NATIONAL STRESS AWARENESS MONTH
The Alliance for Clinical and Translational Research (ALLIANCE), supported by the National Institute of General Medical Sciences (NIGMS) of the National Institutes of Health (Award U54GM133807), has been a key facilitator of stress and health research in Puerto Rico.
The Burden of Stress in Puerto Rico
To the present day, Puerto Rico has endured a series of compounding crises, including Hurricanes Irma and María, a prolonged economic downturn, a major earthquake sequence (2019–2020), Hurricane Fiona, ongoing sociopolitical and financial instability, and the COVID-19 pandemic. These overlapping stressors have placed a disproportionate burden on communities already facing high levels of poverty and limited access to mental health services.
Approximately 39.6% of Puerto Rico’s population lives below the poverty line, more than three times the U.S. national average. This socioeconomic vulnerability not only increases exposure to chronic stress but also restricts access to resources needed for effective coping. As a result, studies have documented elevated rates of depression, anxiety, post-traumatic stress, sedentary behavior, and unhealthy dietary patterns in the aftermath of these events.
Stress, Resilience, and Health Behaviors: Evidence from Puerto Rico
The Puerto Rico Observational Study of Psychosocial, Environmental, and Chronic Disease Trends (PROSPECT) collected data from 1,342 adults aged 30–75 years between 2019 and 2023, capturing both pre-pandemic and pandemic-era conditions. Among participants, 17.9% had low resilience, while 37.7% had high resilience, as measured by the Brief Resilience Scale. Overall, only 53.4% reported a healthy sleep duration (7–8 h/night), and 31.0% engaged in moderate or vigorous physical activity, both of which were markedly higher among adults with higher resilience. Mean perceived stress scores were notably elevated in the low-resilience group (25.0 vs. 17.0 overall on a scale 0–56), as was the mental health morbidity index (3.1 vs. 1.4 overall).
A study published in Preventive Medicine Reports also found that adults with the highest levels of resilience were significantly more likely to consume a high-quality diet, achieve the recommended sleep duration, and engage in moderate or vigorous physical activity. No meaningful associations were found for smoking or heavy alcohol use. Importantly, these relationships were stronger among participants assessed during the COVID-19 pandemic than among those evaluated prior to it, suggesting that resilience may play a particularly protective role during periods of sustained collective stress.
Stress and Cardiovascular Health in Young Adults: The PR-OUTLOOK Study
While existing research on stress and health in Puerto Rico has largely focused on middle-aged and older adults, a new and important study addresses a critical gap among younger populations. The Puerto Rico Young Adults’ Stress, Contextual, Behavioral, and Cardiometabolic Risk (PR-OUTLOOK) Study examines overall cardiovascular health (CVH) and cardiovascular disease (CVD) risk factors in young Puerto Rican adults using Life’s Essential 8, a comprehensive framework that includes sleep, physical activity, diet, nicotine exposure, and key biological indicators.
The study also evaluates how stress across individual, family, social, and neighborhood domains relates to cardiovascular outcomes, and whether protective factors—such as spirituality, social support, religiosity, optimism, and adaptive coping—buffer these effects. Findings indicate that psychological stress is strongly associated with poorer CVH, with anxiety, depression, and low subjective social standing significantly increasing the likelihood of suboptimal CVH. Chronic stress was also linked to worse cardiovascular outcomes. Importantly, optimism and social support partially buffered these associations. In addition, “shift-and-persist” (SP) strategies—defined as adapting to stress while maintaining a future-oriented outlook—were associated with lower psychological distress and reduced mental health impacts from recent disasters, with a clear dose–response pattern. Together, these findings highlight the importance of strengthening psychosocial and coping resources to mitigate the health effects of chronic stress among young Puerto Rican adults.
Stress and Vulnerable Populations: Perinatal Health
International evidence indicates that disasters disrupt daily routines, access to health services, nutrition, and social support networks, with these stressors linked to higher prevalence and severity of depression, anxiety, and post-traumatic stress during the perinatal period. In Puerto Rico, findings from the PROTECT cohort show that exposure to Hurricane María was associated with changes in perceived stress, depressive symptoms, and social support among pregnant women. Symptoms were highest in the immediate aftermath of the disaster and declined over time, while social support increased—potentially reflecting processes of adaptation and resilience. These stressors carry measurable consequences, a study showed that in Puerto Rico, 9.67% of women with live births reported postpartum depressive symptoms (2017–2020), with disaster exposures and pre-existing depression or anxiety as the strongest risk factors. During the COVID-19 pandemic, rates of depression (14%) and anxiety (17%) among perinatal women in Puerto Rico were approximately double the pre-pandemic levels.
Complementing these findings, a binational study conducted in Illinois and Puerto Rico found that higher prenatal maternal stress was associated with fewer but longer non-nutritive sucking bursts per minute among infants aged 1 to 8 weeks. This pattern was consistent across two demographically diverse cohorts and may represent an early marker of central nervous system functioning.
Recognizing Chronic Stress: Warning Signs
Acute stress is a normal and adaptive response; however, chronic or toxic stress—particularly when sustained over months or years—can have serious health consequences. Healthcare providers and individuals should be attentive to the following signs:
Physical symptoms: Persistent headaches, muscle tension, fatigue, gastrointestinal disturbances, or elevated blood pressure without a clear underlying cause.
Sleep disturbances: Difficulty initiating or maintaining sleep, non-restorative sleep, or excessive sleeping.
Behavioral changes: Increased use of tobacco or alcohol, reduced physical activity, or shifts toward less healthy dietary patterns. Of particular concern is the use of alcohol, nicotine, and cannabinoid products as a way of managing extreme stressors, as this pattern can escalate into substance use disorders.
Emotional and cognitive symptoms: Persistent sadness, irritability, difficulty concentrating, feelings of overwhelm, or social withdrawal.
Somatic cultural expressions: In Puerto Rican communities, ataque de nervios—a culturally specific syndrome characterized by episodes of trembling, crying, and uncontrollable shouting—may occur in response to acute stressors and should be recognized as a valid clinical presentation.
These signs are not specific to a single condition but may indicate prolonged exposure to stress and warrant clinical evaluation and appropriate intervention.
Building Resilience: Evidence-Based Strategies
Research from Puerto Rico and other populations demonstrates that psychological resilience and effective coping can be cultivated and strengthened. Findings from the PROSPECT study indicate that resilience is particularly protective during periods of heightened stress, such as the COVID-19 pandemic, and highlight several strategies associated with better health outcomes:
Healthy diet: Consuming a diet rich in fruits, vegetables, whole grains, and lean proteins is associated with higher resilience and improved overall health. Community-based programs that promote food security and access to nutritious foods are especially important in Puerto Rico, where economic hardship can constrain dietary choices.
Regular physical activity: Engaging in at least 150 minutes of moderate-intensity exercise per week is recommended. Physical activity is a well-established buffer against stress and is linked to improved mood, sleep quality, and cardiovascular health.
Adequate sleep: Prioritizing 7–8 hours of sleep per night supports healthier stress responses. Short sleep duration and sleep disturbances are strongly associated with higher stress levels and lower resilience.
Social connectedness: Strengthening social cohesion, community ties, and mutual support networks may enhance resilience at the population level, particularly in disaster-prone settings. The PROSPECT study found that social support was significantly higher among adults with greater resilience.
Meaning-making and spirituality: In Puerto Rican communities, spirituality, religiosity, and a strong sense of collective identity are important cultural resources that may buffer the health effects of adversity.
Mental health services: Access to evidence-based care—including cognitive-behavioral therapy, trauma-informed approaches, and crisis intervention—is essential for individuals experiencing severe or persistent stress, including post-traumatic stress and depression.
Importantly, promoting resilience should not shift responsibility for managing structural stressors—such as poverty, inadequate housing, or disaster risk—onto individuals alone. Public health programs and policy-level interventions are essential complements to individual-level strategies, ensuring supportive environments that foster resilience and health.
Recommendations for Action
Addressing the burden of chronic stress in Puerto Rico requires coordinated, multilevel action across individuals, healthcare systems, and public policy:
Individuals: Prioritize adequate sleep, regular physical activity, and a high-quality diet. Seek professional mental health care when stress becomes persistent or interferes with daily functioning, and do not overlook physical symptoms that may have stress-related origins.
Clinical providers: Incorporate routine assessment of perceived stress, resilience, and coping into clinical care, particularly for patients with cardiovascular risk factors or chronic conditions. Recognize culturally specific expressions of distress, such as ataque de nervios, and facilitate connections to community-based mental health resources.
Public health programs: Expand access to community-based mental health and stress-reduction initiatives, especially in municipalities disproportionately affected by poverty and disaster exposure. Integrate stress screening into broader community health efforts.
Research community: Sustain and expand longitudinal studies such as PROSPECT and PR-OUTLOOK, which are generating critical, locally relevant evidence on stress, resilience, and health. Advocate for funding that reflects the unique vulnerabilities and research priorities of Puerto Rican populations.
Policy makers: Address the structural determinants of chronic stress, including poverty, housing instability, and gaps in disaster preparedness infrastructure, which disproportionately impact communities across Puerto Rico.
Additional Resources
The following organizations provide information, mental health services, and support related to stress and resilience in Puerto Rico:
| Organization | Description | Website |
|---|---|---|
| National Institute of Mental Health (NIMH) | Mental health research, resources, and helplines | https://www.nimh.nih.gov |
| SAMHSA National Helpline | Free, confidential 24/7 mental health treatment referrals | https://www.samhsa.gov/find-help/national-helpline |
| Administración de Servicios de Salud Mental y Contra la Adicción (ASSMCA) | Mental health services and crisis support in Puerto Rico | https://www.assmca.pr.gov |
| PROSPECT Study (UPR / Harvard) | Ongoing study of psychosocial and chronic disease trends in Puerto Rican adults | https://hsph.harvard.edu/research/puerto-rico-prospect/the-study/ |
| PR-OUTLOOK Study (UPR / UMass) | Study of stress and cardiovascular health in young adults in Puerto Rico | https://pubmed.ncbi.nlm.nih.gov/38932562/ |
| American Psychological Association | Stress management resources, mental health education | https://www.apa.org/topics/stress |
| Alliance for Clinical and Translational Research | Clinical and translational research supporting Puerto Rican communities | https://alliance.rcm.upr.edu |
Contributions of the ALLIANCE in Stress and Mental Health Research
The Alliance for Clinical and Translational Research (ALLIANCE), supported by the National Institute of General Medical Sciences (NIGMS) of the National Institutes of Health (Award U54GM133807), has been a key facilitator of research on stress and health in Puerto Rico.
References
López-Cepero, A. A., Spruill, T., Suglia, S. F., Lewis, T. T., Mazzitelli, N., Pérez, C. M., & Rosal, M. C. (2024). Shift-and-persist strategies as a potential protective factor against symptoms of psychological distress among young adults in Puerto Rico. Social Psychiatry and Psychiatric Epidemiology, 59(8), 1357–1365. https://doi.org/10.1007/s00127-023-02601-1
Martínez-González, K. G., Morou-Bermúdez, E., & Buxó, C. J. (2023). Perinatal Mental Health Outcomes Following Natural Disasters. JAMA psychiatry, 80(12), 1185–1186. https://doi.org/10.1001/jamapsychiatry.2023.3564
Mattei, J., Tamez, M., O’Neill, H. J., Haneuse, S., Mendoza, S., Orozco, J., López-Cepero, A., Ríos-Bedoya, C. F., Falcón, L. M., Tucker, K. L., & Rodríguez-Orengo, J. F. (2022). Chronic diseases and associated risk factors among adults in Puerto Rico after Hurricane Maria. JAMA Network Open, 5. https://doi.org/10.1001/jamanetworkopen.2021.39986
Mattei, J., Tucker, K. L., Falcon, L. M., Ríos-Bedoya, C. F., Kaplan, R. M., O’Neill, H. J., Tamez, M., Mendoza, S., Díaz-Álvarez, C. B., Orozco, J. E., Acosta Pérez, E., & Rodríguez-Orengo, J. F. (2021). Design and implementation of the Puerto Rico Observational Study of Psychosocial, Environmental, and Chronic Disease Trends (PROSPECT). American Journal of Epidemiology, 190(5), 707–717. https://doi.org/10.1093/aje/kwaa231
Pérez, C. M., Kiefe, C. I., Person, S. D., Tucker, K. L., Torres, P., Sandoval, E., Boneu, C., Ramírez, Z., Mattei, J., Rodríguez-Orengo, J., Almodóvar-Rivera, I., & Rosal, M. C. (2025). The Puerto Rico Young Adults’ Stress, Contextual, Behavioral, and Cardiometabolic Risk (PR-OUTLOOK) Study: design and methods. American Journal of Epidemiology, 194(3), 587–597. https://doi.org/10.1093/aje/kwae163
Rodríguez-Reynaldo, M., Rivera-Orraca, Z., Pérez-Ríos, N., & Martínez-González, K. G. (2025). Prevalence of Self-Reported Postpartum Depressive Symptoms and Related Factors in Women living in Puerto Rico (2017–2020). Puerto Rico Health Sciences Journal, 44(4), 215–225. https://prhsj.rcm.upr.edu/index.php/prhsj/article/view/3629
Rodríguez-Reynaldo, M., Rivera-Orraca, Z., Ramos Monserrate, G., & Martínez-González, K. (2025). Mental health impact of the COVID-19 pandemic in perinatal women living in Puerto Rico. Journal of Reproductive and Infant Psychology, 43(1), 181–194. https://doi.org/10.1080/02646838.2023.223238
Rodríguez-Soto, N. C., Fuster, F., Gonzalez, P., Rivas-Tumanyan, S., Campos, M., Buxó, C. J., Morou-Bermudez, E., & Martinez-González, K. G. (2026). Long-term negative mental health outcomes in mothers exposed to Hurricane Maria in Puerto Rico during the pre- and perinatal periods. Journal of Traumatic Stress, 39, 119–130. https://doi.org/10.1002/jts.70025
Rosal, M. C., Almodóvar-Rivera, I., Person, S. D., López-Cepero, A., Kiefe, C. I., Tucker, K. L., Uribe-Jerez, M., Rodríguez-Orengo, J., & Pérez, C. M. (2024). Psychological and socio-economic correlates of cardiovascular health among young adults in Puerto Rico. American Journal of Preventive Cardiology, 20, 100875. https://doi.org/10.1016/j.ajpc.2024.100875
Rosal, M. C., Person, S., Kiefe, C. I., Tucker, K. L., & Pérez, C. M. (2026). Associations between chronic stress, resilience resources, and cardiovascular health among young adults in Puerto Rico: the PR-OUTLOOK study. medRxiv (preprint). https://doi.org/10.64898/2026.03.18.26348758
Sampson, L., Kim, A. H., O’Neill, H. J., Tamez, M., Falcon, L. M., Tucker, K. L., Acosta-Pérez, E., Rodriguez Orengo, J. F., Kubzansky, L. D., Koenen, K. C., & Mattei, J. (2024). Psychological resilience, resilient coping, and health behaviors among adults in Puerto Rico after multiple adverse events. Preventive Medicine Reports, 46, 102874. https://doi.org/10.1016/j.pmedr.2024.102874
Valentín-Cortés, M. A., Velez Vega, C. M., Torres Zayas, H. R., Pabón, Z. R., Alshawabkeh, A. N., Meeker, J. D., Cordero, J. F., & Watkins, D. J. (2026). Hurricane María and prenatal maternal mental health: Variations in stress, social support, and depression across disaster recovery periods in Puerto Rico. Environmental research, 291, 123526. https://doi.org/10.1016/j.envres.2025.123526
Zimmerman, E., Aguiar, A., Aung, M. T., Geiger, S. D., Hines, M., Woodbury, M. L., Martens, A., Huerta-Montanez, G., Cordero, J. F., Meeker, J. D., Schantz, S. L., Alshawabkeh, A. N., & Program Collaborators for Environmental Influences on Child Health Outcomes (2023). Examining the association between prenatal maternal stress and infant non-nutritive suck. Pediatric research, 93(5), 1285–1293. https://doi.org/10.1038/s41390-021-01894-9
