摘要：Objectives. We analyzed a probability sample of Guatemalans to determine if a relationship exists between previous violent events and development of mental health outcomes in various sociodemographic groups, as well as during and after the Guatemalan Civil War. Methods. We used regression modeling, an interaction test, and complex survey design adjustments to estimate prevalences and test potential relationships between previous violent events and mental health. Results. Many (20.6%) participants experienced at least 1 previous serious violent event. Witnessing someone severely injured or killed was the most common event. Depression was experienced by 4.2% of participants, with 6.5% experiencing anxiety, 6.4% an alcohol-related disorder, and 1.9% posttraumatic stress disorder (PTSD). Persons who experienced violence during the war had 4.3 times the adjusted odds of alcohol-related disorders ( P < .05) and 4.0 times the adjusted odds of PTSD ( P < .05) compared with the postwar period. Women, indigenous Maya, and urban dwellers had greater odds of experiencing postviolence mental health outcomes. Conclusions. Violence that began during the civil war and continues today has had a significant effect on the mental health of Guatemalans. However, mental health outcomes resulting from violent events decreased in the postwar period, suggesting a nation in recovery. For 36 years Guatemala experienced a violent civil war in which over 200 000 civilians were killed, 440 villages destroyed, and more than 1 million Guatemalans displaced, both internally and into southern Mexico. 1–3 Those killed included indigenous persons, laborers, academics, religious leaders, and others who were clearly noncombatants. 3,4 In 1996, peace accords were signed between a number of rurally based guerrilla forces and Guatemala’s national army. Nearly three quarters of the people in the world’s poorest societies have recently been through a civil war or are still in one. The average civil war lasts approximately 5 years and can be embedded in a societal context that fuels the longevity of the conflict itself by marking it as culturally “normal.” 5–7 Because of cultural normalization and numerous other factors, both within and outside of Guatemala, the Guatemalan Civil War far exceeded the length of the average national civil war and might have long-standing implications for the safety and health of Guatemalans today. Civil wars produce a legacy of postconflict violence and disease, 7–12 and Guatemala is no exception. Today, the northern triangle of Central America, which includes Guatemala, Honduras, and El Salvador, is described as the most violent area of the world outside of active theaters of war. 3,13 Less than a decade after the civil war peace accords were signed in Guatemala, persistent violence reportedly resulted in the second highest rates of fear from armed crime in the world and the proliferation of more private security personnel than members of the regular army. 3,14 Approximately at the same time, some 1500 Guatemalan Civil War refugees living in Mexico reported alarmingly high levels of depression, anxiety, and posttraumatic stress disorder (PTSD). 15 The World Health Organization (WHO) also reported elevated alcohol use disorders in Guatemala in the years following the civil war. 16 These indicators occurred alongside reports that 40% of the country continued to have no mental health services, leaving many Guatemalans, repatriated refugees, and affected citizens, who remained throughout the civil war without a key aspect of care on the road to national recovery. 17 In dealing with the effects of civil conflicts, such as recurring violence, PTSD, depression, anxiety, alcohol abuse, and other mental health issues, postconflict societies like Guatemala face difficult decisions between enacting extraordinary military spending 3,5 or provisions of enhanced social and public health services. 7,18 However, policymakers in Guatemala (and internationally) have limited population-level and epidemiologic evidence 19 with which to make such decisions. With this in mind, we completed the first national probability sample of the mental health of Guatemalans still living in Guatemala. We analyzed these survey data to obtain nationally representative estimates of the prevalence of select mental health problems in Guatemala, 9,11,15 and to determine if a relationship existed between previous violent events and the development of subsequent mental health outcomes. We compared different sociodemographic groups, 20–25 as well as the periods before and after the signing of the 1996 civil war peace accords.
