Introduction
Key Issues
Recommendations

Introduction

In addition to the expected occurrence of mental illness that is found in any country of the world, Cambodia has the additional burden of mental distress that can be attributed to years of conflict and oppression, often referred to as trauma-related mental illness. The two together have a tremendous impact on the development of Cambodia. A world-wide measure of the impact of illness of various types - called Global Burden of Disease, developed by the World Health Organization, the World Bank and Harvard University - states that mental illness, including suicide, is the second greatest cause of lost years of healthy life, second only to heart disease. The millions who suffer from undiagnosed and untreated mental illness represent productive time lost and the loss of ability to participate fully in activities which lead to personal, family, community and national development. It is well documented that the effects of traumatic war experiences can and do impede people's abilities to engage in activities that promote development, for example, planning ahead and forming interdependent relationships with others. 

However, donors and leaders continue to treat the development of a mental health system as though it were a 'frill' that can wait until basic national development has been accomplished. In fact, the development of a comprehensive mental health system is an essential component of development and poverty reduction. 

A comprehensive mental health system is also vital to breaking the cycle of violence in Cambodia. The violence and traumas of the past continue to breed fresh violence and trauma of the present, reflected in the high levels of violent crime and exploitation prevalent in Cambodian society today. Without adequate mental health services, this cycle of violence will continue to impede Cambodia's social and economic development. Without it development will be retarded.

Insufficient resources - human, technical or financial - are devoted to this problem. Needed are culturally relevant and accessible services, research, and a comprehensive system to address the long-term mental health needs of the nation, and thus to increase the capacity of citizens to take full advantage of development programs and strategies. 

Current Situation

• Within Cambodia there are currently six NGO/IOs working in mental health.
  
• Only one program, Center for Child Mental Health, in Takhmau, works in children's mental health sector, while 40% of the national population is under 15.
  
• The Ministry of Health has only one part time staff dedicated to Mental Health, a psychiatrist who coordinates the work of the Mental Health Subcommittee of the Coordinating Committee of the Ministry of Health (COCOM)
  
• Government funding of the mental health system is limited to the provision of essential psychotropic drugs which are provided in limited quantities, and run short every year.
  
• There are ten internationally qualified Cambodian psychiatrists (trained by the Cambodian Mental Health Development Programme) and ten more will graduate in 2001.
  
• Ten nurses have graduated from a one-year psychiatric nurse training program, and ten more will graduate in 2001.
  
• 126 General Practitioners have been given a two week training in mental health work in general hospitals
  
• Four regional outpatient clinics are operated in Battambang, Kompong Cham, Kampot, and Kompong Speu under the supervision of the psychiatrists of CMHDP, and operated by general practitioners and Nurses or Medical Assistants. In addition, in Battambang, 12 local clinics have mental health services.
  
• 102 general physicians from 24 provinces and municipalities have graduated from a mental health training program, operated by Harvard University's School of Public Health, intended to enable them to diagnose and treat - with medication and counseling - mental and psychosocial disorders in their general practices. 
  
• Two NGOs (Transcultural Psychosocial Organization and Social Services of Cambodia) have trained community-based social workers who do counseling, advocacy, community and family education, support groups, and are helping people with mental and psychosocial problems to return to full functioning in their communities and homes.
  
• The Royal University of Phnom Penh's Department of Psychology has produced two graduating classes of psychologists, and more are coming up.
  
• There is one psychosocial rehabilitation center serving 36 clients with severe mental illness at Psar Daum Tkauv Mental Health Center in Phnom Penh, operated by IOM, SSC and the Municipal Department of Health.

Key Issues

• The mental health system is not yet comprehensive or adequate, but planning steps have started. In March 2000, the organizations active in mental health initiated a participatory planning process to create a mental health system, including inpatient, outpatient, and community-based services, human resource development, a legal framework, and mechanisms for coordination between relevant ministries and organizations. A proposal has been written to fund a full time professional mental health planner for one year to coordinate and document the plan. While the current organizations are cooperative and interested, they do not have the necessary time or expertise to conduct such a planning process without expert assistance. 
  
• The Ministry of Health has begun to pay greater attention to mental health, and is proposing to set up a National Mental Health Program.
  
• The attitude of the public and decision-makers towards mental illness is stigmatizing. On April 7, 2001, Cambodia had a major public relations campaign for mental health by celebrating World Health Day for Mental Health. Street banners, t-shirts, and a lively presentation at the Ministry of Health and broadcast on TV helped to bring new ideas about mental health. Further work is needed to raise awareness and create a climate of acceptance and understanding for people with mental illness to be treated and to regain their roles in their families and society.
  
• Many severely mentally ill people are still found on the streets in the cities or chained or tied up in the countryside. Services are not yet available to the vast majority of Cambodians suffering from mental illness, and they are often treated as criminals and objects of fear and hate, rather than people with an illness. The need is for clear and humane laws which are enforced to protect and assure fair treatment of people with mental illness.
  
• Human resource development has begun to provide the needed personnel to staff the mental health system. Mental health services are both medical and psychosocial in nature, and personnel in proportion to the population in need must be developed. Psychiatrists and psychiatric nurses, social workers and paraprofessional community workers are required to provide the needed services in clinics and especially in the community.
  
• Development practitioners are beginning to recognize the need to incorporate awareness of and services for people with mental problems in their work. This phenomenon is shown in the increasing number of requests for training being received by all the current mental health agencies. It is a positive sign of increased interest. 

Recommendations

1. Funds should be made available to support a thoughtful, participatory planning process involving all stakeholders, including both government and NGOs, so that resources are well used and people with mental illness are well served in the future.

2. Donors should seek out and support development programs that incorporate program elements to support people's mental health. 

3. As mental health agencies localize their programs, there is a need for adequate salaries for trained and qualified government staff in mental health so that they can provide professional mental health services to those who need them.