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Mental health services in Cambodia: an overview

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Abstract

Mental health services in Cambodia required rebuilding in their entirety after their destruction during conflict in the 1970s. During the late 1990s there was rapid growth and development of professional mental health training and education. Currently, basic mental healthcare is available primarily in urban areas and is provided by a mixture of government, non-government and private services. Despite the initial rapid growth of services and the development of a national mental health strategy in 2010, significant challenges remain in achieving an acceptable, standardised level of mental healthcare nationally.
COUNTRY
PROFILE Mental health services in Cambodia:
an overview
Sarah J. Parry
1
and Ewan Wilkinson
2
Mental health services in Cambodia required
rebuilding in their entirety after their
destruction during conict in the 1970s.
During the late 1990s there was rapid growth
and development of professional mental
health training and education. Currently, basic
mental healthcare is available primarily in
urban areas and is provided by a mixture of
government, non-government and private
services. Despite the initial rapid growth of
services and the development of a national
mental health strategy in 2010, signicant
challenges remain in achieving an acceptable,
standardised level of mental healthcare
nationally.
Cambodia is a country in Southeast Asia, bor-
dered by Thailand, Laos and Vietnam, with a
population of 15.8 million.
1
The population
remains predominantly rural although the distri-
bution reduced from 81% to 68% rural between
1998 and 2016.
1
The national poverty rate
declined from 48% in 2007 to 13% in 2014.
2
The majority (97%) of the population is
Buddhist.
3
The Cambodian concept of health is
complex, rooted in Hindu-Buddhist beliefs, ani-
mistic spiritual beliefs, the concept of luck and
astrology, and physical/somatic concepts.
4,5
Religious and traditional healers play an import-
ant role in physical and mental healthcare in
Cambodia.
3,4
Traditional approaches to health-
care are usually used rst, particularly in rural
areas.
4,6,7
As in many cultures, there remains sig-
nicant stigma associated with mental disorders
in Cambodia.
6,8
The people of Cambodia experienced a pro-
longed period of intense conict, loss and societal
disruption between 1967 and 1975 owing to civil
war, followed by the Khmer Rouge period until
1979, with up to one-third of the population
dying from starvation, disease or execution. In
1975, Cambodia had just two psychiatrists, run-
ning a single 800-bed psychiatric hospital with a
patient population of approximately 2000.
5,9
During the Khmer Rouge period the mental
health services in their entirety were destroyed,
leaving no psychiatrists or other trained mental
health professionals.
5,6,9,10
When the Paris Peace
Agreement was signed in 1991, marking the of-
cial end of the CambodianVietnamese War
Cambodia had to completely rebuild the health,
education and community services.
4,5,7
The
long-lasting effects of genocide and war com-
pound the challenge of rebuilding the country,
as complex trauma continues to affect the mental
well-being of the people of Cambodia.
3,7
Available
epidemiological data show a high prevalence of
substance misuse, neurological and mental disor-
ders compared with normative populations.
4,7,8
Rebuilding mental health services in
Cambodia
Training
In 1992, the Mental Health Subcommittee of the
Cambodian Ministry of Health was formed to
develop the countrys mental health services.
9
Between 1994 and 2004, partnerships with the
International Organization for Migration and
the University of Oslo trained 26 psychia-
trists
5,7,9,10
and 4045 psychiatric nurses.
6,911
A combined total of 600 nurses and primary
care doctors were trained in basic mental health-
care
6,10,11
through partnerships including the
Harvard Training Program.
5,7,11
In 2005, the Cambodian University of Health
Sciences took over the 3-year psychiatry residency
training programme.
3,10
There are currently
approximately 60 psychiatrists in Cambodia:
1 per 260 000 people,
3
compared with 7068
(1 per 9300 people) in the UK.
12
Despite the rapid early growth in the number
of mental health professionals, when international
funding ended the training opportunities
reduced.
3,5,7
There has been no psychiatric
nurse training in the country since 2006.
5,10
Furthermore, it was estimated in 2012 that 30%
of the psychiatrists and 90% of the primary care
physicians who had received the basic mental
health training were no longer involved with clin-
ical mental healthcare.
4,11
Many professionals
have left to work in other medical specialties
4,10,11
or for non-governmental organisations (NGOs).
10
The Royal University of Phnom Penh has
offered a bachelors degree in psychology since
1994 and a masters degree in clinical psychology
and counselling since 2008.
4
The universitys
Department of Social Work, established in 2008,
offers both bachelors and masters programmes
in social work.
4
However, there are no established
posts for psychologists or social workers in public
hospitals
3
and most graduates work for NGOs.
8
Government services
In 2012, the total health expenditure in
Cambodia was US$1033 million.
2
Government
spending comprised just under 20% of this gure:
1
MBBS, BSc (Hons), Researcher,
OMF International, Phnom Penh,
Cambodia. Email: sarah316103@
gmail.com
2
MBChB, FFPHM, Visiting
Professor of Global Public Health,
Institute of Medicine, University
of Chester, UK
Conicts of interest: None.
Keywords. Low- and middle-
income countries; rebuilding;
strategic plan; mental health
service development; Cambodia.
First received 15 Feb 2019
Final revision 22 Aug 2019
Accepted 16 Oct 2019
doi:10.1192/bji.2019.24
© The Authors 2019. This is an
Open Access article, distributed
under the terms of the Creative
Commons Attribution licence
(http://creativecommons.org/
licenses/by/4.0/), which permits
unrestricted re-use, distribution,
and reproduction in any medium,
provided the original work is
properly cited.
BJPSYCH INTERNATIONAL page 1 of 3 2019 1
US$199.1 million. Of the total government health
spending, it was estimated that 0.02% was on
mental health.
6
There are 25 provinces in Cambodia, includ-
ing the capital city Phnom Penh. In 2015, there
were 1141 community health centres, 102 referral
hospitals, 25 provincial referral hospitals and 9
national hospitals in Phnom Penh. There is no
current systematic referral pathway between
health centres and hospitals, which is a signicant
barrier for delivering integrated mental
healthcare.
3
The rapid growth in mental health services
through international funding in the late 1990s
led to government mental health clinics operating
in 95% of provinces and three in-patient psych-
iatry units were available for emergency assess-
ments by 2007.
9
However, in 2010 this had
reduced to two in-patient psychiatry units provid-
ing a total of 14 beds,
11
and 60% of the referral
hospitals and 2% of community health centres
provided mental health services.
11
The number
of government in-patient beds has remained
low, at 1015, since 2010.
36,11
In 2018, the few
specialist out-patient mental health services were
predominantly located in urban centres.
3
The Centre for Child and Adolescent Mental
Health is the only specialist child and adolescent
mental health service in Cambodia; it is a govern-
ment service supported by an international
NGO.
3,11
In 2012, there were between 11 and 14 drug
treatment and social affair centres in Cambodia.
6
These centres were designed to address drug
dependence and provide social rehabilitation ser-
vices. A community-focused approach to addres-
sing the high prevalence of substance misuse in
Cambodia has since been proposed.
7,11
Non-governmental services
A signicant proportion of healthcare in
Cambodia is provided by private for-prot and
private not-for-prot services, which operate
alongside the government health services.
2
In
2015, there were 8488 registered private health-
care facilities and over 180 healthcare-related
NGOs in Cambodia.
2
A few of these organisations
provide mental healthcare services. People with
mental disorders may be restrained at home as
relatives are not aware of other options; this is a
focus for some human rights organisations.
4,6
NGOs tend to work independently and access to
the services they provide depends on geograph-
ical location and target population.
6
Psychosocial services frequently focus only on
meeting immediate basic needs, including shelter
and protection,
8
and there are limited services
providing psychological therapies.
6
When services
are accessed, there is often a reliance on medica-
tion alone rather than addressing psychological
needs, owing to the lack of resources.
6
However,
some NGOs are currently focusing on providing
psychological services, including trauma-focused
therapy and eye-movement desensitisation
therapy.
8
A number of psychological services are
also available through the rapidly growing private
health sector
2,4,6
and a small number of private
in-patient psychiatric beds are available.
4,10
Availability of medication
There is currently limited availability of psycho-
tropic medications, particularly in rural areas.
3
There is no unied regulation of how or by
whom psychotropic drugs are prescribed.
3
Patients are frequently prescribed several psycho-
tropic medications without being given informa-
tion on the drugs or why they have been
prescribed.
4,6
In 2012, the psychotropic medica-
tion available was mainly older generations of
pharmaceuticals
4,6
and medication shortages
were frequent.
6
Development of a mental health strategy
In 2010, the Cambodian government issued the
Mental Health and Substance Misuse Strategic
Plan for 20112015.
11
This outlined the vision,
mission and strategy for development of the men-
tal health services in Cambodia as well as some of
the key challenges faced. The vision was for All
Cambodian people [to have a] high level of men-
tal health and psychosocial well-being, contribut-
ing to the quality of lifeand the mission was
To ensure all Cambodian people will have access
to the highest quality mental health and substance
abuse services.
11
Despite this promising strategic plan there
have been several challenges to its implementa-
tion and limited progress has been made
since the initial rapid growth in the late 1990s.
It was acknowledged in the subsequent Health
Strategic Plan for 20162020 that the system was
ill-equipped and provided limited services.
2
Mental healthcare funding remains low, human
resources remain limited
3
and training initiatives
and projects frequently rely on external fund-
ing.
7,11
Developing legislation and regulation for
delivering mental healthcare was identied as a
goal in the strategic plan,
11
but there are cur-
rently no national clinical guidelines for diagnosis
and treatment of mental disorders and no mental
health legislation in Cambodia.
3
The global picture
The burden of disease attributable to mental dis-
orders is increasingly being recognised as a global
health concern.
13
It has been noted in recent
years that, despite the growing recognition of
the importance of mental health, progress and
development of services has remained slow in
low- and middle-income countries (LMICs).
13
Five challenges for global mental health identied
in 2018
13
were:
integrating mental health services into the
community setting
improving accessibility to effective psycho-
tropic medications
2BJPSYCH INTERNATIONAL page 2 of 3 2019
training multidisciplinary mental health
professionals
providing community-based care and rehabili-
tation for people with chronic mental disorders
strengthening the mental health competence
of all health professionals.
The slow progress in developing mental
healthcare services in LMICs
13
has resulted in
calls for continued evaluation and analysis of the
barriers to improving mental healthcare in
order to best inform future initiatives and policy.
Conclusions
The ve challenges
13
listed above are of great
relevance to developing mental healthcare ser-
vices in Cambodia, and the importance of devel-
oping community care is recognised in the
Mental Health and Substance Misuse Strategic
Plan.
11
The initial growth in the number of
trained mental health professionals and services
was an extraordinary achievement. Despite this,
it is widely acknowledged that the treatment gap
remains wide for people with mental disorders
in Cambodia and the governments mental health
plan is yet to be fully implemented.
2
Training
opportunities need to be restarted and main-
tained, together with efforts to prevent attrition
of professionals. More resources are needed to
address the treatment gap, improve the quality
of mental health services and implement school-
and community-based preventive initiatives.
13
Acknowledgements
S.P. thanks OMF International and Mrs Shirley Sinclair (OMF
Cambodia) for her support in writing this paper.
Author contributions
S.P. conceived the study in discussion with E.W. S.P. carried out
the literature review and drafted the manuscript and both
authors critically revised the manuscript for intellectual content.
Both authors read and approved the nal manuscript. S.P. is guar-
antor of the paper.
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BJPSYCH INTERNATIONAL page 3 of 3 2019 3
... Another consequence of the KR regime can still be seen in the lack of mental health services in present-day Cambodia (Parry & Wilkinson, 2019). Many mental health professionals were killed during this period and the only psychiatric hospital was destroyed and never reopened (MacCabe, 2007). ...
... Many mental health professionals were killed during this period and the only psychiatric hospital was destroyed and never reopened (MacCabe, 2007). In modern-day Cambodia, services have been developed in a decentralised manner, with NGOs playing a vital role in rebuilding mental health services across the country (Parry & Wilkinson, 2019). However, treatment and psychological support services for trauma survivors remain limited due to a lack of funding (Aberdein & Zimmerman, 2015). ...
... Additionally, mental health resources that are available are often through NGOs. However, despite efforts being made through a collaboration between the government and NGOs to educate mental health professionals, there continues to be a large skill shortage in the fields of psychology and social work (Stockwell et al., 2005;Parry & Wilkinson, 2019). NGOs in Cambodia tend to favour trauma-focused interventions and counselling to support their beneficiaries, although the qualifications for people working in this capacity vary widely (Aberdein & Zimmerman, 2015). ...
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We, the editors, have encouraged contributors to provide historical, 7 cultural, social, economic and political perspectives on the development of mental 8 health in the diverse nations of the Asia-Pacific region. Such a multi-pronged 9 approach is required to understand this complex phenomenon. Most nations in the 10 region were or became colonies of European powers. Just when psychiatry itself 11 was being formed as a branch of medicine in Europe, it encountered non-Western 12 cultures with deeply rooted, different approaches to mental disorders. Despite the 13 subsequent growth of Western-derived psychiatry in such countries, cross-cultural 14 issues remain significant for the current and future development of policy and 15 services. Indeed, as those involved in the new effort to reduce the burden of 16 untreated mental illness in low- and middle-income countries (LAMIC) realise, 17 cultural appropriateness is central to success. In the last decade or so a debate has 18 developed between epistemic and policy communities as to how best to do this. We 19 believe it will advance understanding if we put the current situation in LAMIC, 20 where globalisation is producing rapid, often disruptive, cultural, economic and 21 social change, in a comparative historical context: the health effects, physical and 22 mental, of this current transformation may be compared with the health impact of 23 the ‘modernisation’ of the West in the nineteenth century. The rise of asylum 24 psychiatry itself in Europe may be seen as an organised, expert response to the 25 growth of mental disorders produced by the speedy, initially unregulated, impact of 26 industrialisation and urbanisation on traditional ways of life, just as the rise of 27 public health in the same era may be viewed as an organised, expert response to the 28 growth of threats to physical health from ‘fevers’ and other communicable diseases.
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Cambodia is a developing south-east Asian country located in the fertile Mekong delta. Its recent past has been complicated by European colonialism and internal conflict. Health including mental health services are limited and sparse in regional and rural areas. Very constrained public mental health facilities and services are hampered by a shortage of a skilled workforce and insufficient training programs. The recent formation of the Mental Health Association of Cambodia promises to be a positive step forward in promoting mental health throughout the country.
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  • T Schunert
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  • S Kao
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Mental Health and Substance Misuse Strategic Plan 2011-2015. Ministry of Health, Royal Government of Cambodia
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