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In the chaotic early aftershocks of Hurricane Harvey, dozens of seriously mentally ill evacuees at the George R. Brown Convention Center were left under-treated or without proper medication for days because doctors did not have the right kind of psychiatric drugs.
The only medicine immediately available for any mental health patient, including those with severe schizophrenia and bipolar disorder, was Prozac or Zoloft, according to firsthand medical accounts not previously made public. Those drugs typically are used to treat depression, anxiety, panic or obsessive-compulsive disorder.
Health care officials can’t say exactly why more drugs for psychiatric and some serious medical conditions were not immediately available at the city’s primary shelter. But they know they were lucky to skirt a health care disaster, and they want to be better prepared for the next catastrophe.
The stakes are high, as doctors warn medications for mental health are not interchangeable.
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Giving an anti-depressant to someone with another type of severe mental health condition, for example, is not only unauthorized but can actually worsen the disease. It could trigger a manic episode that spirals out of control, said Dr. Asim Shah, chief of psychiatry at Ben Taub Hospital and executive vice chair of Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine.
So some patients with the most critical needs, wedged among the thousands of frantic evacuees in an overflowing shelter, got no medicine.
“It was the same thing with diabetics without insulin,” said Dr. David Persse, Public Health Authority for the Houston Health Department.
With medications for a wide range of ailments absent in the early days, Persse recalled that in some cases volunteer medical workers had to depend on donated drugs, some from evacuees who left open, half-empty bottles of prescription pills on a table for others to potentially use.
The city’s health department has now put together a draft list of medications to be promptly available, including common antihypertensives, diabetic and psychiatric medications, in the case of future emergencies.
“Our challenge will be funding and a way to ensure the stock is always current, unexpired, and immediately available,” Persse said.
“We got lucky that we didn’t have somebody completely break down and become violent,” he added.
“Very frustrating
Those first nights, teams of mental health workers, American Red Cross nurses and firefighters traversed the rows of cots, looking for people who might be teetering toward crisis. If found, they were quietly escorted to the makeshift mental health clinic.
Once there, however, doctors had to sometimes use over-the-counter Benadryl to help agitated or anxious patients sleep, Shah said.
Treatment was at times also limited to talk therapy and getting patients basic needs such as food and clothing, both designed to help reassure and calm them, he said.
“Mental health providers were among the first responders. We were there,” Shah said, praising the work of volunteer doctors and workers who rallied quickly over coming days and weeks. “But it was very frustrating. Without medication you can’t do anything. You cannot treat psychosis without proper medication.”
It is not as if city officials had not drilled for disaster. They had even occasionally discussed securing some kind of contract with local pharmacies to ensure they could access medication seamlessly.
It does not appear that plan was ever launched, Persse said.
On Sunday morning, Aug. 27, with the water still rising, Houston Mayor Sylvester Turner opened the doors of the massive George R. Brown Convention Center to those who had been plucked from the floodwaters, many of whom had fled with nothing but the clothes on their backs.
The city expected 5,000. Nearly 10,000 showed up.
The next day, two psychiatrists from the Baylor College of Medicine arrived and set up a makeshift psychiatric clinic. A handwritten sign was slapped onto a pillar in the center: “Behavioral Health Need to talk? Hall E.” Over time the ranks of mental health professionals and social workers from across the city swelled to 60.
Prozac and Zoloft may have been the only medications available because they are common. In those early days dozens of medications for all types of medical needs began showing up on a table of donations at the center. Some medication was still in sealed packaging, possibly samples from doctor offices that were grabbed and brought by medical volunteers.
But there were also bottles of pills with patient names on the labels, some expired, others half-empty.
While the donations were welcomed by those scrambling to help people, Persse said health officials were also wary of the legality or even wisdom of using such medications. A quick call was made to the Texas State Board of Pharmacy. Officials there said it was acceptable to use the donated medication as long as it was checked for expiration date and potency by a licensed pharmacist who could then dispense it.
As it happened, a licensed pharmacist stepped forward from the throngs of evacuees, said Persse.
By Tuesday evening after the storm, some additional psychiatric medicine began to arrive, and the pharmacy was fully operational by Wednesday – four days after the convention center was opened to evacuees.
Shah outlined the difficulties in an article in the January issue of the American Journal of Psychiatry, now online.
Over two weeks, 232 evacuees from age 4 to 89, sought mental health help at the convention center. More than half of those treated had a pre-existing mood disorder. About 6 percent required a trip to the emergency room or psychiatric hospitalization, according to the psychiatric journal article.
That suggests the need to establish triage procedures for those struggling most during and after disasters, Shah said.
Before next disaster
The four most common conditions reported at the convention center were bipolar disorder, depression, schizophrenia and anxiety disorders, the article said.
Shah said he is not casting blame but rather shedding light on a problem that should be addressed before the next large-scale catastrophe.
He is among those who would like to see a list of the 10 psychiatric drugs most often used to treat a range of mental illness be part of any future disaster plan.
Years ago, in the era just after Sept. 11, 2001, Houston had an enormous cache of medications for most every ailment, stockpiled and ready. But over time, the drugs expired, and the federal government did not renew the program that supplied them.
Firefighters and the city’s health department have some medications on hand, but they cannot keep a ready supply of maintenance drugs for ongoing conditions.
“We can do better,” Persse said.
While important to have a disaster response plan in place, he said, it is equally necessary to have flexibility to find creative solutions when things go wrong – as they will. For example, roads to pharmacies could become impassable.
“You can make a plan,” Persse said, “but the disaster doesn’t read your play book.”