SAN
JUAN, P.R. — Her memories of the storm came in flashes: neighbors’
screams, gushing water, swimming against the current with her son.
For
Milagros Serrano Ortiz, a 37-year-old grandmother with long, curly
hair, the nightmare did not end there. After two days of sheltering
upstairs in a house across the street, she returned home to find the
walls caked with mud and a vile stench emanating from her cherished
possessions, which were rotting in the heat.
Anguished
and overwhelmed, she confessed recently to a psychologist at an
emergency clinic that she had begun to have disturbing thoughts and
worries that she might act on them.
“Like what?” the doctor asked.
Like swallowing a bottle of pills, she said, “never waking up, and not feeling pain anymore.”
The
violent winds and screeching rains of Hurricane Maria were a 72-hour
assault on the Puerto Rican psyche. There are warning signs of a
full-fledged mental health crisis on the island, public health officials
say, with much of the population showing symptoms of post-traumatic
stress.
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Puerto Rico was already struggling with an increase in mental illness amid a 10-year recession
that brought soaring unemployment, poverty and family separation caused
by emigration. Public health officials and caregivers say that Maria
has exacerbated the problem.
Many
Puerto Ricans are reporting intense feelings of anxiety and depression
for the first time in their lives. Some are paranoid that a disaster
will strike again. And people who had mental illnesses before the storm,
and who have been cut off from therapy and medication, have seen their
conditions deteriorate.
“When
it starts raining, they have episodes of anxiety because they think
their house is going to flood again,” said Dr. Carlos del Toro Ortiz,
the clinical psychologist who treated Ms. Serrano Ortiz. “They have
heart palpitations, sweating, catastrophic thoughts. They think ‘I’m
going to drown,’ ‘I’m going to die,’ ‘I’m going to lose everything.’ ”
With hurricane nearly two months in the past, the island is still in shock. Its residents are haunted by dozens
of deaths caused by the storm, and many more life-threatening near
misses. The reminders are inescapable. They lie in piles of rotting
debris as tall as homes that still line many streets and in cellphones
that are useless for checking on family members.
Returning
to a routine is the most important step toward overcoming trauma,
according to physicians and public health officials. But for most Puerto
Ricans, logistical barriers like scarce water and electricity, as well as closed schools and businesses, make that impossible.
Since Sept. 20, when the storm came ashore
at 6:15 a.m., more than 2,000 calls have overwhelmed an emergency
hotline for psychiatric crises maintained by the Puerto Rican health
department — double the normal number for that period of time, even
though most residents still do not have working phones. Puerto Rican
officials said that suicides had increased — 32 have been reported since
the storm — and many more people than normal have been hospitalized
after being deemed dangerous to themselves or others.
At
the emergency health clinic in Toa Baja, where Ms. Serrano Ortiz lives,
Dr. Toro said that he had been frantically calling for help from
colleagues in other cities because the facility was overrun with people
in need of mental health care.
Because
it is in a flood zone, Toa Baja was one of the worst affected areas in
Puerto Rico. At least four people died there and water levels peaked at
more than 12 feet. The city of 80,000 west of San Juan flooded multiple
times, each time that it rained after Maria passed.
In
his nearly 20 years of practicing psychology, Dr. Toro said he had
never before hospitalized as many people with suicidal or homicidal
thoughts in such a short time period. Of about 2,500 people who had been
to the clinic since it opened two weeks earlier, more than 90 percent
were referred for mental health screenings, Dr. Toro said. He and other
practitioners at the clinic had already referred at least 20 people to
psychiatric wards elsewhere on the island.
“This is an emergency situation,” he said. “It’s still affecting us. There are people that we haven’t seen.”
Health
workers are bracing for effects similar to those seen in New Orleans
after Hurricane Katrina and in Haiti after the 2010 earthquake, where
cases of both moderate and severe psychiatric illnesses spiked. In New
Orleans, many people experienced insomnia, cognitive impairment and
short-term memory loss, which became known colloquially and among researchers as “Katrina Brain.”
Prolonged losses of electricity,
water communications or infrastructure have been linked to the onset of
mental health crises, said Dr. Domingo Marqués, the director of
clinical psychology at Albizu University, a prominent graduate school of
psychology on the island with clinics in two major cities. All of those
elements have been relentlessly present in Puerto Rico.
“And this is all happening at once,” he said. “What we have lost is the foundation that holds a society together.”
He
said that Puerto Ricans would have to adjust their definition of
normalcy in order to function: “It’s ‘I survived. My family didn’t die.’
That’s the new definition of O.K.”
This
hurricane season has caused mental distress, and strained resources for
treating it, throughout the Caribbean, according to reports from the United States Virgin Islands, Dominica and Antigua.
The
mental health division of the Puerto Rican health department received
$3 million from the Federal Emergency Management Agency to coordinate a
response to Maria, said Suzanne Roig, the administrator of the Puerto
Rican agency.
Its
doctors have been knocking on doors in the worst-hit parts of the
island and visiting emergency shelters where people who lost their homes
have been living.
“We
are trying to reach people to tell them that this crisis will pass,”
she said, “and that they should not make permanent decisions.”
The
agency also started an initiative to monitor social media, and staged
interventions in a handful of homes of people who posted what appeared
to be suicide notes.
During
high-volume hours, its staff members have been taking on extra shifts
and working overtime to respond to the increase in phone calls to the
24-hour emergency crisis hotline.
In
addition to struggling with their own emotions, Ms. Roig said that
distressed callers had reported children who had not spoken since the
storm or cried inconsolably when it rained. And people with serious
mental illnesses who had experienced psychotic episodes had been locked
inside rooms by family members who did not know what else to do.
“People
who have a prescription can’t get to a pharmacy,” Ms. Roig said. “If
they can get to the pharmacy it might not be open. If it’s open, they
might not have the medicine.”
Before
the storm, Laura Rodriguez, 39, managed her borderline personality
disorder without medication by relying on a strict routine: Early
morning CrossFit workouts, long hours at work as an interior designer,
going to bed early and never having guests at her home in Río Piedras.
But since Maria hit, her gym had been closed and her therapist had not been working. Neither had she.
“I’m constantly anxious,” she said. “I get these urges to be violent and I can’t control it.”
Memories
of the storm were also tormenting her. She had been trapped inside her
apartment for two days with her boyfriend, her mother and her mother’s
cat. They used plastic tarps, towels, bedsheets and pieces of wood to
try to plug the windows where rain water was surging through.
Without
access to any of the balms that she typically relied on to stabilize
her mood, she was worried about resorting to self-harm, an impulse that
she had struggled to control since she was 8 years old. “What if it’s
like three months, four months?” she said. “I cannot do this for so
long.”
For Ms. Serrano Ortiz, another threat to her mental and physical health loomed.
Before
the storm, a scan of her throat had indicated that she may have cancer
for the second time. But she has not been able to get any more
information about her prognosis because her doctor’s offices have been
closed.
At
the emergency clinic, she told Dr. Toro that she might not have the
energy to fight the disease again. When she looked in the mirror, she
said, she saw in herself a reflection of her home — something dirty,
smelly and tainted.
“I don’t feel like myself anymore,” she said.
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