Mental health care in Cambodia.

Mental health care in Cambodia Daya J. Somasundaram 1 & Willem A.C.M. van de Put 2 An effort is being made in Cambodia to involve grass-roots personnel in the integration of the care of the mentally ill into a broad framework of health services. This undertaking is examined with particular reference to the work of the Transcultural Psychosocial Organization. Voir page 276 le re sume en francËais. En la pa gina 276 figura un resumen en espanÄ ol. Cambodia's health infrastructure, destroyed by decades of war, is slowly being re-established. A primary care approach is envisaged, focusing on health centres with an integrated package of activities including ones concerned with mental health. In Pursat Province, which is very undeveloped and impoverished, the Transcultural Psychosocial Organization (TPO), a nongovernmental organiza- tion, has become involved in a process in which various bodies engaged in development work were invited to promote their projects in villages. Under a UNDP rehabilitation and regeneration project, 45 remote villages were allocated funds and the inhabitants were asked to select matters requiring priority attention in education, transport, agriculture, health, social affairs and other areas. TPO arranged for all the villages to be visited in three months by a core group of Cambodians who had been trained as trainers in community mental health. In all but three of the villages the people considered that dealing with psychosocial problems was the most important matter needing to be dealt with in the social affairs category. The villagers were evidently aware that many of their difficulties in working, maintaining relationships, problem-solving and preventing con- flicts had a psychosocial basis. TPO has also been involved in setting up model mental health services in Battambang Pro- vince. A community-based approach was adopted in which grass-roots workers were trained so that they would be able to tackle most basic problems of mental health in the villages. A referral systemwas set up to tackle the more rare serious neuropsychiatric disorders. Once stabilized and perhaps on main- tenance treatment, patients were referred back to community workers and local health centres for follow-up and rehabilitation. A manual entitled Community mental health in Cambodia was produced, which, together with other texts, including WHO's Diagnostic and management guidelines for mental disorders in primary care (1), has been used in the training of over 500 workers at different levels throughout the country, though mainly in Battambang Province. Among the persons trained have been government ministry staff, nongovernmental organizations, pro- vincial and district hospitals and health centres, village health volunteers, members of village devel- opment committees, monks, nuns, teachers, village elders and traditional birth attendants. The emphasis has been on non-pharmacologi- cal forms of treatment for common psychosocial problems and appropriate referral for help. Psycho- social interventions that have been found effective in the Cambodian context include the formation of self- help groups for women who, for one reason or another, have lost their husbands, and the use of traditional Buddhist relaxation methods such as mindful breathing (Ana Pana Sati) and meditation. These groups have helped people to cope with traumatic memories, to support each other in new ways, and, consequently, to take care of their children and overcome social isolation. The Western type of counselling has not been very popular. TPO has supplied the psychotropic drugs chlorpromazine, haloperidol, imipramine, amitriptyline, phenobarbi- tal, phenytoin, trihexyphenidyl and, more recently, fluphenazine decanoate for the treatment of severe neuropsychiatric conditions in mental health clinics. Apart from encouraging and re-establishing referrals within villages the network of nongovern- mental organizations occupies an important place in the mutual referral system. A widow or a landmine victim with depression due to socioeconomic problems can be referred to an appropriate non- governmental organization for vocational training and introduction to income-generating programmes. On the other hand, nongovernmental organizations having clients with mental problems can refer them to the mental health services. If people are to participate in national reconci- liation, reconstruction and development, they must first regain their mental health. Development and growth cannot be expected to occur unless members of the population are well motivated, possess self- esteem, can maintain friendly relationships, are at 1 Consultant Psychiatrist, Community Mental Health Programme, Transcultural Psychosocial Organization, Cambodia. Correspondence should be addressed to Dr Somasundaram at PO Box 1124, Phnom Penh, Cambodia (tel. and fax: 855 23 218478; e-mail: TPO@forum.org.kh). 2 Director, Community Mental Health Programme, Transcultural Psychosocial Organization, Cambodia. Reprint No. 3247 275Bulletin of the World Health Organization, 1999, 77 (3) # World Health Organization 1999 peace with themselves and the environment and are confident enough to achieve their potential. Although mental health care cannot be given top priority it could be made part of an integrated service at the periphery. Nobody would deny that tuberculosis, malaria, AIDS and landmines present major problems in Cambodia. Well-being clearly has interconnected and interdependent physical, mental, social and spiritual dimensions, and a holistic approach to health is necessary so that most mental health problems can be solved in the community. Problems of HIV/AIDS, landmines and even tuberculosis are related to behaviour. With regard to tuberculosis, patients rarely complete a full course of treatment unless offered special inducements. Mental health problems are responsible for 8% of the global disease burden, a toll greater than that exacted by tuberculosis, cancer or heart disease (2), and 34% of all disability is caused by behaviour-related problems, including violence, exploitation, road traffic accidents, and AIDS (3). In Cambodia one could cite war, child abuse, sexual exploitation, domestic violence, trafficking, gambling, alcohol dependence and the use of landmines among the serious behavioural problems that have psychosocial consequences. Much can be done to treat even rare psychotic conditions in peripheral hospitals by means of inexpensive drugs, good follow-up, and rehabilitation in the community. When adequate referral becomes available in Cambodian villages and the knowledge, skills and attitudes needed for managing most psychosocial problems in the community are acquired, a clear enhancement of self-sufficiency, self-esteem and motivation can be expected to develop, and productivity, healthy behaviour and the quality of life can be expected to improve. The best option for Cambodia, with no structures and resources in mental health other than in the traditional sector, and with 85% of its population living in rural areas, would be to adopt a community-based mental health programme founded on a policy of decentralization and integra- tion of services. The aim should be to deliver adequate coverage of the population and for workers at community level to provide basic mental health care (4) as has been achieved elsewhere (5). n Re sume Les soins de sante mentale au Cambodge Au Cambodge, l'Organisation psychosociale transcul- turelle (OPT) a charge une e quipe de conseillers cambodgiens en sante communautaire de visiter 45 villages isole s. Dans 42 de ces villages, une majorite d'habitants a juge qu'il e tait prioritaire, pour la vie e conomique et sociale, de trouver des solutions aux probleÁmes psychosociaux. Dans la province de Battam- bang, des agents de sante communautaires ont recËu une formation leur permettant de faire face aÁ la plus grande partie des probleÁmes courants de sante mentale observe s dans ces villages, et un systeÁme d'orientation-recours a e te mis en place pour les cas plus graves. Cette formation, sur la base d'un manuel national et de textes de l'OMS sur les soins de sante mentale au niveau de la communaute , a e te dispense e aÁ plus de 500 agents de sante , parmi lesquels des volontaires de village, des personnels hospitaliers et de centres de sante , des agents des pouvoirs publics, des agents du de veloppement, des religieuses, des enseignants et des accoucheuses traditionnelles. Les traitements non psychiatriques e taient privile gie s, y compris la cre ation de groupes d'auto-assistance ainsi que la me ditation et les techniques bouddhistes de relaxation. Pour les cas plus graves oriente s vers les dispensaires de sante mentale, l'OPT a fourni une gamme de me dicaments psycho- tropes. Les organisations non gouvernementales qui assurent par exemple des services de formation professionnelle et des activite s ge ne ratrices de revenus occupent une place importante dans le systeÁ me d'orientation-recours. La prise en charge des probleÁmes de sante mentale est conside re e comme essentielle aÁ la reconstruction nationale. D'autres probleÁmes majeurs de sante , notamment le SIDA, les traumatismes cause s par les mines antipersonnel et la tuberculose ont des effets psychosociaux et comportementaux de sorte qu'une approche pleinement inte gre e de la sante et du de veloppement paraõÃt eÂminemment souhaitable. Resumen La atencio n de salud mental en Camboya La Transcultural Psychosocial Organization (TPO) orga- nizo la visita de un equipo de instructores de salud comunitaria de Camboya a 45 aldeas remotas de ese paõÂs. Una mayorõÂa de los habitantes de 42 de esas aldeas consideraba que la bu squeda de soluciones a los problemas psicosociales constituõÂa una prioridad funda- mental para la vida econoÂmica y social de la comunidad. En la provincia de Battambang se adiestro a agentes de salud rurales para que aprendieran a abordar la mayorõÂa de los problemas ba sicos de salud mental observados en esas aldeas, establecie ndose un sistema de derivacio n de casos para los trastornos ma s graves. Con la orientacio n de un manual nacional y de textos de la OMS sobre la atencio n de salud mental de base comunitaria, se ofrecio formacio n a ma s de 500 agentes de salud, incluidos voluntarios de aldea, personal de hospitales y de centros de salud, funcionarios, agentes de desarrollo, monjas, maestros y parteras tradicionales. Se dio preferencia a los 276 Bulletin of the World Health Organization, 1999, 77 (3) Policy and Practice tratamientos no farmacolo gicos, entre ellos la formacio n de grupos de autoayuda y el recurso a te cnicas de meditacio n y a me todos budistas de relajacio n. La TPO suministro diversos medicamentos psicotro picos para los casos ma s graves derivados a dispensarios de salud mental. Las organizaciones no gubernamentales que ofrecen servicios tales como actividades de formacio n profesional y de generacio n de ingresos son un com- ponente importante del sistema de derivacio n de casos. Se considera que la recuperacio n de la salud mental es un requisito de la reconstruccio n nacional. Otros problemas sanitarios graves, como el SIDA, los traumatismos por minas terrestres y la tuberculosis, presentan tambie n facetas psicosociales y comporta- mentales, de ahõ la necesidad de un enfoque plenamente integrado de la salud y el desarrollo. References 1. World Health Organization. Diagnostic and management guidelines formental disorders in primary care. GoÈ ttingen, Hogrefe & Huber, 1996. 2. World Bank. World development report 1993: investing in health. New York, Oxford University Press, 1993. 3. Desjarlais RL et al.World mental health. Problems and priorities in low-income countries. NewYork, OxfordUniversity Press, 1995. 4. The introduction of amental health component into primary health care. Geneva, World Health Organization, 1990. 5. Report from the WHO collaborative study of strategies for extend- ingmental health care. Geneva,World HealthOrganization, 1981. 277Bulletin of the World Health Organization, 1999, 77 (3) Mental health care in Cambodia