Training

In 1992, the Mental Health Subcommittee of the Cambodian Ministry of Health was formed to develop the country's mental health services.^{Reference MacCabe, Sunbaunat and Bunthoeun9} Between 1994 and 2004, partnerships with the International Organization for Migration and the University of Oslo trained 26 psychiatrists^{Reference Minas and Lewis5,Reference Jegannathan, Kullgren and Deva7,Reference MacCabe, Sunbaunat and Bunthoeun9,Reference Deva, D'Souza and Sundram10} and 40–45 psychiatric nurses.^{Reference McLaughlin and Wickeri6,Reference MacCabe, Sunbaunat and Bunthoeun9–11} A combined total of 600 nurses and primary care doctors were trained in basic mental healthcare^{Reference McLaughlin and Wickeri6,Reference Deva, D'Souza and Sundram10,11} through partnerships including the Harvard Training Program.^{Reference Minas and Lewis5,Reference Jegannathan, Kullgren and Deva7,11}

In 2005, the Cambodian University of Health Sciences took over the 3-year psychiatry residency training programme.^{Reference Olofsson, Sebastian and Jegannathan3,Reference Deva, D'Souza and Sundram10} There are currently approximately 60 psychiatrists in Cambodia: 1 per 260 000 people,^{Reference Olofsson, Sebastian and Jegannathan3} compared with 7068 (1 per 9300 people) in the UK.¹²

Despite the rapid early growth in the number of mental health professionals, when international funding ended the training opportunities reduced.^{Reference Olofsson, Sebastian and Jegannathan3,Reference Minas and Lewis5,Reference Jegannathan, Kullgren and Deva7} There has been no psychiatric nurse training in the country since 2006.^{Reference Minas and Lewis5,Reference Deva, D'Souza and Sundram10} Furthermore, it was estimated in 2012 that 30% of the psychiatrists and 90% of the primary care physicians who had received the basic mental health training were no longer involved with clinical mental healthcare.^{Reference Schunert, Khann and Kao4,11} Many professionals have left to work in other medical specialties^{Reference Schunert, Khann and Kao4,Reference Deva, D'Souza and Sundram10,11} or for non-governmental organisations (NGOs).^{Reference Deva, D'Souza and Sundram10}

The Royal University of Phnom Penh has offered a bachelor's degree in psychology since 1994 and a master's degree in clinical psychology and counselling since 2008.^{Reference Schunert, Khann and Kao4} The university's Department of Social Work, established in 2008, offers both bachelor's and master's programmes in social work.^{Reference Schunert, Khann and Kao4} However, there are no established posts for psychologists or social workers in public hospitals^{Reference Olofsson, Sebastian and Jegannathan3} and most graduates work for NGOs.^{Reference Aberdein and Zimmerman8}

Government services

In 2012, the total health expenditure in Cambodia was US$1033 million.² Government spending comprised just under 20% of this figure: US$199.1 million. Of the total government health spending, it was estimated that 0.02% was on mental health.^{Reference McLaughlin and Wickeri6}

There are 25 provinces in Cambodia, including the capital city Phnom Penh. In 2015, there were 1141 community health centres, 102 referral hospitals, 25 provincial referral hospitals and 9 national hospitals in Phnom Penh. There is no current systematic referral pathway between health centres and hospitals, which is a significant barrier for delivering integrated mental healthcare.^{Reference Olofsson, Sebastian and Jegannathan3}

The rapid growth in mental health services through international funding in the late 1990s led to government mental health clinics operating in 95% of provinces and three in-patient psychiatry units were available for emergency assessments by 2007.^{Reference MacCabe, Sunbaunat and Bunthoeun9} However, in 2010 this had reduced to two in-patient psychiatry units providing a total of 14 beds,¹¹ and 60% of the referral hospitals and 2% of community health centres provided mental health services.¹¹ The number of government in-patient beds has remained low, at 10–15, since 2010.^{Reference Olofsson, Sebastian and Jegannathan3–Reference McLaughlin and Wickeri6,11} In 2018, the few specialist out-patient mental health services were predominantly located in urban centres.^{Reference Olofsson, Sebastian and Jegannathan3}

The Centre for Child and Adolescent Mental Health is the only specialist child and adolescent mental health service in Cambodia; it is a government service supported by an international NGO.^{Reference Olofsson, Sebastian and Jegannathan3,11}

In 2012, there were between 11 and 14 drug treatment and social affair centres in Cambodia.^{Reference McLaughlin and Wickeri6} These centres were designed to address drug dependence and provide social rehabilitation services. A community-focused approach to addressing the high prevalence of substance misuse in Cambodia has since been proposed.^{Reference Jegannathan, Kullgren and Deva7,11}

Non-governmental services

A significant proportion of healthcare in Cambodia is provided by private for-profit and private not-for-profit services, which operate alongside the government health services.² In 2015, there were 8488 registered private healthcare facilities and over 180 healthcare-related NGOs in Cambodia.² A few of these organisations provide mental healthcare services. People with mental disorders may be restrained at home as relatives are not aware of other options; this is a focus for some human rights organisations.^{Reference Schunert, Khann and Kao4,Reference McLaughlin and Wickeri6} NGOs tend to work independently and access to the services they provide depends on geographical location and target population.^{Reference McLaughlin and Wickeri6}

Psychosocial services frequently focus only on meeting immediate basic needs, including shelter and protection,^{Reference Aberdein and Zimmerman8} and there are limited services providing psychological therapies.^{Reference McLaughlin and Wickeri6} When services are accessed, there is often a reliance on medication alone rather than addressing psychological needs, owing to the lack of resources.^{Reference McLaughlin and Wickeri6} However, some NGOs are currently focusing on providing psychological services, including trauma-focused therapy and eye-movement desensitisation therapy.^{Reference Aberdein and Zimmerman8} A number of psychological services are also available through the rapidly growing private health sector^{2,Reference Schunert, Khann and Kao4,Reference McLaughlin and Wickeri6} and a small number of private in-patient psychiatric beds are available.^{Reference Schunert, Khann and Kao4,Reference Deva, D'Souza and Sundram10}

Availability of medication

There is currently limited availability of psychotropic medications, particularly in rural areas.^{Reference Olofsson, Sebastian and Jegannathan3} There is no unified regulation of how or by whom psychotropic drugs are prescribed.^{Reference Olofsson, Sebastian and Jegannathan3} Patients are frequently prescribed several psychotropic medications without being given information on the drugs or why they have been prescribed.^{Reference Schunert, Khann and Kao4,Reference McLaughlin and Wickeri6} In 2012, the psychotropic medication available was mainly older generations of pharmaceuticals^{Reference Schunert, Khann and Kao4,Reference McLaughlin and Wickeri6} and medication shortages were frequent.^{Reference McLaughlin and Wickeri6}