NEW ORLEANS — Brandi Wagner thought she had survived Hurricane Katrina. She hung tough while the storm’s 125-mph winds pummeled her home, and powered through two months of sleeping in a sweltering camper outside the city with her boyfriend’s mother. It was later, after the storm waters had receded and Wagner went back to New Orleans to rebuild her home and her life that she fell apart.

“I didn’t think it was the storm at first. I didn’t really know what was happening to me,” Wagner, now 48, recalls. “We could see the waterline on houses, and rooftop signs with ‘please help us,’ and that big X where dead bodies were found. I started sobbing and couldn’t stop. I was crying all the time, just really losing it.”

Twelve years later, Wagner is disabled and unable to work because of the depression and anxiety she developed in the wake of the 2005 storm. She’s also in treatment for an opioid addiction that developed after she started popping prescription painkillers and drinking heavily to blunt the day-to-day reality of recovering from Katrina.

More than 1,800 people died in Katrina from drowning and other immediate injuries. But public health officials say that, in the aftermath of an extreme weather event like a hurricane, the toll of long-term psychological injuries builds in the months and years that follow, outpacing more immediate injuries and swamping the health care system long after emergency workers go home and shelters shut down.

That’s the rough reality that will soon confront regions affected by this year’s string of destructive hurricanes. As flood waters recede from Hurricanes Harvey, Irma, Maria and Nate, and survivors work to rebuild communities in Texas, Florida and the Caribbean, mental health experts warn that the hidden psychological toll will mount over time, expressed in heightened rates of depression, anxiety, post-traumatic stress disorder, substance abuse, domestic violence, divorce, murder and suicide.

Brandi Wagner's home in Lafitte, La., left, and the nearby bayou, Bayou Barataria, right. Below, sandbags line the street across from Wagner's home as Hurricane Nate approached earlier this month. | Bryan Tamowski for POLITICO

Renée Funk, who manages hurricane response teams for the Centers for Disease Control and Prevention, says it has become clear since Katrina that mental illness and substance abuse aren’t just secondary problems—they are the primary long-term effect of natural disasters.

“People have trouble coping with the new normal after a storm,” Funk said. “Many have lost everything, including their jobs. Some may have lost loved ones, and now they have to rebuild their lives. They’re faced with a lot of barriers, including mental illness itself,” she said.

In New Orleans, doctors are still treating the psychological devastation of Katrina. More than 8,000 patients receive care for mental illness and addictive disorders just from Jefferson Parish Human Services Authority which runs two health centers in the New Orleans metropolitan area. At least 90 percent of the patients lived through Katrina and many still suffer from storm-related disorders, according to medical director and chief psychiatrist Thomas Hauth, who adds that he and most of his fellow clinicians also suffer from some level of long-term anxiety from the storm.

“Every year about this time, I start checking the National Weather Service at least three times a day,” he said.

These long-term mental health effects of extreme weather are a hidden public health epidemic, one that is expected to strain the U.S. health care system as the intensity and frequency of hurricanes, tornadoes, floods, wildfires, earthquakes and other natural disasters increase in coming decades because of global warming and other planetary shifts.

With climatologists promising more extreme weather across the country, mental and behavioral health systems need to start preparing and expanding dramatically or demand for treatment of the long-term psychological effects of future natural disasters will vastly outstrip the supply of practitioners, said Georges Benjamin, director of the American Public Health Association.

Dr. Thomas Hauth, a psychiatrist, in his office at the Jefferson Parish Human Services Authority in Marrero, La., where he treats residents still suffering from anxiety, post-traumatic stress disorder and other mental disorders caused or exacerbated by Hurricane Katrina. Hauth and his colleagues also report post-storm anxiety and other conditions. | Bryan Tamowski for POLITICO

“On a blue sky day, our mental health resources are stretched,” said Carol North, researcher and professor of psychiatry at University of Texas Southwestern in Dallas. “There’s a lot we don’t know yet, but common sense tells us that more disasters and worse disasters will lead to worse psychological effects.”

”Katrina brain”

For climate change believers, this year’s string of record-breaking Atlantic hurricanes was just a warm-up for what scientists predict will be more frequent extreme weather events in the future.

When an entire city experiences a significant trauma at the same time, as New Orleans did during Katrina and Houston did during Harvey, it can push a lot of people over the edge, said Eric Kramer, another doctor who worked in the Jefferson Parish clinic: “Some people can rely on their inner strength and resilience to get through it, but others can’t.”

In the aftermath of Katrina, many survivors struggled with short-term memory loss and cognitive impairment, a syndrome dubbed “Katrina brain,” according to a report by Ken Sakauye, a University of Tennessee professor of psychiatry who was at Louisiana State University at the time.

Even though more than half the population of New Orleans had evacuated, psychiatric helpline calls increased 61 percent in the months after Katrina, compared with the same period before the storm, death notices increased 25 percent, and the city’s murder rate rose 37 percent, Sakauye wrote.

A year after Katrina, psychiatrist James Barbee reported that many of his patients in New Orleans had deteriorated from post-Katrina anxiety to more serious cases of depression and anxiety. "People are just wearing down," Barbee said. "There was an initial spirit about bouncing back and recovering, but it's diminished over time, as weeks have become months.”

In a longitudinal study comparing the mental health of low-income single moms in New Orleans before and after Katrina, one in five participants reported elevated anxiety and depression that had not returned to pre-storm levels four years later, said Jean Rhodes, study co-author and professor of psychiatry at University of Massachusetts Boston.

Hurricane Katrina killed 1,800 people in 2005, and left behind massive property damage. But public health officials are learning that the longest-lasting damage of severe storms is psychological. | Getty Images | Getty Images

For a smaller percentage of people in the study, particularly people with no access to treatment, symptoms of anxiety developed into more serious, chronic conditions such as post-traumatic stress disorder, the researchers found.

These aren’t cheap conditions to treat. One study cited by the CDC estimated the cost of treating even the short-term effects of anxiety disorders at more than $42 billion annually; double-digit regional leaps in rates of anxiety could cause serious financial strain to patients, employers, insurers and the government.

Vicarious reactions

Some damage can take place outside the storm-hit region. Even for people who have never experienced the raging winds, floods and prolonged power outages of a hurricane, this season’s repeated images of people struggling against the storms on television and other news and social media created unprecedented levels of anxiety and depression nationwide, said Washington, D.C., psychiatrist and environmental activist Lise Van Susteren.

“There is a vicarious reaction. When we see people flooded out of their homes, pets lost, belongings rotting in the streets, and people scared out of their wits, we experience an empathic identification with the victims,” she said.

Brandi Wagner pulls out the medications she must take on a daily basis to control a range of storm-related disorders including anxiety, depression, bipolar disorder, and an addiction to opioids. | Bryan Tamowski for POLITICO

“People come in saying they can’t sleep, they’re drinking too much, they’re having trouble with their kids, their jobs or their marriages are falling apart. They may not know where the anxiety is coming from, but everyone is affected by the stress of climate change.”

The same kind of vicarious reactions were documented after the Sept. 11, 2001, terrorist attacks in New York and Washington and after Hurricane Katrina, particularly in children, said Columbia University pediatrician and disaster preparedness expert Irwin Redlener.

“The mental health effects of natural disasters are really important and vastly overlooked, not only acutely but over the long term,” he said.

Everyone who lives through a major storm experiences some level of anxiety and depression. But for low-income people and those without strong social supports, the symptoms are much worse, said Ronald Kessler, an epidemiologist and disaster policy expert at Harvard Medical School. The same is true for people who already suffered from mental illness or drug or alcohol addiction before the disaster occurred.

Repeated exposure to weather disasters is another risk factor for mental and behavioral disorders. Hurricane Katrina decimated New Orleans on Aug. 29, 2005, followed by Hurricane Rita less than a month later. Three years after that, Hurricane Gustav hit the Louisiana coast, followed by Hurricane Ike two weeks later.

In September, many who had fled Hurricane Katrina and resettled in Houston had to relive the same horrors all over again, putting them at higher risk for long-term mental health problems.

TOP LEFT: Wagner in her backyard. TOP RIGHT: Wagner's medications. BOTTOM LEFT: Wagner shows off a photo of her son, Sgt. Aaron Briggs, receiving his sergeant badge in a photo on her phone. BOTTOM RIGHT: Wagner's daughter, Jessica Briggs, her grandson, Jeremy Goudeau Jr., and her daughter, Kristina Briggs, at her home in Lafitte, La.. | Bryan Tamowski for POLITICO

But perhaps the greatest risk of adverse mental health reactions to storms occurs when an entire community like New Orleans’ Lower Ninth Ward is so completely destroyed that people can’t return to normal for months or years, if ever. For those who left and went to live in Houston, Atlanta and other far-flung cities, the dislocation and loss of community was equally harmful, researchers say.

“People are only physically and mentally resilient to a point and then they are either irretrievably injured or they die,” Kessler said. If storms intensify in the future, the kind of devastation parts of New Orleans experienced could become more common, he said.

Psychiatric First Aid

In the past decade, first responders and public health workers began training in a type of mental health first aid that research has shown to be effective in lowering anxiety and reducing the risk that the traumas experienced during a storm will lead to serious mental illness.

Using evidence-based techniques, rescue workers reassure storm survivors that feelings of sadness, anger and fear are normal and that they are likely to go away quickly. But when survivors complain that they’ve been crying nonstop, haven’t slept for days or are having suicidal thoughts, rescue workers are trained to make sure they get more intensive mental health care immediately.

In Houston, for example, teams of doctors, nurses, mental health counselors and other health care professionals offered both physical and mental health services at clinics set up in every storm shelter. The city’s emergency medical director, David Persse, said the clinics were so successful that local hospital emergency departments reported no surges in patients with psychiatric distress or minor injuries.

Another important factor in reducing the psychological impacts of a storm is avoiding secondary traumas like being stranded for weeks in the convention center in New Orleans, said Sarah Lowe, a co-author of the Katrina study who teaches psychology at Montclair University in New Jersey. “Repeated traumas can pile up almost the way concussions do.”

Forced evacuation, whether temporary or permanent, can also trigger psychological problems for people confronted by natural disasters. | Wikimedia Commons

“What I’m seeing in Harvey and Irma is there’s more mitigation of secondary trauma,” Lowe said. People were allowed to take their pets to the shelters with them, for example. In Katrina, survivors either had to leave their pets behind or stay in their homes and be more exposed to physical and mental dangers.

Evacuation and relocation

Some public health experts say that we need to start thinking of longer-term solutions to the longer-term problem of severe weather; instead of trying to treat post-storm psychological damage, we should avoid it in the first place by persuading residents to move out of storm-prone areas.

“We do a great job with preparedness and response to hurricanes in this country. It’s an amazing accomplishment,” said Mark Keim, an Atlanta-based consultant who works with the CDC and the National Center for Disaster Medicine and Health. “But as climate change progresses over the next one hundred years, what are we going to do—respond, respond, respond? We can’t afford that anymore.”

According to Keim, much of the rest of the world is already taking that approach:

“Hurricanes can’t be prevented, but by refusing to rebuild in flood plains and developing the infrastructure needed to reduce inland flooding and coastal surges, we can avoid much of the human exposure to the coming storms. That’s where the world is right now in disaster management. Preparedness and response are older approaches.”

Climate change experts agree. To avoid increasing loss of lives from the mega storms expected in the decades ahead, large coastal populations should relocate, researchers say. Mathew Hauer, a demographer at the University of Georgia, recently found that a predicted 6-foot rise in sea levels by 2100 would put 13 million people in more than 300 U.S. coastal counties at risk of major flooding.

But relocating large populations has its own risks. For the hundreds of thousands of New Orleans residents who rebuilt their lives far from home after Katrina, the loss of social ties and the stress of adapting to new surroundings also took a heavy psychological toll, according to recent research at the University of California.

There’s another problem with relocating people from coastal regions. It’s not just hurricanes that are expected to plague the planet as the climate shifts. Wildfires, droughts, inland flooding, tornadoes, earthquakes and other natural disasters are also expected to increase in frequency and intensity, making it hard to find a safe place to put down new roots.

“Whether people decide to stay or decide to move, which means giving up a way of life, the long-term psychological costs of climate change appear to be inevitable,” Harvard’s Kessler said. “We can expect a growing number of people to have to face that dilemma. They’ll be affected by extreme weather one way or another, and they will need psychological help that already is in short supply.”

Christine Vestal is a reporter for Stateline, a nonprofit journalism project funded by the Pew Charitable Trusts.

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