Puerto Rico Psychiatrists Prepare for MH Crisis

The lingering recession that has caused extensive financial suffering and mental distress among many in the United States has hit Puerto Rico even harder. Mental health advocates in the island territory are scrambling to hit back.

The recession has contributed to rising unemployment and crime rates in Puerto Rico that dwarf those of the 50 states. Both of these major societal problems may worsen in the coming months as the government expects to fire tens of thousands of workers while cutting mental health services.

In response, psychiatrists and other advocates for improved mental health care have begun to educate and coordinate nonprofit organizations and government agencies to watch for those who need help and find ways to respond to expected increases in demand for screening and services.

As a part of that effort, in March the Puerto Rico Psychiatric Society helped bring together 35 nongovernmental organizations, such as the United Way and the Salvation Army, to solicit the support of groups not typically associated with mental health.

“This effort is not only for people with mental illness, but also for those under stress who have never been diagnosed with any formal illness,” Nestor Galarza-Diaz, M.D., president of the Puerto Rico Psychiatric Society, told Psychiatric News.

Among the goals of Puerto Rican mental health advocates are to create mental health hotlines, public awareness campaigns, and respect for people who suffer from mental illness. They hope to prevent bursts of violence stemming from unemployment and to keep people who are under stress from slipping into mental illness.

The island territory of nearly 4 million people has long faced steep rates of violent crime. Last year was one of the most deadly on record with 802 homicides—the most since 1996, when 868 homicides were recorded. By comparison, New York City, where over 8 million people live, had 522 homicides in 2008.

Murder and drug abuse on the island are closely linked. In fact, many of Puerto Rico's homicides are directly related to drug trafficking and sales, according to a June 2008 report by the National Drug Intelligence Center, which noted that heroin is the leading drug abused in Puerto Rico.

Psychiatrists and mental health workers also said more treatment services are needed for alcohol abuse. About 11 percent of Puerto Ricans are identified as binge drinkers (defined as men who have five or more drinks on one occasion or women who have four or more drinks on one occasion), according to the Centers for Disease Control and Prevention (CDC).

Preventing suicide is also a major challenge in Puerto Rico. There were 196 suicides in 2007, according to the Bureau of Labor Statistics (BLS). That number is expected to increase substantially this year, as there were 115 suicides in Puerto Rico by mid-May, according to Silvia Arias, Ph.D., executive director of the National Alliance on Mental Illness Puerto Rico.

Overall health indicators also reveal cause for concern. A 2008 report by the CDC found that nationwide the proportion of adults who reported fair or poor health was 33 percent in Puerto Rico, compared with a U.S. median of 15 percent.

The crime and substance abuse challenges faced by the island have been exacerbated by its longstanding financial problems, according to mental health advocates. Unemployment in Puerto Rico has loomed larger than in much of the United States for many years. In March 2008 the territory had a nearly 10 percent unemployment rate compared with a 5.1 percent overall U.S. rate, according to the BLS. As the recession deepened and the U.S. rate rose to 8.9 percent in March, the rate in Puerto Rico jumped to 15 percent—higher than in any state. The actual rate may be higher—maybe as high as 20 percent, said Arias, because many people who have given up looking for work and those whose unemployment benefits have expired are not counted.

These problems are expected to increase in the coming months if the regional government, one of Puerto Rico's largest employers, follows through on plans to lay off up to 50,000 workers this summer. Media reports said the number laid off could reach 100,000.

The news comes as Puerto Rico government officials have told mental health advocates that they plan to close the territory's budget gap, in part, through large cuts to the island's historically robust public mental health and substance abuse treatment system, according to Arias. The announced cuts follow an expansion of the territory's strong insurance parity law last year to encompass treatment for alcohol and drug addiction.

However, according to advocates, the cuts in public mental health and substance use treatment programs are short-sighted and will produce new costs.

“The money saved from cuts will have to be spent on increased health care needs as these people develop greater problems,” said Jose Ouslan, executive director of the Puerto Rico Psychiatric Society, about the likelihood that untreated minor psychiatric problems will devolve into major mental illnesses.

About 350,000 Puerto Ricans receive publicly or privately funded mental health care annually, said Arias, but it is estimated that 700,000 may need such care.

The response of the Puerto Rico Psychiatric Society to the growing number of serious challenges facing the territory included the creation of a mental health contingency plan for Puerto Rico. The psychiatrists' alliance with other physicians, mental health advocates, and nongovernmental organizations plans to assess the availability and unmet needs for “psychological first aid,” crisis intervention, and referrals to mental health services. The alliance also aims to explore the creation of community outreach efforts and public-information campaigns.

The alliance's first meeting produced an agreement among representatives of the involved nongovernmental organizations that the “strength to face adversity comes from good mental health,” which was an important point in a place where stigma often prevents even members of the same family from openly discussing mental illness.

The alliance created a committee of members to serve as mediators available to ease communications between workforce and employer groups and to avoid violent confrontations as economic problems worsen.

Other alliance measures to minimize the economic and societal impact from the recession include serving as an information resource on available clinical services and support groups, prevention services to “strengthen community resilience,” and training initiatives on crisis intervention and anger and violence management.

The hope among mental health advocates is that the efforts they have undertaken will not only prevent major psychiatric problems during the current period of economic distress but also lay the groundwork for long-term improvements in psychiatric care there.

“This is an effort of APA in Puerto Rico to support the community and families who have been affected by this distress and will be affected in the future,” Galarza-Diaz said.

Information on the Puerto Rico Psychiatric Society is posted at<http://prpsnewsletter.blogspot.com/2009/04/groups-study-financial-crisis-induced.html>.▪