Mental Health Care Spreads to the Provinces

When Doctor Ke Chhum was chief radiologist at the old Russian Hospital in the 1980s, Cambodia had no psychiatrists, very little medicine and no way to care for the troubled survivors of a war-ravaged nation.

But Cambodia did have the support of the Soviet Union, which in 1987 announced it would send one Cambodian doctor to the USSR to study psychiatry. The director of Russian Hospital recommended Ke Chhum for the scholarship.

Three years later, Ke Chhum returned from Moscow as the only doctor in the country with any sort of psychiatric training.

Although his request to practice psychiatry exclusively at Russian Hospital was turned down, his return was a small step toward the establishment of a mental health care system in Cambodia.

Of the 49 doctors in Cambodia who lived through the Khmer Rouge regime, none was a psychiatrist.

But almost every Cambodian who survived the Khmer Rouge has suffered some kind of psychiatric problem, according to Dr Ka Sunbaunat, a professor at the University of Health Sciences who is chairman of the Ministry of Health’s mental health subcommittee.

From 1979 through the 1990s, those who suffered from depression, stress or anxiety—easily treatable in Western countries—had to cope on their own or seek help from traditional healers. Cambodians with serious, potentially violent mental illnesses have ended up in jail or chained inside homes by relatives.

But today, training programs for doctors and nurses, NGO-funded services in several provinces and classes at the Royal University of Phnom Penh and the University of Health Sciences are teaching Cambo­dians to deal with the country’s mental health problems, not the least of which is post-traumatic stress syndrome.

“Mental health care used to be nonexistent here. But now it really exists,” said Victor Gronstad, a psychiatrist with the International Organization for Migration and project director for the Cambo­dian Mental Health De­velopment Program.

The old Russian Hospital—now named Preah Bat Norodom Sihanouk Hospital—today has a busy mental health clinic that sees up to 200 patients a day.

“Mental health problems have gotten more and more serious” since 1990, said Ke Chhum, who works at the clinic with seven other Cambodian psychiatrists.

The seven were part of a class of 10 that graduated in 1998 from a three-year CMHDP program. As fully-trained psychiatrists, with professional recognition from Norway’s University of Oslo, they now help teach the current class of 10 psychiatrists, which is due to finish in December.

Since graduating from the program in 1998, Dr Chhit Sophal has traveled throughout Battam­bang province, training 55 general practitioners and 67 nurses in basic mental health care.

“So I have changed my role as a trainee to a training supervisor,” he said.

Gronstad hopes Cambodian psychiatrists will continue to train other health care workers, both at Sihanouk Hospital and in the provinces, after he leaves Cam­bodia in December. In the current class of trainees, six will return to their provinces to work as psychiatrists.

Cambodians in Kompong Cham, Kampot, Kompong Speu, Siem Reap, Kandal, Pursat and Banteay Meanchey provinces can now get treatment, counseling and education on how to recognize a mental illness through several organizations. Outreach programs in Svay Rieng and Kompong Thom are coming soon.

Prum Reachna of the Transcultural Psycho-social Organization, a Dutch organization working in Cambodia since 1995 to treat psychological and social disorders, estimates that between 70 percent and 80 percent of the people he meets in rural Pursat have mental problems.

Nationwide, Ka Sunbaunat estimates 80 to 90 percent have suffered from some kind of mental problem, including psychosomatic illnesses.

“This has a negative impact on the development of our country,” he said. “We have to build up our nation as soon as possible….But if people lose their judgment, don’t trust each other and fear responsibility, then this will lead to less and less production.”

The staggering rate of mental illness stems from poverty and poor education, not just the dec­ades of war, said Prum Reachna. For example, poverty can mean poor nutrition, which can slow a child’s brain development. Slow learners tend to have low self-esteem, which can develop into mental problems.

Since 1995, the mental health of Cambodia’s children has been looked after at the Center for Child Mental Health at the Chey Chumneas Hospital in Takhmau. Children from as far away as Preah Vihear and Battambang provinces have been brought to the center, which features several buildings and a children’s playground.

“Family members will take [their children] to a monk, to private practitioners, kru Khmers and fortune tellers,” said Dr Jegannathan Bhoomi Kumar, who runs the center. “It can take from seven months to seven years between the onset of the problem until they reach our center.”

Before 1975, Chey Chumneas was known as Prek Thnoat Asylum. Built during the French colonial period, it was the only mental institution in French Indochina. At one time it held more than 300 patients, many of them violent. Electroshock therapy was common.

“A lot of chronic patients were sent there and abandoned by their families,” Ka Sun­baunat said. “There was little treatment. It became very crowded.”

These days, there is treatment for the mentally ill in Cambodia, but no inpatient mental hospital. There is talk of building a small 10- to 20-bed unit at Sihanouk Hospital, but money is lacking. Another goal is to set aside three or four beds in each provincial hospital for patients with serious mental illnesses.

But lack of funding and facilities will likely remain a problem for some time.

And considering that there is only a handful of trained doctors and nurses to take care of the hundreds of thousands of Cambo­dians who have mental problems, more “manpower” is still needed, Gronstad said.

“There is definitely a lot of improvement” in mental health care, said Jegannathan Bhoomi Kumar. “But it is still just a drop in the ocean.”



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