In the days after Hurricane Fiona, Dr. Brenda Rivera-García sat at home without electricity, water and Wi-Fi in San Juan, Puerto Rico.
She was stuck listening to the hum of generators powering households across the neighborhood, drowning out the cheerful coquis that chirp throughout the night.
The sad hum, the droning "lullaby," mirrored the island's collective grief, Rivera-García said.
"It's one thing after the other. There is so much you can take," said Rivera-García, senior director of Latin America and Caribbean programing at Americares, a health-focused disaster relief nonprofit.
Puerto Ricans may be facing a mental health crisis, experts say, as hurricanes, earthquakes, and a global pandemic have traumatized island residents, destroyed homes and ripped families apart over the last five years.
The inadequate local and federal responses to these natural disasters adds another layer of despair as many Puerto Ricans struggle with the island's economic and political status as a U.S. territory.
"There's a real sense of uncertainty of the future of Puerto Rico," said Daniel Gaztambide, clinical psychologist and assistant director of the clinical psychology program at the New School in New York City. "There has to be a response to address the immediate natural disaster and a response to address the past, present, and ongoing political disaster."
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Rise in anxiety and depression
Puerto Rico's Mental Health and Anti-Addiction Services Administration (known as the Spanish acronym, ASSMCA) said calls to its crisis hotline have skyrocketed since Hurricane Fiona hit the island.
The hotline received nearly 3,000 calls in the five days after the storm, with over 1,900 related to Fiona, ASSMCA director Dr. Carlos Rodriguez Mateos told USA TODAY. That's double what the hotline typically gets in a normal week.
"We've seen through those calls how feelings of sadness, anxiety, fear, insecurity, uneasiness, and even loss of appetite have all increased," he said. "And that all coincides with the fifth anniversary of Hurricane Maria."
Hurricane Maria hit the island on Sept. 20, 2017, as a Category 4 storm. Rodriguez Mateos said calls to the hotline have increased after every major natural disaster in Puerto Rico, which tracks with studies showing how mental health on the island has suffered since Hurricane Maria.
A survey by the Washington Post and the Kaiser Family Foundation found more than one-fifth of the island's residents reported needing or receiving mental health services a year after the disaster.
Those who may need mental health and psychosocial support services include students and frontline workers, Rivera-García said.
"Those are some of the populations that we need to start thinking about really carefully," she said. "Our first responder and health care workers have been on the frontlines of everything while still being survivors themselves."
Another study by the University of Illinois at Urbana-Champaign showed more than 49% of workers in Puerto Rico met the diagnostics criteria for post-traumatic stress disorder a year after the disaster.
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"Abandonment issues among the elderly are some of the things that we also need to consider," Rivera-García said, as many young families migrate from Puerto Rico to the mainland in search of stability, leaving their loved ones behind.
In the wake of Hurricane Maria, more than 123,000 Puerto Ricans permanently relocated to U.S. states, especially New York and Florida, according to U.S. Census Bureau estimates.
Mental health services shouldn't be limited to Puerto Ricans on the island, experts say. Dr. Luis Rodriguez, CEO and president of the Puerto Rican Family Institute, said he still wrestles with his own complicated feelings years after leaving.
"I love Puerto Rico, I love to go to Puerto Rico and every time I leave, I feel so sad," he said. "The guilt comes back. It's a cycle, it's a terrible cycle."
The immediate impacts of the storm aren't the only sources of stress for Puerto Ricans, mental health experts say. Many criticize the lack of political and economic response to past natural disasters and worry history will repeat itself.
"The last time this happened, we had a sitting president who threw rolls of Bounty at people," Gaztambide said. "Recent history gives us some pause, some anxiety, and anticipation of what the U.S. response is going to be."
The federal response after Maria was considered slow compared with aid provided after similar disasters in the U.S. mainland, according to critics. It took nearly a year to completely restore power across the island, becoming the largest blackout in U.S. history and the second-largest in the world, according to the Rhodium Group, a policy analysis firm.
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The Puerto Rican government in 2020 signed a 15-year contract with LUMA Energy, a Canadian-American company that pledged to reduce power interruptions. Despite the contract, rolling blackouts persisted. Over the past year, Puerto Ricans have repeatedly protested against the energy company. Last month, hundreds gathered outside the governor's mansion in San Juan, calling on Gov. Pedro Pierluisi to cancel LUMA's contract.
Before Fiona made landfall Sept. 18, it provoked a general blackout affecting the entire U.S. territory of 3.2 million people. Two weeks later, LUMA restored power to about 92% of the island, according to a statement sent to USA TODAY Sunday.
"When Fiona went down, that accentuated a lot of pain and anger because there's a sense of helplessness here," Gaztambide said. "It's a colonial melancholy."
Jenniffer Gonzalez-Colon, Puerto Rico's nonvoting congressional representative and an advocate for statehood, told NPR there's "a direct connection" between Puerto Rico's governmental status and its 47% poverty rate.
"It's a colonial relationship that makes it so a select class in Puerto Rico can become very wealthy while the rest of the population struggles," Gaztambide said.
ASSMCA prepared for the expected emotional toll from Fiona by rolling out a mental health campaign prior to the storm, Rodriguez Mateos said.
The agency launched it on social media and dispatched mental health providers - including psychologists, psychiatrists, social workers and clinicians - to shelters in areas that saw Fiona's biggest impact. As shelters closed, providers knocked on doors.
"We have personnel going house to house, to identify resources and do early interventions," Rodriguez Mateos said. "Providing tools and hope."
In addition to social support, Gaztambide said it's also important to stay connected with loved ones on the island and on the mainland. He suggests connecting with local resource providers, places of worship, or community organizations that can help alleviate feelings of loneliness and fear.
It's normal to feel anxious and depressed after a natural disaster, health experts said. It's important that Puerto Ricans address and validate those emotions, Gaztambide said.
"There is no 5-minute mindfulness exercise to forget about colonialism," he said. "Let there be room to be angry, to be really upset, and really sad about what's happening and allow that anger to be a source for others to call for what we deserve and demand."
The island may be facing a mental health crisis but Gaztambide said Puerto Ricans are uniquely resilient and he's hopeful for the future.
"There is going to be pain and there is going to be this anxiety and sense of sadness and depression," he said. "At the same time, we are a very resilient people and we have been through much in the 500-plus years that Puerto Rico has been in existence.
"We're still standing and figuring out a way to take care of ourselves and each other."
Follow Adrianna Rodriguez on Twitter: @AdriannaUSAT.
Health and patient safety coverage at USA TODAY is made possible in part by a grant from the Masimo Foundation for Ethics, Innovation and Competition in Healthcare. The Masimo Foundation does not provide editorial input.
This article originally appeared on USA TODAY: Mental health in Puerto Rico: Hurricane Fiona reveals 'pain and anger'