CameHelp: Cambodian Mental Health Project
Building a world class mental healthcare system affordable to all Cambodians
The key aim of this initially 2-year project is to research protocols for the assessment and treatment of three prevalent mental health conditions (anxiety, depression, and post-traumatic stress disorder [PTSD]) within Cambodian hospitals. The project will also provide research of global significance, to be published in international journals, in collaboration with relevant people.
Improving mental health services is a key health challenge for developing countries across South East Asia. Cambodia faces particular challenges following a genocide and series of wars in the 1970s and 1980s. During this period, healthcare and university services were nearly entirely destroyed, including through a particular targeting of medical practitioners and academics for execution during the Pol Pot era. In the last two decades, Cambodia has made impressive efforts to rebuild its health and educations systems, including through the establishment of an infrastructure of hospitals and medical education universities. This has led to notable improvements in physical health as seen, for example, in arrested and declining HIV rates. However, with the primary initial focus on physical and not mental health, the Cambodian population is still largely without access to even rudimentary psychiatric or psychological treatments within both primary and secondary care. This project aims to help the Cambodian healthcare system move to the next necessary stage of development, through beginning an integrated mental health care system, enabling both the alleviation of direct suffering and the better treatment of physical health conditions. In doing so, three key challenges within the existing Cambodian healthcare system will be met.
First, rates of untreated mental illness are very high, which are associated with substantial suffering and stigmatisation at the population level. Globally, the World Health Organisation (WHO) estimates that depression alone causes more suffering than that generated by all physical disorders combined. This suffering may be expected to be exceptionally high in Cambodia as almost no one in the older generation will have avoided witnessing or experiencing highly traumatic events, and the younger generation will have been born and parented in the recent aftermath of the trauma. Second, mental health conditions are often misdiagnosed as physical health complaints. This leads to inappropriate (and often invasive) treatment that both wastes resources and risks harming the patient. Further, the original mental health condition is often exacerbated by the side effects of the unnecessary treatments and the additional anxiety and depression caused by the misdiagnosis itself. Third, the treatment of chronic physical health conditions (e.g., diabetes, tuberculosis, etc.) is complicated through a lack of assessment or treatment of co-morbid mental health conditions, resulting in the physical health conditions being more difficult and expensive to treat, as well as causing a considerably worse prognosis for the patient. For example, key challenges of HIV programmes include: (a) missed appointments; (b) patients dropping out of the system; (c) the need to locate patients that have so disengaged; (d) lack of adherence to treatment leading to both the emergence of opportunistic infections and HIV medication failure; (e) the need to use newer, more expensive medication due to first line medication failure; (f) erratic medication compliance risking the emergence of drug resistance at the population level with international implications. Much of these problems emerge from patient disengagement and non-compliance, a key predictor of which in other countries is untreated simple mental health conditions such as anxiety and depression. Adding a mental health assessment and treatment protocol to programmes for chronic physical health conditions may not only reduce mental suffering, but also improve the physical health outcome and lead to a net financial saving for the programme.
The implementation of an evidence based mental health programme is not currently possible due to the near total lack of research on how to assess or treat mental health in Cambodia, and because there is no current mechanism to disseminate new protocols to doctors and hospitals. The aim of the proposed research programme is to begin to meet these needs.
Research and Implementation Plan
Phase 1: Developing a psychiatric assessment protocol for anxiety, depression, and PTSD
The need: Correct diagnosis is the cornerstone of evidence based medicine; it allows for the triage of patients according to need and enables the correct allocation of the patient to treatment. It is not currently known how to assess mental health conditions in Cambodia.
The research: Two new ways of assessing mental health in Cambodia will be developed; (1) a short screening measure to detect probable cases of mental health conditions; (2) a more detailed measure for the accurate diagnosis of the probable cases indicated.
The improvement in practice: Patients across the initially participating hospitals will undergo routine Mental Health (MH) screening. MH triage will be based on; (a) the probably severity of the disease as indicated by the screening measure; and (b) whether the patient is undergoing treatment for a chronic condition which will be affected by the MH problem. All doctors will be trained in the simple screening assessment, and a core team of doctors will have additional training in the fuller assessment. Patients who pass triage will be sent to the MH trained doctors for fuller assessment and diagnosis. All protocols will be presented in easy to understand A4 laminated flow charts (printed in English and Khmer) that can be placed on the walls of consulting rooms.
Phase 2: Developing a medication treatment protocol anxiety, depression, and PTSD
The need: In Cambodia, there are currently several medications (e.g., amitriptyline, citalopram, sertraline, and fluoxetine) that are commonly used to treat anxiety and depression. In the West, these have been shown to be equal in effectiveness and to differ only on their side effect profiles. It is not known whether these medications will be similarly effective in Cambodia, and there are reasons to believe they will not. For example, sertraline leads to rapid (although short) withdrawal symptoms, whereas fluoxetine withdrawal symptoms emerge much later if at all. Cultural differences between the West and Cambodia may mean that in this setting sertraline may be more effective, due to the local cultural tendency to stop taking medicine as soon as the symptoms reside instead of completing the full course. There is little research in any country as to which medication works best for PTSD, as in fully developed mental health systems very in-depth psychosocial therapy is used in preference. Doctors in Cambodia need to know what medication works best for what condition within their cultural context and whether any improvement in efficacy justifies any additional cost of the medication.
The research: Patients will be accurately diagnosed (using the tools developed in Phase 1) as having either anxiety, depression, anxiety and depression, or PTSD. Patients within each diagnostic category will be randomly allocated to receive one of two or more possible medications (each of which have been shown to work well in the West). The outcomes will be (a) drop-out and (b) improvement in symptomology and cure rate, combined with a financial cost/benefit assessment to see whether any additional cost of using the most efficacious medicine is worth the additional resources required.
The improvement in practice: Doctors will know which medicine is most effective for anxiety, depression, co-morbid anxiety and depression, and PTSD respectively. This information will inform hospital policy as to which medication to use with which patient, which will be presented in the form of a simple to use flow diagram, printed on a laminated A4 card, which will be placed on walls of the consulting rooms. Training will be provided to doctors involved in the treatment of mental health in each of the three hospitals, building on the training given to doctors in phase 1.
Phase 3: Extensions
In the third phase (post-2 years) there are a number of options as to how to further develop the project, including; (a) rolling out the assessment and treatment protocols to other hospitals and clinics across Cambodia; (b) recreating the project in other regions (e.g., in other SE Asian countries); (c) researching how to assess and treat more complex conditions (e.g., schizophrenia); (d) establishing full service psychiatric treatment centres that can treat the most complex and challenging conditions; (e) increasing the range of treatment options to include both low and high intensity psychotherapy and equipping the hospitals to deliver these services; (f) establishing the hospitals as regional centres of excellence in mental health training; (g) developing a formal training qualification.
The provision of a depression, anxiety, and PTSD assessment protocol to the participating hospitals.
The provision of a depression, anxiety, and PTSD treatment protocol to the participating hospitals.
Assistance in incorporating the protocols within each participating hospital, based around their own individual needs.
The establishment of a training programme in each of the participating hospitals on how to use the assessment and training protocols.
The publication in peer reviewed journals of at least three papers reporting on the findings of research in the study, with opportunity for involvement from the research team, key people in each of the participating hospitals, the local government, and local universities.
Quotes from doctors interviewed as part of the feasibility phase of the project:
1. “In the rural areas, people with Schizophrenia are tied up to trees. The families don’t know what to do, you know? They love their relative but they must work or they will starve. And the hospitals can’t help, they don’t know, they don’t know…”. Doctor.
2. “Of course we only treat Westerners for anxiety and depression. Cambodian’s don’t get this, it is a Western problem”. Doctor at a premier private hospital; the consultation cost two weeks’ pay at typical local salaries ($20).
3. “We commonly have patients with anxiety coming here with bags of unlabelled medicine they have been given by other hospitals. The other hospitals see sweating, high pulse rate, and shaking and start treating them for heart problems, which makes them sick and their anxiety worse, so they are given more heart medication…” Senior Doctor.
4. “There is only one medicine that I know how to use for depression, amitriptyline [a drug discontinued in the West in the 90s due to side effects and safety fears]. It is all we have. When we have patients who don’t respond I send them to the big psychiatric hospital. Once one came back. He’d been treated with amitriptyline; it seems it was the only one their doctor knew how to use too. Twice I’ve saved someone’s life as I recognised they were having a [common] fatal reaction to the unlabelled medicine they’d been given by another hospital. It was for schizophrenia. Patient no have schizophrenia… Please help us, please help us learn about more medicine and more about side effects.” Cambodian Doctor.
5. “My mother gets very angry, but that’s ok. The doctor explained that this was due to her diabetes. I am very grateful to Sonja Kill [our partner] hospital. If my mother had gone anywhere else she would be dead. If this printing is for them, I’ll keep the shop open and work all night if I have to.” Chance encounter with the son of a patient when asking for printing to be done at a closing shop.