Psychiatry in Cambodia: the phoenix rises from the ashes

Abstract

Cambodia is a low-income country in south-east Asia. It covers an area of 181 035 km² and has a population of 14.5 million, of whom 42% are less than 15 years old. Life expectancy is 56.8 years and 36% of the population live on less than US$0.50 per day. Cambodia experienced a brutal civil war and genocide in the 1970s under the Khmer Rouge regime, during which approximately 1.7 million Cambodians were killed (Chandler, 1999) and the social and medical infrastructure was almost completely destroyed. No mental health services existed throughout the conflict and subsequent Vietnamese occupation, despite the incalculable impact of the Khmer Rouge regime on Cambodians’ mental health. The current political situation is more stable, although there remain concerns about human rights abuses (Khan, 2005).

Historical perspective

From 1935 to 1975, all psychiatric care was provided by a single psychiatric hospital located about 9 km to the south of Phnom Penh. By 1975, the patient population of the 800-bed hospital had grown to around 2000. Under the Khmer Rouge, the psychiatric hospital was destroyed and it is likely that all the patients were murdered. Across the country most professionals of all types were also killed – only 43 doctors survived, none of whom were psychiatrists (Savin, 2000). Between 1975 and 1994, there were no statutory psychiatric services and no mental health training in Cambodia.

Revitalisation of psychiatry in Cambodia

In 1994, a cohort of 10 junior doctors joined the Norwegian-funded Cambodian Mental Health Training Programme; they graduated in 1998. A second cohort of 10 completed training in 2001 and, in addition, 40 psychiatric nurses have now been trained in Cambodia. The first out-patient department was opened in Phnom Penh in May 1994. The present mental health service situation in Cambodia is summarised in Box 1.

Box 1. Current public sector mental health services in Cambodia

Staffing

• 26 psychiatrists

• 40 psychiatric nurses

• About 150 medical doctors have been trained in basic mental healthcare

• About 170 registered nurses have been trained in basic mental healthcare

Services

• 3 in-patient units for emergency assessment

• 18 psychiatric out-patient departments at provincial level (in general hospitals)

• 13 psychiatric units at health-centre level

• 1 child psychiatric out-patient department at national level

• 1 day-care centre at national level

Paradoxically, the complete destruction of the former mental healthcare system presented a unique opportunity to introduce community-based mental health services, as the often difficult tasks of reintegrating institutionalised patients into community settings and retraining staff who are accustomed to a custodial model of care were obviated in Cambodia.

Cambodian beliefs about mental health

Considerable stigma and fear surround mental illness. The majority of Cambodians with mental health problems are cared for by their families, neighbours, friends or traditional healers. Common complaints include tiredness, ‘thinking too much’, ‘feeling very insecure’ and flashbacks or disturbing dreams of traumatic events.

Under traditional belief systems, psychiatric disorders are typically attributed to witchcraft, possession by spirits or curses that pass from one generation to the next within a family. Some syndromes recognised by traditional healers approximate Western conceptions of mental illness, including alcohol dependence, postnatal depression and psychosis. Referral rates from traditional healers to mainstream services were thought to be low, but there is some evidence that they may be increasing.

Mental health policy and services

The Mental Health Subcommittee of the Cambodian Ministry of Health, now known as the National Programme for Mental Health (NPMH), was given responsibility for developing mental health services in Cambodia in 1992. It is helped by the World Health Organization and collaborates closely with foreign aid organisations. Considering the paucity of central government funding, the NPMH has had considerable success in developing community psychiatric services in Cambodia.

Government mental health clinics are now operating in 23 of the 24 provinces and cities of Cambodia, although, because of the poor transport infrastructure, patients commonly have to travel for several days to reach help. Consultation and initial medical treatment are subsidised by the government, but patients are expected to pay for ongoing treatment themselves and this is frequently beyond their means. In some settings, brief psychological interventions are offered, usually in groups. Home visits by psychiatric nurses are occasionally available in some areas. There are small in-patient units at the main psychiatric clinic in Phnom Penh and in two provinces; these are used exclusively for brief assessments, usually for 24 hours or less.

Under a pilot scheme in the province of Battambang, mental health services have been integrated into the existing system of 13 community health centres, which operate at the village level. The NPMH hopes to extend this model into other provinces.

There is no legislation relating to the involuntary detention of patients in hospital.

Voluntary and charitable organisations

In addition to the statutory services, a number of nongovernmental organisations (NGOs) are working in mental health in Cambodia. Probably the largest is the Trans-cultural Psychosocial Organisation (TPO Cambodia), which was set up in 1995 by its parent organisation, TPO Amsterdam. TPO focuses on raising awareness of mental health issues and the training of local health professionals, volunteers, religious leaders and traditional healers in the detection and treatment of psychiatric disorders. It now employs over 60 staff, including two psychiatrists, six psychologists and six social workers. Another NGO, the Centre for Child Mental Health, established Cambodia’s only child mental health service. The Social Services of Cambodia, another NGO, has been working on community mental health projects since 1994.

Patient mix and referral patterns

A survey undertaken by K.S. and P.B. of clinic attenders at the main psychiatric out-patient department in Phnom Penh in 1996 found that around two-thirds were female. Nineteen per cent were diagnosed with psychotic disorders, 40% with mood disorders and 33% with anxiety disorders. Around a third had initially sought advice from traditional healers, a third had consulted general medical services and the remaining third had not consulted previously for their presenting problem.

Training and research

Psychiatry is now part of the undergraduate curriculum for both doctors and nurses, and is taught in all regional training centres. There are plans for a basic 3-month training programme to be made available to doctors and nurses, as well as plans for a 2-week mental health course for general practitioners and registered nurses working at health-centre level.

In order to attract investment in mental health, there is a need for research into the health needs and illness behaviour of Cambodians with mental health problems. In addition, the tragic recent history of Cambodia and the post-conflict situation make the country a potentially important resource for research into the individual and collective psychiatric sequelae of genocide and other traumatic events. Some foreign universities are collaborating in research and training in Cambodia, including the Institute of Psychiatry in London, but there is little research infrastructure within Cambodia itself.

Conclusion

Mental health services in Cambodia have progressed at an impressive rate in the past 10 years, but there is much that remains to be done. So long as the political situation remains relatively stable, and foreign aid continues at current or increased levels, the hard work of the mental health professionals in Cambodia should continue to reduce the gap between the need for and the provision of mental health services.