Cambodia - Cambodia's health care system struggles to cope with mentally ill patients

PHNOM PENH: As soon as the clock struck seven in the morning, a commotion broke out in front of an old, yellow building inside the Khmer-Soviet Friendship Hospital.

More than 40 people flocked to the main metal door separating them from the waiting area and consultation rooms. Some craned their neck to look for a sign of staff inside the building, while others searched for empty spots on the dusty ground to give their feet a rest.

Coming from various parts across Cambodia, they all shared one thing in common; everyone seemed stressed and weary, as they waited to enter the busiest psychiatric clinic in Phnom Penh.

“We’ll open at 9 o’clock today,” a member of the medical staff told the patients as she squeezed through the main entrance. “We have a meeting,” she quickly explained and continued on a dusty path linking the busy outpatient department with another building.

For mental health patients in Cambodia, long waits are far from uncommon at the state-run clinic. Although its outpatient department is the biggest in the country, the facility has 13 registered psychiatrists and 12 nurses to treat hundreds of patients per day. For those with serious conditions that require continual specialised care, there are ten beds available.

“One doctor treats about 50 patients each day,” said one of the psychiatrists at the clinic, Sou Sarifin. The limited resources mean that not every patient can be seen, consultations last minutes, and treatment is often limited to prescription drugs.

Mental health problems are widespread in Cambodia. Some patients are often locked up at home or chained to trees, as their family members do not know how to deal with the symptoms. Health care services exist but are hard to access, particularly in rural areas. And some patients are dropped off at the clinic with their hands and legs tied, Sarifin said.

Anxiety, depression, bipolar disorder and schizophrenia are the most common forms of mental illness diagnosed at the clinic. And a number of patients are survivors of the Khmer Rouge regime, whose legacy has left them with deep mental scars.

"They still have bad memories; some of their family members were killed during the Khmer Rouge regime," Sarifin added.

Under the Communist Party of Kampuchea (CPK), Cambodia was radically transformed into an agrarian society with no social classes. Its citizens were stripped of their basic rights and driven into forced labour in the countryside, while religions, education and financial system were abolished. Between 1975 and 1979, prisons and execution sites popped up across the country, as starvation, diseases, exhaustion and capital punishment killed nearly two million people.

And for those who have survived, many find it hard to deal with the psychological scars.

“I FELL UNCONSCIOUS WHEN THEY STARTED TO RAPE ME”

Some of the Khmer Rouge survivors with mental health problems are old people who still have fresh memories of the past.

One of them is Leang Korn. Her husband was killed in 1975, she said, 20 days before their baby was born. Both were accused of conspiring with the Central Intelligence Agency (CIA) against the Khmer Rouge.

“I couldn’t see my husband but heard his voice through the air. How scared and painful he was. We all couldn’t do anything but only whisper,” the 57-year-old widow said.

After giving birth to her child, Korn joined other Cambodians who were sent to work in the fields.

“One evening, several men came to me and said Angkar (the Khmer Rouge’s ruling body) wanted information about my work. There were about 10-12 men there. I fell unconscious when they started to rape me. They were like animals, not human beings,” Korn said.

Over the past 37 years, the old widow has been trying to live a normal life and forget her past. “But I can’t forget. My feeling is attached with something, something unclear, like a shadow.”

Mental health issues in Cambodia, however, affect more people besides Khmer Rouge survivors such as Korn. A number of mental health patients at the Khmer-Soviet Friendship Hospital have a long history of alcohol and drug use. Social factors such as poverty and gender-based violence also play a key role.

Of the over 15 million population, an estimated 40 per cent suffer from mental health and psychological problems, according to Transcultural Psychosocial Organization Cambodia (TPO) – a non-profit group that promotes mental well-being among Cambodians.

But despite high incidence of mental disorder, Cambodia's public health care is still lacking. It is estimated that only 0.02 per cent of the country's health budget goes to mental health, based on a report by the Leitner Center for International Law and Justice.

"Public mental health care in Cambodia is a little bit better now but there are still a lot of issues. Services provided are poor and to access them is difficult. There is only one hospital in Phnom Penh that provides mental health care," said Sek Sisokhom, Head of the Psychology Department at Royal University of Phnom Penh.

"People don't know about psychology because the concept is very new in Cambodia. When they encounter mental health problems, they often seek help from monks at the temple or spiritual healers," Sek added.

A 'VERY CHALLENGING' SITUATION

The mental health situation in Cambodia is "very challenging", according to Sek. The sector is only allocated a small amount of funds from the national budget and "there is no quota for recruitment of psychologists into the public sector," he said.

New graduates often face difficulties finding jobs in the mental health industry. In the entire nation, there are only a few state-run psychiatric clinics. One of them is located in the capital city and five more in Banteay Meanchey, Ratanakiri, Kampong Cham, Kampot and Battambang. "Mental health is not the government's first priority," Sek added.

Moreover, mentally ill patients at state-run facilities often receive bio-medical treatment rather than psychological or psychosocial treatment. "And this means the government services mainly lack counselling, psycho-education and community-based intervention that addresses the issue through a holistic approach," said Dr Sotheara Chhim, senior consultant psychiatrist and TPO executive director.

"There are huge needs for mental health care."

In a bid to improve mental well-being among Cambodians, many NGOs have set up their own mental health care facilities in response to the limited resources.

In 2015 alone, TPO’s treatment centre provided more than 6,500 consultations. But the group also aims to promote non-medical treatment through its several programmes targetting different groups of mentally ill patients, including the likes of Korn.

For several years, the Khmer Rouge survivor has been receiving mental health support from the NGO, which provides her with counselling every two months. Her conditions continue to improve over the years. Korn is now more open to discuss her past and fully aware of the problems she is facing.

Still, many mentally ill patients in Cambodia are struggling to live a normal life. “They’ve never received support from the government,” Sarifin said before rushing back into his office, as more patients streamed into the mental health clinic.

But soon, the door would be closed, and those who did not make it to the psychiatrists would have to come back again the following day.

Pichayada Promchertchoo

channelnewsasia

Cambodia - Solutions elusive as Kingdom grapples with rise in suicides

They were planning a May wedding. Instead, Phai Kak, 18, found herself dutifully handing out plates of rice as the incense burned at the funeral of her fiancé, San Ren.

Gathered at the ceremony were a clutch of older villagers, their faces deeply lined, dressed in mourning white. A monk, swathed in saffron, incanted as palms were joined in prayer; he later accepted gifts.

Ren, at 21, had taken his own life. The reason, according to local media reports, was an argument with his mother about an iPhone. But that simplistic account obscured crucial pieces of his story.

Despite National Police figures saying suicide in Cambodia is on the rise and suicides appearing almost daily in the local press, experts say critical underlying factors – such as depression or other mental illnesses – still go unreported, untreated and unacknowledged. And without recognition of the scale and causes of the problem, solutions have been slow in coming.

Ren had called his mother, Van Kehn, 38, to talk about a phone just minutes before his death, but he also told her something that alarmed her.

“He said: ‘Mum, there are many police coming and surrounding the house, they came to catch me’,” Kehn said.

Confused, she asked her son if he had done anything wrong. Nothing, he said, and hung up. Just 15 minutes later, his fiancée, Kak, rang with the news: Ren had hanged himself; he was dead. There were no police.

The figures on suicide in Cambodia are sketchy. The National Police began recording suicides in 2011 and the number has been on the rise since, from 513 in 2011 up to 743 last year. However, frontline services and mental health sector experts were unable to confirm or provide a reason for such a dramatic increase.

What’s clear is that these numbers do not reflect the true scale of the problem, as they only signify when police have become involved in violent or suspicious deaths by suicide.

Past estimates of suicide rates in Cambodia have varied wildly, from between one and 42 per 100,000 people, or anywhere from 150 suicides per year to 6,300.

However, the researchers from the Royal University of Phnom Penh psychology department who came up with the latter estimate from a survey in 2012 have since admitted their methodology was flawed.

According to Dr Keith Harris, a researcher at the University of Queensland’s school of psychology, getting decent data is crucial to suicide prevention.

In a recent report, his team of researchers analysed two large Khmer-language newspapers to find a number of suicide deaths, then used an algorithm to calculate a projected figure, putting it at 3.8 per 100,000 people in 2012 – equating to about 565 per year – a figure he says likely falls short of the mark.

His report found suicide death rates of men were twice the rate of women, and twice as high for those under 40.

Statistics aside, there’s no doubt the number of people seeking help for mental health problems is increasing at a rapid rate – and Cambodia’s incredibly limited mental health services are being swamped.

Less than an hour after Ren’s funeral, on Phnom Penh’s Cambodia-Japan Friendship Bridge, a string of motos and tuk-tuks stood still, their drivers dangling arms over the bridge rail, pointing and peering into the river below.

A bystander said a man had jumped. But moments later, dripping, he emerged. A passing fishing boat had scooped him from the water.

Srah Chak commune police later confirmed the 28-year-old man from Tbong Khmum province had attempted suicide.

The man had been suffering from a mental illness, and had just come from the Khmer-Soviet Friendship Hospital, where he was unable to receive medicine for his condition.

A motodop took him to the bridge. He had no money, so he handed over his phone to the driver instead before leaping off and being saved by the fisherman’s boat, police said.

The man was just one of some 500 patients to visit the Khmer-Soviet Friendship Hospital’s psychiatric department that day, and according to its director, Dr Chak Thida, the facility is overwhelmed.

Every day, she said, the hospital received between 400 and 500 patients, and up to 50 of those are new cases, mostly depression and anxiety.

That is a drastic increase compared with a few years ago, she said, when they would see between 100 and 200 patients daily. But the hospital, with only 12 psychiatric doctors, is under-resourced and ill-equipped to deal with the load.

“It’s a burden for us, because each of our doctors need to treat 30 to 40 patients per day for mental illness,” Dr Thida said.

“In other countries, doctors like us would treat only four or five patients.

“We don’t have enough medicine, and there are not enough doctors, and we have no time to treat them attentively.”

Only six of Cambodia’s 25 provinces and municipalities have a psychiatrist at their referral hospital – Phnom Penh, Battambang, Siem Reap, Pursat, Kampong Cham and Kampong Thom – with the latter three having only one specialist apiece.

Although Dr Thida said awareness was growing, it’s likely that even more mentally unwell people would be seeking help if there were greater understanding of the nature of the problem.

Ren’s fiancée, Kak, said it was not the first time he had thought about suicide. The garment worker said Ren had tried to end his life two or three times since they began living together in December.

“He tried to commit suicide a few times, but my mother and I managed to stop him in time,” she said.

In their village in Russey Chroy commune, in Kandal’s Muk Kampoul district, she was unsure where to seek help for suicidal thoughts and turned to the local pagoda.

“I brought him to the monk for a water blessing. I didn’t know where I should go for these symptoms; I had not thought of a hospital,” Kak said.

Despite the previous suicidal thoughts and the strange vision of encircling police, Ren’s father, San Ra, 44, was adamant his son did not have a mental health condition.

“My son has never been sick or taken any medicine, or any drugs, and he has never had any mental problem,” Ra said. “Since he was born, he was very strong and hard-working.”

For his parents, the fact he saw a phantom swarm of police officers surrounding the home bears not a hint of mental illness, but a spiritual premonition.

It was a vision from a “bad spirit”, they said, perhaps the same one that forced him to take his own life.

Compounding Ra’s shock is his perception that children tend to use the threat of suicide as a bargaining chip.

“It is only that they want something, and they are afraid their parents would not give it to them, so they say they will commit suicide,” he said.

Cambodia currently has no suicide prevention plan and, according to Dr Chhit Sophal, director of the Ministry of Health’s department of mental health and substance abuse, when media outlets report suicide as a trivial matter – the result of a love triangle or an unfulfilled material desire – they are mistaking “triggers” of suicide for “causes”.

“Not many Cambodian people understand that suicide is a public health issue or mental health problem. Thus the awareness of suicide among the general population and the development of support services are very important,” he said.

Dr Sophal lists cumulative stress, mental health crises, family conflict, social issues and substance abuse as root causes of suicide, while one unpleasant moment or problem might become a trigger.

Dr Sotheara Chhim, executive director at the Transcultural Pyschosocial Organisation (TPO), agreed that suicide was not always the result of a diagnosed mental illness – it could sometimes be due to “acute stress” that had “overcome individual’s capacity to deal with loss”.

He explains to his patients that depression needs time for recovery, but many, like Kak, still believe a traditional healer would be the best solution.

A suicide prevention hotline, he said, could make a world of difference. “They desperately want someone to talk to,” he said.

“Sometimes they don’t need medication, only someone who has the time for them.”

He said it was crucial to train community members in villages in mental health first aid, giving them the skills to recognise a problem and refer cases to professionals.

Instead of treating suicidal people “like criminals”, he said, police should be trained to speak with those they find teetering on the edge of the bridge. “Instead of pointing a gun at them, they should talk to them, understand them in an empathetic way and refer them [to mental health services],” he said.

Dr Sophal told the Post suicide prevention would be considered as a component in the upcoming Strategic Plan for Mental Health and Substance Abuse 2017-2020, and while he hoped suicide cases would be recorded at health facilities “in the near future”, it was just one priority in a field with scant resources.

“The [Ministry of Health] has recognised that suicide is a public health issue and will take action to prevent it as much as possible within our limited resources and capacity,” he said. “It is a resource-based approach, not a demand-based [approach].”

However, Ra said that in line with his Buddhist beliefs, his son died because it was simply his time.

“When I heard he committed suicide, I was speechless,” Ra said, blotting away tears.

“When people tell me my son tried to commit suicide a few times before, I don’t believe them, because everyone tries so hard to survive; no one wants to die or would like to die,” he said.

Kong Meta and Erin Handley

phnompenhpost