FIG1Chencho Dorji, M.D., is the
first psychiatrist in Bhutan. Ever.
This is an age when it's no longer easy to be the first anything. Pretty
much everything has been done at least once by someone, somewhere.
Of course, you may ask, why does Bhutan need a psychiatrist in the first
place? Isn't that the tiny country locked away in the eastern Himalayas, the
model for the fictional "Shangri-La," a little paradise untouched
by earthly cares? The real-life nation whose official guiding principle today
is the pursuit of "Gross National Happiness?"
Maybe so, but the real Bhutan, with all its mountainous charms, is
populated by 634,982 human beings who, like human beings everywhere else,
sometimes display symptoms of schizophrenia, bipolar disorder, depression, or
Chencho Dorji, M.D., Bhutan's first psychiatrist, seeks to integrate
contemporary psychiatric practice with his country's traditional approaches to
Credit: Johns Hopkins Bloomberg School of Public Health
Bhutan spent centuries in isolation. Roads first connected the country to
the outside world only in the 1960s, and access by air came even later. Until
recently, psychiatric treatment and other forms of tertiary care were
outsourced to India, Bhutan's neighbor to the south.
Dorji got his medical degree in Poona, India, in 1985, then interned in
Calcutta, and returned to Bhutan to serve as a general practitioner until
1995, when he was asked by health authorities to train in psychiatry. He
entered a residency program in Sri Lanka, and then spent 1998 and 1999 in
Australia observing how a community mental health system worked in cooperation
with a specialist hospital, he said in a recent interview.
As the only psychiatrist in Bhutan—another is training now in
India—Dorji is responsible for every aspect of mental health service
delivery for the full spectrum of psychiatric disorders. He was initially
advised by a World Health Organization consultant to build a large psychiatric
hospital, but Dorji chose a different path.
Bhutan has a well-developed primary care network, and Dorji wanted to
integrate mental health into it by teaching primary care clinicians about
psychiatric diagnoses, medications, and counseling so they can identify and
provide appropriate treatment for people with mental illness. He stretched a
$25,000 grant from a Danish nonprofit organization over three years to train
both primary care providers and specialists (including
obstetricians/gynecologists, pediatricians, nurses, and midwives) in basic
Bhutan's traditional medical practices draw on practices developed in
neighboring India, China, and Tibet. For cultural and practical reasons, Dorji
wanted to bring local and Western medical traditions together, so that each
could benefit from the strengths of the other.
As in many non-Western cultures, anxiety and depression often present as
somatic symptoms, said Dorji. Simply treating the somatic symptoms can be a
waste of time and money for both doctors and patients. In some cases, patients
might recover faster if they saw a traditional healer before or along with a
He began with a pilot survey of mental health needs in three of the
country's 20 provinces. In each province, he first called in all local health
care personnel, not only doctors and nurses, but also the shamans, village
health workers, and local leaders. He stimulated a discussion on just what
mental health and mental illness meant to them.
"We got many answers: psychosis, depression, alcohol dependence,
epilepsy, mental retardation, suicide," said Dorji. "These were
all easy to identify and easy to target."
On the second day, he explained all the ICD-10 criteria for each
psychiatric diagnosis. This part of the discussion revealed both a lack of
knowledge and a lot of stigma. Dorji randomly selected eight houses in a local
village and sent his local practitioners out to screen the households and
identify mental health cases using the Composite International Diagnostic
Then the modern health care workers, the traditional healers, the monks,
and others discussed these identified cases and suggested treatments. Each
group educated the others about its own point of view.
"This is the best way to reach out to traditional medicine," he
In 2007-2008, Dorji was based at the Johns Hopkins Bloomberg School of
Public Health in Baltimore as a Hubert H. Humphrey Fellow. The Humphrey
fellowship provides 10 months of nondegree academic study and related
professional experiences at 15 universities in the United States. The Hopkins
program focuses on public health and drug abuse.
Among other topics, Dorji studied cognitive-behavioral and family-systems
models for treating and preventing drug dependency and HIV infection, along
with methadone and buprenorphine treatment of heroin addiction.
He spent several months looking at community-based therapeutic models like
Daytop and medically supervised models like Phoenix House.
"These are the kind of programs that can be transported with
translation," said Wallace Mandell, Ph.D., M.P.H., a professor emeritus
of mental health at the Johns Hopkins Bloomberg School of Public Health and
director of the school's Humphrey fellowship program. "They have a lot
of advantages for a mountainous, rural country where people will have to live
at a residential center and get treated."
On his return to Bhutan, Dorji hopes to begin development of Bhutan's first
drug treatment center. That may sound like an anomaly in Shangri-La, but it
reflects the inevitable influence of the outside world. Most of the drug
problems in the kingdom occur among young people who abuse prescription drugs.
Easy access to cheap medications from unregulated Indian pharmacies has led to
over-doses and deaths among young people, he said. In response, the government
passed a drug control act that included, at Dorji's insistence, a voluntary
drug treatment program as an alternative to jail.
"So now we need a drug treatment center," he said.
While in the United States, he attended a fundraising event in New York for
a proposed day-care program for young patients with schizophrenia and bipolar
disorder. At present, only families of the ill in Bhutan care for them. But
eventually, the families find themselves burdened by problems and run out of
options. The patients often end up on the streets or in jail.
However, if there were settings where patients could be stabilized and
treated for several months, they might be able to return home for longer-term
care. Dorji envisions establishment of a halfway house for chronically
mentally ill individuals whose families have abandoned them. ▪