Overview of Mental Health in Cambodia

1. Background/Cultural Points:

   Mental health disorders are common in Cambodia, though Cambodians don’t have an extensive language for such issues. Generalized anxiety, depression, and substance abuse (alcohol and smoking in men) are most common, followed by somatization disorder, conversion disorder, panic attacks/disorder, and PTSD. Most Cambodians live in stressful situations with contexts of poverty, broken families, and traumatic histories. Cambodians older than 40 typically have clear, disturbing memories of the 1970s genocide and the Vietnamese occupation of the 1980s (which was far less traumatic). More commonly, traumatic memories may include sexual abuse or eyewitnessing a disturbing traffic accident.

   Younger Cambodians reaped the damage of a fractured society resulting from the Khmer Rouge days and a worldview, family/societal structure, and western-media influence that feed a confusing moral climate. Pornography, drug use (especially methamphetamine and marijuana), and sexual promiscuity and rape are common.

2. Work-Up/Diagnosis & Lab:

   1. In the patient presenting with multiple complaints (headache, fatigue, stiff neck, palpitations, abdominal discomfort), consider generalized anxiety with mild depression. Asking about sleep habits can provide a helpful clue.
   2. Rule out organic causes of symptoms in a cost-effective way:
      1. HCT and glucose on site for the fatigued patient
      2. TSH screen may be useful
      3. “Palpitations” 🡪 EKG can reassure an anxious or panic attack patient
      4. Other tests as indicated, such as RPR for syphilis or Head CT if focal neurologic exam or other red flags for intracranial lesion
   3. Consider:
      1. “Chest tightness” 🡪 anxiety, GERD, panic attacks
      2. “Headache” 🡪 insomnia, dehydration, tension
      3. “Think a lot” (especially at night) = anxiety/insomnia
      4. “Discouraged heart” = depression
      5. “Palpitations” upon being surprised = normal variant or generalized anxiety
      6. “Crazy” or “Nerves” may mean psychosis/schizophrenia
      7. Somatoform Disorders, such as conversion, somatization
   4. Referral to psychiatry at Phnom Penh Municipal Hospital grounds is an option. Neurologists are available and may be helpful as well. See In-Country Resources list in patient exam rooms.

3. Management/Education/Treatment:

   1. Medications:
      1. Low-dose amytriptyline (very cheap) is frequently helpful. Improves sleep and breaks cycle of somatization (headaches, etc). Do not prescribe large amounts in the depressed patient or young people who are at higher risk for suicide.
      2. Diazepam is readily available and cheap. Caution dependence.
      3. Fluoxetine is the preferred SSRI, available as generic. We usually do not prescribe this until after a trial of amytriptyline
      4. Haloperidol (with a nonselective Beta-blocker – eg, propranolol - instead of benztropine, for prevention of EPS such as pseudoparkinsonism and akathisia) is preferred. Atypical antipsychotics are not available. Caution the patient regarding anticholinergic symptoms, Extrapyramidal symptoms, and Tardive Dyskinesia.
   2. Resources available:
      1. Free professional counseling at MMC may be available For women recovering from rape, etc – Hagar, White Lotus, Daughters, and other NGO’s are available.
      2. Alcoholic Anonymous (www.aacambodia.org; 012 222 179 helpline)

4. Follow-Up: As indicated.