Cambodia - Solutions elusive as Kingdom grapples with rise in suicides

They were planning a May wedding. Instead, Phai Kak, 18, found herself dutifully handing out plates of rice as the incense burned at the funeral of her fiancé, San Ren.

Gathered at the ceremony were a clutch of older villagers, their faces deeply lined, dressed in mourning white. A monk, swathed in saffron, incanted as palms were joined in prayer; he later accepted gifts.

Ren, at 21, had taken his own life. The reason, according to local media reports, was an argument with his mother about an iPhone. But that simplistic account obscured crucial pieces of his story.

Despite National Police figures saying suicide in Cambodia is on the rise and suicides appearing almost daily in the local press, experts say critical underlying factors – such as depression or other mental illnesses – still go unreported, untreated and unacknowledged. And without recognition of the scale and causes of the problem, solutions have been slow in coming.

Ren had called his mother, Van Kehn, 38, to talk about a phone just minutes before his death, but he also told her something that alarmed her.

“He said: ‘Mum, there are many police coming and surrounding the house, they came to catch me’,” Kehn said.

Confused, she asked her son if he had done anything wrong. Nothing, he said, and hung up. Just 15 minutes later, his fiancée, Kak, rang with the news: Ren had hanged himself; he was dead. There were no police.

The figures on suicide in Cambodia are sketchy. The National Police began recording suicides in 2011 and the number has been on the rise since, from 513 in 2011 up to 743 last year. However, frontline services and mental health sector experts were unable to confirm or provide a reason for such a dramatic increase.

What’s clear is that these numbers do not reflect the true scale of the problem, as they only signify when police have become involved in violent or suspicious deaths by suicide.

Past estimates of suicide rates in Cambodia have varied wildly, from between one and 42 per 100,000 people, or anywhere from 150 suicides per year to 6,300.

However, the researchers from the Royal University of Phnom Penh psychology department who came up with the latter estimate from a survey in 2012 have since admitted their methodology was flawed.

According to Dr Keith Harris, a researcher at the University of Queensland’s school of psychology, getting decent data is crucial to suicide prevention.

In a recent report, his team of researchers analysed two large Khmer-language newspapers to find a number of suicide deaths, then used an algorithm to calculate a projected figure, putting it at 3.8 per 100,000 people in 2012 – equating to about 565 per year – a figure he says likely falls short of the mark.

His report found suicide death rates of men were twice the rate of women, and twice as high for those under 40.

Statistics aside, there’s no doubt the number of people seeking help for mental health problems is increasing at a rapid rate – and Cambodia’s incredibly limited mental health services are being swamped.

Less than an hour after Ren’s funeral, on Phnom Penh’s Cambodia-Japan Friendship Bridge, a string of motos and tuk-tuks stood still, their drivers dangling arms over the bridge rail, pointing and peering into the river below.

A bystander said a man had jumped. But moments later, dripping, he emerged. A passing fishing boat had scooped him from the water.

Srah Chak commune police later confirmed the 28-year-old man from Tbong Khmum province had attempted suicide.

The man had been suffering from a mental illness, and had just come from the Khmer-Soviet Friendship Hospital, where he was unable to receive medicine for his condition.

A motodop took him to the bridge. He had no money, so he handed over his phone to the driver instead before leaping off and being saved by the fisherman’s boat, police said.

The man was just one of some 500 patients to visit the Khmer-Soviet Friendship Hospital’s psychiatric department that day, and according to its director, Dr Chak Thida, the facility is overwhelmed.

Every day, she said, the hospital received between 400 and 500 patients, and up to 50 of those are new cases, mostly depression and anxiety.

That is a drastic increase compared with a few years ago, she said, when they would see between 100 and 200 patients daily. But the hospital, with only 12 psychiatric doctors, is under-resourced and ill-equipped to deal with the load.

“It’s a burden for us, because each of our doctors need to treat 30 to 40 patients per day for mental illness,” Dr Thida said.

“In other countries, doctors like us would treat only four or five patients.

“We don’t have enough medicine, and there are not enough doctors, and we have no time to treat them attentively.”

Only six of Cambodia’s 25 provinces and municipalities have a psychiatrist at their referral hospital – Phnom Penh, Battambang, Siem Reap, Pursat, Kampong Cham and Kampong Thom – with the latter three having only one specialist apiece.

Although Dr Thida said awareness was growing, it’s likely that even more mentally unwell people would be seeking help if there were greater understanding of the nature of the problem.

Ren’s fiancée, Kak, said it was not the first time he had thought about suicide. The garment worker said Ren had tried to end his life two or three times since they began living together in December.

“He tried to commit suicide a few times, but my mother and I managed to stop him in time,” she said.

In their village in Russey Chroy commune, in Kandal’s Muk Kampoul district, she was unsure where to seek help for suicidal thoughts and turned to the local pagoda.

“I brought him to the monk for a water blessing. I didn’t know where I should go for these symptoms; I had not thought of a hospital,” Kak said.

Despite the previous suicidal thoughts and the strange vision of encircling police, Ren’s father, San Ra, 44, was adamant his son did not have a mental health condition.

“My son has never been sick or taken any medicine, or any drugs, and he has never had any mental problem,” Ra said. “Since he was born, he was very strong and hard-working.”

For his parents, the fact he saw a phantom swarm of police officers surrounding the home bears not a hint of mental illness, but a spiritual premonition.

It was a vision from a “bad spirit”, they said, perhaps the same one that forced him to take his own life.

Compounding Ra’s shock is his perception that children tend to use the threat of suicide as a bargaining chip.

“It is only that they want something, and they are afraid their parents would not give it to them, so they say they will commit suicide,” he said.

Cambodia currently has no suicide prevention plan and, according to Dr Chhit Sophal, director of the Ministry of Health’s department of mental health and substance abuse, when media outlets report suicide as a trivial matter – the result of a love triangle or an unfulfilled material desire – they are mistaking “triggers” of suicide for “causes”.

“Not many Cambodian people understand that suicide is a public health issue or mental health problem. Thus the awareness of suicide among the general population and the development of support services are very important,” he said.

Dr Sophal lists cumulative stress, mental health crises, family conflict, social issues and substance abuse as root causes of suicide, while one unpleasant moment or problem might become a trigger.

Dr Sotheara Chhim, executive director at the Transcultural Pyschosocial Organisation (TPO), agreed that suicide was not always the result of a diagnosed mental illness – it could sometimes be due to “acute stress” that had “overcome individual’s capacity to deal with loss”.

He explains to his patients that depression needs time for recovery, but many, like Kak, still believe a traditional healer would be the best solution.

A suicide prevention hotline, he said, could make a world of difference. “They desperately want someone to talk to,” he said.

“Sometimes they don’t need medication, only someone who has the time for them.”

He said it was crucial to train community members in villages in mental health first aid, giving them the skills to recognise a problem and refer cases to professionals.

Instead of treating suicidal people “like criminals”, he said, police should be trained to speak with those they find teetering on the edge of the bridge. “Instead of pointing a gun at them, they should talk to them, understand them in an empathetic way and refer them [to mental health services],” he said.

Dr Sophal told the Post suicide prevention would be considered as a component in the upcoming Strategic Plan for Mental Health and Substance Abuse 2017-2020, and while he hoped suicide cases would be recorded at health facilities “in the near future”, it was just one priority in a field with scant resources.

“The [Ministry of Health] has recognised that suicide is a public health issue and will take action to prevent it as much as possible within our limited resources and capacity,” he said. “It is a resource-based approach, not a demand-based [approach].”

However, Ra said that in line with his Buddhist beliefs, his son died because it was simply his time.

“When I heard he committed suicide, I was speechless,” Ra said, blotting away tears.

“When people tell me my son tried to commit suicide a few times before, I don’t believe them, because everyone tries so hard to survive; no one wants to die or would like to die,” he said.

Kong Meta and Erin Handley

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