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Promoting Integrated Mental Health Care Services in Disaster Response Programs: Lessons Learned After the Impact of Hurricane María in Puerto Rico

  • Julio C. Jiménez Chávez (a1), Esteban Viruet Sánchez (a1), Fernando J. Rosario Maldonado (a1), Axel J. Ramos Lucca (a1) and Barbara Barros Cartagena (a1)...


Meteorological and even human-made disasters are increasing every year in frequency and magnitude. The passage of a disaster affects a society without distinction, but groups with social vulnerability (low socioeconomic status, chronic medical, or psychological conditions, limited access to resources) face the most significant impact. As a result, psychological and behavioral symptoms (eg, depression and anxiety) can ensue, making the immediate response of mental health services crucial. Secondary data from a database of a temporary healthcare unit were analyzed. A total of 54 records were reviewed to collect information; univariate and bivariate analyses were done. The purpose of this article is to present our experience regarding the incorporation of a mental health services model, with its respective benefits and challenges, into a temporary healthcare unit, after Hurricane Maria in 2017.


Corresponding author

Correspondence and reprint requests to Julio C. Jiménez, PO Box 7004, Ponce, PR, 00732-7004 (e-mail:


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1. Aitsi-Selmi, A, Egawa, S, Sasaki, H, et al. The Sendai Framework for Disaster Risk Reduction: renewing the global commitment to people’s resilience, health, and well-being. Int J Disaster Risk Sci. 2015;6(2):164-176. doi: 10.1007/s13753-015-0050-9
2. Goldmann, E, Galea, S. Mental health consequences of disasters. Annu Rev Public Health. 2014;35(1):169-183. doi: 10.1146/annurev-publhealth-032013-182435
3. Brown, P, Daigneault, A, Tjernstrom, E, et al. Natural disasters, social protection, and risk perceptions. World Dev. 2018;104:310-325. doi: 10.1016/j.worlddev.2017.12.002
4. Kishore, N, Marqués, D, Mahmud, A, et al. Mortality in Puerto Rico after Hurricane Maria. N Engl J Med. 2018;379(2):162-170. doi:10.1056/nejmsa1803972
5. Fink, G. Stress: definition and history. In: Squire, LR, ed. Encyclopedia of Neuroscience. Vol. 9. Oxford, England: Academic Press; 2009:549-555. doi: 10.1016/b978-008045046-9.00076-0
6. Davis, JR, Wilson, S, Brock-Martin, A, et al. The impact of disasters on populations with health and health care disparities. Disaster Med Public Health Prep. 2010;4(01):30-38. doi: 10.1017/s1935789300002391
7. Joseph, NT, Matthews, KA, Myers, HF. Conceptualizing health consequences of Hurricane Katrina from the perspective of socioeconomic status decline. Health Psychol. 2014;33(2):139-146. doi: 10.1037/a0031661
8. Osofsky, HJ, Hansel, TC, Osofsky, JD, et al. Factors contributing to mental and physical health care in a disaster-prone environment. Behav Med. 2015;41(3):131-137. doi: 10.1080/08964289.2015.1032201
9. Martin, U. Health after disaster: a perspective of psychological/health reactions to disaster. Cogent Psychol. 2015;2(1). doi: 10.1080/23311908.2015.1053741
10. Lowe, D, Ebi, K, Forsberg, B. Factors increasing vulnerability to health effects before, during and after floods. Int J Environ Res Public Health. 2013;10(12):7015-7067. doi: 10.3390/ijerph10127015
11. Rhodes, J, Chan, C, Paxson, C, et al. The impact of Hurricane Katrina on the mental and physical health of low-income parents in New Orleans. Am J Orthopsychiatry. 2010;80(2):237-247. doi: 10.1111/j.1939-0025.2010.01027.x
12. Ford, ES, Mokdad, AH, Link, MW, et al. Chronic disease in health emergencies: in the eye of the hurricane. Prev Chronic Dis. 2006;3(2):A46. Accessed July 23, 2018
13. Lowe, SR, Kwok, RK, Payne, J, et al. Why does disaster recovery work influence mental health?: pathways through physical health and household income. Am J Community Psychol. 2016;58(3-4):354-364. doi: 10.1002/ajcp.12091
14. Mokdad, AH, Mensah, GA, Posner, SF, et al. When chronic conditions become acute: prevention and control of chronic diseases and adverse health outcomes during natural disasters. Prev Chronic Dis. 2005; 2 Spec no:A04. Accessed July 2018.
15. Acierno, R, Ruggiero, KJ, Galea, S, et al. Psychological sequelae resulting from the 2004 Florida hurricanes: implications for postdisaster intervention. Am J Public Health. 2007;97(Suppl 1):S103-S108. doi: 10.2105/ajph.2006.087007
16. Math, S, Nirmala, M, Moirangthem, S, et al. Disaster management: mental health perspective. Indian J Psychol Med. 2015;37(3):261-271. doi: 10.4103/0253-7176.162915
17. Shultz, JM. Perspectives on disaster public health and disaster behavioral health integration. Disaster Health. 2014;2(2):69-74. doi: 10.4161/dish.24861
18. Evans, S, Banerjee, S, Leese, M, et al. The impact of mental illness on quality of life: a comparison of severe mental illness, common mental disorder and healthy population samples. Qual Life Res. 2007;16(1):17-29. doi: 10.1007/s11136-006-9002-6
19. Brenes, GA. Anxiety, depression, and quality of life in primary care patients. Prim Care Companion J Clin Psychiatry. 2007;9(6):437-443. doi: 10.4088/pcc.v09n0606
20. Walker, HK, Hall, HD, Hurst, JW, eds. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition, Chapter 201. Boston, MA: Butterworth Publishers; 1990.
21. Dixon, LB, Holoshitz, Y, Nossel, I. Treatment engagement of individuals experiencing mental illness: review and update. World Psychiatry. 2016;15(1):13-20. doi: 10.1002/wps.20306
22. Kar, N. Disaster management: mental health perspective. In: Chavan, BS, Nitin, G, Priti, A, Ajeet, S, Sushrut, J. Community Mental Health in India. New Delhi, India: JayPeeDigital; 2012:257-266. doi: 10.5005/jp/books/11688_24
23. Frahm, KA, Barnett, SD, Brown, LM, et al. Posttraumatic stress disorder and use of psychiatric and alcohol related services: the effect of the 2004-2005 Florida hurricane seasons on veterans. Community Ment Health J. 2012;49(6):636-642. doi: 10.1007/s10597-012-9558-2
24. Ali, JS, Farrell, AS, Alexander, AC, et al. Race differences in depression vulnerability following Hurricane Katrina. Psychol Trauma. 2017;9(3):317-324. doi: 10.1037/tra0000217
25. Nazumber, AH. Disaster mental health and crisis interventions. International J Emerg Mental Health Hum Resil. 2015;17(1):368.
26. James, LE, Noel, JR, Favorite, TK, et al. Challenges of postdisaster intervention in cultural context: the implementation of a lay mental health worker project in postearthquake Haiti. Int Perspect Psychol. 2012;1(2):110-126. doi: 10.1037/a0028321
27. World Health Organization. Disasters and mental health. World Health Organization web site. July 13, 2017. Accessed December 9, 2018.
28. Mattei, J, Tamez, M, Ríos-Bedoya, CF, et al. Health conditions and lifestyle risk factors of adults living in Puerto Rico: a cross-sectional study. BMC Public Health. 2018;18(1):491. doi: 10.1186/s12889-018-5359-z
29. Administración de Servicios de Salud Mental y Contra la Adicción. Need Assessment Study of Mental Health and Substance Use Disorders and Services Utilization among Adult Population of Puerto Rico. San Juan, PR: Administración de Servicios de Salud Mental y Contra la Adicción, Puerto Rico Department of Health; 2016. Accessed September 2018.
30. Payne, RA, Abel, GA, Guthrie, B, et al. The effect of physical multimorbidity, mental health conditions and socioeconomic deprivation on unplanned admissions to hospital: a retrospective cohort study. CMAJ. 2013;185(5):E221-228. doi: 10.1503/cmaj.121349
31. Leventhal, H, Weinman, J, Leventhal, EA, et al. Health psychology: the search for pathways between behavior and health. Annu Rev Psychol. 2008;59(1):477-505. doi: 10.1146/annurev.psych.59.103006.093643
32. Brannon, L, Feist, J, Updegraff, JA. Health Psychology: An Introduction to Behavior and Health. 9th edition. Boston, MA: Cengage Learning; 2018.
33. Michaud, J, Kates, J. Public health in Puerto Rico after Hurricane Maria. November 20, 2017. The Henry J. Kaiser Family Foundation. Accessed September 28, 2018.
34. World Health Organization. Global Strategy on People-centered and Integrated Health Services. Geneva, Switzerland: World Health Organization; 2014.
35. Carameli, KA, Eisenman, DP, Blevins, J, et al. Planning for chronic disease medications in disaster: perspectives from patients, physicians, pharmacists, and insurers. Disaster Med Public Health Prep. 2013;7(03):257-265. doi: 10.1001/dmp.2010.46
36. Winfield, L. In the wake of hurricanes, hospitals should revisit their emergency preparedness plans. Healthc Financ Manage. 2017;26.
37. Department of Homeland Security. National Response Framework. Washington, DC: Federal Emergency Management Agency, Department of Homeland Security; 2008. FEMA Publication P-682. Accessed September 2018.
38. Kessler, RC; Hurricane Katrina Community Advisory Group. Hurricane Katrina’s impact on the care of survivors with chronic medical conditions. J Gen Intern Med. 2007;22(9):1225-1230. doi: 10.1007/s11606-007-0294-1
39. Reiss-Brennan, B, Brunisholz, KD, Dredge, C, et al. Association of integrated team-based care with health care quality, utilization, and cost. JAMA. 2016;316(8):826. doi: 10.1001/jama.2016.11232
40. Ruskin, J, Rasul, R, Scheinder, S, et al. Researchers report on Hurricane Sandy’s mental health impact on older adults. [ScienceDaily Web site]. June 18, 2015. Accessed September 3, 2018.
41. Pietrzak, RH, Southwick, SM, Tracy, M, et al. Posttraumatic stress disorder, depression, and perceived needs for psychological care in older persons affected by Hurricane Ike. J Affect Disord. 2012;138(1-2):96-103. doi: 10.1016/j.jad.2011.12.018
42. Jiménez, J, Rivera, D, Benítez, P, et al. Integrating mental health services into a general hospital in Puerto Rico. J Clin Psychol Med Settings. 2013;20(3):294-301. doi: 10.1007/s10880-012-9352-x
43. Rodríguez-Gómez, JR, Davila-Martínez, MG, Collazo-Rodríguez, LC. Factor structure of the Beck Depression Inventory-Second Edition (BDI-II) with Puerto Rican elderly. P R Health Sci J. 2006;25(2):127-132. Accessed September 26, 2018.
44. Contreras, S, Fernandez, S, Malcarne, VL, et al. Reliability and validity of the Beck Depression and Anxiety Inventories in Caucasian Americans and Latinos. Hisp J Behav Sci. 2004;26(4):446-462. doi: 10.1177/0739986304269164
45. Nomura, S, Parsons, AJ, Hirabayashi, M, et al. Social determinants of mid- to long-term disaster impacts on health: a systematic review. Int J Disaster Risk Reduct. 2016;16:53-67. doi: 10.1016/j.ijdrr.2016.01.013
46. Substance Abuse and Mental Health Services Administration. Disaster Technical Assistance Center Supplemental Research Bulletin - Greater impact: how disasters affect people of low socioeconomic status. Rockville, MD: Substance Abuse and Mental Health Services Administration, US Department of Health & Human Services; 2017. Accessed August 2018.
47. Adini, B, Ohana, A, Furman, E, et al. Learning lessons in emergency management: the 4th International Conference on Healthcare System Preparedness and Response to Emergencies and Disasters. Disaster Mil Med. 2016;2(1):16. doi: 10.1186/s40696-016-0026-3
48. Pourhosseini, S, Ardalan, A, Mehrolhassani, M. Key aspects of providing healthcare services in disaster response stage. Iran J Public Health. 2015;44(1):111-118. Accessed August 2018.
49. Gray, L. Social determinants of health, disaster vulnerability, severe and morbid obesity in adults: triple jeopardy? Int J Environ Res Public Health. 2017;14(12):1452. doi: 10.3390/ijerph14121452
50. World Health Organization. Environmental health in emergencies: vulnerable groups. World Health Organization web site. August 24, 2012. Accessed September 28, 2018.
51. Davis, JR, Wilson, S, Brock-Martin, A, et al. The impact of disasters on populations with health and health care disparities. Disaster Med Public Health Prep. 2010;4(1):30-38. doi: 10.1017/s1935789300002391
52. Bethel, JW, Burke, SC, Britt, AF. Disparity in disaster preparedness between racial/ethnic groups. Disaster Health. 2013;1(2):110-116. doi: 10.4161/dish.27085
53. Census Bureau, US. US Census Bureau QuickFacts: Puerto Rico, 2017. Accessed September 2018.
54. American Community Survey Office. 5-year data profiles 2017. November 19, 2018. Census Bureau QuickFacts. Accessed December 8, 2018.
55. Ranabir Singh, S, Reza Eghdami, M, Singh, S. The concept of social vulnerability: a review from disasters perspectives. International Journal of Interdisciplinary and Multidisciplinary Studies. 2014;1(6):71-82.
56. Bara, C. Factsheet Social Vulnerability to Disasters. Zurich, Switzerland: Center for Security Studies, Federal Office for Civil Protection; 2010.
57. Department of Health. Report of Chronic Diseases, Puerto Rico 2013-2015. San Juan, Puerto Rico: Department of Health; 2017.
58. Miller, AC, Arquilla, B. Chronic diseases and natural hazards: impact of disasters on diabetic, renal, and cardiac patients. Prehosp Disaster Med. 2008;23(02):185-194. doi: 10.1017/s1049023x00005835
59. Bethel, JW, Foreman, AN, Burke, SC. Disaster preparedness among medically vulnerable populations. Am J Prev Med. 2011;40(2):139-143. doi: doi: 10.1016/j.amepre.2010.10.020
60. United Nations Office for Disaster Risk Reduction. Sendai Framework for Disaster Risk Reduction. UNISDR Web site. Accessed January 8, 2019.
61. United Nations Office for Disaster Risk Reduction. Sendai Framework for Disaster Risk Reduction 2015-2030. United Nations Office for Disaster Risk Reduction UNISDR Web site; 2015. Accessed July 2018.
62. Sartorius, N. Comorbidity of mental and physical disorders: a central challenge for medicine of the 21st century. Shanghai Arch Psychiatry. 2013;25(2):68-69. doi: 10.1016/s0924-9338(12)74058-0
63. López-Ibor, J, Christodoulou, G, Maj, M, et al. Disasters and Mental Health. Hoboken, NJ: John Wiley & Sons; 2005.
64. Veenema, TG, Rains, AB, Casey-Lockyer, M, et al. Quality of healthcare services provided in disaster shelters: an integrative literature review. Int Emerg Nurs. 2015;23(3):225-231.


Promoting Integrated Mental Health Care Services in Disaster Response Programs: Lessons Learned After the Impact of Hurricane María in Puerto Rico

  • Julio C. Jiménez Chávez (a1), Esteban Viruet Sánchez (a1), Fernando J. Rosario Maldonado (a1), Axel J. Ramos Lucca (a1) and Barbara Barros Cartagena (a1)...


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