‘Mental health is ignored the world over, not just in Bhutan’

Dr. Chencho Dorji, Bhutan’s first psychiatrist and recipient of the Hubert Humphrey Fellowship award talks to Business Bhutan’s senior reporter Chencho Dema on the country’s mental health landscape and issues plaguing the happy country. He is currently a professor of Psychiatry in the Faculty of Post-Graduate Medicine, Khesar Gyalpo University of Medical Sciences of Bhutan.

Q. Bhutan is known as a happy nation to the outside world but beneath the exterior we have people who suffer from mental disorders like depression. What could be the reasons for this and how can this issue be tackled?

A. Many people believe that Bhutan is the happiest place on the earth and this is good for our country! Our happiness brand is selling like hotcakes to the outside world and attracting a lot of people to visit Bhutan. Whenever I travel outside Bhutan, I tell people that Bhutanese aspire to be the happiest people on this earth and that’s why we have a development philosophy of Gross National Happiness by which we try to balance material development with psychological wellbeing and happiness.

The concept of GNH becomes even more relevant to Bhutanese now as we move forward to join the global community and aspire to become more economically affluent. As a human species, we are no different than any other nationality or race and we are as vulnerable to mental disorders like any other human being.

However, I believe that the prevalence of mental disorders in Bhutan is much less than when compared to other countries. Whether our culture and society is more resilient to mental illness or more accepting of them, it is difficult to tell. We have not done country wide prevalence studies, which would give us precise figures. Of course depression is a common illness worldwide and we have our share of people suffering from depression.

The cause of depression is multi-factorial like all other mental disorders and it is difficult to pinpoint one cause or the other. One can have a genetic inheritance of the disorder, or adverse traumatic childhood experiences that can predispose an individual to the disorder. Psychosocial stressors in life can aggravate onset of illness while lack of social support and poor coping skills can perpetuate the course the illness.

Modernization factors such as migration, loss of traditional family and community support, increasing competition and demands of work and career, use of addictive substances increase the risk of developing mental disorders. GNH values and practices are developed to counter act some of these modern vices to our well being and health and that is why it is important that we promote GNH not only in the country but also the world!

Q. What are the main mental disorders in Bhutan? Which illness tops the list? What is being done about it?

A. Anxiety disorders among youth, alcoholism among middle aged men and somatoform pain disorder among middle aged women tops the list of mental disorders in our country, whilst mood disorders like depression are common in all aged groups. We have now established under-graduate clinical counseling courses in the Khesar Gyalpo University of Medical sciences of Bhutan. The first batch of clinical counselors will graduate this summer. They will provide psychotherapy and counseling to youth with anxiety disorders.

All health workers in the country are trained and provided with essential medicines to provide detoxification and treatment of patients affected by alcohol and drugs, and other mental disorders. All health facilities in the country are equipped to manage common mental disorders whilst severe cases can be referred to psychiatrists in Jigme Dorji Wangchuck National Referral Hospital, which has 20 dedicated beds for people affected by severe mental disorders and addiction. At the moment, we have four psychiatrists in the country. We have now initiated psychiatry residency training in the country as well and soon we will have enough psychiatrists to treat patients.

Q. Is advocacy and awareness enough to get rid of social stigmatization on mental disorder? What else can be done?

A. The main reason for stigma and shame related to mental illness is due to lack of knowledge of the illness, their causes, symptoms and how to treat them. Myths, superstitions and false information about the causes and treatment of mental disorders prevail in our culture. Traditional methods of treatment are not effective to treat severe mental disorders like schizophrenia and mood disorders. Some people develop fear of people affected by mental disorders as they are not predictable or sometimes they are violent, while others get emotionally overwhelmed or burn out looking after them.

Treating people with mental disorders poses extra challenge when compared to other illness. Quite often people affected by severe mental disorders like schizophrenia and mood disorders lose their insight and capacity to make rational judgment. They do not know or accept that they have a mental disorder and so they refuse treatment. Sometimes, treatment has to be given involuntarily without the consent of patient.

So while it is important to educate the general population about mental disorders, it is particularly important to do so with the families of people suffering from mental disorders because they are the backbone of social support to patients. Families need to be specifically educated on medications as they have to supervise medication at home. Most mental disorders are chronic in nature and need long term medications and social support.

Q. Why do you think the issue of mental disorders in Bhutan does not get adequate attention?

A. Mental disorders are neglected in all countries especially in poor ones and not just in Bhutan. One of the main reasons is that mentally ill people do not have much of a voice in both politics and public media. Mentally ill people drift down the social ladder and lives in the fringes of society. They are not able to assert their needs individually or collectively. However, the Bhutanese situation is much better than most developing countries. The government provides free medication and treatment to all patients including mentally ill through a program called community-based mental health care. All health workers are trained on basic psychiatric skills to manage patients and provided with psychotropic drugs. Patients can be admitted in any health centre in the country. A limited budget is allocated every year for training of health workers and purchase of medications. 

Q.  Suicide cases have been on the rise. How can we get to the bottom of the issue and prevent losing lives?

A. The increase in reported cases of suicide in the country can be due to two reasons: either actual number of suicides is increasing or more reporting is available now. Suicide is a complex human phenomenon with multi-factorial causes and there is no simple solution to prevent it. Majority of the suicide cases can be attributed to mental disorders while others causes are social,   drug and alcohol related. It is well known that fast pace of development, while it benefits majority of people, some of the weaker and unfortunate ones suffer the consequences of not being able to catch up and succumb to suicide.

Suicide can be prevented though. All we need is a comprehensive and multi-stakeholder approach to suicide prevention. Mental health services will address internal factors for suicide such as mental illnesses, while social and regulatory services can address external factors for suicide such as providing social security and minimizing the means to suicide risks. Bhutan has done a review of 5 years suicide deaths 2009 – 2013 and formulated and implemented suicide prevention action plan 2015-2018. There is a dedicated suicide prevention program in the Ministry of Health and they are evaluating the previous plan and formulating a new plan of action now.