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Mental Health in Colombia: Why We Should Care

Guests of The Psychedelic Blog do not endorse, support, or otherwise advocate on behalf of any particular treatment approach for mental illnesses unless stated otherwise. The views expressed during this interview do not necessarily reflect the opinions or endorsement of The Psychedelic Blog. Readers should always consult with qualified healthcare professionals and conduct their own research before considering any treatment options. The blog and its authors are not responsible for any decisions made based on the information provided.


Man
The Psychologist

"Why are you so interested in

Colombia's mental health?"


I was surprised by the question, though I pretended not to be. (I'm pretty sure that the involuntary arch of my eyebrow exposed my weak front.) I had meticulously studied every detail of my pitch and anticipated every inquiry except the most obvious, "Why are you so interested in Colombia's mental health?"


It was May 2023. We met at Medellín's Town Hall in a cozy office notable only for the infrequency of its furnishings. Walking into the room, I was impressed, thinking to myself "now, this is prudent use of taxpayer pesos!" Beside me was my Colombian friend, Kelly who had helped to arrange the meeting. Across the table from us was the mental health representative for the Mayor of Medellín's office. She was accompanied by an older male psychologist with a cane who, they said, was along to provide technical support. He kind of stared at me in, what I later determined to be, a half suspicious and half supportive way.


This meeting was not easy to organize. I was there to find out if the City of Medellín might be interested in having a US-based hospital share knowledge and training with Colombian mental health experts regarding their Phase III clinical trials on MDMA-assisted therapy for treating post-traumatic stress disorder (PTSD). Only if I could convince Medellín to show moderate interest would I then go back and propose the Medellín mental health project to the US-based hospital. It's like trying to arrange a blind date with chocolate and peanut butter; you know they belong together if you could only get them alone in a room. In case you're wondering, I am not a medical or mental health professional and I'm not an evangelist for psychedelics in Colombia. Maybe something more like a matchmaker.


My relationship to the hospital was through a director there with whom I'd collaborated several years ago on an anti-human trafficking project. (She's an incredible person whose story I may tell another day.) I called her and we met in her office in July 2022. I raised the idea of bringing her hospital's MDMA clinical trials to Colombia. She promised to advance my proposal to the key decision-making administrators if I was able to craft one.


My goal was simply to connect a need to a potential solution. It's true that "need" and "potential solution" are subjective concepts, particularly when applied to mental health, and may be best understood through a lens of urgency and viability. And, yes, assessing urgency and viability should be done by experts, a group to which, I'll repeat, I don't claim membership. So the question remains, Why am I trying to coordinate some kind of United Nations summit to introduce potentially game-changing experimental mental health drugs in a country where most of the people I knew were sitting in that same room? And, again, Why am I so interested in mental health in Colombia?


I still didn't have an answer, but, during the meeting, I resorted to statistics to emphasize the urgency piece. I mentioned things they already knew, like more than 9.6 million people in Colombia had self-identified as victims of armed conflict. That's about 18% of the population. The Observatorio de Memoria y Conflicto says that while more than 270,000 died, thousands were victims of sexual violence, sequestration, and the violence of war. They document 11 types of violence that occurred between 1958 and 2022. According to the UNHCR nearly 7 million people have been internally displaced. In my experience, these numbers mean trauma. That's real urgency.


My perception of viability was that, at the time, there were more than 100 active clinical trials reporting high success rates in treating a range of mental illnesses including depression, anxiety, PTSD, and substance abuse disorders. There was definitely some kind of revolution brewing in the field of psychiatry. Exactly how psychiatry would be affected seemed to be a matter of degree. Would psychedelic-assisted therapies replace conventional treatments? Would they become another option in the psychiatry toolkit? Or might they langer forever in underground obscurity?


Still, I had to consider why I was so interested in mental health in Colombia. I decided that my interest must have started with me. As revealed in an earlier blog, I've struggled in the past with panic attacks and, in part because of that, I try not to take mental health for granted. Also, having known survivors of abuse and PTSD, I can empathize with both the people that are living with trauma and those who love them. The theories behind Epigenetics* lend further urgency to addressing trauma-related illnesses by underscoring the possibility that the impact of traumatic experiences may extend into subsequent generations.


From A Glossary of Terms - The Psychedelic Blog


*Epigenetics

  • Definition: Epigenetics is the study of changes in gene expression that do not involve alterations to the underlying DNA sequence – a change in phenotype without a change in genotype. These changes can affect how cells read genes and can be influenced by several factors including age, environment, lifestyle, and disease state.

  • Explanation: Epigenetics focuses on understanding how behavior and environment can cause changes that affect the way genes work. Unlike genetic changes, epigenetic changes are reversible and do not change the DNA sequence, but they can change how the body reads a DNA sequence. This field is crucial for understanding how certain diseases and traits develop.

  • Example: In epigenetics research, scientists might study how certain environmental factors like diet, stress, or exposure to toxins can alter gene expression patterns in a way that affects health or disease risk. For instance, the study of how smoking affects gene expression leading to cancer is an application of epigenetics.

  • Quote: "Epigenetics bridges our understanding between the environment and our genetic code, revealing how our experiences can directly influence our genetic expression." - Bruce Lipton


Mental illness hobbles human productivity whether you want to define that economically or through family and community development. Good mental health nurtures creativity and innovation. Better mental health awareness can lead to increased understanding across cultures, a reduction in conflict, and the promotion of global cooperation.


Maybe it was best that I skirted the question posed to me in the Mayor's office because it may have just led to more questions. "But who are you?" they may have asked. Well, I'm no one, but I can't try to help. Mental health is something I care about no matter where I am and, because I want to be here, Colombia's mental health is important to me.


I definitely harbor some naive notions about what can be accomplished by an individual with an idea. In this case, I failed to achieve my goal of securing interest. What I hadn't accounted for at the time of the Mayor's office meeting is the fact that this Mayor's term would soon be ending. When the Mayor leaves so does everyone in the administration. Starting an ambitious project with seven months left in office wasn't going to work for anyone. Not all was lost however. What I had done in researching and drafting the project proposal and the meeting at the Mayor's office left me a lot to think about. And those steps ultimately led to my next conversation.


Let's meet our guest, Germán Andrés Alarcón Garavito. He's the lead author of an important review of Mental Health Services Implementation in Colombia. I caught up to him via Zoom from London.



Man
Germán Andrés Alarcón Garavito

"You know that this issue existed, but right then you realize how it exists"

-Germán Andrés Alarcón Garavito


Robert: Nice to see you, Germán.


Germán: Nice to see you too. How are you?


Robert: Good. I want to congratulate you and your colleagues. This Mental health services implementation in Colombia–A systematic review is incredible. I'm speaking to you from your home country and you're in London. Having read your bio, I know you're originally from Bogotá. I’m interested to know, what motivates you personally to focus on mental health?


Germán: Yes, I am from Bogotá. And, this field is something that has happened across my life and it has not been entirely voluntary. That's the thing with mental health, it's just there. You don't notice it. Your life becomes mental health.


I was trained as a nurse, so I went to nursing school. I then moved to London to do my masters, and, later, I stayed here working as a researcher. When I was in the nursing school, between 2013 and 2018, one of the biggest debates was—and it’s still a debate—what is the real meaning of studying health sciences? What is health? Many people have this really medicalized concept of health, that health is basically the absence of disease. This is one of the, let's say, old fashioned definitions of health. Once you start to study more, go beyond the physiology, the biology, you start to open your eyes to the social, economic, and cultural part of life. You realize that there’s more to health; health is everything.


It's similar with mental health. Mental health is present across your life. This is how you basically interact with everyone. And not only people, but animals and your environment, in general, with all that is external and the many outside problems [that] can disturb this relationship with your inner self. That could be quite philosophical, but that's basically mental health.


So, across my life, I started studying mental health quite involuntarily. When I was in nursing school, I had my clinical internship in mental health (In nursing school, an internship, or clinical internship, is an essential part of the educational curriculum that offers students the opportunity to gain practical experience in various healthcare settings). I did two placements during one year: one was more clinical, like in a clinical facility. It’s what many people think about when they think of mental health as people who are “crazy”. These are people in asylums or psychiatric facilities and they are just there trying to get better. But that's complicated with the medications and how they are used. It's something that is really complex to see. You know that this issue existed, but right then you realize how it exists and [start to think that] there must be other ways of supporting people who have mental health problems. This was about literally throwing people into psychiatric facilities. There is more to it than that and I think that our work (the review) proves that there are many community-based alternatives that are really, really good to track.


I mentioned my placement. The second one was more of a mental health community placement. It was in a school in Bogotá, in a really, let's say, complex neighborhood that, in that moment, had many problems occurring such as violence and problems between neighbors. That was good for me because we worked mainly with children and young people. From that moment, I realized the importance of mental health from two different perspectives: the clinical part—including all of the debates [around the medical model of treatment] but also the community part—more focused on children and young people which I think is really important (the recovery model).


Some time later I moved to live in the US because my research scholar placement was in Indiana. My thesis was about non-pharmaceutical interventions in US nursing homes. It was a global scope, but quite focused on the US considering nursing homes and assisted-living facilities are more prevalent in the US and other countries rather than in Colombia. They don't exist that much there. So, in the US and in the UK, my focus has been on mental health, especially on dementia, and the kinds of diseases that affect senior adults.



College
Purdue Campus, Courtesy of Purdue University

Robert: Which Indiana university did you attend?


Germán: Purdue University. Then, after I finished nursing school and before moving to the UK, I worked two years in Colombia. I worked with a pharmaceutical company, doing analysis of clinical trials and pharmacovigilance*. Seeing the things that I saw there [regarding] data about drugs and the processes to validate medication or drug development, it was super interesting, but I [learned] that I didn't like it that much. I stopped working there and decided to return to academia and the research and policy community. I moved to the UK to do a masters here at University College London in England. Here I have wonderful colleagues, and we started working on this project.


This review was part of my masters dissertation, but also is part of a bigger project which, in Colombia, is called the STARS-C program** It's basically about mental health. It's a research partnership between universities in Colombia, Universidad de los Andes in Bogotá, and two universities from here (the UK), University College London and the London School of Economics (LSE). The project also includes two community-based organizations, Corpomanigua and the Cooperative for Good Living and Peace in Caqueta (COOMBUVIPAC). They won an important grant from the Economic Research Council here in the UK. It’s a four-year project about community mental health interventions in Caquetá, Colombia. It’s trying to prove that there are other ways of doing mental health services delivery in settings that were affected by conflict.


From A Glossary of Terms - The Psychedelic Blog


*Pharmacovigilance

  • Definition: Pharmacovigilance is the science and activities relating to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems.

  • Explanation: It involves monitoring the safety of pharmaceutical products and taking action to reduce risks and increase benefits to patients. This includes reporting, evaluating, and responding to issues such as side effects, medication errors, and lack of efficacy.

  • Example: An example of pharmacovigilance in action is when a new side effect of a widely used medication is identified through patient reports, leading to a change in the drug's labeling or usage recommendations.

  • Quote: "Pharmacovigilance is essential for ensuring the ongoing safety of medications in the market and for protecting public health." - Dr. Margaret Hamburg



Four years into the transition towards a post-conflict society in Colombia, barriers to the implementation of the Psychosocial Care and Comprehensive Health Services for Victims programme (PAPSIVI) and the Psychosocial Wellbeing Component in the reintegration route for ex-combatants (Resolution n. 4309) persist.


Scaling-up services is important but only a partial response; sustainable solutions require dialogue between systems and communities to improve mental health.


In response to these demands, our project will implement and evaluate a participatory intervention to strengthen community mental health care systems in two territories which are currently the focus of Territorially Focused Development Plans (PDETs in Spanish) in Caquetá-Colombia.


Our partners, Corpomanigua, a women’s community-based organisation that works to enhance human rights, build peace, and increase gender equality, and The Cooperative for Good Living and Peace in Caqueta (COOMBUVIPAC) are critical partners in engaging with citizens as part of efforts to build better mental health systems from the bottom up.

Together, we form STARS-C, and we are working collectively to integrate bottom-up, community level experiences of mental health and mental distress with institutional responses by state level actors. Through the creation of a novel participatory intervention, we are integrating multiple knowledge systems to build better community mental health systems in Colombia.


One part of the project was an evidence review about what mental health interventions exist in Colombia, at least in the literature, and issues of implementing mental health interventions, considering the historic, cultural, and socioeconomic setting in the context of Colombia.


Town
Caquetá, Colombia

Robert: On the subject of armed conflict, according to your paper, the National Health Institute of Colombia says the consequences of armed conflict on mental health include high rates of PTSD, depression, anxiety and suicidal behavior. When trying to understand the mental health landscape in Colombia, like I'm trying to do, do you think we should start with 60 years of armed conflict? Is that the place where we should begin to understand mental health?


Germán: Not for everyone. Even though the conflict has been a constant for generations in Colombia, many people, like my colleagues and friends, may not feel the same. In Colombia there exists at least three or four Colombias. We are a really large and diverse country. We're all together in some stuff, like the cultural part, and divided on others. So, for instance, if you ask someone, let's say a 20 year-old person born and raised in Bogota, about armed conflict and mental health, she would probably tell you it is something that’s happening in other places, something that has happened across the years, probably to my parents or my grandfather. The concern in Bogotá is more security, like from thieves on the streets, stealing your phone or traffic jams. If you asked a question about mental health or any question about the conflict, you will receive a different answer from someone in Caquetá. In places like Caquetá, Putumayo, Cauca, these places are in conflict still today, even after the peace agreement in 2016. There is still conflict happening, they are still afraid of armed groups that patrol their cities or towns. This happens in rural areas and makes a lot of impact on people's mental health. Experiences are super different.


Robert: Nearly 3 million have migrated to Colombia (2.89 million Venezuelans as of October 2022) with a lot of those people having suffered violence and displacement. Many go to larger cities in Colombia. Does that mean that the need for mental health services is spread throughout the country?


Germán: There's not one easy answer to that. Before thinking about how to deliver mental health services, you need to know how to make the delivery easier. Let's say, as an institution—thinking more on the macro side of everything—if an institution is interested in making a big impact on mental health in Colombia and wants to intervene, you need to try to intervene [while understanding] the real causes; know what’s behind [mental health illnesses]. I'm saying this because some people think that mental health service is just sending a psychologist to a community setting and just waiting for people to talk about their problems and that's mental health. But no. As you may have seen in the paper, and in other literature, we try to understand the mental health beyond the conflicts of your mind with your emotions, the things inside you. It's also about trying to understand how the problems of society like racism, xenophobia, violence, or phenomenon like migration, all of these affect or impact your mental health.


It's good to try to deliver mental health service but the real problem, for instance, with migration, is why these people are migrating. When you resolve that you will have an easier pathway to deliver mental health services. If you mitigate or prevent an armed group in these rural area in Colombia, that are doing activities like illegal mining or narco-trafficking, these things will have a mental health impact.


Robert: Did your review find that any gender or any specific ethnic group has suffered disproportionately from conflict?


Germán: Yes, but let's say the findings in that sense are limited. These keywords [such as, gender, women, ethnicities] are not highly mentioned in the review. However, to answer your question, there is more literature in Colombia to show that, in terms of gender, at least, probably women have suffered in different ways. It's not about who suffers more, but who suffers in different ways. And, in previous studies, there are armed groups, like the army or guerillas, that are usually [made up of] men. They are, say, the more direct victims of a conflict. But right now, there are more recent studies that go beyond that and try to understand how women, how indigenous communities, how Afro-Colombian communities have suffered in different ways. One place to read more is the National Health Observatory. That is part of the National Institute of Health. They did amazing work probably two years ago on this; about trying to have this ethnic, cultural, and gender lense, to try to see how harmful armed conflict has been for the Colombian people.


Robert: So, implementation was really the crux of your review: What are the most significant barriers to implementing the recovery approach in mental health services?


Germán: I think that there are many and the review gives a snapshot of some of them, but one is that there is still stigma in Colombia. There is still something cultural about mental health especially in rural areas. In some places there is mysticism behind the mental health. People feel like they have their thoughts about mental health problems that are more related to spiritual problems, and that they need to be addressed in a different way. That's one thing. The other thing is about how the health system works, how mental health services exist inside the current health system. Probably one of the most shared and discussed news stories in 2023 probably was health reform in Colombia.


Basically, this government wants to change a lot of the previous laws from many, many years ago. They have basically shaped health delivery and all of the health subsystems in Colombia in a way that is based on neoliberalism, more like a market and private participation in this market. In Colombia, there is a divider, if something is good for one group it’s bad for the other. If you asked me my opinion, I think this not good. In the literature, we say that the current health system is not good in the sense that you cannot coordinate the mental health services in some communities, because there is always an administrative barrier between the providers and insurers. So what the reform that is currently on debate wants to do is change the role of insurers. They want to basically minimize the role of insurers because they want to do something more direct. So yeah, in the the results that we found, basically, these administrative barriers were one of the problems for implementing mental health services, either if you're a public institution or an international institution, because there are many international and global institutions that are interested in implementing mental health services in Colombia.


Robert: Would you say that part of the goal of people looking to reform mental health care in Colombia is to integrate mental health more into primary care?


Germán: Yes, but also, I think that it's trying to give them the understanding that taking care of people's mental health should be a priority. That mental illness should be treated as something similar to hypertension or diabetes, something that just happens. You can prevent hypertension or diabetes, of course, you can prevent it by following some guidelines. Also, what I like about this field is that everything is about social change. Social injustice has led to many mental health problems. So, I think that there should be a debate in Colombia about how to put mental health into primary care as you mentioned, but, also, how can we work more for Colombians and change society at all levels so we don’t end up making Colombia’s mental health worse in the future. Hopefully [we can do this] not just in the long-term but in the short to mid-term as well.


Robert: If tomorrow you and your colleagues devised the most perfect approach to mental health care in Colombia, what would be the greatest obstacle to implementing it?


Germán: Well, I wouldn’t call it an obstacle but maybe a challenge is moving from planning something centrally, from Bogotá, and trying to plan and implement it in areas directly concerned, usually rural areas. When this happens, it's not likely that you would get cooperation. We are very different, those of us from Bogotá and someone from other parts of the country. Not everyone wants to achieve the same things and people generally are more concerned with their local issues while policies are over-centralized.


Another similar example is that these regions or communities outside of Bogotá have their own politics that work differently than politics work in larger cities. Everything requires consulting with the mayor's offices, governorships, decision-makers/policymakers and the community in the region. Trying to implement something without knowing how all this works is probably going to be chaos and probably fail.


Therapy
Psychiatry Hegemony

Robert: You talk about the “psychiatry hegemony” and efforts to prevent the re-colonization of mental health. Has mental health care in low to middle income countries (LMICS) really been decolonialized or is that, in a sense, what you and your colleagues are advocating?


Germán: And that is the current debate in global mental health. I think that is a process that is happening, both de-colonizing and preventing re-colonizing. It is about ending the hyper-psychiatrization of mental health. A lot of LMICs are working on that and the pathway they’re following is good. It’s going slowly because not everyone will allow it. Part of that success of de-colonizing mental health is that there’s a lot of activism trying to do that. You can infer that things are going that way. You don’t say it out loud, “Hey, we are de-colonizing mental health” but with the actions, like what we identified in the study, what is called “increasing the multi-disciplinary teams" and stop over-using psychiatrists. Obviously, psychiatrists are important and play a role in every team but should exist as a [member of a] team. So I would say Colombia is moving forward in this process like a lot of other LMICs but it is a work in progress.


One of the first versions of this manuscript that we sent to a different journal, whose editor-in-chief was a psychiatrist, when he read these statements that we made about the consequences of the over-psychiatrization of mental health, he rejected the paper. We thought he had some good feedback and we learned in the second version not to give that sensitive punch to psychiatry. That happens a lot; the medicalization of human life and obviously there are some research groups that are against that. The power imbalance in health care professionals, physicians versus everyone basically. And the gender part too. I’m happy to know that’s changing but it still happens.


Stat
The “psychiatry hegemony”, Statista.com

Robert: I recently interviewed a psychotherapist who touts the efficacy of MDMA-assisted therapy via Zoom. Two part question: Is there a role for alternative medicines like MDMA, psilocybin, and ayahuasca in Colombia’s mental healthcare future? And, even though face-to-face interaction is ideal, can telemental health services be a way to one day meet the overwhelming mental health needs of Colombia and the world?


Germán: I will answer the second one first. Telemedicine is a good approach in countries like Colombia. When you talk about places that are very hard to reach, not only for mental health appointments but other kind of stuff. If you only need to talk to this person, it’s not super critical that you be there in person considering you may need to travel four hours to arrive. Telemedicine is already working in Colombia and needs to be enhanced.


With respect to the other question, I think the use of these alternative therapies should be part of the debate and it is part of the debate here in Colombia. More at a slow pace. First, we have to reduce the stigma on some substances. In our congress, for instance, they debated decriminalizing marijuana which failed. But I think it’s good they’re having the conversation. It’s at a very slow pace in Colombia unlike other parts of the world. I think we will reach a point where substances like MDMA, psilocybin, ayahuasca are used in therapy in-person or via zoom. I think it will be a part of mental health services soon.


Robert: Who are the three most important Colombians on mental health care?


German: 1) Former minister of health Carolina Corcho. She’s been really good in a sense of health reform, changes for an equitable health care. 2) All the activists who are literally fighting to reach social justice in health services delivery and, 3) Mental health practitioners who are always there to support you.


Robert: Who are your role models in life, and what qualities do you admire in them?


Germán: I think, obviously, my parents with the way they raised me. And, also, my partner, she's also a nurse and we share a similar mindset with the things we are talking about. And, maybe not so much a role model, but there is lots of hope in the country now, so I would say the current leadership in Colombia is something I admire a lot and think that everyone should support them as much as they can. Of course, that’s difficult because everyone wants change tomorrow and they’re expecting a lot. Having this kind of leadership who keeps going and going when people want you to fall. The president and VP, I admire them a lot but everyone in the government gives me an idea of how my leadership could be.


Robert: What kind of music do you listen to when you need to relax or get motivated?


Germán: Good question. I listen to a lot of music. I try to listen to music that connects me to Colombia so it could be like modern music, rock, indie music made in Colombia, but also like salsa, merengue, dancing music. We listen a lot while we’re working because it’s really entertaining.


Robert: Thank you, Germán. It's really been a pleasure.


I feel very encouraged after speaking with Germán. He seems to care so deeply about the work he's doing. This is a person who will break new ground in the future and is already having a tremendously positive effect on mental health.


In the meantime, I'm going to get to work on the new Mayor of Medellín.


If you enjoyed this blog, please consider sharing it with a friend. Interested in writing a blog article like this? Contact Robert@thepsychedelicblog.com. 


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