Picture: Many homeless, especially in Bangkok, suffer from schizophrenia which is the most common mental health disorder in Thailand. Abandoned by their families they live estranged solitary lives at the edge of society
1. Role of the Principal Government Agency in Thailand
In Thailand public mental health services are governed centrally for all of its 76 provinces by the Department of Mental Health (DOMH) as a subdivision of the Ministry of Public Health. The agency is overseeing 122 outpatient facilities nation-wide which are located in general hospitals and 17 designated mental hospitals. Thailand has no day treatment facilities. The agency provides an average of 7.29 mental health workers comprising of predominantly nurses, psychiatrists and administrative staff for every 100,000 population (WHO, 2006) which, by all means, is very little.
2. The role of DOHM in providing formal advice on mental health founded in EBT
In order to understand why the DOMH has not embarked on evidence-based treatment
and practice (EBP) one needs to understand how the historical and cultural contexts of
mental health services have developed. Services have been provided since the 1950s
predominantly by psychiatrists while local psychologists are regarded a ‘paramedical
profession’, limited to the role of technicians who administer tests, write reports and
receive orders from the psychiatrist (Tapanya, 2001, p.69-71). Almost all psychologists in
Thailand work in psychiatric units while most of the work given to them only requires a
Bachelor degree. More recently, overseas-educated psychologists are starting to change this perception.
The dominance of expert consensus by DSM-IV-TR and ICD-10 diagnosis does not conceptually entail data-driven case formulation (Clark et al, 1995, p.147). Another reason for the narrow range of diagnoses in Thailand is that only most common disorders are addressed which are schizophrenia, mood disorders and substance abuse (Singh et al., 2008, p.414) while no routine provisions for follow-up community care are provided (WHO, p.10). The limitation to the greatest public denominators and lack of follow-up measurements beg questions providing evidence for treatment efficacy, flexibility and adequacy.
Clinical psychiatric training sanctioned by the DOMH entails interviewing techniques,
psychological treatments, psychiatric management skills and ECT training while
overarching concepts such as the biopsychosocial model or EBP appear not as integral
parts of standardized training programs (Singh et al., 2008). Paradoxically, Thailand faces a huge public health burden by an epidemic of conditions such as heart disease, stroke, depression, various types of addictions and sexually transmitted diseases which are closely related to health risk behavior (Tapanya, p.70) and would largely benefit from EBP data-collection within the local context. For the treatment of children comorbid psychological issues are not considered to merit treatment as long as they don’t interfere with medical procedures due to serious understaffing (Ularnthinon, 2012, p.567).
3. Possible reasons why clinicians may not accept the formal advice provided by
the government agency
Although no direct data is available due to the absence of EBP initiatives on national
level, parallels can be concluded from EBP medical practice in South-East Asia. Shortage
of staff, time and funds for EBP training are the biggest obstacles in most clinical settings. Practitioners generally agree that EBP guidelines support standardizing clinical practice while promoting best practices (Turner, 2009). Guidelines are also perceived as unnecessary bureaucratic mechanisms to please government reporting demands rather than supporting clinical practice. Concerns relate to the reliability, up-to-date status and accuracy of EB-guidelines, the quick-and-easy translation into situational practice and explaining the reasoning behind guidelines as they relate to evidence. In SE-Asian countries the lack of English skills appears as a major obstacle, e.g. an Indonesian nurse mentioned that she can access the Cochrane Library but has issues understanding the publications. Limited internet access and difficulties achieving consensus among staff, e.g. a more confident group dominating others, add to the conundrum (Turner, 2009, p.3-6).
Several factors can be identified that prevent Thailand embarking on EBP. A major
progress would entail the shift from generalized health care for common disorders to
individualized mental health care. The lack of qualified psychologists prevents diagnosis
for many mental disorders that are not based on the medical model while sub-clinical
cases generally go untreated. Clinical decision-making in EBP encompasses access to best available research, including the patient’s characteristics and preferences as well as to apply clinical expertise based on systematically collected data (Spring, 2007, p.613, Hunsley et al., 2005). A prerequisite for EBP-implementation is the communicative competence of staff. Problem-Based Learning (Barrows & Tamblyn, 1980) as developed by the McMaster group who spearheaded EBP in the 1980s (Spring, p.616), would be a most suitable approach to train the next-generation of Thai practitioners. PBL defuses the notion of bureaucratic overregulation and disconnectedness to clinical practice since its hypothesisbased structure combines clinical assessment, research, critical research review and case formulation into a single, evidence-based process. The PBL-Tutorial Process entails the collaborative verification of individual case assessment, critical outcomes definition and treatment planning, application of best-available research and continuous review during solutions development (Barrows, 1992), rendering it a perfect candidate to facilitate single case experimental designs [SCEDs] (Turpin, 2001).
Such an optimistic outlook would entail an adequate government funding for mental health care and training more qualified psychologists. Sadly enough many mentally disordered people are even held in cages and chains in rural areas of Thailand since relatives do not know how to handle the burden. Human rights organizations mention that there is no proper supervision and public register listing who is held (and on which account) in psychiatric facilities, for example patients who have been institutionalized by their families (WHO, 2006). Admitting to mental disorders constitutes, like in Singapore (see previous posting), a huge stigma and most commonly people prefer to stay in denial when their children or their relatives are involved.
Barrows, H. S. (1992).The Tutorial Process. Springfield, IL: Southern Illinois School of Medicine.
Barrows, H.S., Tamblyn, R.M. (1980). Problem-based Learning: An Approach to Medical Education.Volume 1 of Springer Series on Medical Education. Springer Publishing Company, 1980
Clark, L. A., Watson, D., & Reynolds, S. (1995). Diagnosis and classification of psychopathology:Challenges to the current system and future directions. Annual Review of Psychology, 46, 121–153.
Singh, B., & Ng, C. (2008). Psychiatric education and training in Asia. International Review Of Psychiatry (Abingdon, England), 20(5), 413-418. doi:10.1080/09540260802397362
Spring, B. (2007). Evidence-based practice in clinical psychology: What it is, why it matters; what you need to know. Journal of Clinical Psychology, 63(7), 611–631.
Tapanya, S. (2001). Psychology in Medical Settings in Thailand. Journal Of Clinical Psychology In Medical Settings, 8(1), 69-72.
Turner, T. (2009). Developing evidence-based clinical practice guidelines in hospitals in Australia, Indonesia, Malaysia, the Philippines and Thailand: values, requirements and barriers. BMC Health Services Research, 9235. doi:10.1186/1472-6963-9-235
Turpin, G. (2001). Single-case methodology and psychotherapy evaluation: From research to practice. In C.Mace, S. Moorey, & B. Roberts (Eds.), Evidence in the psychological therapies: A critical guide for practitioners (pp. 89–110). Hove, England: Brunner-Routledge.
Hunsley, J., & Mash, E. J. (2005). Introduction to the special section on developing guidelines for the evidence-based assessment (EBA) of adult disorders. Psychological Assessment, 17(3), 251-255. doi:10.1037/1040-35184.108.40.206
Ularntinon, S. S. (2012). Child psychiatric consultation to pediatric inpatient services in Thailand.Pediatrics International, 54(4), 566-568. doi:10.1111/j.1442-200X.2012.03667.x
World Health Organization. (2006). WHO-AIMSREPORT ON MENTAL HEALTH SYSTEM IN THAILAND. Retrieved from http://www.who.int/mental_health/thailand_who_aims_report.pdf