PHILADELPHIA—Violence during the civil war in Guatemala from 1960 to 1996 resulted in the development of significant mental health problems and conditions for the county’s people, according to a new multi-institution study from researchers under the Guatemala-Penn Partnership. People who experienced or witnessed violence were four times more likely to suffer from alcohol-related disorders and post-traumatic stress disorder (PTSD) during the civil war, researchers from the University of San Carlos in Guatemala, the University of Pennsylvania, Columbia University, and Brown University report this week in the American Journal of Public Health.

The mental health consequences resulting from violent events decreased in the postwar period, suggesting a nation in recovery.

The study was co-led by Victor D. Puac-Polanco, MD, MSCE, of the Epidemiology Department at the Mailman School of Public Health, Columbia University, formerly of Penn’s MSCE program in the department of Epidemiology, and senior author Charles C. Branas, PhD, of the department of Biostatistics and Epidemiology at the Perelman School of Medicine at the University of Pennsylvania.

The researchers’ findings occur amidst reports that 40 percent of Guatemalans continue to have no mental health services.

In a countrywide representative sample, the study assessed almost 1,500 Guatemalans, men and women between 18 and 65 years old. One-in-five of these Guatemalans had witnessed or experienced at least one prior serious violent event (26.1 percent of males and 19.3 percent of females).

Witnessing someone severely injured or killed was the most common event. Persons who witnessed or experienced violence during the war had 4.3 times the adjusted odds of alcohol-related disorders and four times the adjusted odds of post-traumatic stress disorder compared with the postwar period, beginning in 1996 after the conflict formally ended.

Overall, 4.2 percent of the randomly selected Guatemalans in the study had experienced depression, 6.5 percent anxiety, 6.4 percent an alcohol-related disorder, and 1.9 percent post-traumatic stress disorder. What’s more, women, indigenous Maya, and urban dwellers had greater odds of experiencing post-violence mental health problems. These were troubling disparities for a developing nation like Guatemala, the authors said.

"This is the first advanced epidemiological analysis of the Guatemalan National Mental Health Survey,” said lead author Puac-Polanco. “The linkage between violence and mental health problems remains significant in Guatemala and our study will hopefully raise awareness of this linkage and the need for greater investment in mental health resources in Guatemala and other nations affected by persistent violence.”

Of the 338 survey participants who experienced any previous violence, 61.1 percent reported witnessing or experiencing one violent event; 24.8 percent witnessed or experienced two violent events; 9.8 percent witnessed or experienced three violent events; and 4.4 percent witnessed or experienced four or more violent events in their lifetime. A further analysis of these 338 survey participants demonstrated that 31.8 percent were exposed to their most serious violent event during the civil war and 65.4 percent after.

The study is the first national random sample of the mental health of Guatemalans in their home country (previous studies had smaller sample sizes and nonrandom sampling, limiting the conclusions they could draw). The questionnaire-based survey was administered by 138 interviewers completing their final year of medical school at the University of San Carlos of Guatemala.

Nearly three quarters of the people in the world’s poorest societies have recently been through a civil war or are still in one.

"Our findings show that witnessing or experiencing a violent event, which is quite common in civil wars around the world, does indeed take a serious toll on many people,” said Branas. "We are concerned for survivors of violence in these conflicts, and are hopeful that public health problems related to violence, such as mental illness, will continue to improve as the Guatemalan people further emerge from the toxic conditions created by the war."

Similar findings of higher rates of mental health problems during periods of war, as opposed to postwar periods, have been reported in other nations.

The average civil war lasts approximately five years. In addition to its mental health consequences, the exceedingly long civil war in Guatemala resulted in displacement of 1 million people from their homes and workplaces, over 200,000 civilian deaths, destruction of hundreds of villages, crops and fields, the elimination of local leaders and authorities and, in the worst cases, torture, rape, and collective extermination of entire families and communities. The Guatemalan Civil War was primarily fought between the government and various leftist rebel groups.

The study is part of the Guatemala-Penn Partnership, led by Dr. Branas, which draws on almost a century of Penn involvement in Guatemala, including public health, medical, anthropologic and archaeological activities and discoveries. A key component is Penn’s Guatemala Health Initiative, started in 2005, which offers experiences to Penn students from six schools (Medicine, Nursing, Arts & Sciences, Social Policy and Practice, Engineering, Design, and Wharton) to improve health in the country. Projects include: violence prevention, maternal and child health, mental health, food and nutrition, road traffic safety, chronic disease treatment and prevention, raising funds and medical supplies for local hospitals, and trauma treatment.

Other Penn co-authors are Dawei Xie, PhD, and Therese S. Richmond, PhD. Victor A. Lopez-Soto, MD, and Robert Kohn, MD, are also co-authors.

This work was funded in part through grants from the US National Institutes of Health’s Fogarty International Center and the Trauma and Global Health Program of the Global Health Research Initiative (D43TW008317 and D43TW008972).

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