The number of hotline calls reporting suicide attempts in Puerto Rico nearly tripled after Hurricane Maria hit the region last September.

The suicide rate is now the highest it’s been in four years, following a historic low in 2016, according to data from Puerto Rico’s Department of Health.

It will take Puerto Rico years to fully recover from the devastation of Hurricane Maria — it’s already taken several months just to restore power and provide clean water to most of the island.

Julio Santana Mariño, a psychology professor at Universidad Carlos Albizu, told Vox, “when you add the stress of more than five months without power, without food, living patterns change … it makes it harder for people to manage daily life.”

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