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The following was written by and from the perspective of Dr. Joshua Gordon, Director of the National Institute of Mental Health (NIMH).

Disparities in mental health play outsized roles in our society. People from racial and ethnic minority populations, as well as those from lower socioeconomic strata, and those who live in rural communities, are less likely to have access to mental health care and more likely to receive lower quality care. There have been recent investments in community mental health centers and the expansion of Medicaid, but more work is needed to eliminate these disparities. To address mental health disparities, we need to identify and understand the contributing factors and study the efficacy of programs to remedy them. In recognition of National Minority Mental Health Awareness Month, I am highlighting this important element of NIMH’s research portfolio.

From causes to effects

In some ways, addressing disparities in the mental health system should start with the basics—and by that, I mean basic science. In our search for the roots of mental illnesses, an area that has made great progress over the past five years is genetics. As I have written about before, we now know hundreds of places in the genome where genetic variation raises the risk for psychiatric disorders. While we can be justifiably proud of these successes, we must also acknowledge a serious shortcoming—historically, the vast majority of the subjects in these genetic studies were of European ancestry, and it is therefore unclear how much these discoveries will benefit the majority of people of differing ethnicities.

Emerging data from an NIMH-funded study of the genetics of post-traumatic stress disorder (PTSD), for which our Psychiatric Genetics Consortium made a concerted effort to include studies with participants from the African American community, illustrates the importance of recruiting subjects from diverse genetic backgrounds. This analysis, which combined data across 11 multiethnic studies, revealed strong heritability and overlap between the genetics of PTSD and that of schizophrenia.  These were interesting scientific findings—but limited in that they only applied to the Caucasian participants. It turned out that the genetics of the African American sample set was much more complex and varied than in Caucasians, so even though the researchers had included data from a large number of African American participants, there were still too little data to provide information on disease heritability with respect to African genetic ancestries. These and other data point to the need to increase the recruitment of individuals of African descent in our psychiatric genetics studies, as we are doing with NIMH’s component of the NIH-wide H3Africa program, a collaborative effort to enroll large numbers of individuals from sub-Saharan Africa in genetic studies of schizophrenia, as well as an NIMH-supported effort to increase the diversity in genetic studies of autism, schizophrenia and bipolar disorder.

Like the causes, the consequences of mental illnesses differ for minorities as well. Nowhere is this more evident than for one of the most devastating effects of mental illnesses: suicide. According to the Centers for Disease Control and Prevention, the rates of suicide vary significantly by race/ethnicity (see figure). In particular, individuals from American Indian and Alaska Native (AI/AN) communities die from suicide at significantly higher rates than whites or other racial or ethnic minorities—the suicide rate for AI/AN youths is especially alarming, being over 3.5 times higher than those among racial/ethnic groups with the lowest rates. To address this devastating issue, the NIMH, in partnership with the National Institute on Minority Health and Health Disparities (NIMHD), funds three collaborative research “hubs” that bring together academics, tribal leaders, and peers. These partnerships aim to build capacity for research in AI/AN communities; to determine what factors lead to this increase in suicide risk; to develop and tailor treatments that work in these communities; and, to learn how to implement these strategies using novel approaches and technologies suited to the unique needs of AI/AN communities.

In addition to supporting these research hubs, the NIMH has participated along with other federal partners in the Arctic Council’s RISING SUN initiative, aimed at reducing the incidence of suicide in indigenous groups living in the far northern regions of North America, Europe, and Asia. A major output of this effort is the RISING SUN toolkit, which aims to help clinicians, communities, policymakers, and researchers measure the impact and effectiveness of suicide prevention efforts in rural and tribal communities.

Understanding differences in treatment effects

The good news is there are treatments that work, even if they don’t always work for everyone. Recent research has shown, however, that paying attention to differences in treatment responses in specific groups can help make our treatments work better. Including diverse groups in research can also reveal why there are differences in treatment effects. A case in point: an NIMH-funded study published just last year showed one way to improve the effectiveness of depression and anxiety treatment in Hispanic youth. Scientists were studying two alternative methods of delivering treatment to adolescents suffering from anxiety and depression in primary care settings: one, an “assisted referral to care” method that helped patients get care at an outpatient mental health center, and the other, a “brief behavioral therapy” delivered in the primary care setting itself.

The results of the trial showed that in the non-Hispanic group, children generally did better with the therapy delivered in the primary care setting, with about 50 percent of children responding to the treatment compared to 30 percent who received assisted referral care. 

But this difference in efficacy was even more dramatic in Hispanic children. Nearly 80 percent of Hispanic children responded to the brief behavioral therapy delivered in a primary care setting, while less than 10 percent of these children responded to treatment delivered through assisted referral. These data demonstrate that delivering care to Hispanic children may be better off done in primary care offices than through specialty mental health care settings.

Of course, most mental health disparities are not so easily addressed. In particular, we need to know more about the “whys” behind these disparities, so that we can begin to design strategies to remedy them. An ongoing NIMH-supported study is examining the effects of dietary supplementation with vitamin D and omega-3 fatty acids on depression in the elderly. Early results from the study suggest that the effects of these supplements vary with ethnicity. The scientists are using the second phase of the study to try to ask why. Do individuals from different ethnic backgrounds absorb these substances differently? Do they have different metabolic responses to the supplements? That study is examining biological factors contributing to mental health disparities; other NIMH-supported efforts focus on psychosocial factors such as the impact of race-related violence exposure on mental health, or the environmental and social factors behind elevated rates of depression in minorities.

Finally, we must acknowledge that disparities in access to care arise from workforce issues as well. The distribution of psychiatrists and other mental health care professionals is skewed heavily towards urban areas. Rural areas, and areas with many residents of lower socioeconomic classes, are particularly underserved. NIMH supports several studies aimed at understanding the precise distribution of the mental health workforce in relation to its needs, the impact of this distribution on minorities and others in underserved communities, and potential remedies, including the use of task-shifting and telepsychiatry approaches.

The future of disparities research at NIMH

NIMH recognizes a unique and compelling need to reduce and eliminate mental health disparities in communities across the nation. Measuring, monitoring, understanding, and reducing mental health disparities that disproportionately affect minority communities are priorities of the NIMH. In keeping with our focus on high-quality, impactful science, we particularly want to expand opportunities for performing cutting-edge research in mental health disparities targeting underserved groups. We believe that increased focus on approaches such as big data, deep phenotyping, tailored therapies, personalized medicine, and rigorous implementation science will help meet the challenges imposed by mental health disparities.

One of the most important things we can do to understand the sources of these differences is to promote diversity in research, both in those who participate in clinical research and those conducting the research. Innovative approaches aiming to solve problems that contribute to mental health disparities will pave the way toward equitable and appropriate care for all individuals.

Read more on NIMH.NIH.gov.

Inside this story:

• African Americans are 20 percent more likely to experience serious mental health problems than non-Hispanic whites.
• African Americans consistently receive lower-quality and culturally incompetent mental health care, and frequently turn to spiritual advisors and circles to fill the gap.
• God’s Way Christian Baptist Church is one of 11 faith-based organizations funded through the Hogg Foundation’s Faith-Based Initiative for African American Mental Heath Education, which aims to build on the unique strengths of churches and faith-based organizations in African American communities to educate about mental health.
• God’s Way’s Wellness and Empowerment Community Ministries provides a welcoming and inclusive space for congregants to engage in dialogue around mental health, and has created a positive ripple effect, enhancing overall community well-being.

For more than 12 years, Eugenia Kleinpeter endured an uphill climb as she attempted to locate mental health services for her children. It’s a struggle African Americans living in rural Texas know all too well.

Even though the proportion of African Americans living with mental health conditions is comparable with that of the general population, the National Alliance on Mental Illness reports that African Americans consistently receive lower-quality and culturally incompetent mental health care. This contributes to the greater severity of mental health issues among African Americans compared to non-Hispanic whites.

For years, Eugenia sought the right kind of support for her eldest son Greg, who, like four of his younger siblings, has special needs. As a child, he not only lacked adequate assistance for his speech impediment, but also had to stomach stigma from strangers and peers—even fellow churchgoers. “At church, my kids basically hung around me,” said Eugenia. “There was a lot of rejection—a lot of people keeping their kids close to them, or not saying hello.”

Often, in lieu of clinical sources of aid, African Americans turn to spiritual advisors and circles instead. At God’s Way Christian Baptist Church, however, Eugenia and her son found both. Eugenia shared, “They don’t stigmatize people there. God’s Way truly embraced my children and encouraged them to use their talents.”

Led by Reverend Dr. B.R. Reese, God’s Way is one of 11 faith-based organizations that received funding through the Hogg Foundation’s Faith-Based Initiative for African American Mental Heath Education, which aims to build on the unique strengths of churches and faith-based organizations in African American communities to increase awareness about and change perceptions of mental health, recovery and wellness, and to connect congregants with culturally competent behavioral health resources. Grantees have used the funds to start or strengthen dialogues about mental health—both within their respective places of worship and with providers in surrounding communities.

Mental Health Dialogues: From Pulpit to Barbershop

When Greg was a teenager, Eugenia brought him to God’s Way for the first time. Now, over 20 years later, she serves the church as an Assistant Minister and Sunday School teacher. “My son loves to go to church,” she said. “He lights up when he sees the pastor. They’ve always included him—telling him they missed him, and asking how he’s been.”

Based in Taylor, Texas, the church and its pioneering Wellness and Empowerment Community Ministries (WECM) initiatives have created a culture of inclusivity and sensitivity that provides for the congregation’s spiritual and psychological needs. Though of modest size—the church convenes 50 to 100 attendees every Sunday—lessons learned and taught by God’s Way clergy have, thanks to evidence of success and word of mouth, traveled far and wide.

Health fairs, conferences, vacation bible school programs, and other community awareness events are helmed by the leaders at God’s Way—whose passion for mental health education, like Eugenia’s, often stems from their own experiences of enlightenment.

Sonya Hosey, the church’s Associate Pastor and Project Director of WECM, recalled the experience of growing up with a war veteran father who suffered from post-traumatic stress disorder (PTSD). “I never had answers as a child—there was never a name for it,” she said. “Only as I began to work in the area of mental health did I finally understand some of the things he was going through.”

That sense of understanding is what WECM education efforts try to impart on participants. With the help of partnerships with Bluebonnet Trails Community Services, social service agencies, and other churches in Central Texas, Sonya organizes outreach events to share the critical mental health knowledge that is so beautifully helping God’s Way congregants with other community members and leaders.

One of WECM’s most successful programs is a series of barbershop dialogues, wherein representatives from God’s Way and local law enforcement chat with barbershop patrons about the mental health issues afflicting the criminal justice system. The initiative is informed by Pastor Reese’s belief in the need for first responders—pastors included—to come together and familiarize themselves with the unique nature of mental health emergencies. “We can educate them,” he said. “We can let them know how to talk to someone with mental illness, instead of handcuffing or tazing them.”

“I see us as a connector. We really look at the gaps and explore ones that some entities might not even be aware of,” Sonya shared.

Mental Health Education: Supporting Youth, Ending Stigma

Greg’s story sheds light on the importance of another principle of mental health education at God’s Way: its focus on the youth. As a Sunday School teacher, Eugenia can attest to the enthusiasm her students show when learning about topics that typically don’t see the light of day in public school curricula. “They’re really inquisitive, and that helps us out,” said Eugenia. “Because if we can help them, they’ll help somebody else.”

Youth-oriented activities mix entertainment—in the form of pizza parties, bowling nights, and other fun-filled diversions—with mental health education and guidance. Attendees even bring along friends. At these events, Sonya said, “They begin to understand signs and symptoms shown by their peers. And for them to ask so many questions—that’s significant.”

The dependable flood of questions is not just a sign of curiosity. It indicates that WECM educators have succeeded in fostering a quality of acceptance around subjects that might otherwise be misunderstood or stigmatized. “In our church, there are a lot of young people who live below the poverty line, or in single-parent households,” said Pastor Reese. “Because they might not have all the resources they need, we have to run programs that will help them feel better about themselves—help them build self-esteem.”

It’s difficult to overstate just how valuable that can be for kids who are merely grappling with the normal emotions of coming of age, and more so for those experiencing stress and anxiety—or worse, trauma. “They’re really trying to find out who they are, and it’s more confusing now than when I was growing up,” said Sonya. “We have to give them a voice. We have to listen.”

The Ripple Effect: A Community That Supports Well-Being

The accomplishments of Pastor Reese and his church—playing the various roles of healer, educator, connector and civic leader—have caught the attention of pastors in nearby locales and beyond, who often phone him about WECM. “The perimeter of what we’re doing at God’s Way far outreaches the four walls of the church. It’s regional and more profound.” says Pastor Reese. Pastors, churches and congregants come to this work with differences in personal experience and belief, so it’s to be expected that some might not adopt God’s Way’s WECM’s mission wholesale. But according to Sonya, absolute buy-in isn’t necessary when it comes to generating impact.

Just talking about mental health—and debunking misunderstandings about mental illness—validates people’s experiences and opens the door for collaboration among churches, behavioral health providers and families to better address community needs. “We tell them that we don’t have to take the lead,” said Sonya. “They just have to take the information. Take the resources. Share with their community, their church, their youth. When you have that type of network, it helps develop you as a person, and as a community.”

Read more on Hogg.UTexas.edu.

A mindfulness-based therapy in which individuals learn to repeat personalized mantras to relax their thoughts appears to be more effective at reducing posttraumatic stress disorder (PTSD) symptoms than a problem-solving psychotherapy known as present-centered therapy, reports a study in AJP in Advance.

Mantram therapy is based on the premise that silently repeating a personally meaningful word or phrase (mantra) promotes relaxation, increases emotional regulation, and reduces stress. Present-centered therapy is a psychotherapy that focuses patients on the present to help them actively target daily challenges related to their past trauma and PTSD symptoms.

“Mantram therapy may be a valuable addition to current PTSD treatments because it incorporates some components of evidence-based treatments, yet without the trauma focus that can deter some clients,” wrote Jill Bormann, Ph.D., R.N., of the University of San Diego and colleagues.

Previous uncontrolled studies of veterans have suggested that mantram therapy can reduce PTSD symptom severity, help veterans manage sleep disturbances, and more. For the current study, Bormann and colleagues compared PTSD outcomes in veterans who were randomly assigned to either mantram therapy or present-centered therapy. A total of 173 veterans from two Veterans Affairs outpatient clinics diagnosed with military-related PTSD were assigned to receive eight individual weekly one-hour sessions of either mantram or present-centered therapy.

The mantram group experienced significantly greater improvements in their symptoms as assessed by the Clinician-Administered PTSD Scale at both the end of the study and at a two-month follow-up. Additionally, 59% of participants in the mantram group who completed the two-month follow-up no longer met criteria for PTSD, which was significantly higher than the 40% rate in the present-centered group. Participants who received mantram therapy also reported greater reductions in insomnia, a common occurrence in patients with PTSD, compared with those who received present-centered therapy.

Bormann and colleagues acknowledged that the study did not compare mantram therapy with either cognitive processing therapy or prolonged exposure, two evidence-based PTSD therapies currently used by the Veterans Health Administration. “It would be premature to draw any conclusions about the efficacy of mantram therapy compared with these established treatments, or other treatments, without head-to-head trials,” they wrote.

“Further assessment of mantram therapy in trials and real-world settings is clearly desirable, especially because mantram therapy may appeal to some veterans who may prefer therapies that are not trauma-focused, that include some element of spirituality, or that reduce sleep disturbances,” they concluded.

Read more on Alert.PsychiatricNews.org.

The following is a transcript created from the Hawai’i Public Radio interview by Chris Vandercook of Heather Lusk, the Executive Director of the Hawai‘i Health & Harm Reduction Center.

CHRIS: HIV and AIDS may no longer dominate the headlines but more than 2,500 deal with it and its stigma every day. The new Hawai’i Health & Harm Reduction Center has as its mission: “Reducing harm, promoting health, creating wellness, and fighting stigma in Hawai’i and the Pacific.” It’s Executive Director Heather Lusk is with us in our studio.

CHRIS: This is a new organization formed of two existing organizations, tell me about that.

HEATHER: Yes, the Hawai’i Health & Harm Reduction Center, which launched July 1st is combined from two organizations, the Life Foundation which is 35 years old, and the largest and oldest HIV organization in the Pacific; and the CHOW Project which stands for Community Health Outreach Work Project, which is a 30-year-old agency dedicated to state-wide outreach, harm reduction, and runs our state-wide syringe exchange program.

CHRIS: I’m figuring that in the past, their missions pretty much overlapped?

HEATHER: Yes, and ironically, syringe exchange started at the Life Foundation over 35 years ago, then CHOW came along, so they’re kind of coming back full circle to combine.  We’ve been co-located for about 7 years and collaborating, so our joke is that we lived together and now we’re married.

CHRIS: Well, many happy returns!

HEATHER: Thank you.

CHRIS: But it’s an increasingly difficult situation that you folks face, and it’s not, as I said in the lead, HIV and AIDS aren’t at the top of the news anymore, it’s not a new crisis right?

HEATHER: Right. Why it’s not a new crisis is we have medications that can basically manage HIV, it’s really a chronic, manageable disease.  The reality is in Hawai’i, we still have many people who don’t know that they have the disease, or don’t have access to the lifesaving treatments they need – so that’s a big focus of our work to address the homelessness, the substance use and mental health issues of our whole community. But then using that to leverage and supporting people with HIV in a kind of whole, comprehensive approach.

CHRIS: Because enormous overlap between homelessness, opioid addiction, HIV, you know a lot of HIV is transmitted through needles right?

HEATHER: Exactly.  Because of the state-wide needle exchange that started here in Hawai’i in ’89 – we were the first state to have state-wide syringe access – we have lower HIV rates than many states on the continent, but that doesn’t mean it doesn’t still happen.  And particularly our folks with HIV now have a lot more other issues, such as I mentioned, substance use, homelessness, mental health, and then we’ve broadened beyond HIV because we now have street-based outreach for homelessness, substance use outreach, we have a street-based wound care, and now a clinic in our office for would care.  So we’re trying to use a kind of “no wrong door” approach to be able to get folks into the care they need and then address a multitude of issues.

CHRIS: What’s it like out on the street these days?

HEATHER: Oh Chris, as folks know, homelessness is a very complex issue and therefore we really need kind of complex, multi-sector responses to homelessness.  I will admit that as we’ve done a big success in getting folks off the street with housing first, it’s also led to, we believe some instability because we’ve kind of worked with the folks that we were able to more easily able to connect with services. And who’s still on the street they often have many more reasons why they’re still out there.  And that’s led – we have seen- to some increased chaos and even violence.  So we’re partnering right now, honestly, with HPD (Hawai’i Police Department) and other public safety folks to do more public health, public safety outreach.  So on Wednesday night, you may have heard that a group of folks went out with HPD and 23 people were able to get into housing because they could go do outreach in places they may not normally be able to because they had HPD there for the safety part.  So I think we’re looking at unique partnerships to be able to address this in a multitude of ways.

CHRIS: Is there housing available and people out on the street who could be in that housing but aren’t, is it just there’s no room at the inn?

HEATHER: Yeah, you’re right.  So one thing that we do for these coordinated outreaches, is we get a shelter vacancy count so that we know exactly how many spots and we used kind of all 23 open spots on the island the other night.  But honestly Chris, we have 3,000 people on what’s called the binay list, so these are 3,000 people that are homeless that our outreach workers across all of the agencies- they know them, they’re ready, they’ve been assessed, they’re document ready -but there’s no housing for them to go into.  So honestly, we have more of a housing crisis than a homelessness crisis.  We don’t have the inventory to put people even when they’re ready, willing, and able into housing.  We have 3,000 on Oahu ready and we don’t have the spaces for them. So our systems are coordinating better, we’re working with city, state, and our community partners better, but as you know, it’s still a big issue out there.

CHRIS: Well that’s 3,000 documented.

HEATHER: Right. Not even counting those that aren’t documented, exactly.

CHRIS: One of the criticisms that’s been advanced of the point-in-time count is that a lot of people chronically homeless, the last thing they want is someone coming toward them with a clipboard asking them for personal information, is that fair to say?

HEATHER: I think that is fair to say and in order to get them to the list for housing, you have to be willing to share some information about yourself. And so that’s what our outreach workers do every day is build rapport, and go out there and be consistent.  We just got someone that’s been 30 years on the street, got them into housing because it took years of relationship building, but when they were ready, the outreach worker was there to do that what we call “warm handoff” to that next level.  But it’s constant building.  And then working with our business community, we know that they’re very frustrated with what they see as lack of progress, so we’re really hoping that we can continue to build upon the successes we’ve seen over the past couple of years.

CHRIS: A lot of the people, that the frustrated business owners you just alluded to, might see are those who are pretty far gone, and not likely to be filling out forms and able to get a job, and you know, chronically, because now we’re talking about the intersection of homelessness and mental illness.

HEATHER: Exactly Chris, with mental illness. And as we were discussing earlier, our criminal justice system is unfortunately somewhat of our de facto mental health system.  We don’t have community mental health, particularly residential mental health services unless you’re involved in the criminal justice system.  So there’s really very few options for these folks who don’t even have the capacity to make the decisions that they would need to do to get into the housing.

CHRIS: Is that a growing number? The off-the-books homeless?

HEATHER: Yes.  At least the data that we’ve seen. There’s a lot of focus on mental illness this year.  I don’t know if you’ve heard of Assisted Community Treatment? which is trying to make it easier for folks that are working with those with mental illness to get a court order so they can get some access to treatment. There’s more and more focus.  So this year I’m part of Partners in Care, I’m the vice chair, that’s our homeless coalition, and we’re about to apply for our 10 million dollars from HUD (Office of Housing and Urban Development) for the island, and there’s a focus this year on the chronically homeless with mental illness – that’s who we’re going to really try to focus on for that application.

CHRIS: You know Heather, there are so many brick walls that you hit in the work that you do.  How do you hold on to the optimism?

HEATHER: I’ll be honest, for me it’s the staff of Hawai’i Health & Harm Reduction center, we’re rooted in 6 core values of compassion, respect, advocacy, quality care, harm reduction, and integrity.  And the staff really reflect that, not just in the way they deliver services, but in the way that we treat each other.  We want to, we’re really a sanctuary, not only for those struggling with mental illness, homelessness, substance use, and HIV, but the center also is that sanctuary for the staff.  Because they’re out in the streets doing incredible work, they see so much trauma every day, so I think that together we try to highlight the light in someone – I know that sounds a little bit cheesy, but we really are looking at a strength-based model of where’s are, where’s our strength, where’s our community resilient, where they are doing well, and how can we build on that? Instead of focusing on the, all the hard part.

CHRIS: Well the community clearly needs your strength, Heather. Thanks very much for coming in.

HEATHER: Yeah, thank you so much for having me.

Listen to the full interview on HawaiiPublicRadio.org.

The Center for Juvenile Justice Reform has released a request for applications for the 2018 Reducing Racial and Ethnic Disparities Certificate Program, which will take place November 5-9, 2018, at Georgetown University in Washington, DC.

About

The Reducing Racial and Ethnic Disparities in Juvenile Justice Certificate Program is an intensive training program designed to support local jurisdictions in their efforts to reduce racial and ethnic disparities in their juvenile justice systems. The program seeks to reduce over-representation of youth of color in the juvenile justice system, disparate treatment of youth of color as compared to white youth within the juvenile justice system, and unnecessary entry and movement deeper into the juvenile justice system for youth of color. While the program will primarily address disparities in the juvenile justice system, it will also include a focus on the relationship between disproportionality in the juvenile justice system and disparate treatment in other child-serving systems, including child welfare and education.

Participants will receive instruction from national experts on cutting-edge ideas, policies, and practices. Upon completion of the program, participants will receive an Executive Certificate from Georgetown University, membership into CJJR’s Fellows Network, and ongoing support from the staff.

Capstone Project

As part of the Certificate Program, participants are required to develop and submit a Capstone Project – a set of actions designed to initiate or enrich collaborative efforts related to reducing racial and ethnic disparities. The Capstone Project can be a large, systemic change initiative, or it can be a targeted proposal.

Examples of Capstone Projects include: implementing an objective decision-making tool, such as a detention risk assessment instrument; creating a system of graduated incentives and sanctions for youth supervised in the community; implementing a multi-system strategy to address the disparate treatment of youth that is resulting in disparities in the juvenile justice system, such as the development of a protocol among police, schools, and juvenile justice officials aimed at reducing arrests of students.

Learn more about Capstone Projects.

Tuition & Application

The application period is now open through Friday, July 27, 2018. Download the 2018 Application Packet.

Tuition subsidies are available through CJJR’s Janet Reno Scholarships and the Office of Juvenile Justice and Delinquency Prevention’s Center for Coordinated Assistance to States. These competitive scholarships of up to $1,000 per person will be provided to teams that show a heightened readiness to utilize the curriculum to undertake changes in their local community, as determined by CJJR’s review of the individual and team applicants. There will also be a separate category of need-based subsidies available through CJJR to support the participation of individuals and teams with demonstrated need.  Read more about tuition.

Learn more & apply at Georgetown.edu.

One of the less visible effects of Hurricane Maria has been PTSD. Many Puerto Ricans are dealing with trauma related to the storm, especially as the next hurricane season begins.

MICHEL MARTIN, NPR HOST: It’s beautiful here in Puerto Rico. The palms have grown back. The flame-red flamboyan are flowering again. But the beauty cannot hide a hard fact – just about everyone here has a story of loss – of homes, of property, of loved ones, even of faith. Mental health professionals here say that they’ve seen an increase in depression, anxiety, insomnia – even suicide.

And yet, people have found ways to cope. In Humacao, the volunteer cooks at the Apoyo Mutuo have become defacto therapists, checking in on the well-being of their neighbors who stop by for a hot lunch. Maria Laboy is one of the ladies working here.

MARIA LABOY: After the storm, everybody was depressed, sad and everything.

MARTIN: She scoops up a huge slice of steamed pumpkin for one of the regulars, Georgie Ortiz, who makes the trip up the hill every day for lunch and conversation. He used to make his living as an auto mechanic, but people around here aren’t maintaining their cars anymore, he says. They’re saving their money for more urgent expenses like home repair and fuel for generators. He didn’t have any documentation to prove that he owned his home, so he wasn’t eligible for emergency funds from FEMA. He says he does have a blue tarp.

GEORGIE ORTIZ: (Speaking in Spanish).

MARTIN: But he lives alone, and he can’t install it by himself. During the day, he finds ways to stay busy and distracted from his problems. But at night…

ORTIZ: (Speaking in Spanish).

LABOY: He say he sleep depressful (ph). It won’t go down.

MARTIN: Over the past few months, Maria Laboy and the other lunch ladies have become friends with neighbors like Georgie.

LABOY: I really worry about him because he just lost his mother, and he’s – he don’t have work now. (Unintelligible) and he can’t survive like that. And he’s down because no help – he haven’t have no help from nobody. So, you see, it’s not a pretty picture right now.

MARTIN: There was a 29 percent increase in suicide on the island in 2017 according to the Puerto Rican Department of Health. The majority were men and people over 50 years old. Researchers are working to determine how many of those were hurricane-related. Calls to the suicide prevention hotline have spiked, but with so many people without phone service months after Maria, that method of getting help was not a reliable option.

Down the mountain from Georgie Ortiz and the community kitchen, five EMTs are gathered at the emergency management center of Humacao.

UNIDENTIFIED PERSON: (Speaking in Spanish).

MARTIN: They’re here for mental health and resiliency training to learn how to cope with their own stress so they can help people struggling in their communities. It starts by acknowledging the fact that they’re stressed. One exercise near the end of the session brings the point home. The trainers ask everyone to participate.

ELEXIA SUAREZ: I’m going to go through some phrases, and if anyone has – you have experienced it or touch you, please stand up. (Speaking in Spanish). I have lost a loved one through Hurricane Maria or after.

MARTIN: One EMT stands up. But by the end of the list – if you’ve had damaged property, if you’ve seen your community impacted, if you worked through the disaster – everyone in the room is standing. After the session, I asked the EMT supervisor, Frank Torres, why he thought this training was important for his employees.

FRANK TORRES: (Speaking in Spanish).

MARTIN: He says the hurricane was difficult on first responders. He has 18 EMTs to cover the whole city of Humacao, and everyone worked around the clock for four days straight responding to emergencies. The stress of working the hurricane was coupled with the personal stresses the EMTs faced at home.

TORRES: (Speaking in Spanish).

MARTIN: And they’ve still not rested, Torres tells us. Nobody has had any vacation. They work all the time, and on all their days off, they rebuild. Caesar Rosario was one of the EMTs who stood up when asked if anyone lost their home due to Maria. He lost his home of 20 years but didn’t find out for a few days because he was on duty.

CAESAR ROSARIO: (Speaking in Spanish).

MARTIN: He walked from the station to his house once the storm had passed.

ROSARIO: (Speaking in Spanish).

MARTIN: He lost everything, says Rosario. It’s not easy.

The training these EMTs are receiving today is part of an island-wide initiative from the nonprofit group Americares to address the mental health crisis in Puerto Rico. Ivalis Morales and Elexia Suarez are the two people leading the session. Both of them are psychologists who practiced in the region before Maria. One’s office was destroyed, along with her 25-year private practice. The other’s home experienced major damage. They agree that these sessions help them feel useful to the island’s overall recovery. Elexia Suarez says that strong communities and relationships are essential for surviving a major event like the hurricane last fall.

SUAREZ: As we have seen and again and again and again, the community leaders, the community resources – between one another, people have become so tight, so together. That is a collective hope, a collective support, because you could not have survived this without someone, even if it is one neighbor – you couldn’t.

MARTIN: They end the session by passing around a photo of a mango tree. The trunk is completely severed, but one little branch shoots off the stump. Off the fragile shoot hangs a huge, bright mango. Suarez says this is a symbol for post-Maria Puerto Rico.

SUAREZ: Saying that we have been cut, taken away. Even though we’re together, we’re standing. We’re giving fruits, and we’re blooming. We’re doing it for ourselves, our family, our communities in Puerto Rico.

Read more and listen to the story on NPR.org.