Suicidal ideation in an ethnically mixed,highland Guatemalan community

Abstract

Reported suicide rates in Latin America remain low, but there is evidence to suggest they may be increasing, particularly among indigenous populations. To better understand who may be at risk for suicide, we examined the prevalence of suicidal ideation and explored factors contributing to suicidal thoughts in an ethnically mixed, highland Guatemalan community. The data presented in this article are from a mixed methods ethnographic field project conducted over 15 months from 2010 to 2011 in Panajachel, Guatemala. We surveyed a random sample of 350 community members. Survey questions included standardized modules from the Mini-International Neuropsychiatric Interview, as well as questions on experiences of violence and mental health care. We also conducted semi-structured interviews with 13 self-selected survey participants with current suicidal ideation. These interviews included questions regarding survey responses, experiences of mental illness, and access to mental health care. A total of 55 survey participants (N = 350; 15.7%) scored positive for suicidality. Ethnic identity, gender, psychiatric illness, and experiences of violence were all correlated to suicidal ideation. Qualitative interview data highlight distinctions between genders within prominent themes of religion, family, experiences of violence, and seeking resources. Three key findings emerged from our research that are relevant to the literature: 1) ethnic identity may be both a critical risk and a protective factor for suicide in some indigenous people; 2) intersections between violence and gender highlight different patterns in suicidal ideation; and 3) high rates of suicidal ideation and other psychiatric comorbidities underscore the need for greater access to mental health services.

Keywords

Guatemala indigenous mental health rural mental health suicidal ideation suicide

Introduction

Latin America has one of the lowest rates of suicide (Prtichard & Hean, 2008), yet studies suggest that the rate of fatal suicide attempts may be increasing in some countries throughout both Central and South America (Bertolete et al., 2006; Godoy-Paiz, 2005). Risk factors reported in the Latin American literature are generally similar to those in other Western populations and dissimilar to those in Eastern populations, while also showing variability among often-cited correlates such as gender (Medina et al., 2011; Teti et al., 2014). For example, similar to men and women in other Western societies, men in Latin America were more at risk of dying by suicide, while women were more likely to have a non-fatal suicide attempt (Teti et al., 2014). In China and India, however, women are just as likely as men to die by suicide overall, and women in rural areas of both countries are much more likely to die by suicide (Phillips & Cheng, 2012).

This suggests that not all risk factors for suicide are universal (Teti et al., 2014) and that more research in different countries and cultural settings is necessary (Medina et al., 2011). With notable exceptions (see Azuero et al., 2017 for examples), the majority of literature on suicide in Latin America has focused on non-indigenous populations in urban centers, despite recent United Nations reports on increasing rates of suicide among indigenous youth in Latin America (United Nations [UN], 2015). Furthermore, research in other parts of the globe indicates a higher than average rate of suicide among indigenous populations worldwide (Clifford et al., 2013; Hunter & Harvey, 2002). Yet the mental health of indigenous populations of Latin America remains underrepresented in the literature (Incayawar & Maldonado-Bouchard, 2009). There is a further paucity of mental health research with indigenous communities in rural sectors of Latin America (Incayawar & Maldonado-Bouchard, 2009). As such, we have limited understanding of suicide in Latin American countries with expansive rural areas and large indigenous populations, such as Guatemala.

Guatemala is a multiethnic country, with indigenous peoples constituting over 40% of the national population and residing mostly in rural regions (Central Intelligence Agency [CIA], 2018). While Spanish is the official language, over 20 indigenous languages have been recognized since 2003 (CIA, 2018). Approximately 79% of the indigenous population lives in poverty, and 40% live in extreme poverty (CIA, 2018). Guatemalans suffered through a 36-year long civil war from 1960 to 1996, where the vast majority of the 200,000 people killed were indigenous noncombatant civilians (Commission for Historical Clarification, 1999). The signing of the Peace Accords in 1996 officially ended the political violence, yet the level of interpersonal violence since then has fluctuated dramatically, with a homicide rate that rose to 45.1 per 100,000 people in 2009 (UN, 2019). The current homicide rate has dropped significantly but still remained high at 26.1 per 100,000 people in 2017 (UN, 2019). The previous political violence (mostly in rural areas) and the current interpersonal violence (mostly in urban areas) contribute greatly to mental distress in Guatemala (Branas et al., 2013; Puac-Polanco et al., 2015). In 2009, researchers at the University of San Carlos (USC) conducted the first and only national epidemiological study on mental health in Guatemala (USC, 2009). They report that one in four Guatemalans suffers from a mental health disorder (USC, 2009). Nationally, women, indigenous populations, and urban populations are at greatest risk for mental health problems (Puac-Polanco et al., 2015). Psychiatric and psychological professional services are located almost entirely in urban areas, leaving at-risk women and indigenous populations in rural areas with limited access to therapeutic resources (Alarcón, 2003; Alarcón & Aguilar-Gaxiola, 2000; Rodriguez et al., 2007).

The World Health Organization (WHO) Global Health Observatory reported a suicide rate for Guatemala of 2.9 deaths per 100,000 in 2016 (WHO, 2018). While the reported suicide rate in Guatemala remains low, there are few systematic studies examining the extent to which suicide is a problem in the country (Godoy-Paiz, 2005), and there are no studies that report on suicide among indigenous populations in Guatemala (Azuero et al., 2017). Recent literature suggests that reported suicide rates for Guatemala and much of Latin America may be considerably inaccurate (e.g., González-Andrade et al., 2011; Jørs et al., 2014; Marín-León et al., 2012; Pritchard & Hean, 2008). Guatemala has the highest rates in Latin America of unexplained accidental deaths, of which some may be unreported suicides (Pritchard & Hean, 2008). Pritchard and Hean (2008) suggest that these deaths may be classified as “undetermined” in order to spare Catholic families, in particular, from further pain. Catholicism has historically been considered protective against suicide (Durkheim, 1951), but the religious values could potentially only serve to conceal it (Pritchard & Hean, 2008). Global studies indicate that stigma around suicide may adversely affect the accuracy of reported rates (Mars et al., 2014; Nock, Borges, Bromet, Cha et al., 2008). Contributing to the underestimation in national rates are death reports that may not always explicitly identify the intent of injury or overdose (Bakst et al., 2016). The potential inaccuracies in reported suicide rates, thus, warrant further investigation into understanding how problematic suicide may be for the country.

Poor reporting practices are unlikely to change in a timely manner. As such, other methods to evaluate the problem of suicide in places like Guatemala must be considered, which may then provide an impetus for reforming death reporting. Suicidal ideation is often used as a proxy for examining risk of suicide and is generally predictive of suicide deaths albeit with some limitations (Klonsky et al., 2016). Global studies demonstrate a lifetime prevalence rate of approximately 9.2% for suicidal ideation, with a 2.7% rate for suicide attempt (Nock, Borges, Bromet, Alonso et al., 2008). While suicidal ideation does not always progress to suicide, it does give us some insight into who might be most at risk for suicide to better inform future interventions. Assessing for previous suicide attempts is critically important as they are strongly predictive of future attempts (Teti et al., 2014; Klonsky et al., 2016).

The USC (2009) study showed a national rate of 5% for suicidal ideation, which is considerably less than the global average rate. Yet slightly over half (56%) of those who reported suicidal ideation also reported previous suicide attempts, which approximates the global rates reported by Nock, Borges, Bromet, Alonso et al. (2008). While the USC (2009) study found more psychiatric illness in the urban sectors, specific conditions for suicidality within indigenous populations and non-urban regions remain unclear. We conducted this exploratory research to identify populations at risk for suicide in a highland community in Guatemala and to describe the motivations underlying suicidal ideation and potential suicidal attempts. We sought to further our understanding into issues faced particularly by the indigenous population in this region.

Methods

Research site

The data presented in this article are from a mixed methods epidemiological and ethnographic field project conducted over 15 months from 2010 to 2011 in the Guatemalan highland town of Panajachel located on the shores of Lake Atitlán in the Department of Sololá (Guatemala is divided into 22 departments). According to the last published census data (Instituto Nacional Estadística [INE], 2002), Panajachel’s estimated population in 2011 was approximately 16,000 inhabitants. Nearly 70% of the population identifies as indigenous Maya, primarily Kaqchikel or K’iche. The remaining 30% are predominately non-Maya Guatemalans of European ancestry (“ladino”), with a growing foreign expatriate community. This latter group also includes some people of Maya heritage who do not speak a Maya language, as language is often considered a defining feature of indigeneity (Harvey, 2011; Hinshaw, 1975). Both Spanish and various Maya languages (mostly Kaqchikel) are spoken by the majority of the population, but Spanish is the prevailing language throughout the community.

The last century has witnessed Panajachel emerging as a major tourism destination, attracting both national and international visitors. This status provides residents of Panajachel with increased economic opportunities and more direct access to health care resources. As such, some psychosocial stressors that might underlie suicidal ideation may be mediated. Yet the social, economic, and health disparities visible in the area reflect other potential stressors found throughout the highland region. For example, 11% of Panajachelenses remain in poverty, which is just below the 14.6% average for the department (INE, 2013). Homicide rates remain low in Panajachel and throughout the department, which is typically considered one of the safest in the nation (there were three homicides in 2017; Secretaría Técnica, 2017). However, research indicates gender-based violence is on the rise nationally (Carey & Torres, 2010; Walsh & Menjívar, 2016), and Panajachel is no exception (INE, 2017). Moreover, impunity towards gender-based violence remains high throughout the nation (Walsh & Menjívar, 2016). Other non-fatal violence and non-violent crime rates are also on the rise throughout the department, with clear crime rate surges during times of social and economic stress after major climactic disasters (Adams, 2015). Security forces in Panajachel include the national police and a special tourism police force, both of whom are notorious for ignoring the safety needs of the indigenous population (McDonald & Hawkins, 2016).

Participants

With the assistance of two Kaqchikel Maya and one ladino local research assistants, we conducted a cross-sectional mental health survey in Panajachel from January to November 2011. We applied a grid pattern on a town map to develop a random sampling matrix that included households and businesses in each sector of town. Since surveys were conducted primarily during standard work hours, we included businesses to ensure an equal representation of male and female participants, as well as employed and unemployed. On selected streets, all visible doors/gates were knocked on, and all open businesses were entered. At gates that opened onto property with multiple households, we typically interviewed the person who answered the gate. Market and street-side vendors were approached if they were not with a customer at the time of passing. All survey participants spoke Spanish fluently and did not voice preference for the survey being administered in a different language. Because of the large numbers of tourists and short-term volunteers, we excluded people who did not speak Spanish or a Maya language fluently.

Fluency in a Maya language is often considered the distinguishing marker of indigenous ethnicity (Harvey, 2011; Hinshaw, 1975). As such, participants responded to questions about their own language fluency as well as that of their parents. Based on local categorizations, we considered three ethnic groupings: 1) bicultural Maya, those who spoke both a Mayan language and Spanish fluently and whose parents spoke a Mayan language; 2) indigenous antecedent, those who did not speak a Maya language fluently but whose parents did; and 3) non-indigenous, those who did not speak a Maya language fluently and whose parents also did not speak a Maya language fluently. This last category consists primarily of Guatemalans of European ancestry who are typically referred to as “ladino.” However, since our sample includes Panajachel residents not originally from Guatemala, we have opted to use the term “non-indigenous” for anyone without recent Maya ancestry, as determined by language fluency.

We received informed consent from 414 participants, of which 64 were subsequently found to meet exclusion criteria (i.e., under the age of 18 or did not live in Panajachel). We conducted data analyses on the remaining 350 surveys. Sample demographics are reflective of the Panajachelense population demographics.

Measures

The survey questions covered demographics, exposure to violence, and past experiences with mental health services. The initial survey only asked about experiences with mental health services for alcohol use disorders. We added a question about experiences with general mental health treatment about halfway through the fieldwork period. The survey also included standardized modules from the Mini International Neuropsychiatric Interview (M.I.N.I.), Spanish version 5.0.0, to evaluate prevalence of various psychiatric disorders. The M.I.N.I. is a fully structured, close-ended interview, allowing its use by nonspecialist interviewers, and its brevity makes it ideal for research settings (Sheehan et al., 1998). While it has not been tested specifically with indigenous populations, the Spanish version has been validated with Spanish-speaking populations (Bobes et al., 2004). This article focuses on detailed analyses of the suicidality module, which consists of six questions regarding wanting to die, wanting to self-harm, thinking about suicide, planning suicide, and attempting suicide. Suicidality was marked positive if participants had endorsed any suicidal thoughts in the past month or any suicide attempt throughout their lifetime. We assessed level of risk for suicide (low, medium, high) following M.I.N.I. guidelines and compared to the modules assessing for alcohol use disorder, depression, generalized anxiety disorder, and post-traumatic stress disorder.

Follow-up interviews

We conducted in-depth follow-up interviews with 13 self-selected survey participants who endorsed questions on the suicidality module (seven bicultural Maya; five indigenous antecedents; one non-indigenous). These semi-structured interviews included questions regarding survey responses, experiences of mental illness, and access to mental health care. Participants of the follow-up interviews spoke openly about their current and previous suicidal ideation and suicide attempts. Interviews were audiotaped with participant approval, and all recordings were transcribed.

Ethical considerations

The University of Texas at San Antonio Institutional Review Board provided institutional oversight for this study (IRB #10-156). The Public Health Director for the Department of Sololá granted local community approval. Each individual participant provided verbal informed consent prior to the interview. Due to informed consent parameters and accessibility issues, we did not interview community members in an active state of psychosis or alcohol/drug intoxication.

Several protocols were in place to minimize any potential emotional distress and provide resources to those in need. During surveys and follow-up interviews, participants were reminded both before and during the interview that they could pause or stop completely at any time. We offered each survey participant and interviewee information on local mental health resources. These resources were typically limited to the regional public hospital with a psychiatrist on staff and a local private psychology clinic (which has since closed). The research assistants also provided to all participants the contact information of the lead author for any questions about the research and for assistance with accessing resources. The lead author followed up with all research participants who provided their own contact information. We made direct resource connections when possible and requested assistance from local organizations as necessary. For approximately six months during the research, the lead author worked directly with two graduate psychology students completing their internship in the area to coordinate sessions with survey participants. For the remaining time of the research, the lead author was available to assist participants in coordinating services elsewhere.

Data analysis

We calculated descriptive statistics to describe characteristics of the study population. We conducted bivariate analysis using chi-square or Fisher’s exact testing to detect associations between suicidal ideation and categorical variables. Outcomes of particular interest were relationships between ethnicity and religious affiliation, financial stress, and experiences of violence. We measured statistical significance at a p < .05. We calculated Cramer’s V for effect size on all significant differences. We used SPSS, version 25.0, to conduct our statistical analyses. We descriptively coded transcripts of follow-up interviews for presence of variables of interest: religion, financial stress, experiences of violence, and all talk in reference to suicide or dying. We used MaxQDA 2018 (VERBI Software, 2017) to calculate frequencies of codes and measure for qualitative emphasis. However, given the self-selective process of the sample for the follow-up interviews, exemplars are drawn for general illustrative purposes of overall themes, without statistical distinctions based on ethnicity.

Results

Suicidality

Demographic and mental illness characteristics for the total sample and the sub-sample for those with suicidal ideation are presented in Table 1. Overall, 55 of the 350 eligible survey respondents (15.7%) indicated they had experienced suicidal ideation in the past month or had a history of at least one non-fatal suicide attempt. Bivariate analyses comparing those with suicidal ideation to those without indicate there was no statistically significant difference between age groups, χ² (3, N = 346) = 2.053, NS, financial stress, χ² (1, N = 343) = 2.623, NS, marital status, χ² (1, N = 346) = 0.010, NS, religious affiliation [Catholic, Protestant, Other], χ² (2, N = 346) = 5.870, NS, and frequency of church attendance [regular vs. irregular], χ² (1, N = 321) = 0.225, NS. Religion was an important theme, however, in the follow-up interviews.

Table 1.

Demographic and mental illness characteristics of total sample and subset of respondents with suicidal ideation.

	Suicidality (Total N = 55)		Total sample (Total N = 350)
	N	Median (IQR) or number (%)	N	Median (IQR) or number (%)
Age	55	33 (20–43)	350	28 (21–39)
Female	55	20 (36.4%)	350	187 (53.4%)
Ethnicity
Bicultural Maya	55	23 (41.8%)	350	212 (60.6%)
Indigenous antecedent	55	25 (45.5%)	350	92 (26.3%)
Non-indigenous	55	7 (12.7%)	350	46 (13.1%)
Catholic	55	11 (20.0%)	350	80 (22.9%)
Marital status
Spouse/partner	55	24 (43.6%)	349	171 (49.0%)
Separated	55	3 (5.5%)	349	5 (1.4%)
Divorced	55	4 (7.3%)	349	7 (2.0%)
Widowed	55	3 (5.5%)	349	11 (3.2%)
Never married	55	21 (38.2%)	349	155 (44.4%)
Financial stress present	54	30 (55.6%)	347	158 (45.5%)
Experiences of violence
Been hit	55	22 (40.0%)	343	50 (14.6%)
Has hit someone	53	8 (15.1%)	336	21 (6.3%)
Traumatic event	55	20 (36.4%)	350	72 (20.6%)
Alcohol use disorder	54	15 (27.8%)	347	34 (9.7%)
Major depressive disorder	54	27 (50.0%)	344	35 (10.2%)
Generalized anxiety disorder	51	13 (25.5%)	340	26 (7.6%)
Post-traumatic stress disorder	55	1 (1.8%)	348	5 (1.4%)

In the month prior to participating in the study, 12.6% of participants (N = 350) thought on at least one occasion that they would be better off dead or wished that they were dead, 5.7% wanted to do harm to themselves, 7.2% had contemplated suicide, 3.2% had planned suicide, and 1.7% had attempted suicide. Moreover, 41.8% of the suicidal sample (N = 55) had attempted suicide at some point in their life (6.7% of all survey respondents; N = 350). Men were more likely to endorse questions of suicidal ideation in the survey, χ² (1, N = 346) = 7.690, p < .006, V = .149. However, there was no significant difference between men and women for previous suicide attempts (χ² (1, N = 344) = 0.318, NS).

Generalized anxiety (χ² (1, N = 336) = 26.540, p < .001, V = .281), major depressive disorder (χ² (1, N = 341) = 109.991, p < .001, V = .568), and current alcohol use disorders (χ² (1, N = 343) = 22.906, p < .001, V = .258) were significantly correlated with suicidal ideation. It is important to note that all participants who had suicidal ideation and were found to have an alcohol use disorder (27.8%) were male, while there were no gender differences for generalized anxiety or major depressive disorder. Post-traumatic stress disorder was not common among those with suicidal ideation (1.8%), or among the overall study population (1.4%).

During the fieldwork period, there were two known suicide deaths: 1) an indigenous antecedent male in his 20s who shot himself, and 2) a bicultural Maya male in his 50s who drowned after expressing suicidal thoughts to friends and family. Both had been drinking alcohol prior to their deaths. We were unable to confirm how these were reported on death certificates. The second case may be considered accidental, yet many people who knew the man believed it was intentional. Additionally in follow-up interviews, a total of seven participants (four males and three females) reported details of previous attempts or plans for a suicide death, and three of these participants (two males and one female) mentioned considering or attempting suicide by drowning, which we interpret to mean drowning is a likely mechanism for suicide given the town’s location on the lake.

Ethnicity and suicidality

Our primary variable of interest was ethnicity. Those categorized as “indigenous antecedent” were most likely to have suicidal thoughts, χ² (2, N = 346) = 13.359, p < .001, V = .196. We further examined other demographic and mental illness differences by ethnicity in the portion of the sample who scored positive for suicidality (Table 2). Of this sample, the indigenous antecedent group were more likely to be younger, female, Protestant, and never married. They were also more likely to have financial stress present. Yet it was the non-indigenous group who were most likely to have a previous suicide attempt. The non-indigenous group were also more likely to have an alcohol use disorder.

Table 2.

Demographic and mental illness characteristics of suicidal sample by ethnic group.

	Bicultural Maya (N = 23)		Indigenous antecedent (N = 25)		Non-indigenous (N = 7)
	N	Median (IQR) or number (%)	N	Median (IQR) or number (%)	N	Median (IQR) or number (%)
Age	23	38 (25–48)	25	20 (19–35)	7	42 (27–53)
Female	23	6 (26.1%)	25	12 (48.0%)	7	2 (28.6%)
Catholic	23	7 (30.4%)	25	2 (8.0%)	7	2 (28.6%)
Christian (not-Catholic)	23	11 (47.8%)	25	22 (88.0%)	7	5 (71.4%)
Marital status
Spouse/partner	23	15 (65.2%)	25	6 (24.0%)	7	3 (42.9%)
Separated	23	0 (0%)	25	2 (8.0%)	7	1 (14.3%)
Divorced	23	0 (0%)	25	3 (12.0%)	7	1 (14.3%)
Widowed	23	1 (4.3%)	25	1 (4.0%)	7	1 (14.3%)
Never married	23	7 (30.4%)	25	13 (52.0%)	7	1 (14.3%)
Financial stress present	22	10 (45.5%)	25	16 (64.0%)	7	4 (57.1%)
Experiences of violence
Been hit	23	11 (47.8%)	25	7 (28.0%)	7	4 (57.1%)
Has hit someone	22	4 (18.2%)	24	3 (12.5%)	7	1 (14.3%)
Traumatic event	23	6 (26.1%)	25	10 (40.0%)	7	4 (57.1%)
Alcohol use disorder	23	6 (26.1%)	24	6 (25.0%)	7	3 (42.9%)
Major depressive disorder	22	12 (54.5%)	25	11 (44%)	7	4 (57.1%)
Generalized anxiety disorder	22	8 (36.4%)	23	4 (17.4%)	6	1 (16.7%)
Post-traumatic stress disorder	23	0 (0.0%)	25	1 (4.0%)	7	0 (0.0%)
Suicidality
High risk	23	6 (26.1%)	25	8 (32.0%)	7	5 (71.4%)
Moderate risk	23	6 (26.1%)	25	2 (8.0%)	7	0 (0.0%)
Low risk	23	11 (47.8%)	25	15 (60.0%)	7	2 (28.6%)
Previous attempt	23	6 (26.1%)	25	12 (48.0%)	7	5 (71.4%)

Follow-up interviews

We conducted in-depth follow-up interviews with 13 self-selected survey participants who endorsed questions on the suicidality module (seven bicultural Maya; five indigenous antecedents; one non-indigenous; eight male; five female). The only interviewee who referenced their ethnicity was a non-indigenous male. He spoke about general ethnic tensions in town, but his comments were not voiced in connection to his suicidal ideation. While many themes were common in all interviews, there were considerable differences noticed between genders.

The most common theme to emerge was religion. All interviewees mentioned “God” as a source of support at least once throughout their interview. Sixty-two percent (n = 13) mentioned the church or church teachings as beneficial in decreasing suicidal ideation, as the following quote from an indigenous female suggests:

Since I’m Christian, I have heard many sermons, a lot of advice, where they say that death is not the solution for all your problems. Because if I take my own life, I am making a major mistake, and it would not be correct.

The next most common theme was family, with 12 of the 13 people interviewed mentioning their family in general or a specific family member. In most cases, participants spoke about strained familial relationships resulting in a feeling of lack of support as primary stressors for their suicidal ideation. Both men and women spoke of loneliness and feelings of familial abandonment, yet the particulars did differ by gender. Women spoke of being abandoned, particularly by spouses, but they did not often express any desire for reconciliation. Instead, they spoke more in terms of wanting to “liberate” themselves from their spouses, or fathers, particularly those who were physically and/or emotionally abusive. Women with children voiced wanting to be able to provide for their family independently.

As mentioned previously, only males were found to have alcohol use disorders, and all eight of the men interviewed had an alcohol use disorder (one was in recovery). In the interview, they often connected their alcohol problems with problems or a rupture in the family unit, lamentation of low economic opportunities, and overall feelings of displacement. Men regularly mentioned issues of abandonment and wishing for reconciliation with family. In some cases, the division was between father and son, and in other cases it was between husband and wife. Only one male interviewed voiced having continued support from their family. All eight men made explicit connections between their alcoholism and suicidal ideation, as demonstrated in the following quote:

The truth is that I have the urge to die and with the sickness [alcoholism] that I have, I have a feeling that I might die tomorrow and that’s how I think every day, and I think that many people hang themselves or sometimes throw themselves from a ravine who are in the same situation as I am and I get the terrible urge to commit suicide, but the truth is that people don’t see it. It seems that everything is alright, but the people don’t know what one has.

Other notable differences between groups in the follow-up interviews were how men and women differed in their discussions of experiences of violence. As noted in Table 1, 40% of those who scored positive for suicidality had at some point in their life been hit by someone. All women who were interviewed mentioned having been hit by their husband, father, or someone else (e.g., a woman was beaten by someone her husband’s lover had hired or another woman had almost been raped by a stranger). Throughout the study, domestic violence was often considered the most pressing issue faced by women in the community. The women interviewed did not indicate reflecting much on the violence in their lives. Instead, they often repeated the reasons their abusers gave them for being hit, as is demonstrated in the following quote: “It’s not like that anymore. He hits us now only sometimes, but it’s like he says—it’s for a specific reason. It’s not like he just wants to.”

Violence was not a common topic among the males interviewed, even though it was just as common for men to have been hit as it was for women among those with suicidal ideation, χ² (1, N = 55) = 2.946, NS. One person discussed seeing someone get shot, while another talked about the physical fights he would get into with his father. When violence was mentioned by males, they often reflected on their guilt over the violence in their lives. In one case, a man was beaten up while drunk, and this event triggered him to reflect on the many times he had beaten his wife. He mentioned during the interview he had not hit his wife since the time he had been beaten up. This episode also spurred him to quit drinking, which in turn led to an overall improvement in mental well-being and suicidal ideation. For some men, their experiences of violence were directly connected to their alcohol use: “I don’t know in which street of Panajachel they hit me and they stabbed me with a knife, here in my chest. And overall, I have had many experiences and also suffering in my life because of drinking alcohol.”

Lastly, as mentioned previously, we asked halfway through the survey about receiving mental health care. Of the 111 survey participants who responded to the question, only 10 (9%) had sought mental health treatment previously, even though 65 (58.6%) were identified by M.I.N.I. results to have some kind of psychiatric illness. Thirty of these survey participants scored positive for suicidal ideation, and only five of these 30 (16.6%) had received mental health care previously. Participants in the follow-up interviews, however, indicated their interest in speaking with someone about their problems but were not clear on who. Some were afraid to discuss issues with their friends, while others were not aware of any local resources. Almost all participants voiced some concerns about people (friends or professionals) using the information against them. They would rather speak to someone who was not from the community. Both male and female interviewees were interested in speaking with someone about their family and social issues, while only female participants also expressed an interest in being further connected to financial assistance organizations.

Discussion

We examined prevalence of suicidal ideation and explored factors contributing to suicidal thoughts in a highland Guatemalan community. Our data suggest that suicide may be a greater problem than initially considered in Guatemala. The two potential suicide deaths that occurred within a few months of each other during the research period exceed the global annual rate of approximately one in 10,000. Notably, one of the deaths could not be confirmed as suicide, which would indicate the rate in Panajachel is similar to global trends. However, the significantly high rates of unexplained accidental deaths in Guatemala that may actually be suicide deaths (Pritchard & Hean, 2008) lead us to believe this death was likely by suicide and that, perhaps, the rate may even be higher. The rate of suicidal ideation in Panajachel (15.9%) also exceeds the global average rate (9.2%; Nock, Borges, Bromet, Alonso et al., 2008). While the national rate of suicidal ideation reported by the USC study (5%) is below the global average, the significantly higher rates in Panajachel demonstrate the need for a nuanced examination of variability across the country.

We further examined various common risk factors: gender, psychiatric illness, religion, and ethnicity (by way of language heritage and fluency). Globally, men account for roughly three times the number of suicides than women (WHO, 2014). This statistic would appear to hold true in Panajachel given that the two known suicides during the study period were both male. While women were just as likely as men to report a previous suicide attempt (3.2% vs. 3.5%, respectively), our follow-up interviews suggest women employ less lethal methods. Psychiatric illness was present in a significant portion of the study sample. PTSD is a common risk factor for suicide globally (Klonsky, et al., 2016), as well as specifically in Latin America (Teti et al., 2014). National survey data indicate a PTSD rate of 1.5% in Guatemala, which is less than many other nations without a recent history of civil conflict (Puac-Polanco et al., 2015). Rates of PTSD in Panajachel were similar to the national rate found in Puac-Polanco et al. (2015; 1.8% vs 1.5%, respectively). Yet Panajachel has a higher rate of suicidal ideation than at the national level as well as the global average. Experiences of trauma and violence do correlate to suicidal ideation in Panajachel, and more research is necessary to further understand how these experiences may impact mental well-being in ways other than PTSD. Other common risk factors such as major depressive disorder, generalized anxiety, and alcohol use disorders were all found to be correlated with suicidal ideation. Religion, namely Catholicism, does not appear to play a significant role in preventing suicidal ideation but may still deter individuals from attempting suicide. Finally, indigenous Maya Panajachelenses who do not speak a Maya language are most at risk for suicidal ideation.

Three key findings emerged from our research that are relevant to the literature and warrant further discussion: 1) ethnic identity may be a critical risk factor for suicide in some indigenous people; 2) intersections between violence and gender highlight different patterns in suicidal ideation; and 3) high rates of suicidal ideation and other psychiatric comorbidities underscore the need for greater access to mental health services.

Ethnic identity

It is interesting to note the association between suicidal ideation and ethnicity. The category of “indigenous antecedent” as defined by this project was statistically more likely to voice suicidal ideation. While there was a small effect size [χ² (2, N = 346) = 13.359, p < .001, V = .196], we would argue these findings should not be taken lightly given the potential for suicide among those with suicidal ideation. Moreover, research in other indigenous communities indicates a relationship between suicide and indigenous language loss. For example, Hallett et al. (2007) found that lack of “native tongue” knowledge was strongly predictive of indigenous youth suicide in British Columbia. Our findings suggest the predictive value of language fluency may hold true among the Maya as well. Additionally, the first author met with local community leaders to discuss data interpretation, and they were not entirely surprised by the results. Community leaders suggested that a “more holistic” (i.e., bicultural) upbringing, where indigenous children are raised valuing indigenous ideologies and practices alongside non-indigenous ideologies, may be protective for suicidal ideation. Extant literature on acculturative stress and suicide in Native American populations (e.g., Lester, 1999) and “cultural death” and suicide in Latin American indigenous populations (e.g., Azuero et al., 2017) supports this perspective.

For this project, only objective measures based on language fluency were used to categorize people into ethnic groupings. Previous anthropological work done in Panajachel suggests that to identify as Maya someone has to speak the Mayan language (Hinshaw, 1975). Yet many people who are not able to speak a Maya language with fluency continue to self-identify with their indigenous heritage. Ethnic identity is a mixture of self-identification and acceptance by others. Thus, the lack of fluency in a Maya language may prevent them from being accepted as fully Maya, while other physical characteristics mark someone as not a member of non-indigenous society, resulting in a form of acculturative stress or social exclusion. As such, people who have indigenous heritage but do not speak the language may be in a liminal state that impacts their well-being, whereas even basic fluency in a heritage language has been noted to be a protective factor for health crises (McIvor & Napoleon, 2009). The mental health concerns present in this sector of the population may be due to feelings of not belonging and of discrimination related to being denied their ethnic identity. Many of the interview respondents noted feelings of displacement and discrimination, but this was not strictly limited to any one ethnicity. Current national language and cultural revitalization programs promoting the learning of indigenous languages in public schools may help to mediate some of the discrimination felt by all indigenous peoples, regardless of language fluency. Language revitalization programs among Native American indigenous populations have been noted as successful health promotion strategies (King et al., 2009), while overall cultural reclamation initiatives in “culture as treatment” programs among First Nation communities have been found to be effective in improving overall well-being (Barker et al., 2017). Given the increasing rates of suicide among indigenous populations in Latin America and across the globe, it is necessary to conduct further research assessing the level to which someone may adhere to indigenous ideologies and practices in their daily life, regardless of whether they speak the language or not, and how this may impact suicidal ideation.

Experiences of violence

Guatemala, like many countries in Latin America, has a significant history of state-sponsored violence, particularly aimed at the indigenous population. Moreover, the present day is marked by high levels of social violence affecting the entire population. Connections between experiences of violence and poor mental well-being are well documented. The USC study is one of the only known attempts to assess the prevalence of psychiatric illness nationally, yet our data indicate the need for local specificities. This is particularly salient as exposure to violence is quite variable throughout the country, with higher rates of contemporary social violence in urban centers. Panajachel, furthermore, did not witness the extreme levels of violence during the civil war that has been documented for other highland towns. Only 14.6% of the overall study sample (N = 343) reported having been hit at least once in their life, but 40% (N = 55) of those with suicidal ideation indicate that they had been hit at least once before. For important and necessary reasons, research on violence and suicide among indigenous populations focuses considerably on state violence and historical trauma. Less attention is paid to contemporary experiences of interpersonal violence. Research that does examine recent experiences of interpersonal violence are generally focused on indigenous women. For example, domestic violence is a contributing risk factor for suicide among women in indigenous populations in North Queensland in Australia (Hunter et al., 1999), and interpersonal violence is related to suicide attempts in female Inuit youth (Fraser et al., 2015). However, more research is necessary to fully explore the ways in which contemporary social violence affects suicide and suicidal ideation among indigenous populations.

Connections between women’s experiences of violence and suicide are noted significantly in low- and middle-income countries (Devries et al., 2011). From our data in Panajachel, it may be that the gendered responses to violence could contribute to higher rates of suicidal ideation and suicide in males, in contrast to the noted higher rates among women. While all of the women we interviewed reflected on recent and sometimes ongoing experiences of violence, the majority of the men did too. Males were more likely to express remorse and guilt with regards to their experiences of violence. This could potentially indicate an increased level of hopelessness resulting in suicidal ideation. Since women voiced desires for “liberation,” interventions and programs promoting empowerment and financial independence may serve a secondary yet crucial purpose as a means for suicide prevention. More research is necessary to further understand how experiences of violence may differ by gender as a contributing risk factor for suicide and suicidal ideation in Guatemala. In particular, the role of “thwarted belongingness” (Joiner, 2005) may be an important indicator for further study since both men and women reflected on their feelings of abandonment in connection to familial violence.

Lack of resources

The formal psychiatric care system in Guatemala does not meet the needs of its citizens, particularly in rural areas (Alarcón, 2003; Alarcón & Aguilar-Gaxiola, 2000; Pezzia, 2015; Rodriguez et al., 2007). Mental health interventions targeting those most at risk may be particularly useful in resource-poor areas, like highland Guatemala. Throughout the country, there is approximately one psychiatrist for every 200,000 inhabitants (Rodriguez et al., 2007), with nearly all of these providers working exclusively in urban centers. The national public health system does sometimes include some formal mental health care programming in rural areas, but these services are severely limited in providing adequate and consistent care (Pezzia, 2015). Identifying those most in need of intervention provides an opportunity for limited resources to be used efficiently and most effectively.

A prevailing thought in the region is that people will not access mental health care resources for fear of being stigmatized. These views only serve to further marginalize mental health care services (Kohrt et al., 2015). It was clear from our interviews that people in the community wanted greater availability of psychological and psychiatric services. Men, in particular, spoke openly about their problems and wished they had someone they could speak to regularly. Interestingly, women were more likely to request financial resources, but they also spoke about the issues they had with their family and other social relationships. Most interviewees acknowledged they had concerns that friends and family would not understand why they were seeking mental health services, but these concerns did not seem to affect their willingness to meet with professional providers.

Historically, family has been considered a direct source of care for relatives experiencing mental illness in the highland region (Paul, 1967). Our data suggest family dysfunction underscores suicidal ideation for many residents of Panajachel. Family dysfunction is considered an important risk factor for suicide (Teti et al., 2014), but there is no clear definition for what constitutes family dysfunction. Approaches in family therapy may be beneficial to meet cultural practices in the area, as well as improve family relationships driving some suicidal ideation. However, these approaches and any proposed interventions should be adapted into a culturally informed framework to ensure success (Barker et al., 2017).

Limitations

Data for this project were collected over the course of a year with considerable fluctuations in weather patterns that may have had an impact on people’s mental well-being and responses. For example, some residents who were particularly affected by Hurricane Stan or Tropical Storm Agatha, both of which did significant damage to the area in 2005 and 2010, respectively, may have been affected by the memory of these events if they were interviewed during the rainy season (approximately May to October). While the underlying argument for this work assumes suicidal ideation is a trait-like variable that may be predictive of suicide (Klonsky et al., 2016), this is not to suggest that all ideators are constantly depressed or suicidal. Indeed, suicidal ideation may be considered a fleeting moment (Kessler et al., 2012). It may be important to consider trends of suicidal ideation on a shifting continuum rather than a static statistic to account for changing situations throughout the year (Hovey, 2000). More research is necessary to determine the effects of seasonal patterns on suicidal ideation and attempts. Finally, while the categories of ethnicity were considered appropriate by the local research assistants and other community members, these categories are not clearly distinct.

Conclusion

The data presented in this article illustrate high rates of suicidal ideation that suggest suicide may be more of a concern in Guatemala than previously considered. Gender, a history of psychiatric illness, ethnicity, and experiences of violence are all correlated with suicidal ideation in Panajachel. Religious affiliation and adherence were less important in protecting from suicidal ideation but may still protect from attempting suicide. The group most at risk for suicidal ideation is those with indigenous heritage who do not speak a Maya language. Gendered experiences of violence may be an important avenue for future exploration of suicidal ideation. People with suicidal ideation in rural areas may be further at risk due to lack of mental health care resources.

Footnotes

Acknowledgments

The authors would like to thank the residents of Panajachel who participated in this research, as well as the local research assistants who helped to collect the data.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical standards

The University of Texas at San Antonio Institutional Review Board provided institutional oversight for this study. The Public Health Director for the Department of Sololá granted local community approval. Each individual participant provided verbal informed consent prior to the interview.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The University of Texas at San Antonio Graduate School, Department of Anthropology, and Brackenridge endowment all provided funding support for data collection. The Brocher Foundation provided additional support dedicated for the writing of the initial draft of this article.

ORCID iD

Carla Pezzia

Carla Pezzia, PhD MPH, is an assistant professor in the Department of Human and Social Sciences and Director of Latin American Studies at the University of Dallas, USA. Dr. Pezzia researches mental health services for underserved populations, particularly in Latinx and Latin American communities. She is currently a collaborating investigator of the Community Assistance Research Network, a community–academic partnership addressing the needs of low-income populations in the Dallas/Fort Worth Metroplex. Her published works focus on mental health services research, experiences of mental illness and health care among indigenous Maya, and experiences of food insecurity among low-income populations.

Luisa M. Hernandez, BA, is an administrator at Nimitz High School in Irving, TX, USA. She is currently completing her final semester of the M.Ed. program in Urban Educational Leadership at Southern Methodist University. Ms. Hernandez researches issues of identity, stereotypes, and discrimination in low-income communities experiencing gentrification.

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