Mental health disorders in population displaced by conflict in Colombia: Comparative analysis against the National Mental Health Survey 2015.

BACKGROUND AND OBJECTIVES: Colombia is one of the countries with the highest levels of internal displacement resulting from armed conflict. This population has greater chances of experiencing a mental health disorder, especially in territories historically affected by armed conflict. Our objective was to compare the levels of possible mental health disorder in people experiencing internal displacement in Meta, Colombia, a department historically affected by armed conflict, compared to the internally displaced population in the National Mental Health Survey of 2015. METHODS: Analysis of data collected in the National Mental Health Survey (ENSM) of 2015, study with representative data at national level and the Conflict, Peace and Health survey (CONPAS) of 2014, representative study of the degree of impact of the conflict on the municipality, conducted in the department of Meta, Colombia. To measure possible mental health disorder, the Self-Report Questionnaire-25 (SRQ-25) was used. Internal displacement is self-reported by people surveyed in both studies. An exploratory analysis is used to measure possible mental health disorders in the displaced population in the ENSM 2015 and CONPAS 2014. RESULTS: 1089 adults were surveyed in CONPAS 2014 and 10,870 adults were surveyed in the ENSM 2015. 42.9% (468) and 8.7% (943) of people reported being internally displaced in CONPAS 2014 and ENSM 2015, respectively. In both studies, internally displaced populations have greater chances of experiencing any mental health disorder compared to non-displaced populations. For CONPAS 2014, 21.8% (95%CI, 18.1-25.8) of this population had a possible mental health disorder (SRQ+) compared to 14.0% (95%CI, 11.8-16.3) in the ENSM 2015. Compared with the ENSM 2015, at the regional level (CONPAS 2014), displaced people had a greater chance of presenting depression by 12.4% (95%CI, 9.5-15.7) compared to 5.7% (95%CI, 4.3-7.4) in the ENSM 2015, anxiety in 21.4% (95%CI, 17.7-25.3) compared to 16.5% (95%CI, 14.2-19.1) in the ENSM 2015, and psychosomatic disorders in 52.4% (95%CI, 47.5-56.7) in CONPAS 2014 compared to 42.2% (95%CI, 39.0-45.4) in the ENSM 2015. At the national level (ENSM 2015), displaced people had greater possibilities of presenting, compared to the regional level, suicidal ideation in 11.9% (95%CI, 9.3-14.1) compared to 7.3% (95%CI, 5.0-10.0) in CONPAS 2014 and bipolar disorder in 56.5% (95%CI, 53.2-59.7) compared to 39.3% (95%CI, 34.8-43.9) in CONPAS 2014. CONCLUSIONS: The greater possibilities of displaced populations at the regional level of experiencing a mental health disorder, compared to this same population at the national level, may represent and indicate greater needs in mental health care services in territories affected by conflict. Therefore, and given the need to facilitate access to health services in mental health for populations especially affected by armed conflict, there is a need to design health care policies that facilitate the recovery of populations affected by war and, simultaneously, that reduce inequities and promote the fulfilment of one of the most important and, at the same time, least prioritised health objectives in international development: mental health.

Trastornos de salud mental en población desplazada por el conflicto en Colombia: análisis comparado frente a la Encuesta Nacional de Salud Mental 2015

Introducción y objetivos: Colombia es uno de los países del mundo con mayor volumen de desplazamiento interno a causa de un conflicto armado interno. Esta población tiene mayores posibilidades de sufrir un trastorno de salud mental, sobre todo en territorios afectados históricamente por el conflicto. El objetivo es comparar la prevalencia de posibles trastornos de la salud mental entre las personas en condición de desplazamiento en Meta, departamento de Colombia históricamente afectado por el conflicto armado, frente a población desplazada en todo el país según la Encuesta Nacional de Salud Mental (ENSM) de 2015. Métodos: Análisis de datos recolectados en la ENSM 2015, estudio a escala nacional, y la encuesta Conflicto, Salud y Paz (CONPAS) de 2014, estudio representativo del grado de afectación por el conflicto en el municipio, realizado en el departamento del Meta. Para medir un posible trastorno de la salud mental, se utiliza el Self Report Questionnaire-25 (SRQ-25). La condición de desplazamiento fue declarada por los encuestados en ambos estudios. Se hizo un análisis descriptivo sobre el posible trastorno de la salud mental en la población desplazada de la ENSM 2015 y la CONPAS 2014. Resultados: Se encuestó a 1.089 adultos en la CONPAS 2014 y 10.870 adultos en la ENSM 2015. El 42,9% (468) y el 8,7% (943) de las personas reportaron estar en condición de desplazamiento en la CONPAS 2014 y la ENSM 2015 respectivamente. En ambos estudios, la población desplazada tiene mayores posibilidades de sufrir cualquier trastorno de la salud mental que la población no desplazada. En la CONPAS 2014, el 21,8% (intervalo de confianza del 95% [IC95%], 18,1-25,8) de esta población tenía un posible trastorno de la salud mental (SRQ+) frente al 14,0% (IC95%, 11,8-16,3) en la ENSM 2015. Los encuestados en condición de desplazamiento de la CONPAS 2014 tuvieron mayor probabilidad que los de la ENSM 2015 en depresión -el 12,4% (IC95%, 9,5-15,7) frente al 5,7% (IC95%, 4,3-7,4)-, ansiedad -el 21,4% (IC95%, 17,7-25,3) frente al 16,5% (IC95%, 14,2-19,1)-y trastornos psicosomáticos -el 52,4% (IC95%, 47,5-56,7) frente al 42,2% (IC95%, 39,0-45,4)-. Los desplazados de la ENSM 2015 tenían mayor probabilidad de ideación suicida, el 11,9% (IC95%, 9,3-14,1) frente al 7,3% (IC95%, 5,0-10,0) en la CONPAS 2014, y trastorno bipolar, el 56,5% (IC95%, 53,2-59,7) frente al 39,3% (IC95%, 34,8-43,9). Conclusiones: La mayor probabilidad de trastornos de la salud mental (SRQ+) de la población regional en condición de desplazamiento frente a toda la población nacional en esa condición puede representar una mayor necesidad de servicios de atención en salud mental en los territorios afectados por el conflicto. Así pues, y dada la necesidad de facilitar el acceso y la atención médica en salud mental a poblaciones especialmente afectadas por el conflicto armado, es importante el diseño de políticas de atención en salud que faciliten la recuperación de poblaciones afectadas por la guerra y, simultáneamente, reducir inequidades y promover el cumplimiento de uno de los objetivos en salud más importantes y, a la vez, usualmente menos priorizados en el desarrollo internacional: la salud mental. © 2021 Asociación Colombiana de Psiquiatría. Publicado por Elsevier España, S.L.U. Todos los derechos reservados.

Background and objectives: Colombia is one of the countries with the highest levels of internal displacement resulting from armed conflict. This population has greater chances of experiencing a mental health disorder, especially in territories historically affected by armed conflict. Our objective was to compare the levels of possible mental health disorder in people experiencing internal displacement in Meta, Colombia, a department historically affected by armed conflict, compared to the internally displaced population in the National Mental Health Survey of 2015. Methods: Analysis of data collected in the National Mental Health Survey (ENSM) of 2015, study with representative data at national level and the Conflict, Peace and Health survey (CONPAS) of 2014, representative study of the degree of impact of the conflict on the municipality, conducted in the department of Meta, Colombia. To measure possible mental health disorder, the Self-Report Questionnaire - 25 (SRQ-25) was used. Internal displacement is self-reported by people surveyed in both studies. An exploratory analysis is used to measure possible mental health disorders in the displaced population in the ENSM 2015 and CONPAS 2014. Results: 1,089 adults were surveyed in CONPAS 2014 and 10,870 adults were surveyed in the ENSM 2015. 42.9% (468) and 8.7% (943) of people reported being internally displaced in CONPAS 2014 and ENSM 2015, respectively. In both studies, internally displaced populations have greater chances of experiencing any mental health disorder compared to non-displaced populations. For CONPAS 2014, 21.8% (95%CI, 18.1-25.8) of this population had a possible mental health disorder (SRQ+) compared to 14.0% (95%CI, 11.8-16.3) in the ENSM 2015. Compared with the ENSM 2015, at the regional level (CONPAS 2014), displaced people had a greater chance of presenting depression by 12.4% (95%CI, 9.5-15.7) compared to 5.7% (95%CI, 4.3-7.4) in the ENSM 2015, anxiety in 21.4% (95%CI, 17.7-25.3) compared to 16.5% (95%CI, 14.2-19.1) in the ENSM 2015, and psychosomatic disorders in 52.4% (95%CI, 47.5-56.7) in CONPAS 2014 compared to 42.2% (95%CI, 39.0-45.4) in the ENSM 2015. At the national level (ENSM 2015), displaced people had greater possibilities of presenting, compared to the regional level, suicidal ideation in 11.9% (95%CI, 9.3-14.1) compared to 7.3% (95%CI, 5.0-10.0) in CONPAS 2014 and bipolar disorder in 56.5% (95%CI, 53.2-59.7) compared to 39.3% (95%CI, 34.8-43.9) in CONPAS 2014. Conclusions: The greater possibilities of displaced populations at the regional level of experiencing a mental health disorder, compared to this same population at the national level, may represent and indicate greater needs in mental health care services in territories affected by conflict. Therefore, and given the need to facilitate access to health services in mental health for populations especially affected by armed conflict, there is a need to design health care policies that facilitate the recovery of populations affected by war and, simultaneously, that reduce inequities and promote the fulfilment of one of the most important and, at the same time, least prioritised health objectives in international development: mental health.

Health in Conflict Zones: Analyzing Inequalities in Mental Health in Colombian Conflict-Affected Territories.

Objectives: Colombia's civil conflict and persistent socio-economic disparities have contributed to mental health inequalities in conflict-affected territories. We explore the magnitude of mental health inequalities, contributing socio-economic factors, and sociodemographic characteristics that explain these differences. Methods: The study draws on data collected in 2018, using the household survey Conflicto, Paz y Salud (CONPAS) applied to 1,309 households in Meta, Colombia. Logistic regression and decomposition analysis were used to analyze the risk of mental health disorders, measured with the Self-Reporting Questionnaire -20 (SRQ-20). Results: Individuals with lower socio-economic status are at a higher risk for mental health disorders. Forced displacement accounts for 31% of the measured mental health inequalities. Disparities in employment, education level, disability and conflict incidence between municipalities are other contributing factors. Women and people with disabilities are respectively 2.3 and 1.2 times more prone to present a mental health disorder. Conclusion: It is necessary to tackle the identified risk factors and sociodemographic circumstances that contribute to mental health inequalities in conflict-affected territories, as these hinder adequate/equitable access to mental health services.

Inequalities in catastrophic health expenditures in conflict-affected areas and the Colombian peace agreement: an oaxaca-blinder change decomposition analysis.

BACKGROUND: The present study analyzes inequalities in catastrophic health expenditures in conflict-affected regions of Meta, Colombia and socioeconomic factors contributing to the existence and changes in catastrophic expenditures before and after the sign of Colombian Peace Agreement with FARC-EP guerilla group in 2016. METHODS: The study uses the results of the survey Conflicto, Paz y Salud (CONPAS) conducted in 1309 households of Meta, Colombia, a territory historically impacted by armed conflict, for the years 2014 and 2018. We define catastrophic expenditures as health expenditures above 20% of the capacity to pay of a household. We disaggregate the changes in inequalities in catastrophic expenditures through the Oaxaca-Blinder change decomposition method. RESULTS: The incidence of catastrophic expenditures slightly increased between 2014 to 2018, from 29.3 to 30.7%. Inequalities in catastrophic expenditures, measured through concentration indexes (CI), also increased from 2014 (CI: -0.152) to 2018 (CI: -0.232). Results show that differences in catastrophic expenditures between socioeconomic groups are mostly attributed to an increased influence of specific sociodemographic variables such as living in rural zones, being a middle-aged person, living in conflict-affected territories, or presenting any type of mental and physical disability. CONCLUSIONS: Conflict-deescalation and the peace agreement may have facilitated lower-income groups to have access to health services, especially in territories highly impacted by conflict. This, consequently, may have led to higher levels of out-of-pocket expenditures and, therefore, to higher chances of experiencing catastrophic expenditures for lower-income groups in comparison to higher-income groups. Therefore, results indicate the importance of designing policies that guarantee access to health services for people in conflict -affected regions but also, that minimize health care inequalities in out-of-pocket payments that may arouse between people at different socioeconomic groups.

Mental Health Disorders in Population Displaced by Conflict in Colombia: Comparative Analysis against the National Mental Health Survey 2015. / Trastornos de salud mental en población desplazada por el conflicto en Colombia: análisis comparado frente a la Encuesta Nacional de Salud Mental 2015.

BACKGROUND AND OBJECTIVES: Colombia is one of the countries with the highest levels of internal displacement resulting from armed conflict. This population has greater chances of experiencing a mental health disorder, especially in territories historically affected by armed conflict. Our objective was to compare the levels of possible mental health disorder in people experiencing internal displacement in Meta, Colombia, a department historically affected by armed conflict, compared to the internally displaced population in the National Mental Health Survey of 2015. METHODS: Analysis of data collected in the National Mental Health Survey (ENSM) of 2015, study with representative data at national level and the Conflict, Peace and Health survey (CONPAS) of 2014, representative study of the degree of impact of the conflict on the municipality, conducted in the department of Meta, Colombia. To measure possible mental health disorder, the Self-Report Questionnaire - 25 (SRQ-25) was used. Internal displacement is self-reported by people surveyed in both studies. An exploratory analysis is used to measure possible mental health disorders in the displaced population in the ENSM 2015 and CONPAS 2014. RESULTS: 1,089 adults were surveyed in CONPAS 2014 and 10,870 adults were surveyed in the ENSM 2015. 42.9% (468) and 8.7% (943) of people reported being internally displaced in CONPAS 2014 and ENSM 2015, respectively. In both studies, internally displaced populations have greater chances of experiencing any mental health disorder compared to non-displaced populations. For CONPAS 2014, 21.8% (95%CI, 18.1-25.8) of this population had a possible mental health disorder (SRQ+) compared to 14.0% (95%CI, 11.8-16.3) in the ENSM 2015. Compared with the ENSM 2015, at the regional level (CONPAS 2014), displaced people had a greater chance of presenting depression by 12.4% (95%CI, 9.5-15.7) compared to 5.7% (95%CI, 4.3-7.4) in the ENSM 2015, anxiety in 21.4% (95%CI, 17.7-25.3) compared to 16.5% (95%CI, 14.2-19.1) in the ENSM 2015, and psychosomatic disorders in 52.4% (95%CI, 47.5-56.7) in CONPAS 2014 compared to 42.2% (95%CI, 39.0-45.4) in the ENSM 2015. At the national level (ENSM 2015), displaced people had greater possibilities of presenting, compared to the regional level, suicidal ideation in 11.9% (95%CI, 9.3-14.1) compared to 7.3% (95%CI, 5.0-10.0) in CONPAS 2014 and bipolar disorder in 56.5% (95%CI, 53.2-59.7) compared to 39.3% (95%CI, 34.8-43.9) in CONPAS 2014. CONCLUSIONS: The greater possibilities of displaced populations at the regional level of experiencing a mental health disorder, compared to this same population at the national level, may represent and indicate greater needs in mental health care services in territories affected by conflict. Therefore, and given the need to facilitate access to health services in mental health for populations especially affected by armed conflict, there is a need to design health care policies that facilitate the recovery of populations affected by war and, simultaneously, that reduce inequities and promote the fulfilment of one of the most important and, at the same time, least prioritised health objectives in international development: mental health.

A light of hope? Inequalities in mental health before and after the peace agreement in Colombia: a decomposition analysis.

BACKGROUND: The present study seeks to evaluate the change in mental health inequalities in the department of Meta after the signing of Colombia's Peace Agreement in 2016 with the FARC guerrilla group. Using a validated survey instrument composed of 20 questions ('SRQ-20'), we measure changes in mental health inequalities from 2014, before the signing of the agreement, to 2018, after the signing. We then decompose the changes in inequalities to establish which socioeconomic factors explain differences in mental health inequalities over time. METHODS: Our study uses information from the Conflicto, Salud y Paz (CONPAS) survey conducted in the department of Meta, Colombia, in 1309 households in 2018, with retrospective information for 2014. To measure inequalities, we calculate the concentration indices for both years. Through the Oaxaca change decomposition method, we disaggregate changes in mental health inequalities into its underlying factors. This method allows us to explain the relationship between changes in mental health inequalities and changes in inequalities in several sociodemographic factors. It also identifies the extent to which these factors help explain the changes in mental health inequalities. RESULTS: Mental health inequalities in Meta were reduced almost by half from 2014 to 2018. In 2018, the population at the lower and middle socioeconomic levels had fewer chances of experiencing mental health disorders in comparison to 2014. The reduction in mental health differences is mostly attributed to reductions in the influence of certain sociodemographic variables, such as residence in rural zones and conflict-affected territories, working in the informal sector, or experiencing internal displacement. However, even though mental health inequalities have diminished, overall mental health outcomes have worsened in these years. CONCLUSIONS: The reduction in the contribution of conflict-related variables for explaining mental health inequalities could mean that the negative consequences of conflict on mental health have started to diminish in the short run after the peace agreement. Nevertheless, conflict and the presence of other socioeconomic inequalities still contribute to persistent adverse mental health outcomes in the overall population. Thus, public policy should be oriented towards improving mental health care services in these territories, given the post-accord context.