What happened to you?”

Ms. Andersen concluded by inviting the audience members to conjure the image of one woman in their lives who has had to survive trauma or mental illness. She asked them to keep that image close at hand during the course of this workshop as a reminder of how closely the issues of mental disorders, trauma, and violence touch everyone directly and through the women they love.

“I see this work as more than a job. I see it as a tribute to my mother and my grandmother.”

– Richard H. Carmona

U.S. Surgeon General

Vice Admiral Richard H. Carmona, M.D., M.P.H., FACS, U.S. Surgeon General, shared his experience of being a high school dropout and growing up in an environment of poverty and hardships. He spoke of his grandmother trying to raise her children and grandchildren in Harlem; his father, with no high school education, unable to sustain a life with four children; and a mother trying to instill in her children the value of education and knowledge as a way to escape poverty. The Surgeon General described a childhood living in substandard apartments, being homeless, and moving into the projects with 12 people in a tiny apartment. He talked about the critical roles his mother and grandmother played as the powerful women in his life, who continually battled to sustain their families despite poverty, homelessness, being immigrants, alcohol abuse, and other difficulties. Their continued determination to take care of their families, he explained, taught him about resilience and made him keenly aware of the roles women play in our society.

“The purpose of this meeting is to bring you all together as parents, providers, scientists, consumers, and so forth to guide the development of these communiqués, whatever they end up being. I welcome the opportunity to argue with you to figure out the right path so that girls and women will say we got it right.”

– Richard H. Carmona

U.S. Surgeon General

The Surgeon General told of how his mother would say that men have run this world for most of eternity – and are running it into the ground. She would point out that men see the world differently from women and that women tend to be more conciliatory and try to bring people together to resolve problems.

Dr. Carmona turned to the audience of workgroup participants and described their role as the foot soldiers in the battle to address women’s mental health and the broader issue of how it fits into their overall health. He recognized the risk they face of being marginalized by other events of the day, but he offered his commitment and support.

Dr. Carmona noted that when he was chosen to be the U.S. Surgeon General, the President described the primary issue to be addressed as that of becoming a Nation that embraces prevention, health, and wellness – because ultimately, we all pay the price for poor health or health care crises. Thus, he explained, prevention and preparedness are the primary areas of focus in the Office of Surgeon General.

In the area of health preparedness, Dr. Carmona stressed the importance of being ready in the face of emerging infectious diseases, such as SARS, mad cow disease, and avian flu, as well as other natural and manmade threats. He pointed to the need to determine how to prepare first responders and other critical support personnel to be ready to deal with these issues. In addition, he referred to the importance of looking at prevention and preparedness at the household level – where it is almost universally the women who bear the responsibility for taking care of the health of the family, making the health decisions, and being the family health leaders.

The Surgeon General also discussed the importance of the issue of health disparities – noting that he has had personal experience with these disparities and knows firsthand what it is like not to go to the doctor for years. He underscored the need not to lose sight of the fact that ours is still a nation divided as it relates to race and health. We should be outraged, he suggested, to be living in the greatest nation in the world but one where not everyone has the same health care access and outcomes.

“Those of you taking part in this workshop, you are the foot soldiers. You run the risk every day of being marginalized by the events of the day, but I’ll be right with you. My commitment is 110 percent.”

– Richard H. Carmona

U.S. Surgeon General

Dr. Carmona pointed out that we need a common currency and language to reach into the streets, into the “hood”, or among the ranks – and that often those we most need to reach are the ones furthest away from us. He stressed the need to understand that cultural competence is about more than just finding a translator – and that we must figure out ways to translate the great advances we have from science into packages that can reach people. One key factor in this area, he noted, is health literacy – the need to communicate with a language and at a level that people can understand. This is why, explained Dr. Carmona, every time a Surgeon General’s Report is published there is also an accompanying “People’s Piece” publication that takes the key messages and information from the report and presents it in a clear manner, written at a sixth-grade reading level.

The reason for convening this workshop, noted the Surgeon General, is to help guide the development of any document or materials to come out of the Surgeon General’s Women’s Mental Health Project. Dr. Carmona specified that he felt these recommendations needed to come from the ground up – from the sample of parents, consumers, policymakers, advocates, providers, scientists, and others represented at the meeting. The Surgeon General said that he welcomed the opportunity to face arguments and disagreements – to figure out the right path ultimately and come out of this together.

Dr. Carmona concluded by re-emphasizing his personal commitment to this project and the important work of this Surgeon General’s Workshop on Women’s Mental Health.

About the Surgeon General’s Women’s Mental Health Project

Wanda K. Jones, Dr.P.H., Deputy Assistant Secretary for Health, OWH, gave a slide presentation providing the background of the Surgeon General’s Project on Women’s Mental Health to help set the context for this workshop. Dr. Jones began by pointing out the long history of supporting reports and documents, starting with the publication of Mental Health: A Report of the Surgeon General in 1999, which laid the scientific groundwork for this project. Subsequent supporting documents include:

• The Surgeon General’s Call To Action To Prevent Suicide (1999)
• Report of the Surgeon General’s Conference on Children’s Mental Health: A National Action Agenda (2000)
• Mental Health: Culture, Race, and Ethnicity, a supplement to Mental Health: A Report of the Surgeon General (2001)
• Youth Violence: A Report of the Surgeon General (2001)
• Achieving the Promise: Transforming Mental Health Care in America (2003), from the President’s New Freedom Commission on Mental Health

She specified the project’s four main objectives. The first three include identifying the critical issues affecting the mental health of women and girls, assessing the state of the science, and developing a framework for a long-term strategy to address the issues. The fourth objective is the one most directly related to this workshop, namely to develop additional supporting endeavors and products to increase awareness and activity related to these critical issues.

Dr. Jones described in more detail the background activities of the Surgeon General’s Women’s Mental Health Project that were undertaken to begin to address the project objectives and lay the groundwork for this workshop. The first of these, she explained, consisted of a concept mapping activity designed to define women’s mental health and develop a conceptual framework for addressing the issues that affect the mental health of women and girls. It involved 245 participants representing experts and communities of interest who responded to this statement: “A specific issue that is relevant to the mental health of women and girls is….” Dr. Jones noted that this activity generated 107 issues, which were then rated according to their level of importance and their potential for action.

The next step, she explained, involved the development of cluster areas grouping these different issues according to common themes, which were in turn organized to create a conceptual framework. That framework encompasses individual, environmental, and systemic issues affecting women’s and girls’ mental health. Because of the central importance ascribed to protective and resilience factors by respondents, these were placed at the center of the framework. The conceptual framework was further refined during the process of two additional background activities. These included a set of leadership interviews with 25 high-level individuals representing governmental, provider, and consumer organizations along with a series of facilitated discussions in three cities with diverse groups of consumers, providers, and the local government staff. The resulting framework is presented below. A more detailed version that lists the specific issues associated with each cluster area is included in Appendix A.

Conceptual Framework of Issues Affecting the Mental Health of Women and Girls

When the eight cluster area topics emerging from this framework were cross-walked with the 1999 document, Mental Health: A Report of the Surgeon General, explained Dr. Jones, there were clear differences in identified priorities, particularly in the research base. While issues such as sex and gender differences in specific mental disorders or developmental factors were referenced in the Surgeon General’s Report, others such as “trauma, violence, and abuse” or “resilience and protective factors” barely appeared at all – reflecting the lack of research evidence on these important topics at the time.

The Surgeon General’s Women’s Mental Health Project’s targeted literature review and other background activities revealed several changes or developments since the publication of the 1999 report. Regarding sex and gender differences, noted Dr. Jones, there is a growing body of evidence to increase our understanding of the significant sex and gender differences in the risks, prevention, diagnosis, course, and treatment of mental illness. She added that we clearly need to address these differences not only in research but also in social policies and in the training of health providers.

Another major area that has received significantly more research attention in recent years, said Dr. Jones, is the importance and prevalence of trauma, violence, and abuse in the lives of girls and women. She referenced a new World Health Organization (WHO) study that looks at this issue and its long-term impacts worldwide.⁵ Dr. Jones also noted that this evidence further underscores the fact that women need to be screened routinely for trauma, violence, and abuse as part of their regular health care.

One of the important cross-cutting issues to emerge throughout the background activities was the importance of cultural differences and disparities. The issues of culture, race, and ethnicity clearly cut across all of the areas of the conceptual framework, explained Dr. Jones, but the scientific literature is sparse. She mentioned recent research that investigates both the protective factors of culture and potentially deleterious effects of acculturation – suggesting that culture may weigh more heavily than race or ethnicity in terms of our attitudes and behaviors regarding mental health and mental disorders.

Yet another issue to come up consistently and in a cross-cutting way is stigma that keeps families in denial and keeps individuals from seeking care, said Dr. Jones. She pointed to the need for continued education and outreach to providers, to women and girls, and to the general public.

Regarding the issue of resilience and protective factors, Dr. Jones noted that this was clearly a critical topic, in which there is so much more we need to know regarding both protective factors and successful prevention-focused activities.

Dr. Jones concluded that with the combination of the science base, these background activities, and the input from the members of this workshop, we have the potential to create an array of new products. These have been identified as Surgeon General’s communiqués – a term intentionally chosen to be broad to reflect the wide array of possibilities. Dr. Jones also pointed out that the term brings together both the words “communications” and “unique.” She presented this as a challenge to the workshop participants to debate, discuss, and craft creative ideas for ways we can communicate important issues affecting the mental health and long-term wellness of our Nation’s women and girls.

The State of Women’s Mental Health – What We’ve Learned

Richard Nakamura, Ph.D., Deputy Director, NIMH, presented the scientific perspective on the status of what we have learned about women’s mental health. Dr. Nakamura emphasized that while critical, research is only part of the picture, and the side that affects individuals on a personal level is equally important. Thus, he noted, the NIMH and the Center for Mental Health Services (CMHS) play complementary roles, with NIMH providing the research piece and CMHS providing the direct service that is informed by the research.

“We are challenging you to help us devise ideas for new Surgeon General communiqués – a word that appropriately combines ‘communications’ and ‘unique’. I invite you to meet that challenge here.”

– Wanda K. Jones

Deputy Assistant Secretary for Health

DHHS Office on Women’s Health

The mission of NIMH is to address the burden of mental health through research, explained Dr. Nakamura. He noted that worldwide, this burden is considerable, according to data from WHO and World Bank, and it is expected to increase. For example, the data show that within developed countries, major depression is second only to heart disease as the leading source of disease burden, and for women, it is already the number one cause of disease burden. Schizophrenia and bipolar disorder are also among the top 10 causes of Disability-Adjusted Life Years (DALYs). Depression, alcohol and substance abuse, and self-inflicted injury also constitute major causes of disability – and taken together, mental disorders account for nearly one-quarter of the total disease burden in the United States.

“Why focus on women’s mental health? Because sex matters!”

– Richard Nakamura

Deputy Director

National Institute of Mental Health

National Institutes of Health

Dr. Nakamura explained that though we commonly speak of the disability burden associated with mental disorders, there is also an important elevated risk of death as well. For example, he noted that 90 percent of individuals who commit suicide have had a mental disorder – and we know that women are four times more likely than men to attempt suicide, though less likely to die from the attempt. This says much about the level of pain and hopelessness these disorders can bring.

Dr. Nakamura then turned his attention to one of the fundamental questions of this workshop; namely, “Why focus on women’s mental health?” His simple response was, “Because sex matters!” Dr. Nakamura elaborated on this point and offered a more detailed presentation of the interplay among sex, gender, and mental health issues. His presentation highlighted the following points:

• There are considerable differences in the sex ratios for selected mental disorders, with women having much higher rates of disorders such as major depressive disorder, anxiety disorders, posttraumatic stress disorder, and eating disorders.
• There are important biological differences related to hormones and brain structure that may affect mental health risks, rates of disorders, and the course of those disorders. For example, research has demonstrated that estrogen and progesterone influence brain function and stress response. These findings are interesting given that at puberty, the female-to-male ratio for depression rises from 1:1 to 2:1. Some women also experience increased vulnerability to depression during times of reproductive endocrine changes, such as the premenstrual, postpartum, and perimenopausal periods. There also are sex-based differences in the size and structure of the human brain. Men’s brains are larger than women’s. Women’s brains are lighter but more complex, with proportionately larger frontal lobes (attributed to executive functions such as judgment, language, memory, problem solving, and socialization).⁶

  “The continued, effective integration of women and diversity in academic medicine and research is essential for ensuring that the research base reflects gender, racial, ethnic, and cultural diversity – not only regarding research topics but also in the interpretation of the findings.”

  – Richard Nakamura

  Deputy Director

  National Institute of Mental Health

  National Institutes of Health

• Clearly environmental factors play a significant role in the risk and prevalence of certain mental disorders. Environmental factors may include both artifact (e.g., women may be more likely than men to seek treatment, there may be diagnosis bias) and psychosocial factors (e.g., gender socialization, gender roles, lower social status, reaction to social cues, experiences of abuse, gender-related differences in coping mechanisms).
• There is important overlap between biological and environmental factors, although the interplay between the two is complex. For example, in the gene that codes for the serotonin transporter, individuals with a short version of that gene seem to have a greater vulnerability to the deleterious effects of a history of maltreatment than do those with a longer version of that gene.
• There is clearly much still to be learned about social and protective factors that affect mental health, including the effects of race, ethnicity, and culture. For example, while we see that the overall ratio of female-to-male rates of depression is 2:1, there are enormous differences in range. Rates of depression are higher among Hispanic and Caucasian women compared with African-American women. Similarly, there are considerable differences among women in rates of attempted suicide. Although women are more likely on average to attempt suicide than men, the rates of suicide attempts in African-American women are very low. These differences lead us to wonder if there are social or protective factors at play and underscore the fact that we need to understand more fully what happens with groups that do well.
• New science is rapidly changing our understanding of lifetime and intergenerational cycles affecting mental health – and the extent to which environmental manipulations can lead to positive changes. For example, recent evidence shows that when a mother rat licks and grooms her pups, it actually changes their brain function and affects how they themselves parent, producing pups that are better parents.⁷ This is supported by other studies that suggest that environmental enrichments can change the brain and have long-term, intergenerational effects – potentially through epigenetic effects.

Dr. Nakamura concluded his presentation by pointing to the continued need to integrate more women and diversity effectively into academic medicine and scientific research. He pointed to the slow growth of women in academic medicine – representing one-fourth of medical faculty members in 1995 and one-third today, and still highly underrepresented among associate and full professors in academic medical institutions. Dr. Nakamura emphasized that greater participation of women, including women of color, is necessary to ensure that the research base reflects gender, racial, ethnic, and cultural diversity not only in the types of topics that are being researched but also in the interpretation of the findings.

Like the presenters before him, Dr. Nakamura noted that women’s mental health issues have a personal side that touches every family. He dedicated his thoughts from this meeting to an aunt, who was subjected to a frontal lobotomy during the 1950s as a treatment for her bipolar disorder – and shared the hope with the workshop participants that the continued work of this group and others will ensure that no one will go through that experience ever again.

“It’s time we harness the power of these [scientific] discoveries to offer new hope in both treatment and prevention for women and girls. We have the tools. It’s time to put them to use!”

– A. Kathryn Power

Director

Center for Mental Health Services SAMHSA

A. Kathryn Power, M.Ed., Director, Center for Mental Health Services, SAMHSA told the workshop participants that it is time to change the way we think about, develop, and deliver mental health services. Ms. Power emphasized that the knowledge exists now to make real headway toward the goal of helping women and girls achieve holistic lives of greater self-determination, power, and self-dignity. She argued that we know from the evidence that recovery is possible and that with the right treatments and supports, recovery can be the expected outcome for every woman and girl in America living with mental health conditions.

In order to promote recovery, she added, it is imperative that the woman herself become the director of her own treatment, since only she knows the truth about the conditions of her life. It also becomes imperative that we move from a model focused on illness, acute treatment and symptom mitigation to one that is recovery-focused and strengths-based, since virtually all behavioral health conditions will require environmental or lifestyle changes as well as biological treatments.

Our current mental health services system, Ms. Power argued, has neglected to incorporate respect for and understanding of the unique histories, beliefs, attitudes, and value systems of culturally diverse populations. Our efforts to bring all of the relevant health and human service components to the table to address the totality of women’s health have been haphazard at best – and clouded by stigma and discrimination.

Ms. Power called for an integrated, holistic approach to mental health services that cares for the whole woman. She described this approach as including such things as making routine use of self-administered depression screening tools at primary care clinics, in OB/GYN offices, by breast cancer specialists, and in prenatal and birthing centers to address unrecognized and untreated depression. Ms. Power also noted that in order to take care of the whole woman it is important to take care of her children and to help keep them from getting caught in a cycle of mental illness themselves. She said that a comprehensive, family-based approach to prevention works. She also noted that there are promising treatment strategies for eating disorders that use cognitive behavior therapy methods and involve family members.

Ms. Power also brought up the need to improve systems of care for women in our nation’s jails and prisons, including effective interventions around parenting and child custody issues; services for pregnant inmates; and services and supports to resolve mental health issues related to victimization and violence.

“What do we know about trauma interventions? We know that multi-target, multi-modal treatment approaches and coordinated community responses have had the most positive impacts.”

– A. Kathryn Power

Director

Center for Mental Health Services SAMHSA

As the Director of CMHS, Ms. Power explained that one of her personal and professional priorities is to open the Nation’s eyes to the impacts of trauma on women’s lives and to the power of recovery. Through the work of its National Center on Women, Violence, and Trauma, SAMHSA is developing leadership networks to spread information about emerging best practices and to stimulate local change. In FY 2006, the CMHS Women’s Coordinating Committee – a group charged with promoting the importance of health issues of women across SAMHSA – is planning a series of activities, including trainings focused on the integration of trauma-informed services in public health facilities. CMHS is making a major investment of resources in the issue of women and trauma, explained Ms. Power. CMHS’s groundbreaking Women and Violence Study is a shining example.

Ms. Power also cited the Kaiser Permanente/CDC-sponsored Adverse Childhood Experiences (ACE) Study, which provides strong evidence of a causal link between violence-induced neurological damage, the use of self-medicating measures, the adoption of health risk behaviors, and consequent chronic disabling health morbidity and early mortality.⁸ She noted that the ACE Study is just one example of the substantial body of research investigating the impacts of trauma, particularly on women. Ms. Power emphasized that what we have learned about the pervasive lifelong impacts of violence and trauma in women and children brings urgency to our need to act now.

She supported that statement by offering the following highlights about what is known regarding the impact of trauma:

• Trauma is no longer regarded as an anomalous experience. It is increasingly seen as a widely prevalent experience of public mental health and human service recipients.⁹
• Addressing trauma is increasingly recognized as essential for recovery for other mental health disorders such as substance abuse. Improvement in symptoms such as depression and substance-use disorders will not occur without integrating a focus on an underlying history of trauma.¹⁰
• A recovery-oriented system is not possible if we do not integrate trauma into mental health services.
• The failure to address trauma results in major and costly human service systems failures, such as seclusion and restraint, self-injury in adult criminal and juvenile justice, repeated failures to maintain housing or employment, heavy use of health care services, and suicide.
• Childhood physical and sexual abuse may lead to harmful coping strategies such as dissociation, self-injury, eating disorders, running away, and substance use that may delay development and create a legacy of lifetime disabilities associated with chronic mental health problems, addictions, and major health problems.
• The intergenerational and historical costs of trauma are being increasingly recognized.
• “Treatment as usual” that does not address trauma results in spiraling costs, lack of reduction in symptoms and misery, and continued cynicism regarding recovery on the part of consumers.

“The Report from the President’s New Freedom Commission on Mental Health challenges us to change the way this nation thinks about, delivers, and finances mental health care. It calls on us to create a new, recovery-oriented national mental health system that meets the needs of every American living with mental illness.”

A. Kathryn Power

Director

Center for Mental Health Services SAMHSA

Ms. Power went on to discuss effective interventions for trauma. She noted that multi-target, multi-modal treatment approaches and coordinated community responses have had the most positive impacts. She explained that SAMHSA sponsored a five-year Women and Violence Study, which has provided the most authoritative and comprehensive view to date of what can be accomplished in the public health system with women who have histories of physical and sexual abuse, who are in need of services for both mental health and substance-use disorders. She explained that this groundbreaking study featured a trauma-integrated counseling approach that addressed both mental health and substance-use conditions. Findings suggest that integrated counseling (e.g. group and individual therapy that addressed trauma, mental health, and substance-use disorders issues) was the key element associated with better outcomes, which improved significantly over a 12-month period.

Citing the findings and recommendations of Achieving the Promise: Transforming Mental Healthcare in America, the landmark final Report of the President’s New Freedom Commission on Mental Health, Ms. Power said that she saw our Nation as being on the cusp of a new evolution in mental health services. Achieving the Promise, she explained, calls for the creation of a new, recovery-oriented national mental health system that meets the needs of every American living with mental illnesses.

Ms. Power warned, however, that this change will require true transformation – a revolution, as she described it, in how we do things, how we think, and how we work together. She commented that with this type of change, new sources of power emerge that create a profoundly different system that is changed in structure, culture, policy, and programs.

Embedded in transformation is the core belief in recovery and the belief that adults with mental illnesses can take charge of their own lives, their own wellness, and their own care, said Ms. Power. It is the belief that systems should help children and their families build on existing strengths, foster resilience, and create promising futures.

She described her vision of a transformed mental health system as one in which:

• Services for women and girls will recognize the complex linkages between biology and environment and the role of violence and poverty in health conditions – and new treatments will grow out of this recognition.
• Culturally relevant, strengths-based approaches, which encompass creativity and spirituality and address the unique needs of refugees and immigrants, will be commonplace.
• The power of technology will be tapped to connect women to, and educate them about, the wealth of effective recovery-focused services that are available to them.

Cooperation and collaboration, noted Ms. Power, are the lifeblood of transformation. She asked the workshop participants at the local, State, and national level to act and to advocate for the comprehensive, coordinated, consumer-centered mental health system that will give women, and all Americans, access to the full range of services they need to recover.

In closing, Ms. Power quoted the American-born Buddhist nun, Pema Chödrön, “Now is the only time. What we do accumulates. The future is the result of what we do right now.” She called on participants to act, one person, one program, one community at a time, so that those actions do accumulate and lead to a point when recovery is the expected outcome for all. She challenged them to seize this moment rife with promise and use the power of it to transform the lives and future of millions of Americans.

Cheryl Bowers-Stephens, M.D., M.B.A., Assistant Secretary for the Office of Mental Health, Louisiana Department of Health and Hospitals, described her experience of leading a mental health care system impacted by a severe natural disaster. She noted in her presentation that she was speaking not only as a person in charge of mental health for the State of Louisiana but also as a wife, with a husband who is Director of Health for the city of New Orleans, and as a mother. Through the lens of each of these perspectives, Dr. Bowers-Stephens shared the story and lessons of trying to meet mental health needs in Louisiana before and following Hurricane Katrina.

Prior to the hurricane, Dr. Bowers-Stephens explained, she and others had been planning strategic objectives for transforming the State mental health system to address more fully the need for mental health services. Pre-Katrina State figures indicated that of Louisiana’s 4.5 million people, more than 900,000 were estimated to have a mental disorder – including nearly 180,000 adults and 65,000–77,000 children with a serious mental illness. Of these, only 46,000 were being served by the State Office of Mental Health. Thus, even before the storm, there was a great unmet need for mental health services.

With warnings that the storm was on its way, the Office of Mental Health acted to evacuate psychiatric units and hospitals, said Dr. Bowers-Stephens. She noted that though the public heard mainly about those left behind in New Orleans, it is important to understand that 1.5 million people were evacuated from the city through a huge and largely successful effort. The Office of Mental Health disaster preparedness had included disaster response drills, evaluation plans, disaster training for employees, and a staff callout registry. Prior to and during the storm, multiple command centers were activated; mobile crisis teams and call centers were put into place; Southeast Louisiana State Hospital, Charity Hospital Acute Unit, and New Orleans Adolescent Hospital were evacuated to other systems in eastern and central Louisiana; and special-needs shelters were activated across the State.

Dr. Bowers-Stephens reminded the workshop participants that Hurricane Katrina was the most destructive natural disaster in U.S. history. As a category IV storm with winds of nearly 150 miles per hour, it ripped apart homes, destroyed infrastructure, and toppled hundred-year-old trees like saplings. This was followed by a storm surge of nearly 30 feet, which caused levees to give way and sent people scrambling to rooftops and attics in desperate attempts to avoid the rising water. New Orleans and cities and towns across eastern Louisiana were devastated.

“Women should be considered as a special-need or vulnerable group during periods of disaster. Gender role differences and power differentials between men and women must be integrated into disaster preparedness training and planning activities.”

– Cheryl Bower-Stephens

Assistant Secretary

Office of Mental Health

Louisiana Department of Health and Hospitals

The impact of Katrina on the State’s mental health system was enormous and far reaching, and Dr. Bowers-Stephens presented some numbers to illustrate its severity. She noted the following:

• An estimated 3.2 million individuals were in need of crisis counseling services.
• More than 1 million registrations were submitted for Federal Emergency Management Agency assistance through local parishes.
• Among those moderately exposed to the destruction, estimates are that 5–10 percent will experience clinically significant mental health issues and an additional 5–10 percent will experience subclinical issues that still will require support.
• Among those in severely exposed communities, an estimated 25–30 percent of the population can be expected to experience clinically significant issues, with an additional 10–20 percent experiencing subclinical ones.

While these numbers are significant, Dr. Bowers-Stephens explained that the impact of Hurricane Katrina was particularly severe for women. She noted that research on gender and natural disasters has found that women are more vulnerable than men in these situations and indeed should be considered a “special population.” This is due to a host of historical, social, cultural, and societal factors, such as domestic and economic burdens, lower incomes, lower social status, male flight, and increased risk of violence and abuse. In addition, women face an interaction of biologic and social risk factors, such as a higher baseline prevalence of depression and the risk of adverse reproductive events (e.g., there were numerous premature deliveries during and after Katrina).

Dr. Bowers-Stephens pointed out that the research evidence was indeed confirmed in the case of Katrina and its aftermath, where women were left behind by men to take care of the family, meet immediate survival needs, and face the risks of disorganization and increased violence that characterized the post-storm situation in New Orleans. Dr. Bowers-Stephens noted that with her husband immediately called to the Superdome, she herself was left to make the family decisions regarding where to evacuate with their three children to meet both her family and professional responsibilities.

Dr. Bowers-Stephens highlighted the fact that there are many important lessons that should be drawn from the experiences of Hurricane Katrina in terms of emergency planning and preparedness. Specifically, she offered the following recommendations:

• Anticipate postdisaster male flight in disaster preplanning, including first responder support. Ensure that there are special supports for women and families (e.g., there were no schools or day care on the cruise ships supplied for evacuees in New Orleans).
• Ensure that specific structures, policies, and procedures are put into place to address postdisaster domestic violence and sexual assault prevention and intervention.
• Institute policies to support the care of children. More than 1,000 children were listed as missing after Katrina and many were separated from their families. Predisaster planning must address the need to prevent family separations and lost children.
• Teach families to be prepared. Incorporate messages into public health policies and messages about the importance of making emergency plans as a family before disaster hits.

Dr. Bowers-Stephens concluded by noting that the lessons of Hurricane Katrina must serve as a timely reminder of the critical need to incorporate gender into emergency preparedness planning and training.

Footnotes

5

World Health Organization. WHO Multi-country Study on Women’s Health and Domestic Violence Against Women. Geneva, Switzerland; 2005.

6

Rabinowicz T., Dean D.E., Petetot J.M., de Courten-Myers G.M. Gender differences in the human cerebral cortex: more neurons in males; more processes in females. J Child Neurol. 1999 Feb; 14(2):98–107.

7

Weaver ICG, Cervoni N, Champagne FA, d’Alessio AC, Sharma S, Seckl JR, Dymov S, Szyf M, Meaney MJ. Epigenetic programming by maternal behavior. Nature Neuroscience. August 2004;7(8):847–854.

8

Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study. Am J Prev Med. 1998;14:245.

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