the Fall of Bhutan

When Dr Chencho Dorji was growing up in Thimphu, Bhutan, his 19-year-old brother became delusional, so the family turned to traditional health practitioners. "They tried everything that was around," he says. "Rituals, rites, shamanistic practices." Nothing helped.
Eventually, the family had to lock the troubled young man in his room. Years later, when his parents could no longer care for him, he wandered the streets.
Such stories are becoming increasingly common in the Himalayan kingdom, in part owing to rapid urbanization and development, which in some populations brings with it increasing rates of depression and other mental health conditions.
In 2008, Bhutan vaulted to international attention when it proposed to use "gross national happiness" instead of gross national product as the key barometer of its success. The idea that a government should value not only material wealth but also physical and mental health, social ties, and even spirituality has, perhaps ironically, fueled tourism and development that might be detrimental to the tiny nation's collective mental health.
"We have to do a lot of fast-track catching up to the world," says Dorji, who, after traditional healing approaches failed his brother, earned his MD at a Western medicine school in India. "But we have also acquired a lot of the baggage that comes with globalization."
We had been secluded in the mountains, unaware of the things we did not have.
After medical school, Dorji studied psychiatry in Sri Lanka, eventually returning to Bhutan as the country's first psychiatrist in 1999, a transitional time for Bhutanese culture. In that year, the reclusive kingdom's government first permitted its citizens to legally access television and the Internet—a harbinger of the rapid societal transformation to come.
Much of the change has been for the better. Per capita income almost tripled from 2003 to 2018; the poverty rate has dropped; literacy is growing.
But the country is mired in an identity crisis of sorts that Dorji and others in prominent cultural positions are struggling to navigate.
"We had been secluded in the mountains, unaware of the things we did not have," says Needrup Zangpo, executive director of the Bhutan Media Foundation. "Now we are seeing them." Global media tantalizes the children of farmers with images of shiny new cars, gadgets, and appliances, and shocks them with images of violence and pornography, says Zangpo.
Bhutanese youth are flocking to universities and the city, but jobs requiring white collar skills cannot keep pace. The unemployment rate for young people with bachelor's degrees reached 67% in 2016.
"On the farm, everybody is engaged, and at the end of the day everyone comes home and has the fireplace and they are together," Dorji says. "There is this glitter and myth that life is better in towns. Now I'm seeing that urban people are not so happy."
According to Dorji, families across Bhutan are becoming more westernized. Increasingly, both parents work outside of the home or village, leaving children home with gadgets and television. Once-sleepy towns are now waking up to noise, dust, traffic, and crime.
Although the incidence of mental illness in Bhutan is lower than in the United States, there has been an alarming increase in diagnosed mental illness: The number of treated cases rose from just over 2000 in 2008 to nearly 3700 in 2018. This inflation could be due in part to increased diagnosis as the country westernizes, but still, the figures are striking.
Bhutan is not the only country to experience an increase in mental health problems along with increased wealth. More-developed countries as a whole have relatively higher rates of schizophrenia, self-harm, and depression than the least developed countries.
We are not the happiest people in the world. We aspire to be the happiest people in the world.
What sets Bhutan apart is that its leaders have for decades sought a way to avoid such perils. Inspired by Buddhist ideals of compassion and concordance, it enshrined in its gross national happiness principle a "harmonious balance between material well-being and the spiritual, emotional and cultural needs of our society."
Although the concept captured the imagination of many around the world, it should not be misunderstood as a boast, Dorji says. "We are not the happiest people in the world. We aspire to be the happiest people in the world. It's just a goal that we have set up."
Overall, Bhutan is succeeding by its own estimates. From 2010 to 2015, the country increased its gross national happiness by 1.7%, with 91.2% of those surveyed reporting that they were happy. The government survey, which looked at multiple elements of happiness, found improvements in most, including living standards, health, and education. But it also noted a decline in "psychological wellbeing" and "community vitality." More Bhutanese in 2015 reported struggling against negative emotions, such as anger, fear, worry, selfishness, and jealousy, than in 2010.
To cope with the rising challenges of mental illness, Bhutanese health practitioners have continued their traditional approaches, while adding on treatments devised in developed countries. After years of being only the practicing psychiatrist in the country, Dorji has been joined by three others. And he has seen the difference that allopathic medicine can make.
Psychotropic medications, such as antipsychotics, anxiolytics, antidepressants, mood stabilizers, and antiepileptic drugs, are all now available in Bhutan. Dorji was able to diagnose his own brother with schizophrenia and prescribe him effective antipsychotic medication. "Now he is a useful member of the family," Dorji says. "Some conditions are biological. At least modern science has given us some answers."
The extensive reliance on drugs at Jigme Dorji Wangchuck National Referral Hospital in Thimphu, where three of the psychiatrists work, surprises some visitors from the West. "In this Western-Eastern dance, some of the Buddhist professionals are being more Western," says Dr Trina Nahm-Mijo, professor of psychology, dance, and women's studies at the University of Hawaii Community College in Hilo, Hawaii, who previously worked at Jigme Dorji Wangchuck hospital.
Nahm-Mijo found that even the nonpharmaceutical treatments used at Wangchuck relied heavily on Western concepts, namely cognitive behavioral therapy (CBT), rather than the mindfulness-based therapy that originated in Buddhism. In CBT, patients learn to identify irrational negative thoughts and counter them with more reasonable ones. In mindfulness, practitioners learn to note emotions without judging or reacting to them. Both have proven effective in treating such conditions as depression and chronic pain.
While practicing in Bhutan, Nahm-Mijo treated many patients with sandplay therapy. The treatment entails using a sandbox and figurines to create a sort of diorama reflecting a person's thoughts, conflicts, and environment. It's an approach derived from Buddhist healing practices, Jungian psychology, and play therapy. "It's very Buddhist, because you start where the client is and then you go down to the shadow, to all the repressed stuff," says Nahm-Mijo. Bhutanese colleagues have sometimes raised their eyebrows at the approach, though they have also expressed interest in learning whatever can help their clients, she says.
One reason for the reliance on pragmatic, short-term approaches at Jigme Dorji Wangchuck hospital is that many clients make long trips there to receive a diagnosis and treatment, yet can't afford to return for follow-up care, says Melissa Milbert, a psychotherapist and associate lecturer at Khesar Gyalpo University of Medical Sciences in Thimphu. "I have patients who have traveled for days."
But despite its newly elevated prevalence, she finds CBT less effective in Bhutan than in Pittsburgh, Pennsylvania, where she practiced for 5 years before moving to Bhutan. CBT was developed primarily in white, middle-class Americans, she says, whereas a Bhutanese farmer may not have the cultural context to examine thoughts in the same way.
Mindfulness is more familiar to patients in Bhutan, but this can actually work to its disadvantage, because many of her patients were required to participate in mindfulness meditation in school and think of it as a chore, says Milbert. "So I might have to repackage it in a different way."
The traditional practice of Buddhism does remain an important part of mental healthcare in Bhutan. Karma Gyeltshen, a former monk and now academic manager at Royal Thimphu College near Thimphu, says the monasteries that are spread throughout the country can ease depression and anxiety through the serenity they offer, and the prayers and meditation that they teach. "If a Bhutanese person is not feeling well, they will visit the hospital," he says. "But equally important is to visit the monastery."
At least one study supports the notion that spirituality and belief in karma protect against mental illness.
FS

A man turns prayer wheels during a visit to a Buddhist monastery in Thimphu, Bhutan.
The gross national happiness survey in 2015 found a decline in such spiritual practices in Bhutan. Many of Milbert's clients started with a spiritual approach, including the religious rites known as pujas, before coming to her, she says. She notes, however, "They don't end up in the psych ward seeking Western medicine unless the pujas failed."
At the Institute of Traditional Medicine Services, also located in Thimphu, physician Nime Deme sees the flow going in the opposite direction. "Many patients are treated first at the referral hospital," she says. "They don't get better; then they come here."

Figure 1. Nime Deme, a physician at the Institute of Traditional Medicine Services in Thimphu, Bhutan.
Just as the Bhutanese state religion derives from Tibetan Buddhism, traditional Bhutanese medicine closely resembles traditional Tibetan medicine. For most mental illness, Nime Deme starts therapy with herbs. If that is not effective, she offers hot compression, then golden needles—a therapy similar to acupuncture. But she also prescribes meditation for the patient to practice at home. "Many patients get improvement here," she says.

Figure 2. Patients wait to be seen at the Institute of Traditional Medicine Services.
Bit by bit, Bhutan is finding ways to harmonize the disparate elements of its mental healthcare system. Both traditional and allopathic medicine are offered free through the government health service, and their practitioners are collaborating, sometimes even working in the same offices.
Dorji sees value in the multiple approaches. "There are a lot of advantages to traditional medicine," he says. "These practitioners are not as invasive in asking questions and in their procedures. They use medicines that are mostly herbs, and they are cheap and don't have many side effects. Sometimes our allopathic doctors can do more harm."
He has organized teams with traditional healers, monks, shamans, and psychotherapists to share diagnoses and figure out the appropriate modality for each case.
For people with schizophrenia, for example, he argues that allopathic Western medicine has the best chance of success. Meanwhile, he thinks people with psychosomatic disorders may benefit more from traditional remedies. "For that category of people, it's less about whether the illness gets better; it's more about whether they are satisfied with what they are getting," he says. "They are not confined to bed, but they think they are ill. It's also a way of getting away from the responsibilities that they have to do."
Still, to truly stem the tide of mental illness in Bhutan, Dorji believes the country will have to find ways of revitalizing its spiritual tradition. "They are beautiful concepts," he says. "Impermanence, compassion, loving-kindness, coexistence, interdependence. We have to make use of our traditional Buddhist knowledge."
Follow Medscape on Facebook, Twitter, Instagram, and YouTube