2005 Hurricane Season

Transcript of Press Briefing - Mental Health and Hurricane Katrina

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
"Hurricane Katrina"
Press Briefing on Mental Health
Wednesday, September 7, 2005

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OPERATOR: Now I will turn the meeting over to Mr. Bill Hall with HHS Public Affairs.

MR. HALL: Thank you, Josh, and thank you, everyone for joining us today.

As you know, issues regarding mental health, grief, stress and so forth related to the hurricane are certainly paramount and becoming more and more prevalent. And we wanted to take some time today to sort of do an educational kind of session, allow folks to learn a little bit about what some of the issues are and how we're responding, what kind of things that we're providing to the region to help, and to talk about some of the issues that perhaps that responders also could be facing.

So with me today I have Mr. Charles Curie, who is the Administrator of our Substance Abuse and Mental Health Services Administration. I also have with him, Mr. Dan Dodgen, who is the Emergency Coordinator for SAMHSA, that same agency. And also with us is Dr. Thomas Insel, the Director of the National Institute of Mental Health at the National Institutes of Health.

So at this point I will turn it over Mr. Curie to start us off.

MR. CURIE: Thank you, Bill.

I want to first articulate the mission of HHS and in particular SAMHSA being tasked with the responsibility to assure that there's a mental health and substance abuse response to Hurricane Katrina. And those missions include, in partnership with our state, local authorities, mental health and substance abuse authorities, as well as the private sector and voluntary sector, we are to ensure mental health assessment and crisis intervention and counseling our readily available to the evacuees and those that have been victims, or are victims of Hurricane Katrina.

Also we are ensuring ongoing care for people with serious mental illness and addictive disorders, as well as children with serious emotional disturbances who have been receiving treatment, to assure there's continuity of care in their treatment that they're receiving.

And a third mission that's overall part of this is we have a focus on suicide prevention in the affected areas, including both first responders who are extremely vulnerable in these kinds of situations, as well as the evacuees and the victims of Hurricane Katrina.

To give a quick update as to what we have done thus far, we did activate the SAMHSA Emergency Response Center early last week, and that is a point of contact for all state mental health and substance abuse authorities, as well as all federal agencies and local mental health providers, to receive information, to also have access to resources, both in terms of staffing resources to be deployed. We work in partnership and as part of the public health service deployment down to the impacted areas. Also that Emergency Response Center is the coordinating body for the federal response overall for mental health and substance abuse issues around Katrina.

We also are working in partnership with FEMA to facilitate the application process for immediate funds to support the crisis counseling efforts, and again, we work in partnership with the Red Cross, we work in partnership with the faith-based organizations in helping to ensure that the crisis counseling, grief counseling, and those things that need to be immediately available at this point in time.

We also have provided last week immediately an initial payment of half a million dollars for an emergency response for clinical services including pharmaceuticals to ensure continuity of care for those requiring ongoing treatment. And we also are looking to set the stage to assure that there is adequate capacity where the evacuees are going to be settling, where they are now, where eventually they're going to be, and working closely with all of those states to assure that's their capacity to address what we are anticipating in the area of post traumatic stress disorders.

We're also working consistently with the mental health units that are in the different temporary medical facilities of the shelters serving the evacuees, assuring that there is going to be staff that comes in to support the staff that already have stepped forward.

I had the opportunity to travel with Secretary Leavitt to New Orleans, to Baton Rouge, to Houston and Dallas, and was able to personally visit those mental health units, and the local mental health providers and medical providers have really stepped up and are sacrificially providing excellent care. The units are set up in such a way that the care that they're providing is the top-notch type of care that's available. We're looking to help support them and assure that there is staff able to come in, because they could only do that so long with their immediate resources.

So we're working with the Department and the pool of medical providers. Right now we have over 210 mental health professionals certified to be part of deployment. Already there are people being deployed not only out of SAMHSA, but also out of the National Institutes of Mental Health or other federal partners, and mental health public health service on site.

We're also looking--and the Secretary's made a strong commitment to assure that mental health will be part of the embedded public health service teams in each of the areas, so that we can assess that.

We're also very focused and are in the planning process now to look ahead to assure that there is adequate mental health capacity, and also I'd like to stress we cannot forget the substance abuse consequences of this disaster as well. So the focus is on mental health, but also is on substance abuse because there's always spikes in alcohol and substance use after this type of disaster, and again, our concerns about the extent of this disaster and the fact that you have hundreds of thousands of individuals that are not going to be returning to a home in anywhere in the near future, have complicating factors in this disaster compared to previous disasters in terms of the scope.

We also have announced today, in terms of looking at suicide prevention, a hotline that is available, and we're making sure that that number is available to all the medical and mental health and substance abuse workers right now in the shelters in the impacted area, but this will be available ongoing after the, again, the evacuees are placed in other areas throughout the country. That number is 1-800-273-TALK, and it's connected to a network of local crisis centers across the country that are committed to crisis counseling, and they are connected to local mental health and substance abuse providers.

And this resource is now immediately available to the public, but we have additional capacity that we're putting into place in the areas that have been impacted by this disaster and where evacuees are currently being housed.

I also might mention that we have staff on-site right now in Louisiana, Mississippi, Alabama and Texas to provide ongoing technical assistance and support, and again, assuring that all the federal agencies' responses, including all the wonderful resources NIMH has to offer, as well as in our clearinghouses of information are readily available to those who need them who are addressing this issue right now in the Gulf Coast area.

MR. HALL: Dan Dodgen is going to just spend a couple minutes in talking about some of the issues related to responders and mental health issues.

MR. DODGEN: Hi. This is Dan Dodgen from SAMHSA also. I think that there are a number of issues that we have learned from experience in prior responses as well as some of the information that we're getting anecdotally regarding the kinds of needs that we'll expect responders to have. As you can imagine, the situation that they're facing is very intense in terms of all of the functions that first responders are part of, everything from recovery of remains all the way up to just helping reunify families.

As you can imagine, the populations being served include a really wide variety of folks, and there are a number of unaccompanied minors, families that have been separated, et cetera, as well as people who have acute medical conditions, along with psychological, psychiatric substance abuse conditions that some people have as well.

And the first responders are the folks who are the first contact with most of the people that are facing these situations, so the pressure on them is intense along with the shifts that they're working, et cetera. I imagine everybody on the call already knows what I've just said, but I'm saying it by way of setting up that we know from past experiences, for example in Oklahoma City, September 11th, as well as disaster responses, that first responders often experience additional problems over and above other populations because of what they're exposed to.

The kinds of things that we might expect to see among first responders would be many of the stress reactions that perhaps Dr. Insel is going to talk about a little bit in a minute in terms of short-term things like depression, stress symptoms from sleeping difficulties, managing things that normally are easy to handle, but in a high-stress situation, which means things like concentration, decisionmaking, et cetera.

So those are some of the things that you'll see, sleep problems, all of the kinds of symptoms that--if you think about it in terms of your own experiences, what are the kinds of symptoms that you might have in a stressful situation? And then magnify that by, you know, about 100-fold. That's what we expect to see with these folks.

In addition to that, there are reports both from past experiences as well as in the current one of increased rates of substance abuse, things like alcohol and other drugs. And I don't think by any means do we want to imply that all first responders are doing that, but simply that when people are having difficulty coping, sometimes they don't always use the best strategies to cope, and in this particular situation, sometimes people use coping strategies that maybe aren't super effective, and sometimes things like alcohol or other drugs can be part of that.

In addition, I think that we would expect to see sort of that some of these kinds of things that we'll see happen in an acute phase fairly shortly after the incident occurs. But then I think what we also see is over time people who have the highest exposure to the event, whatever it is--in this case a hurricane--are going to also continue to experience higher levels of these kinds of symptoms than folks might expect.

So often what happens is two, three, four months into an event or after an event has happened, people will find that they're still experiencing some of these kinds of symptoms, or that they're starting to experience them and they hadn't before, and that's also not unusual. And again, I mention Dr. Insel will talk about that a little bit, but there actually are in a sense almost two phases of the kinds of symptoms that we would see, sort of an acute phase, the things that you see in that very initial step, and then things that you see further on, and I think in first responders, they're a population that are particularly at risk because they're exposed to so much trauma.

MR. HALL: Thanks, Dan.

Dr. Insel?

DR. INSEL: Thank you, Bill.

I think everyone's aware of just how serious this disaster is, and for us it's probably unprecedented. But it's equally important to remember that we've had plenty of other disasters to deal with and we've learned some lessons from those, especially from research that's taken place around those disasters that should help us as we think about how to respond to this one.

I think there are really three main parts of those lessons that need to be focused on. The first is, as you just heard, the importance of psychological first aid, both to the responders and to the victims, that we really have to be prepared to provide what they need for psychological distress, and I'll talk a little bit more about that in a moment.

The second is, as Dan was just saying, the longer term, you could call it the second wave of this hurricane that will come at some point later, maybe not in days, maybe not in weeks, sometimes in months and years where you begin to get the second wave of distress that often shows up as a disorder like post traumatic stress disorder or oftentimes other kinds of syndromes such as substance abuse or just mental discord.

And then the third important lesson, which Secretary Leavitt has already spoken to--and you heard this from Mr. Curie as well--is that the very simple but profound lesson that mental health care must be an essential part of the overall medical response, the overall public health response. Both acutely and subacutely we need to make sure that the needs of people with mental distress are front and center.

So let me say a little bit about the first aid piece, the psychological first aid, because what we know about that is that it may be absolutely most important for those who have a preexisting serious mental health condition. That's about 6 percent of the general population, so we're talking about a lot of people who come into this with very serious mental health problems.

When you talk to people who are working in the Astrodome the last three or four days, the people who are part of the psychiatric team, and they've got about a patient base now of about 33,000 people between the Astrodome and the Brown Convention Center, the two biggest problems they've faced are, one, the provision of antipsychotic medication to people who left home without their pills. There are a lot of people who are dependent on getting their medication to be able to function at all. And the second is the provision of methadone to people who are drug addicted and don't have access.

And that's much of what they did on Saturday and Sunday. By Monday things were much quieter, and by Tuesday they were basically settling into a routine.

So I think that's important for us to remember, that we're not dealing with a blank slate here. People come into this tragedy with already a number of disasters behind them and a number of very serious mental health problems that need acute and subacute care.

I think though for all of the victims of such a catastrophe there's a whole series of things, and we usually think of about five of them that really need to be focused on in terms of providing the best first aid, psychological first aid.

First they need very clear information.

Second, it's critical to keep families together. That really is probably one of the most important things we've learned, is the importance of social support particularly of familiar social support.

Developing routines is critical. For those people who were in these large facilities like the Astrodome, they need to have a time when they can sleep regularly. There's a tendency not to want to turn the light down. It's important actually to have an evening and a nighttime in a place like that. Routine times for sleeping, for eating, for going to school for the children.

Providing privacy is a fourth part of this that's really critical for people who are in these large facilities.

And the fifth, which is one that is already happening in a number of ways, is encouraging a sense of community. To the extent possible you want to make sure that people have an opportunity to be part of the solution and not just part of the problem. That's what people want. They want to have the sense of being effective. We need to make sure that there's an opportunity for them to do that.

So after the sort of dust settles, there are a number of other issues that need attention. The first is, even at a time like this, you want to make sure that you don't do certain things to make matters worse. We know from previous research that a lot of what you see on television, which is the debriefing or the simple reassurances that are given to people who have survived these kinds of traumas, we know that's actually not helpful and sometimes could be making matters worse.

Debriefing is the idea that you tell people that they need to talk about what they've been through, they need to relive it and to re-experience it and go through in some detail. That is actually not something that the science would indicate is a good idea at a time like this. Nor is it useful to medicalize the trauma that many people feel and the kind of distraught experience that people have, which is part of the adaptive response to such a terrible displacement, a terrible tragedy. That's to be expected and that's to be permitted and it's not something that needs to be labeled.

I guess it would be sort of the third arm of this, that a important thing to remember is the attention to what is likely to come in this second wave, and Dan mentioned this, that the threat of lots of other disorders that can be expected here. We're very conscious of this because we know from other disasters that sometimes that's late occurring and sometimes it is really catastrophic for people who develop something as serious as post traumatic stress disorder. Many times people with that disorder actually die of suicide. Most of them develop very serious depression at the same time. Substance abuse is a very high complication of PTSD.

But the take-home message here ought to be that the vast, vast majority of people, the word is resilience here. Most people will recover completely. They're going to end up with an opportunity to put their lives together, to get back to work, to have their kids in school, to reconstitute their families, and basically be left with some incredible stories to tell their grandchildren.

This isn't to minimize the experience, but it's to remember that we are a very resilient species. We have survived lots of disasters and lots of challenges, and generally recovery is the name of the game. Most people recover. There are a few who will develop these other kinds of complications, and part of the importance of having this psychological first aid is trying to minimize for those people who have the most negative complications.

MR. HALL: Great. Thank you to all three of you for those comments.

Why don't we go ahead now and open up the lines and take some questions for a few minutes?

OPERATOR: We are ready to take questions. If you would like to ask a question, please press star-one. You will be announced prior to asking your question and will be prompted to record your name. You may with draw your request by pressing star-two. Once again, to ask a question, please press star-one.

Joanne Silberner, you may ask your question.

QUESTION: I have a question for Mr. Curie, and it is this. You mentioned the health line that you set up very early on for workers. Can you tell me how many calls you've gotten and what kind of calls they are?

MR. CURIE: This would be at our SAMHSA emergency response center. Let me ask Dan Dodgen. Approximately how many? It's been a consistent flow of calls, I know.

MR. DODGEN: I don't know the exact number, but perhaps that's something that we can get back to you on, perhaps even before the end of this call.

QUESTION: Do you know the nature of the calls?

MR. DODGEN: Well, the nature of the calls that we're receiving at the SAMHSA emergency response center, Joanne, include states letting us know what their needs are, state mental health authorities. We've been in consistent contact with Louisiana, Texas, Alabama, Mississippi, and now we're beginning to get more and more contact from those states that are anticipating evacuees.

We also--other federal agencies. And HHS agencies are using us as a point of contact. When they see a mental health need that needs to be addressed in terms of an expert or consultation in one of the shelters. Medical shelters, for example, are first responders. That line is used.

Also, anyone who's requested information from these entities in terms of wanting publications. And also, this emergency response center the response center that is coordinating with HHS the number of individuals who are volunteering, that are mental health professionals, such as these professionals from around the country. And they're coordinating that effort as well.

OPERATOR: Malcolm Spicer, you may ask your question.

QUESTION: Thank you. Mr. Curie, as far as the emergency response grants that you've made available to Texas, Louisiana, Alabama, and Mississippi, what controls are there on how the states can use those? And you mentioned that these are the initial grants. Do you anticipate additional grants, additional emergency response grants to these states?

MR. CURIE: Those are great questions. In terms of control or scope of these grants, first of all, these grants are not to do any type of service that may be paid for by the FEMA dollars. FEMA, initially after a catastrophe like this, has dollars available to assure that crisis intervention and initial response is taken care of. And those are typically short-term dollars for the first few months after any crisis. These dollars specifically are for the needs that would not be met by that buy that are still facing local communities--mental health providers, substance abuse providers, health care in states.

For example, as you've heard from both Dr. Insel and Dan, there are individuals who were in treatment at the time of Hurricane Katrina hitting their communities. They're now in medical shelters or other types of shelters. They need psychotropic medications. They need methadone. These dollars can be used to meet that need initially. Some of these were not eligible for Medicaid but were receiving services from non-Medicaid sources. So these dollars are to also--another scope is if Medicaid's going to pick it up, these dollars would not be paying for that. These dollars are going to help fill that gap. Also, if a state wants to use these dollars to help develop a mental health support to their first responders and they don't have resources to do that, they can use these dollars for that.

So we do offer flexibility, but we offer clear guidance that if there's another source of payment, that's not for these dollars. These dollars are going to help fill that gap and give them some immediate resource out of the chute.

QUESTION: And as far as additional grants of this type?

MR. CURIE: You know, that assessment's going on right now in terms of dollars to be available. Already in the first supplemental that was given to the Department of Homeland Security, I know all federal agencies are engaged with DHS about what the needs are that are emerging. My understanding is there are some additional supplementals that are being considered. And we've all been asked to give our assessment of the need and are now ascertaining that information. So I do anticipate there will be further financial response to this disaster.

OPERATOR: [Inaudible] Willidge [ph], you may ask your question.

QUESTION: Hi. In terms of the federal response that's going on in shelters and in affected areas, give us an idea of how systematic is it. You mentioned making a mental health professional part of all the Public Health Service teams. Dr. Cramona told us yesterday that there's at least one PHS personnel member in every shelter, or at least that there's supposed to be. Are mental health professionals, the ones that have been deployed or going to the places, is it systematic throughout every shelter and every affected area, or is it a question of people kind of going out on an as-needed basis and helping after they hear that help is needed?

MR. CURIE: Basically yes and yes. There is a systematic approach. We are looking right now to systematically assure that there is that mental health resource person attached to the Public Health team. But we're also, as part of the suicide response center I mentioned earlier, they're a point of gleaning information from the field as needs emerge. For example, there's a need in the shelters that have emerged to have a specific focus on people who are experts in trauma in children, because children have been through tremendous trauma in this situation both in terms of--you've heard about the sexual assaults that have occurred earlier in some of the shelters. That's manifested itself in the mental health units, and we have our child trauma network experts from around the country providing that type of technical assistance. Also, whenever both adults and children have seen people die and have witnessed the things they've witnessed, that's manifesting itself.

So as these types of needs emerge, we also are meeting those needs.

QUESTION: So it's not the case that there right now is a mental health professional necessarily installed in each one of the 400 and some-odd shelters that are-- Some have them and some don't?

MR. CURIE: Yeah, I would say most of them have a mental health individual there, or access. Definitely where there's a medical shelter, there's a mental health component. And between the Public Health Service, other federal agencies where employees have stepped forward as volunteers who are qualified mental health professionals--again, as I mentioned earlier, NIMH, within SAMHSA, within CDC, within the Indian Health Service, within the Health Resources Services Administration. There's been many deployed.

So there's mental health capacity in all those medical areas. We are now making sure systematically, though, that there will be a mental health and/or substance abuse expert attached to each of the Public Health teams and that the embedded Public Health Service officers that the surgeon general discussed will have direct access to an individual as well.

MR. DODGEN: This is Dan Dodgen again from SAMHSA. One of the things, just to follow up on Mr. Curie's remarks, that I think would be worth publicizing is the fact that the department is in fact putting forth a call for volunteers who are not government employees but have a health care service background in fields from addiction and substance abuse to mental health on up into more traditional medical fields, to go online and actually sign up to do that. And one of the things that we're doing here is, of course, keeping a very close look at that to see, as mental health and substance abuse experts are signing up, how we can best utilize them and what their qualifications are so that they, too, can be used. The need, as Mr. Curie has described it, is very great.

If it's appropriate, I can give that 800 number as well as the Web link.

MR. HALL: Sure.

MR. DODGEN: Okay. The best way to access it through the Web is simply to go to the HHS Web home page, which is www.hhs.gov, and there's a Katrina icon right at the--as soon as you get on that Web site. And once you click on that, there's a link that says "donations and volunteers." And if you click on that, it will bring you into the place to find that, if you want to provide instructions to your readers.

There's also a phone number, which is 866-KAT-MEDI. I mention this in this context because, as Mr. Curie has described, we're doing our very best to make sure that we are aware of mental health needs and that we're getting mental health people into the places where they're most needed. But we have an appreciation of the magnitude. As you describe, the number of shelters operated by the Red Cross, by counties, cities, states, as well as by independent agencies is extreme. And we're probably going to continue to need more folks who will be willing to volunteer, particularly over time.

So publication of those numbers and Web sites would actually, I think, do us a service in accessing more qualified people.

DR. INSEL: Let me just add, from the National Institute of Health perspective, where NIMH sits, Dr. Elias Zerhouni, the NIH director, has pushed forward a three-pronged approach to this, beginning last Monday. The first was deploying both some Commission Corps and some civilian health care workers, and each of those teams included experts in mental health. A second was to provide some search capacity in our hospital at the clinical center in Bethesda, as well as at the Family Lodge, where family members can stay when people are hospitalized. And that includes both mental health care and other kinds of medical care.

And finally, we have put together a national, what we call a telemedicine triage effort, which is an opportunity to really coordinate information and resources across the nation. We have over 200,000 grantees, many of them who are in major academic health centers. And with Dr. Zerhouni's leadership, there's been now the infrastructure put into place so that we can coordinate resources and make sure people know what's available and where, and in particular for patients who have been affected who need very complex medical care. We can make sure that they are able to find that. And that would include those with mental health as well as with other kinds of medical problems.

MR. HALL: Next question?

OPERATOR: Marilyn Elias, you may ask your question.

QUESTION: Thank you. I have a couple of questions. First of all, for Dr. Insel, on this debriefing and the science that we have about debriefing, I'm curious as to what we know specifically about how much of this debriefing is going on in the Gulf Coast right now.

And then the other question I had has to do with the first responders, which, as you say, there's going to be a second wave of the hurricane and the problems could be magnified a hundredfold. What specifically is being done right now to help first responders, and what's going to be done down the line when we expect there to be some of the damage that surface?

DR. INSEL: Okay. Good questions on both counts. On the first question, the fact is we simply don't know how much debriefing is happening in places where people now reside. We do know that this was a common practice after 9/11, and that's where we got much of the information that tells us that, wait a minute, that sounds good, it's what we've seen on television and in the movies, but in fact it's scientifically not worthwhile and seems to have potentially some downside as well as not providing any obvious upside.

In terms of the question about what's being done for first responders and for others to build some protection against this second wave, I'm going to let Mr. Curie respond to that a little bit in terms of what the services are that are being put in place, because that really is where SAMHSA has been right in the center of the storm and is trying to put a number of things in place at all of these various sites.

MR. CURIE: Yes, in fact we've had discussions with each of the states that are responding at this point. We have several ways that we're approaching this. We actually have been working with states in those grant applications I mentioned earlier to assure that there are dollars that would support expert mental health teams. Plus we are able to provide both consultation, technical assistance and actually deploy teams just to focus in that area. And in partnership with the CDC, CDC I know is looking to have what they are calling resilience officers on each of their teams, and we'll be working with those officers, with the folks we have, to make that resource available to other first responders.

Let me ask Dan Dodgen to fill in some more detail with that.

MR. DODGEN: This is Dan Dodgen again from SAMHSA. I think a couple of other things that folks may or may not be aware of. Certainly, most police and fire departments have got EAPs, employee assistance programs, that already have some kind of organized crisis response, crisis support mechanism to support their own employees. And they use a number of different models for doing that. But most folks have that in place already because this is something that they so frequently deal with. Now, those folks are probably going to be overwhelmed relatively quickly, but there is a mechanism in place.

In addition to that, what we've already seen from the applications coming in to SAMHSA is that some of the states are going to make these kinds of services to first responders one of their top priorities in their application, because the needs are so great. And actually, after 9/11, SAMHSA established a public safety workers grant program specifically to meet the needs of first responders in the seven most impacted states in the metro New York and D.C. areas.

So this is an issue that we're very, very cognizant of and are already, I think, as part of our planning process, beginning to look at how can we provide that kind of support, not just in this acute phase where we're trying to just get people out to the scene, but also in our long-term strategic planning, what kind of support can we provide to those folks.

MR. HALL: Before we go to the next question, I'd like to just remind folks that are asking questions if you could also give us the name of your organization that you're with. Thank you.

OPERATOR: Paul Bashkin, you may ask your question.

QUESTION: Thank you. Paul Bashkin with Lindberg News.

I've been getting a lot of, I guess, qualitative description. I wonder if I can get some numbers on some of what we're talking about here in terms of federal staff who are actually being in the area, dollars. I know the president's come out with a request now for another $50 billion today. I'm wondering if maybe you're able to give us any sense as to what portion of that number you're talking about in the things you're describing here. Any numbers, even rough estimates, and how many people total are in this kind of need that you're talking about?

And just finally, is there any--you sort of alluded to it, but is there any direct effort to try and connect people with their existing doctors from before, you know, rather than trying to find them new mental health professionals; just sort of coordinate them back to the people they were actually seeing before? Thank you.

MR. CURIE: Those are excellent questions. In terms of numbers, I'll have Dan follow up with some estimates that we're seeing. Actually, to get an accurate count right now, with everything that's been set up and everything that's been on the move, it's--they've literally been setting up these units as MASH units, so the data would not be real specific or accurate. But we can give you somewhat of an idea, and Dan's working on that right now.

In terms of hooking people up with--oh, in terms of the numbers, in terms of resources, we'll have to break out for you as time goes on out of that $50 billion, how much we'll be seeing with the HHS response. We have been putting estimates in. and what we've learned in past disasters is that you have this acute phase and you begin to look at the up-front money you need to move out. You know, the half a million was just first urgent money to get out. I mean, I would anticipate that we're probably talking in the interim somewhere in the vicinity of anywhere from a five-to-fifteen-million-dollar response kind of in a next phase, and then beyond that, I think there is a longer-term phase in which we have to give some strong consideration to the type of services that will need to be in place, and capacity that will need to be in place, where evacuees are going to be at least for an interim period after the shelter phase as states have stepped forward in indicating that they can accommodate numbers. Again, we're going to be working with each of those state authorities as well as with the private providers to address that issue.

So this is going to be a phased approach. We're looking ahead to what those phases are going to look like. Dollars are going to be a top priority in terms of what this costs, because our goal is at HHS, and it's a goal that we're hearing from all these state authorities, from the states that have stepped forward, is to make sure when people need services, they get services. So we want to make sure that we have that infrastructure in place.

In terms of hooking people back to their original doctors, again, it's an excellent point. Ideally, this is what we would be trying to do, is making sure that there's a link from the practitioners that have been treating individuals for years for mental illness or for addictive disorders, children as well. And one of the challenges they've found in these units that have been set up is they have to rely on the self-report of the individual who came in from New Orleans, for example, who is being displaced totally out of state, in particular. And that's been one of the major challenges of the mental health professionals, the psychiatrists in particular, is setting down and piecing together. If someone knew they were on psychotropic drug, many can name what that medication is and give an idea of the dosage. Some may not be real clear. They may say "I was taking a red pill and I was, you know, taking it so many times a day." So they would need to do an assessment and screening and you have an idea of what would be appropriate.

Every effort is going to be made to link back to providers, but I think it's going to be extremely challenging and perhaps in some situations impossible. When you take a look at providers in the New Orleans area, records--if they had primarily paper records that were history, that were under water. And again, if it was an electronic record, I think it's much more hopeful that they'll be able to find that information and link it back. But right now, a lot of what's being relied on is self-report of the evacuee themselves, the individual themselves.

DR. INSEL: Dr. Insel again. I do hope that you'll ask those same questions again in one month and six months and in one year, because the struggle that we always face here is that the problems we're talking about are ones that may not show up until the dust settles from a catastrophe like this. You all have moved on to other stories, but the people who have these disorders are just starting to have the greatest intensity of their suffering.

Another piece of this, I think, as you think about what this is going to look like going forward, is to recognize that, yeah, we weren't doing all that great before, that for many of these people, the kind of mental health care that they were receiving wasn't optimal. And the question ought to be asked at a time like this, as we think about this going forward, can we do much better? If we're thinking about rebuilding cities and we're thinking about rebuilding lives, can we rebuild health care in such a way, in this case, that it really works much better in the future than it has worked in the past.

MR. CURIE: Well, and I might add to that. I think clearly, as we are looking--and I know the secretary is tasking us with assessing in terms of rebuilding a system, you want to rebuild that in the right way. And clearly, we know more today than ever before. And if we are going to be investing dollars--and we will be--as we invest dollars in rebuilding that system, we need to invest the dollars in evidence-based practices that we know are going to work, put the incentives in the right place as these systems are being rebuilt, and do it right.

Again, I'm asking Dan to share some information about what we know in terms of, not numbers of people, but one set of numbers that may be of interest are the numbers--the amount of capacity that was lost around mental health in light of Katrina.

MR. DODGEN: And what I'm looking at--and this is just as an example to give folks a sense of this scope--is I'm looking particularly at our OPA treatment programs, which are the methadone treatment programs that some of you are probably familiar with. And what we're finding there, for example, is there were five facilities in the New Orleans area prior to this; none of those are open anymore. One has a mobile unit that is still working. And of course they need methadone, they need all of the medications, et cetera, that you would expect that they would need. As a result of that, then what we're finding is the Texas Methadone Treatment Association is reporting that they're getting a significant influx of people from New Orleans, many of whom are from the downtown area where the methadone treatment programs were. So as of early yesterday, they had already serviced 40 people who had come in from New Orleans to begin the process of putting them in their system.

I could give you more examples like that if it's helpful, but I don't want to spend a lot of time other than saying that basically, the majority of facilities that were in the New Orleans area are shut down, and what we're finding is we're getting census counts going up, particularly in Texas, that are adding to the numbers of, you know, what was going on in their system. And of course different counties and neighboring states had different levels of strength in their system before all this happened. The report says, for example--and this is a number that perhaps Bill can confirm--but we're getting reports of literally tens of thousands of people that had been seen in medical clinics in Houston at the temporary shelter that they've sent up there just to do the screening in the Astrodome.

So in terms of numbers, I think because they're so great, the folks that are responsible for giving them to us are still putting their own information databases together. And I think, as Dr. Insel was saying, in the next couple of weeks we're going to have a much, much better picture. But I think it's safe to assume that any facilities that were providing mental health or substance abuse services, certainly--really in the metro New Orleans area, but certainly in the most flooded areas, are gone. And their service recipients are going to be looking to neighboring communities to provide help.

MR. HALL: I think we have time for one more question.

OPERATOR: Our last question is from Lydia Lively of NBC News.

QUESTION: Actually, somebody a while back asked the question I had.

OPERATOR: Okay, Joe Verengia, you may ask your question.

QUESTION: Thanks. Joe Verengia from AP.

Just to follow up a little bit on when they're seeing patients. Is there a standard protocol that you're following if you don't know who this patient is and you're relying on self-report, in terms of what kind of medication they use, what kind of dose? Or is it up to the individual practitioner to make a best-judgment call?

MR. CURIE: Well, that's a very good question. And again, this is more of a report based on my own observation as I visited the mental health units. And they were using the protocols that they would use in their practice at their local hospitals' psychiatric units, because this is being staffed by the major medical centers in the area. So it was standard practice as you find in those hospitals in that area. And again, that's consistent fairly much across the country in terms of mental health units, in terms of diagnosis assessment and medication protocols. And I was able--if it wasn't for the mobile nature of what they set up in terms of, you know, having the partitions and the curtains and they being in a large convention center or athletic field, they were functioning as they would in a hospital or a clinic. So they were using their standard protocols.

MR. HALL: Okay. Thank you all very much for joining the call. I appreciate it. Thank you.

OPERATOR: That concludes today's conference call. All lines will be disconnected at this time.

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