Perspectives in Global Mental Health
Depression: A Case Study From Cambodia
Sunbaunat Ka, M.D.
Mikazer Ka, M.D.
Daniel Savin, M.D.
M r. C, a 22-year-old single man from a distant
province, arrived at our private medical and psychiatric
clinic in Phnom Penh, carried by his father. On arrival,
Mr. C was pale, severely malnourished (weight, 37 kg; BMI,
12.4), with a nasogastric tube in place; his arms and legs
were tremulous and in a exed position. His pulse was
97 and his respiratory rate 24; he was afebrile but had a
cough. Mr. C did not respond to his name or to simple com-
mands. He made no eye contact, looked sad, and did not
speak, either spontaneously or in response to questioning.
We obtained the following information from his father.
Mr. C came from a well-off family and
held a university degree in business man-
agement. He had no history of medical
or psychiatric problems until 3 years
earlier, when he returned home from
his clerical job in another province to
attend his grandmothers funeral. At
that point he was very thin, ate little,
appeared sad and tired, and had dif-
culty sleeping. He also had several
episodes resembling generalized tonic-
clonic seizures, followed by loss of con-
sciousness and high fever. He was treated
for meningitis (the medications were not
identied) but made minimal recovery.
Mr. Cs parents, having little faith in
Cambodian health care, took him to a well-known Vietnamese
hospital, where various tests were performed. Results of
blood tests, malaria smears, lumbar puncture, and CT scan
of the brain were all within normal limits. Nonetheless, the
patient was treated presumptively for bacterial meningitis.
After 3 weeks, he regained consciousness, was afebrile, and
began eating, and he was discharged shortly thereafter.
Over the next 3 years, Mr. Cs symptoms persisted despite
outpatient treatment in Cambodia and two additional in-
patient admissions in Vietnam. The family, believing that
they had brought on the illness by offending ancestral spirits,
visited a Kru Dors Ampeu (a healer who can dispel evil spirits)
and Buddhist monks, to no avail. Mr. C was discharged from
his third hospitalization in Vietnam weak and confused, with
a nasogastric tube for feeding. The discharge diagnosis was
cerebral injury postmeningitis.
One hour after our initial interview, as the radio hap-
pened to play a song that narrated the sad tale of a bro-
kenhearted man, Mr. C turned toward the music. His tremors
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decreased. When one of his clinicians asked if he liked the
song, Mr. C looked at him, replied Yes, and turned back
toward the music. At this point, we suspected that he suffered
from depression linked to a romantic loss and hypothesized
that the song reminded him of his own situation. We
tentatively diagnosed major depressive disorder with severe
anorexia. Neurological sequelae postmeningitis, somatiza-
tion disorder, epilepsy, chronic brain infection, and malin-
gering were also on the differential diagnosis.
To improve Mr. Cs hydration and nutritional status and
to treat possible pneumonia, we administered intravenous
uids with amino acids, vitamin B, and ceftriaxone. As the
patient could not take oral medication, we added intrave-
nous amitriptyline (25 mg/day) and diazepam (10 mg/day)
for treatment of depression.
On the morning after his arrival, Mr. C removed his na-
sogastric tube, sat up in bed, and ate some bananas. He
was more lucid, and his tremor and abnormal movements
had decreased. He asked to listen to other love songs. We
supplied the requested recordings. He
began to eat soft food, but still did not
answer our questions.
Beginning the second week after ad-
mission, Mr. Cs cognitive function im-
proved. He related the following
history: While working at his clerical
job, he fell in love with a beautiful
young coworker. They talked as friends,
but he dared not confess his love.
He worried constantly that she didnt
like him, or that she would marry a
richer man. Subsequently, when at her
parents request she became engaged
to a man from her home province,
Mr. C was devastated. After her wed-
ding, Mr. C became deeply sad, cried every night, and
developed anhedonia, poor concentration, excessive worry,
insomnia, anorexia, fatigue, guilt feelings, hopelessness, low
self-esteem, self-neglect, and lack of initiative. Too embarrassed
to tell anyone about his broken heart, he decided to starve
himself to death, choosing starvation rather than another form
of suicide to avoid shaming his family. Death from a natural,
unexplained illness, he said, would not shame his family as
would shooting, overdose, or hanging.
Listening to the love songs reactivated his experience of
romantic loss. While talking with family members about
his broken heart would bring great embarrassment, he
felt comfortable conding in his clinicians. Music played
an important role in helping him disclose his secret.
Once Mr. C began speaking, the infusions were stopped
and he was switched to oral medications. We started him
on uoxetine, titrated to 60 mg/day, and nortriptyline,
25 mg at bedtime (for sleep and depression), as well as vita-
min supplements. After 1 month of treatment, Mr. Cs weight
Am J Psychiatry 171:10, October 2014
 PERSPECTIVES IN GLOBAL MENTAL HEALTH

increased to 49 kg and his BMI to 16.4, his suicidal thinking often present with physical symptoms, considerable effort
abated, his depressive symptoms began to remit, his cog- and expense (often enough to bankrupt families) are given to
nitive functioning improved, and he looked more cheerful. medical workups. Patients do not usually talk at length with
To help deal with his suicidality, we reminded Mr. C that their doctors: rather, doctors who ask too many questions
suicide is against Buddhas rules. By incorporating Buddhist
before diagnosing may be seen as less skilled.
concepts, we helped Mr. C see that the young woman he
Most Cambodians believe that illness has spiritual,
loved was not meant to be his future wife. In fact, had he
rather than (or in addition to) psychosocial or biological
married her, his suffering might actually have increased. With
this in mind, Mr. C decided to care for himself so that he could origins. Accordingly, help is often sought from Buddhist
work, earn money, and nd a different woman to marry. monks and traditional healers. To improve the treatment
After a 6-week inpatient stay at our clinic, Mr. C returned alliance, mental health practitioners must respect their
to his home province. He continued outpatient treatment, patients beliefs and the healers they choose.
mostly by telephone. Two years later, his mood remained As most Cambodians are Buddhist, problems are inter-
good; he was married, had successfully started a small preted through Buddhist perspectives. Buddhism advises
travel agency, and reported no more seizures. Fluoxetine recasting events in positive ways: When you suffer from
and nortriptyline were gradually one problem, you are lucky that
tapered and discontinued.
you are not suffering from an
In Cambodia, psychiatric even more severe problem. Bud-
Discussion problems are often overlooked, dha taught right thinking and
Initially, diagnosis and treatment right actions. For Mr. C, wrong
of this patient focused on the most
misinterpreted, and neglected thinking (he could not believe that
common causes of high fever with by patients, families, and there were other beautiful young
seizures in Cambodia: meningitis women he might marry) led to
health professionals. wrong action (he gave up looking
and cerebral malaria. In Vietnam,
Mr. C was again treated for men- for other potential brides).
ingitis despite negative tests; the Vietnamese physicians In Cambodia, psychiatrists strive to combine the les-
may have believed that the lumbar puncture results were sons of Western psychiatry with local beliefs regarding
negative because of previous partial treatment. Mr. Cs causation and treatment of mental illness. Stigma is still
condition improved, likely as a result of intravenous great; efforts to raise mental health awareness among
hydration and nutritional supplements, and he returned nonpsychiatrist physicians and the general public must
home. During subsequent treatments in Vietnam, where continue.
physicians paid little attention to psychosocial aspects of
the case, he achieved very limited recovery.
In Cambodia, psychiatric problems are often overlooked, Received March 5, 2014; accepted March 18, 2014 (doi: 10.1176/appi.
ajp.2014.14030292). From the Department of Psychiatry, University
misinterpreted, and neglected by patients, families, and of Health Sciences, Phnom Penh, Cambodia; and the Depart-
health professionals. Before reaching a psychiatrist, patients ment of Psychiatry, University of Colorado School of Medicine,
have often seen multiple practitioners, including primary Aurora. Address correspondence to Dr. Savin (daniel.savin@ucdenver.
edu).
care physicians, specialists, and traditional healers. The stigma The authors report no nancial relationships with commercial
of mental illness is high, and patients may be ostracized by interests.
family, friends, and community. Because psychiatric problems

Editors Note:
Perspectives in Global Mental Health

The Journal welcomes submissions for its new series, Perspectives in Global Mental Health. Our readers
throughout the world are interested in learning about the practices of their colleagues in other coun-
tries and cultures. In these articles, authors describe a patients diagnostic presentation, history, and
treatment in up to 600 words. Generally, there are both universal and culturally distinct elements. Then
the article concludes with up to 600 words on the authors perspective on psychiatric practice in their
country. Articles can be from any culture or country. They should be submitted to our reviewing website:
http://mc.manuscriptcentral.com/appi-ajp.

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