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SPECIAL Armed conflict and mental health in

PAPER
Colombia
William Tamayo-Agudelo1,2 and Vaughan Bell3,4

1
Profesor de Psicologia, hostilities between numerous groups, including
Universidad Cooperativa de Although significant progress has been made
Colombia, Medellín, Colombia state actors, remaining and dissident revolutionary
in the peace process, Colombia still
2
Division of Psychiatry, University guerrilla groups, right-wing paramilitaries and
experiences high levels of ongoing violence
College London, UK criminal drug trafficking organisations. For the civil-
3 and a legacy of more than five decades of
Senior Clinical Lecturer, Division ian population, the conflict has been characterised
of Psychiatry, University College armed conflict. Epidemiological studies show
London, UK, email vaughan.bell@ by frequent and extensive forced displacements, vio-
markedly raised levels of mental health
ucl.ac.uk lent control of communities, forced labour, targeted
4 problems in people affected by the conflict,
South London and Maudsley killings and massacres, disappearances, sexual vio-
National Health Service with internally displaced people being a large
Foundation Trust, UK lence, extortion, corruption and the systemic
and important group with unmet needs.
embedding of violence within community life.
Provision of mental health services is uneven
Conflicts of interest. V.B. is sup- Political debate surrounding the peace process
ported by a Wellcome Trust Seed and subject to significant underinvestment.
Award in Science (200589/Z/16/ has led to marked social and political polarisation.
Priority mental health treatment for victims of
Z) and the University College Key points of disagreement include justice and
London Hospitals National the conflict is now established in law, although
Institute for Health Research compensation for those affected by the conflict,
the effectiveness of these programmes has
Biomedical Research Centre. The integration of increasing numbers of demobilised
authors have no other interests to yet to be established.
declare.
guerrillas and government response to ongoing
violence. Mental health has become part of this
doi:10.1192/bji.2018.4 debate because of the direct effects of the conflict
The Colombian armed conflict has continued for
on the population as well as the challenges faced
© The Authors 2018. This is an over 50 years and has left approximately 220 000
Open Access article, distributed by mental health services in Colombia.
people dead, 6 million displaced and more than 27
under the terms of the Creative
Commons Attribution licence 000 kidnapped; leading to huge social and eco-
(http://creativecommons.org/ nomic costs to the country, and massive personal Exposure to the armed conflict as a
licenses/by/4.0/), which permits
unrestricted re-use, distribution, costs to those affected (Grupo de Memoria predictor of mental health problems
and reproduction in any medium, Histórica, 2016). The recent demobilisation of the Although Colombia’s armed conflict is often
provided the original work is
properly cited Revolutionary Armed Forces of Colombia (FARC- described as ‘low intensity’, independent data
EP) following the 2016 peace accord has reduced suggest remarkably high levels of exposure to
the overall intensity of the conflict. However, some conflict-related violence in the civilian population.
areas maintain high levels of violence due to Gómez-Restrepo et al (2016a) examined this using

40 BJPSYCH INTERNATIONAL VOLUME 16 NUMBER 2 MAY 2019

https://doi.org/10.1192/bji.2018.4 Published online by Cambridge University Press
 two data sources: the 2015 National Mental levels of drug use and gender-based violence are
Health Survey (NMHS), which reports formally more common. Furthermore, displaced people
sampled epidemiological data stratified by region often face significant social stigma and women,
(Atlántica, Oriental, Central, Pacífica and Bogotá) children and already-marginalised groups (for
covering both urban and rural populations and example, African–Colombian citizens) are
including participants aged 7 years and older, over-represented.
and CERAC, which is an independent register
of conflict-related violence. Experience of per- Impact on children and adolescents
manent conflict (defined as the presence of The impact of the armed conflict on children and
armed groups) was reported by 47.2% of indivi- adolescents is still poorly understood. Published
duals and in 21.8% of municipalities, and inter- analyses of the 2015 NMHS data on children
mittent conflict was reported by 44.1% of (Gómez-Restrepo et al, 2016c) and adolescents
individuals and in 65.5% of municipalities. (Gómez-Restrepo et al, 2016d) found that dis-
Anxiety, mood disorders and suicide were ele- placement by violence was not associated with a
vated in areas with a higher constancy and inten- significantly increased chance of meeting the cri-
sity of conflict. However, possible post-traumatic teria for psychiatric diagnosis, although past
stress disorder was most frequent in areas with trauma was a strong and significant predictor
lower intensity and intermittent conflict, which (odds ratio: 4.2; 95% CI: 2.3–7.8). Previous stud-
potentially reflects the persistence of ies on smaller samples typically report that expos-
trauma-related experiences after periods of ure to conflict or community or domestic violence
more intense violence. is a clear predictor of mental health problems and
behavioural difficulties. For example, Flink et al
Impact and nature of forced (2013) investigated mental health problems in
displacement preschool children in Bogotá and found mark-
More people have been displaced by violence in edly higher rates of problems (odds ratio: 3.3;
Colombia than in any other country in the 95% CI: 1.5–6.9) in children from families dis-
world (Shultz et al, 2014), and the mental health placed by violence.
needs of internally displaced people are central
to understanding the effects of the armed conflict. Current challenges
A 2014 systematic review of mental health in dis- Colombia faces a unique combination of chal-
placed people found high levels of symptoms lenges with respect to mental health. Adequate
(range of 9.9–63%) and diagnosable disorders services need to be available to (a) the population
(1.5–32.9%), but large variability due to the rela- as a whole, as they have traditionally had poor
tively poor quality of studies (Campo-Arias et al, access to mental health services and have lived
2014). Later, a study by Tamayo Martínez et al with internationally high levels of systemic vio-
(2016) (using the 2015 NMHS data) reported a lence for many decades; (b) people displaced by
15.9% lifetime prevalence of diagnosable psychi- the conflict, as they make up almost 15% of the
atric disorders in displaced adults. Although this Colombian population and have additional
study did not report a direct statistical comparison needs but often live in communities with further
with non-displaced individuals, the baseline rate risk factors for poor mental health and lack of
for adults in Colombia using the same data set is access to support; and (c) individuals with very
10.1% (Gómez-Restrepo et al, 2016b), suggesting high exposure to the conflict, as they may have
a higher prevalence of mental health problems more severe and complex problems that require
in displaced adults. specialist treatment. This latter group includes
Importantly, the impact of forced displace- civilian victims of violence, torture and other
ment on mental health is likely to arise from mul- human rights abuses but also includes combatants
tiple sources over a protracted period. To capture and ex-combatants from armed groups who need
this, Shultz et al (2014) applied trauma signature to be reintegrated into society. Combatants may
analysis to profile forced displacement in also have been both victims and perpetrators of
Colombia. This is a systematic method for identi- human rights abuses, leading to complex care
fying the features of a natural or human- needs that involve balancing personal well-being,
generated disaster that characterises stages, public protection and political acceptability.
hazards, stressors and impact to better guide However, uneven availability of services and
effective mental health and psychosocial support. relatively low levels of investment in mental health
They found that forced displacement in Colombia and the mental health workforce are still major
typically involves already-vulnerable groups flee- obstacles (Chaskel et al, 2015). Mental health ser-
ing violence in rural areas, risking violence and vices are most widely available in urban centres
exploitation during migration, and then settling and can be either be absent or sparse in the
in areas on the outskirts of large cities which are rural areas most affected by the conflict.
often under the control of armed groups. It is Although Colombia provides almost universal
also notable that essential services such as sanita- healthcare coverage, the current two-tier system
tion, electricity, health, transport and education provides a markedly poorer level of care for peo-
are often slow to extend to these areas, and social ple on the government-subsidised system. In add-
problems such as criminal exploitation, high ition, corruption, stalled reforms, health system

BJPSYCH INTERNATIONAL VOLUME 16 NUMBER 2 MAY 2019 41

https://doi.org/10.1192/bji.2018.4 Published online by Cambridge University Press
 debts and closure of mental health hospitals and References
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