Tuesday, April 21, 2009

Mental illness in Cambodia

Dr Andrew Grimes who in 1999, founded Tokyo Counselling Services left me an interesting comment on my post Suicide in Asia .

Dr Grimes pointed readers to this site counsellingjapan.com, which notes in a 2002 newsletter:
During the Pol Pot period from 1975 to 1979 it is estimated that 1.7 million people were killed or died in captivity.

The two psychiatrists practicing in Cambodia when the Khmer Rouge took power in 1975 were sent to do farm labour disappeared without trace. The only Mental Health Hospital, built in 1960's, was closed. Psychiatric patients were killed or sent to work in the fields.

Now in 2002 in Cambodia serving a population of about 12 million people there are approximately only 350 mental health care providers including 20 psychiatrists, 20 psychiatric nurses and 215 psychiatric clinical psychologists. Through the incredible efforts of people like these individual psychiatric practice and individual and group counseling programs have been established in Phnom Pen and some of the provinces of Cambodia.
I did a bit of research and found this report Developing Psychiatric Training and Services in Cambodia, which notes, "In 1979 none of 43 surviving medical doctors in Cambodia were psychiatrists."

It was only in 1993, under the first Cambodian National Health Plan that psychiatry was made a priority. At that time, there must have been many traumatised and depressed people among the 10 million Cambodians.

In the beginning, 10 Cambodian physicians were trained under the Norwegian-funded Cambodian Mental Health Development Program, which was jointly implemented by the International Organization for Migration (IOM), the University of Oslo, and the Cambodian Ministry of Health. They also spent two months learning inpatient psychiatry in Thailand.

In the fall of 1998, about 2,000 consultations were performed each month. "Depression and mixed anxiety-depression were clearly the most common primary diagnoses, followed by schizophrenia and panic disorder."

Things did not seem to be much different 6 years later, in 2004. Household survey of psychiatric morbidity in Cambodia in Kampong Cham province found this:
- 42.4% reported symptoms that met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition criteria for depression

- 53% displayed high anxiety symptoms and 7.3% met post-traumatic stress disorder (PTSD) criteria.

- Post-traumatic symptoms of intrusion and avoidance were present in 47.8% and 45.4% respectively.

- When reviewing co-morbidities [which is the presence of one or more disorders (or diseases) in addition to a primary disease or disorder], 29.2% had depression and anxiety symptoms, 16.5% anxiety symptoms, 6.1% depression and 7.1% had triple comorbidity (PTSD, depression and anxiety).

- Regarding social functioning, 25.3% reported being socially impaired. Respondents with comorbid symptoms for depression, anxiety and PTSD were associated with an increased risk for social impairment compared with others.

- Being over 65 years and having experienced violent events were other factors associated with social impairment.

Conclusion: Five years after the return of a more stable context in Cambodia, the prevalence of psychiatric symptoms in the community remains high. In addition, these symptoms are strongly associated with social impairment. This suggests that beyond psychosocial programs, the implementation of adapted clinical psychiatric care should be considered as a priority.
There has been progress in psychiatric training here in Cambodia. In 2006 alone, 13 years on from the project, the IOM reports that 26 psychiatrists were trained to international standards. Others trained include 40 psychiatric nurses and 254 general practitioners and 269 non-specialized nurses (three months’ basic training in psychiatry) .

Last year, I had written about Superstitions and mental illness among Khmers, and I found this, from the first report mentioned, really interesting:
"Cambodian psychiatrists must be conversant with the beliefs of their countrymen. Most patients presenting with severe mental illness first consult traditional Cambodian healers, either monks or kru khmer. They may be told that their illness results from having angered the spirits of their ancestors. Possible traditional remedies include herbs and ceremonies conducted to appease the spirits of the ancestors. While these treatments may be helpful with certain nonpsychotic difficulties, they are generally regarded as less effective in the treatment of psychosis.
It is something Westerners and other foreigners like me have to keep in mind. I sometimes lose patience with superstitious people, but it is not easy to change traditional beliefs. Just recently, Sina had an operation for tonsillitis and was told by the Khmer doctor to eat only fish and pork, no other meat and no eggs or cold drinks. He met a friend of mine, Simone, a Swiss nurse who was volunteering here who told him it's ok to eat all of the above and that ice-cream in particular can soothe his throat. Sina's eyes widened as he looked in disbelief. He genuinely believes that both prescriptions are correct; it's just that one works for foreigners and one for Cambodians.

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