Developing Psychiatric Training and Services in Cambodia

The Cambodian mental health system, like any other system in the country, must contend with scars from the country's traumatic past as well as grinding poverty in the present. Psychiatric services before 1975 included one psychiatric hospital, located on the outskirts of Phnom Penh, directed by French-trained Cambodian psychiatrists. Outpatient psychiatric services were not available. During the Khmer Rouge reign from 1975 to 1979, about 1.7 million people, or about one-fifth of the country's population, lost their lives by execution, starvation, or disease. The country's entire infrastructure, including the health system, was destroyed. In 1979 none of 43 surviving medical doctors in Cambodia were psychiatrists. After the ouster of the Khmer Rouge, a civil war continued until 1996. The political situation remains unstable today.

Between 1979 and 1992, no mental health services were available in Cambodia, although services and training programs did exist in some of the refugee camps at the Thai-Cambodian border. The first Cambodian National Health Plan established after elections in 1993 made psychiatry one of its priorities. Since then, several nongovernmental organizations have helped provide mental health services and training in the country.

The first psychiatrists to be trained in Cambodia were ten Cambodian physicians trained under the Norwegian-funded Cambodian Mental Health Development Program. The program was implemented jointly in 1994 by the International Organization for Migration, the University of Oslo, and the Cambodian Ministry of Health.

The first phase of training began with several months of study of English, followed by three years of didactic instruction and on-the-job training. Three Norwegian psychiatrists each spent one full year providing training and supervision for the residents. Trainees spent two months learning inpatient psychiatry in Thailand, where they had a chance to observe the mental health system of a neighboring country spared the ravages of war. Several times a year, consultant psychiatrists conducted two-week teaching blocks on specific subjects. Most of the consultant psychiatrists were from other Asian countries, although a few were from North America and Europe. In the summer of 1998, during the last three months of the first phase of the program, I had the opportunity to teach a brief course in child psychiatry and to act as the program's supervisor.

Residents in the program saw patients at the Preah Norodom Sihanouk Hospital in Phnom Penh. Because of the program's limited budget, and fear that chronically ill patients might be abandoned by their families in an inpatient facility, outpatient services were given priority. Because inpatient facilities were not available, psychiatrists and families were required to devise creative treatment strategies for difficult and sometimes dangerous clients. Depression and mixed anxiety-depression were clearly the most common primary diagnoses, followed by schizophrenia and panic disorder. Residents also assisted with teaching medical students and helped set up a day treatment program for chronically mentally ill patients.

The steady commitment of the psychiatrists and nursing staff as well as increasing awareness of mental health needs led to growing numbers of clients. In the fall of 1998, about 2,000 consultations were performed each month. Consultations and medication are either free or are highly subsidized, depending on the patient's circumstances. Families who come from distant provinces for care face a considerable economic burden for transportation.

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.

In October 1998 the Mental Health Development Program was extended to train ten more Cambodian doctors in psychiatry and to provide specialist training in psychiatry to 20 nurses. Many of the new residents come from provinces far from Phnom Penh and thus will distribute psychiatric services throughout the country after they graduate. Graduates of the first program help train the new group of residents, although expatriate psychiatrists continue to offer instruction. With continued hard work by the Cambodians, outside help in the form of funding and instruction, and some degree of political stability, high-quality mental health care will continue to become increasingly available for those in need.

Dr. Savin's experience in Cambodia began in 1991, when he spent two and a half years as psychiatrist in a refugee camp at the Thai-Cambodian border and as a general physician in western Cambodia. He currently is assistant professor of psychiatry at the University of Colorado and director of mental health for the Colorado Refugee Health Program. His e-mail address is [email protected].