Mental Health in Laos

Mental Health in Laos

Lao People’s Democratic Republic

GENERAL INFORMATION

Lao People’s Democratic Republic is a country with an approximate area of 237 thousand sq. km. (UNO, 2001). Its population is

5.787 million, and the sex ratio (men per hundred women) is 100 (UNO, 2004). The proportion of population under the age of 15

years is 41% (UNO, 2004), and the proportion of population above the age of 60 years is 6% (WHO, 2004). The literacy rate is

77.4% for men and 55.5% for women (UNESCO/MoH, 2004).

The country is a low income group country (based on World Bank 2004 criteria). The proportion of health budget to GDP is 3.1%.

The per capita total expenditure on health is 51 international $, and the per capita government expenditure on health is 29 international $ (WHO, 2004).

The main language(s) used in the country is (are) Lao. The largest ethnic group(s) is (are) Lao Lourm, and the other ethnic group(s)

are (is) Lao Theung and Lao Soung. The largest religious group(s) is (are) Buddhist (three-fifths), and the other religious group(s) are

(is) indigenous groups.

The life expectancy at birth is 54.1 years for males and 56.2 years for females (WHO, 2004). The healthy life expectancy at birth is

47 years for males and 47 years for females (WHO, 2004).

EPIDEMIOLOGY

The Opium Survey was conducted across 11 provinces of northern Laos. The average prevalence rate of dependence was almost

3% in those above 15 years of age. Opium dependence was associated with age (age group 41-50 years and 61-70 years) and

gender (male) (UNODC and LCDC, 2004). Choulamany (2000) showed that the use of Amphetamine-Type-Stimulants (ATS) had

increased since the mid 1980s. Lifetime prevalence of drug use among school population ranged from 5.5% to 17.5% in different

regions. ATS use was associated with gender (male), age (15-19 years), socioeconomic status (higher), presence of psychopathology

related to methamphetamine use and deterioration in neurocognitive performance. Westermeyer (1976) noted that initially heroin

use mostly occurred among indigenous Asian addicts, who had gradually switched from opium to heroin. Following the passage

of an anti-opium law, a new group of indigenous addicts emerged: young, single, unemployed males in urban areas whose first

narcotic drug was heroin. Gradually, American expatriates also started to use heroin. Westermeyer (1979) estimated opioid dependence rates in 10 communities (representing eight ethnic groups and three provinces). In six rural communities, data were obtained

by a house-to-house survey and in four urban communities by opium den registration. Communities raising opium poppy as a cash

crop had highest crude rates of dependence (7.0-9.8%). Those involved in opium commerce had intermediate rates (4.1-5.5%).

Where neither opium production nor commerce was present the communities had the lowest rates of dependence (1.8-2.3%).

Westermeyer (1977) showed that drug use was affected by availability in another study that compared opium use among two

cultures in Laos, the Hmong (who have easy access to opium) and the Lao (who have a more difficult access). The Hmong’s open

availability appeared to favour the following: a greater proportion of female addicts; younger age of opiate usage and addiction;

use of the more intoxicating route of administration; earlier onset of problems related to addiction; and shorter duration of addiction before seeking treatment. Westermeyer (1988) reported that much diversity occurred among the various ethnic groups with

regard to male-female use of drugs and alcohol. Social changes were reflected in choice of substance made by younger and older

people (e.g. cigarettes vs. pipes or cigars, heroin vs. opium, manufactured vs. village-produced alcohol). Westermeyer and Peng

(1977) compared 51 heroin dependent patients with 51 matched opium dependent patients. Heroin dependent patients were more

often from an urban background, had more frequent daily doses of drug, spent considerably more money for their drug, required

higher initial methadone doses for detoxification and showed earlier worsening of condition leading to an earlier treatment contact.

Westermeyer (1978a) compared a sample of drug dependent patients of Lao origin with expatriate Asian dependent patients living

in Laos. Lao and expatriate addicts show marked similarity in their sociodemographic profiles and patterns of narcotic use. Some

differences in their recent use of narcotic drugs appear related to the greater cash income of the expatriate Asians and their greater

access to heroin. Treated prevalence figures in the year 2003 and 2004 suggest that neurosis (one-fourth of all cases), Schizophrenia

(one-sixth), Epilepsy (one-sixth), Substance abuse (one-tenth) mainly ATS and depression (one-fifteenth) were common (Mental

Health Unit, 2004). Westermeyer (1978b) found that subjects with psychosis had reduced longevity as compared to the general

population and those with organic psychosis had a greater mortality than those with functional psychosis. Hempel et al (2000)

found similarities between patients of Amok and those of sudden mass assault by a single individual. Both groups showed social isolation, loss, depression, anger, pathological narcissism and paranoia. According to a survey conducted by Handicap International and

NCRM (1999) in 370 villages in 7 districts (n=400 000) the rate of handicap was 0.8%. Intellectual handicap was the 4th leading

cause of disability (10% of all cases) and psychological problems were ranked 6th (7% of all cases), multiple handicaps represented

6% and epilepsy 4% of all disabilities.

MENTAL HEALTH RESOURCES

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Substance Abuse Policy A substance abuse policy is present. The policy was initially formulated in 2003. The Lao National

Commission for Drug Control and Supervision (LCDC) launched national drug demand reduction strategies in January 2003, including the following components: prevention, treatment and rehabilitation of drug abuse/drug abusers. It emphasized the need for reliable data collection and drug information systems and the understanding of geographical distribution (e.g. urban versus rural areas),

type of risk groups and main categories of substances abused.

National Mental Health Programme A national mental health programme is absent.

National Therapeutic Drug Policy/Essential List of Drugs A national therapeutic drug policy/essential list of drugs is present. It

was formulated in 1997.

Mental Health Legislation The article 18 in the penal code mentions that persons suffering from mental disorders are not responsible for committing damages. The code of penal procedure dated on 23/11/1989 gives more details on the process. In most cases,

conciliation is obtained either by village leaders or the police before the offences reach the tribunal. It there is a suspicion of mental

disorder, the police will lead an investigation and refer the person to the hospital for diagnostic evaluation before sending a report to

the tribunal. However, psychiatric evaluation is only available in the capital. Civil damages are to be paid by the family who is considered as responsible. If there is a need to look after the mentally disturbed, the head of the village might be requested to arrange

this. Mental illness is not considered as a reason for divorce.

Details about the year of enactment of the mental health legislation are not available.

Mental Health Financing There are no budget allocations for mental health.

Details about expenditure on mental health are not available.

The primary sources of mental health financing in descending order are out of pocket expenditure by the patient or family and tax

based.

Nearly all medication have to be bought by the patient’s family.

The country has disability benefits for persons with mental disorders.

Mental Health Facilities Mental health is not a part of primary health care system. Actual treatment of severe mental disorders is

not available at the primary level.

Regular training of primary care professionals is not carried out in the field of mental health. Two provincial hospitals provide limited

mental health care on an outpatient basis because of the availability of two general practitioners who received on-the-job training at

the mental health unit of the Mahosot hospital.

There are no community care facilities for patients with mental disorders.

Psychiatric Beds and Professionals

Total psychiatric beds per 10 000 population 0.07

Psychiatric beds in mental hospitals per 10 000 population 0

Psychiatric beds in general hospitals per 10 000 population 0.07

Psychiatric beds in other settings per 10 000 population 0

Number of psychiatrists per 100 000 population 0.03

Number of neurosurgeons per 100 000 population 0.07

Number of psychiatric nurses per 100 000 population 0

Number of neurologists per 100 000 population 0.02

Number of psychologists per 100 000 population 0

Number of social workers per 100 000 population 0

There are two full fledged psychiatric units, one in a general hospital setting and one in the military setting. The mental health unit

at Mahosot hospital has 9 general nurses, 2 psychiatrists, 1 neurologist and 4 general practitioners. While the military hospital is

staffed with 13 general nurses and 4 general practitioners. All psychiatrists and neurologists were trained in Europe.

Non-Governmental Organizations NGOs are involved with mental health in the country. They are mainly involved in advocacy,

promotion, prevention, treatment and rehabilitation. NGOs focus on the management of substance use issues. Monks have participated in TV and radio programmes on health promotion and prevention of drug abuse. In 2002, they sponsored youth gatherings in

temples as part of a national campaign on drug abuse. Save the Children/UK and UNICEF provide some child mental health services.

Handicap International provide free access to care for people suffering from epilepsy and mental handicap/retardation in some sites

in collaboration with the mental health unit. However, these services are mainly accessible to those living in and around the Capital.

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Information Gathering System There is mental health reporting system in the country. Reporting system on mental health is still

in a preliminary stage of development and is mainly based on daily data register of out and inpatients seeking treatment at the

mental health unit, Mahosot Hospital. This unit sends monthly data to the Department of Planning and Statistics of the Ministry of

Health.

The country has no data collection system or epidemiological study on mental health. A mental health situation analysis (Didier &

Choulmany, 2002) was carried out using in-depth interviews, with medical professionals and key informants including village leaders, teachers, monks or healers, focus groups and case reports. Lao folk diagnosis of mental problems covered 32 types. Spiritual

causes were perceived as being predominant, followed by genetic and biological causes. Karma was referred as well as a cause.

People suffering from mental health problems had had several ways of seeking help or services, e.g. modern medicines, moral support, traditional medicine, religious treatment and magical string and traditional souls calling ceremony. Major mental illnesses were

also discussed.

Programmes for Special Population Details about any special mental health programmes are not available.

Detoxification centres are available in the community where opium dependent patients are detoxified using tincture of opium, mainly in the northern parts of the country. The cost of a 15 day detoxification, including medication and food for the opium addict, was

found to be around US$ 25 per addict. This does not include logistics costs for Government staff and villagers. (Kham Noan Hsam:

Community Based Treatment and Rehabilitation as part of Drug Demand Reduction in on-going UNODC projects in the Northern

Provinces of the Lao PDR, 2002). However, there is no rehabilitation programme.

Therapeutic Drugs The following therapeutic drugs are generally available at the primary health care level of the country: phenobarbital, diazepam.

The 4th revision was made in 2004.

Other Information

Additional Sources of Information

Choulamany, C. (2000, 2001) ‘Drug abuse among youth in Lao PDR’.

Choulamany, C., et al. (July 2003) ‘Evaluating the treatment of ATS abuse in the Mental Health Unit, Mahosot Hospital’.

Bertrand, D., Choulamany, C. (December 2002) ‘Mental health situation analysis in Lao PDR’.

Einfield, S. (1999) Child psychiatry in Laos. Australasian Psychiatry, 7, 189-191.

Government document (2000) République Démocratique Populaire LAO. Paix, Indépendence, Démocratie, Unité, Prosperité.

Hempel, A. G., Levine, R. E., Meloy, J. R., et al (2000) A cross-cultural review of sudden mass assault by a single individual in the oriental and occidental

cultures. Journal of Forensic Sciences, 45, 582-588.

Kham Noan Hsam: Community Based Treatment and Rehabilitation as part of Drug Demand Reduction in on-going UNODC Projects in the Northern

Provinces of the Lao PDR, 2002.

LCDC and UNODC (2003) ‘National drug demand reduction strategies’.

Mental Health Unit (October 2004) ‘Statistics on new mental health cases seeking treatment at the Mental Health Unit, from 2000 – 2004’.

Service de Santé Mentale (Government document).

UNODC and LCDC (July 2004) ‘Laos Opium Survey 2004’.

Westermeyer, J. (1976) The pro-heroin effects of anti-opium laws in Asia. Archives of General Psychiatry, 33, 1135-1139.

Westermeyer, J. (1977) Narcotic addiction in two Asian cultures: a comparison and analysis. Drug & Alcohol Dependence, 2, 273-285.

Westermeyer, J. (1977) Opium and heroin addicts in Laos. I. A comparative study. Journal of Nervous & Mental Disease, 164, 346-350.

Westermeyer, J. (1978a) Indigenous and expatriate addicts in Laos: a comparison. Culture, Medicine & Psychiatry, 2, 139-150.

Westermeyer, J. (1978b) Mortality and psychosis in a peasant society. Journal of Nervous & Mental Disease, 166, 769-774.

Westermeyer, J. (1979) Influence of opium availability on addiction rates in Laos. American Journal of Epidemiology, 109, 550-562.

Westermeyer, J. (1988) Sex differences in drug and alcohol use among ethnic groups in Laos, 1965-1975. American Journal of Drug & Alcohol Abuse, 14,

443-461.

Westermeyer, J., Peng, G. (1977) Opium and heroin addicts in Laos. II. A study