Mental Health of Puerto Ricans Living On and Off the Island After Hurricane Maria

On September 20, 2017, Puerto Rico was hit by one of the most intense and deadly hurricanes to make landfall in United States history. Hurricane Maria was a deadly category 5 hurricane with maximum sustained winds of 175 miles per hour, and “Maria” has now joined the list of retired names due to this hurricane’s destructive force. Its devastation was felt by nearly everyone living on the island of Puerto Rico. Puerto Rico had not been hit by a natural disaster of such magnitude in many years, and most Puerto Ricans had never experienced such damage and human destruction. As a result, most Puerto Ricans were lost and confused in the immediate aftermath of the storm, with grave repercussions. Mental illness became a growing concern as the effects of the hurricane in terms of the loss of properties and lives became known. In the wake of Hurricane Maria, there was loss of life, destruction of property, and loss of electrical power on nearly 100% of the island. Almost a year later, and after much struggle and controversy, the government of Puerto Rico announced that 2975 lives had been lost.(1)

Seeking some type of normalcy and sanity, many Puerto Ricans migrated to Central Florida and New York. A study conducted by a team from the University of Miami, Miller School of Medicine surveyed 213 people in the Orlando and Miami metropolitan areas and on the island to compare how this storm affected their mental health as survivors. Among those interviewed, the people residing in Central Florida reported having the most difficulty adapting to their new environment. They noted that they were experiencing issues with their living arrangements, facing a lack of job opportunities and transportation, and reported a feeling of rejection from local residents.(2)

The Washington Post/Kaiser Family Foundation also conducted a study, which included those who remained on the island.(3) In this study, a survey conducted a year after the hurricane reported that more than one-fifth of the island’s residents had reported needing or receiving mental health treatment. The study also showed how, in comparison to the years before Hurricane Maria, suicides increased by 18% and calls to the main suicide hotline rose by 13%.

Prior to Hurricane Maria, the Boricua Youth Study conducted a study of the mental health of Puerto Ricans living on the U.S. mainland compared with that of those living on the island.(4) Interestingly, the research showed that there were more cases of depression among those living on the U.S. mainland than in those living on the island. The mainland Puerto Ricans who participated in the study were residents of Brooklyn, New York.

Methods and Materials

When Puerto Rico was ravaged by Hurricane Maria, the widespread devastation was so significant that the government of Puerto Rico assessed damages amounting to at least $90 billion.(5) Splintered homes, towns inundated by flood waters, sweltering heat, and destruction from high winds were risk factors for developing both physical and mental illness. The punishing winds of Hurricane Maria left an entire island in the dark and with little communication. Among the immediate short-term impacts were physical injuries and deaths. The long-term impacts resulted from limited access to food, drinking water, and healthcare (mental and physical). Medical treatment for the urgent physical and mental issues, including stress, depression, and suicide attempts, was unattainable. The population was completely traumatized, and many resorted to migration as a means of coping with the unimaginable loss. It is estimated that about 200,000 Puerto Ricans fled the island after the storm—4% of the island’s population at that time.(6)

In November 2017, two months after Hurricane Maria made landfall on Puerto Rico, Michaud and Kates(7) reported on the mental health of those who had survived the storm, and how in such a short time there had been 32 known suicides and a considerable number of people reporting, for the first time, moderate and severe symptoms of anxiety disorders and depression.

Hinojosa et al.,(8) working on behalf of the Center for Puerto Rican Studies, found that the areas more impacted by the hurricane were rural and low-income housing areas whose residents were subjected to dire conditions as they returned to uninhabitable houses. Due to poor housing infrastructure and lack of resources, these communities suffered the loss of both housing and lives. Furthermore, many school buildings were damaged beyond a reasonable repair time; thus, many families migrated to states such as Florida and New York. According to Florida’s Department of Education, a total of 11,554 students from Puerto Rico enrolled in public schools, which was a 12% increase since before Hurricane Maria.(8)

In search of a more normal way of life, 30,000 to 50,000 Puerto Rican families relocated to Florida, specifically Orlando. From March through April 2018 (6 months after Hurricane Maria) Scaramutti et al.(6) compared the effect of Hurricane Maria on posttraumatic stress disorder (PTSD) among Puerto Ricans who moved to Florida after the storm versus those who stayed on the island. Rates of PTSD were significantly higher, at 65.7%, among those residing in Florida, versus 43.6% in those living in Puerto Rico. Although both rates of PTSD are high, the subjects living in Florida confronted additional stress factors as they faced the challenges of moving to a completely new state, confronted with language barriers, and leaving loved ones and friends behind.(9)

The Puerto Rico 2017 Mental Health Nation Outcome Measures prepared a statistical measurement of the mental health data.(10) There were 3995 subjects who received mental health services, a utilization rate of 1.1 per 1000 people. The gender distribution was 59.4% males and 40.6% females. The study also covered different age groups in order to determine which ages were most affected by the hurricane. The study compared these subjects to 7.5 million U.S. citizens (non-Hispanic). The study looked at employment status to determine any effect of damage arising from the hurricane.(10) It is evident that those who were employed at the time of the hurricane were emotionally and mentally distracted compared with those who were unemployed, and the focus of those who were employed was on their damages, their loss of property, and the far distant possibilities of recuperating economically. Holding a job provides mental stability, because it serves as a distraction and an additional economic resource to help alleviate the damages. Lack of economic opportunities and unemployment could serve as the spark to ignite more problems, including mental health crises.

Table 1 illustrates that the age group most strongly affected after the hurricane was adults aged 45 to 64 years. This comparison is noticeable even considering the average adult living in the United States who had experienced the stress associated with a hurricane. Men were more affected than women. Most of the people who suffering from mental health issues were previously unemployed.(10)

A larger study conducted by the Behavioral Sciences Research Institution at the University of Puerto Rico looked at the prevalence rates of nicotine dependence, alcohol abuse, alcohol dependence, and drug abuse.(11) Among those between the ages of 18 to 64 years, women had less probability of being diagnosed with a substance use disorder than men. During this study, residents who lived in San Juan, the capital of the island, had the highest 12-month prevalence rate of alcohol use disorder (8.9%), alcohol abuse (8.2%), and alcohol dependence (2.5%). Based on this study, a total of 2.5% of the adult population in Puerto Rico, were considered in need of substance use counseling.(11)

A study by Orengo-Aguayo et al.(12) focused on nearly 100,000 students from grades 3 to 12 in the public schools throughout the island This study investigated around the magnitude of the disaster and its impact on the mental health of these young people. The study revealed that 83.9% experienced seeing housing destruction, 57% had friends or family members leave the island, 45.7% reported damage to their own homes, 32.3% experienced shortage of food and water, 29.9% perceived their lives to be at risk, and 16.7% were still experiencing electrical power outage 5 to 9 months after the hurricane. Overall, 7.2% of youths reported clinically significant symptoms of posttraumatic stress disorder. The study concluded that these students were exposed to high levels of disaster-related stressors, and youths reported high levels of PTSD and depressive symptoms.

A study by Del Mar Quiles and Moscoso(13) addressed climate change post–Hurricane Maria and its direct impact on mental health in Puerto Rico. Hurricanes disrupt health-care routines and access to psychiatric care, and medications for people with preexisting mental disorders. Direct encounters with hurricane wind and water hazards, coupled with resource losses and enduring adversities—including delayed building repairs, school closures, and financial hardships—increase risks for new-onset post-traumatic stress disorder and major depression in people without previous psychiatric history.

First, the authors state that only 18% of Puerto Ricans received federally funded mental health services after the hurricane. As an example, the article mentions how Rafael Negron Santos, a Puerto Rican who was living in Puerto Rico during Maria, developed a mental health condition. Due to his mental illness, he lost his relationship with his partner, he experienced loss of appetite, and he experienced several panic attacks. He sought treatment for his multiple stress factors and was diagnosed with depression and PTSD six months after the hurricane.

Secondly, in their investigation of mental health problems associated with Hurricane Maria, the authors report on another Puerto Rican who experienced a similar mental health crisis. They relate the story of Lisandra Cruz Marín, who constantly felt nervous and had trouble sleeping. She was diagnosed with anxiety disorder. The authors launched a survey in which they asked a sample of Puerto Ricans who lived through the hurricane to respond to the questionnaire. It can be extrapolated from the data they collected that the feelings of loss experienced by the participants may be directly associated with the devastation that they experienced. Sadly, many of the participants stated that their new-onset mental health condition post-hurricane had gone untreated. The reasons for the absence of mental health treatment varied amongst the participants, but all of them revealed that they had faced similar situations and anxieties as Rafael and Lisandra. Moreover, more than half of those who were surveyed stated that they had faced four or more emotional challenges in the first year after the disaster, and 78% answered that they have lasting or chronic effects from the disaster.(13)

The Crisis Counseling Program funds free emotional assistance for anyone affected by a major disaster.(13) The study reports how this program has been used in Puerto Rico. New York is the state that that has received the most funding since 1985, but in the five years since the article was written, the place that has had received the highest amount of money is Puerto Rico.(13) Close to 41% of Puerto Ricans on the island benefited from the counseling sessions made possible by this program. According to the Federal Emergency Management Agency, at least 25% of residents in most towns received counseling, whereas in some towns, such as Ponce, 35% of residents applied for such counseling but only 7% received help.(13)

Lessons We Have Learned From Hurricane Maria

Disasters, whether natural or manmade, result in increased levels of stress and anxiety. Reactions to a disaster vary from person to person, with shock and disbelief, difficulty concentrating, trouble sleeping, changes in eating habits, changes in alcohol and tobacco use, dramatic mood swings, and feelings of anger, guilt, and grief among the most common emotional responses. These levels of stress are predictable and impact both those remaining on Puerto Rico and those who leave and take refuge on the mainland. According to Ready.gov, in disaster situations, “Children, senior citizens, people with access of functional needs and those for whom English is not their first language are especially at risk.”(14)

Mental health preparedness prior to a natural disaster often is overlooked due to the more immediate and basic physical needs in disaster situations.

Most Caribbean islanders have become accustomed to taking steps to prepare for their physical needs such as water, food, batteries, first aid supplies, and shelter, when threatened by a hurricane. However, there has been little attention to the emotional needs of the population before and after a disaster. The truth is that mental health issues can be more challenging than preparation for the physical needs of those who are going to experience a disaster. Unfortunately, mental health preparedness prior to a natural disaster often is overlooked due to the more immediate and basic physical needs in disaster situations.

One of the lessons learned is the importance of being prepared for the unexpected, because as this is one of the best ways to lessen the impact of a disaster, not just physical but also mental. Many natural disasters, such as earthquakes, tornadoes, floods, and tsunami happen in just a few seconds without any warning. However, hurricanes, the disaster that most often affects Caribbean islands, usually provide advance warning, giving islanders ample time for preparation. It is likely that climate change may result in more frequent natural disasters, especially affecting the Caribbean islands; therefore, the necessity for preparation for the mental health needs of those living on the islands or those who have evacuated to the mainland will be greater.

The take-home message is that preparation for natural disasters needs to include attention to the emotional needs that are likely to impact islanders whether they remain on the island or leave for the mainland.

The take-home message is that preparation for natural disasters needs to include preparation for the emotional needs that are likely to impact islanders, whether they remain on the island or leave for the mainland. Hurricane Maria demonstrated that disaster mental health preparedness would result in a significant reduction in the detrimental psychological effects arising from natural disasters.

One of the basic aspects of adequate preparation is the requirement for continuous mental health care in the community following any disaster.(15)

The research of Clay and his colleagues demonstrated a positive connection between disaster preparedness and mental health, and the probability of the mental disorder following disasters is due to an absence of preparedness.(16)

Bottom Line: Providing only financial and medical help immediately after a disaster cannot ameliorate the long-term psychological effects of disasters that are predictable following a natural disaster. Because natural disaster has a potentially negative impact on the mental health of Caribbean islanders, the islanders and their communities need to prepare psychologically and emotionally for confronting a disaster. We believe that more research is needed in the psychological effects of natural disasters and the necessity for mental health preparedness.

To our knowledge there are currently no systems in place to evaluate community mental health preparedness of Caribbean islanders. Mental health services should be developed so that there is a community mental health structure in place before any disaster impacts the area that can provide immediate support and then be part of the healthcare system.

References

1. Kishore N, Marqués D, Mahmud A, et al. Mortality in Puerto Rico after Hurricane Maria. N Engl J Med. 2018;379:162-170.

2. Ocasio BP. Puerto Ricans who fled to Orlando after Hurricane María struggled more than those in South Florida, study finds. Orlando Sentinel. February 1, 2019. https://www.orlandosentinel.com/weather/hurricane/puerto-rico-hurricane-recovery/os-ne-study-puerto-ricans-florida-mental-health-20190201-story,amp.html

3. Schmidt S, Hernandez AR. Puerto Rico after Maria: A year of Disruption. The Washington Post. August 23, 2018. https://www.washingtonpost.com/graphics/2018/national/a-year-after-hurricane-maria-a-puerto-rican-town-is-still-in-upheaval/#:~:text=A%20Washington%20Post%2DKaiser%20Family,are%20almost%20back%20to%20normal . Accessed February 12, 2020.

4. Jennings WG, Maldonado-Molina M, Fenimore DM, et al. The linkage between mental health, delinquency, and trajectories of delinquency: Results from the Boricua Youth Study. Journal of Criminal Justice. 20919; 62:66-73.

5. Barrett-Rodriguez TJ. Assessing the Effects of Reconstruction on the Commercial and Civil Construction Industry Following Hurricane Maria in Puerto Rico. Doctoral dissertation, Brigham Young University, 2020. https://scholarsarchive.byu.edu/etd/8699/

6. Scaramutti C, Salas-Wright CP, Vos SR, Schwartz SJ. The mental health impact of Hurricane Maria on Puerto Ricans in Puerto Rico and Florida. Disaster Med Public Health Prep. 2019;13(1):24-27.

7. Michaud J, Kates J. Public health in Puerto Rico after Hurricane Maria. Kaiser Family Foundation. November 2017. www.kff.org/other/issue-brief/public-health-in-puerto-rico-after-hurricane-maria . Accessed May 6, 2018.

8. Hinojosa, J., Roman, N., & Melendez, E. (2018, March). Puerto Rican Post-Maria Relocation by States. Retrieved June 30, 2022, from https://centropr.hunter.cuny.edu/

9. Vergara, A. (n.d.). The effects of looping on student achievement and self-efficacy . . . - stars. Puerto Rico After Hurricane Maria: Responses to Trauma and Constructing a New Life in Central Florida. Retrieved June 30, 2022, from https://stars.library.ucf.edu/cgi/viewcontent.cgi?article=1623&context=etd

10. Puerto Rico 2017 Mental Health National Outcome Measures (NOMS): SAMHSA Uniform Reporting System. www.samhsa.gov/data/sites/default/files/cbhsq-reports/PuertoRico-2017.pdf

11. Canino G, Vila D, Santiago-Batista K, et al. Need Assessment Study of Mental Health and Substance Use Disorders and Service Utilization among Adult Population of Puerto Rico. https://assmca.pr.gov/BibliotecaVirtual/Estudios/Need%20Assessment%20Study%20of%20Mental%20Health%20and%20Substance%20of%20Puerto%20Rico%202016.pdf

12. Orengo-Aguayo R, Stewart RW, de Arellano MA, et al. Disaster exposure and mental health among Puerto Rican youths after Hurricane Maria. JAMA Netw Open. 2019;2(4):e192619. DOI:10.1001/jamanetworkopen.2019.2619.

13. Del Mar Quiles C, Moscosos L. Recurrent trauma: the effects of climate change on mental health in Puerto Rico. Centro de Periodismo Investigativo. September 11, 2020. https://periodismoinvestigativo.com/2020/09/recurrent-trauma-the-effects-of-climate-change-on-mental-health-in-puerto-rico/

14. Coping with disaster. Ready.gov. December 17, 2020. https://www.ready.gov/coping-disaster

15. Khankeh HR, Nakhaei M, Masoumi G, et al. Life recovery after disasters: a qualitative study in the Iranian context. Prehospital and Disaster Medicine. 2013;28:573-579.

16. Clay LA, Goetschius JB, Papas MA, et al. Influence of mental health on disaster preparedness: findings from the behavioral risk factor surveillance system, 2007–2009. J Homel Secur Emerg Manag. 2014;11:375-392.