Monroe County already had one of the highest suicide rates in the state of Florida.
Then came Hurricane Irma. And although most of the debris has been removed from land - and lots of repairs are underway — the storm continues to impact the Keys, almost a year later.
Debby Zutant tends bar at Coconuts on Big Pine Key on weekend afternoons where, a few months ago, she said goodbye to a regular. He was a local taxi driver, someone everybody in town knew and liked.
"He left the bar and I remember I walked over to him and I said, 'Not only are you my favorite customer, you're one of my favorite people in the world,' and I gave him a big smooch," Zutant said.
A couple hours later, he took his own life.
He was the fifth person Zutant knew on Big Pine Key to die by suicide since Hurricane Irma last September.
The suicide rate in Monroe County was already higher than the state average before the storm. The Keys averaged 21 suicides a year for the last five years. The rate per 100,000 people was 82 percent higher than the statewide average.
By July of this year, there were 20 suicides in the Keys. On track to double the county's average.
An obvious factor is Hurricane Irma, according to the Monroe County Health Director Bob Eadie.
"It's like this miasma, this cloud hangs over anybody that had to go through it," he said.
Getting through the hurricane and the immediate aftermath was hard. But the stress is really showing months later as people are still trying to find a place to live that they can afford, still trying to rebuild their homes or businesses. And lot of people are still fighting with insurance companies.
"Anything we can do as a community to try and help alleviate that stress, especially now, post-Irma, I think would be very helpful," said Summer DeBastiani, an assistant professor of nursing at the University of Miami. "Improving people's quality of life. It's odd to say that because we live in paradise, right?"
Before Irma, DeBastiani wrote her PhD dissertation about suicide risk in the Keys.
She lives in the Keys now and used to work at the Centers for Disease Control on disaster preparedness and response.
She says after a disaster, there's what's called a “honeymoon period."
"That's when the community is joining together and there's a lot of rallying and support," she said.
After a few months, that goes away. The volunteer forces go back home.
"And then you kind of are left with 'oh well.' Still the remnants," she said. "And that's when the mental health aspects start setting in pretty strongly."
DeBastiani said it's important for people to reach out to friends who may be at risk — and for the community as a whole to realize that a lot of their neighbors are dealing with some pretty severe stress.
She said that's why she keeps a sticker on her phone that says 'Are you OK?' just as a reminder to check in with people around her regularly. She also keeps the suicide prevention hotline number in her phone so she can easily share it by text.
Quality of life can be something that doesn’t seem like that big of a deal, but it is.
Bob Eadie from the county health department recently moved. He wound up giving some fishing gear to one of the movers who lives in Big Pine and lost everything.
"He had not been able to justify spending money on some fishing gear with all the other things he needs," Eadie said.
But taking time to do things you really enjoy — that's a real need, Eadie said. That stuff matters.
"For his mental health it's something he should be doing," Eadie said. "But he just couldn't do it."
Another challenge in the Florida Keys is the famous island character of independence and resilience — a character that is distilled to its essence on Big Pine. It's a rural community, between the cities of Marathon and Key West.
"It's always kind of been an outlaw, smuggler, kind of off-the-wall community," said Debby Zutant, the bartender. "Very proud and very stubborn and hardheaded."
Eadie and Debastiani both say that's one of the biggest public health challenges in the Keys: persuading those independent islanders that it's OK to ask for help.
"The Keys are tough people. And that's good news and bad news," Eadie said. "There is such a tendency I've seen, that they're going to take care of everything by themselves without asking for help."
The Monroe County Health Department is looking for national models on coping with suicide and other long-term mental health impacts after a disaster.
If you or someone you know is having thoughts of suicide, can call the suicide hotline 24 hours a day at 800-273-8255.
Resources and support for preventing suicide can be found here.
In the Florida Keys, mental health services are provided by the Guidance Care Center.