While foreigners generally enjoy a lifestyle in the Kingdom far better than they would at home – and far, far better than most Cambodians – loneliness, dislocation and culture shock still all take their toll

David didn’t feel depressed when he relocated to Cambodia from Italy in 2012, though he had suffered from the illness in the past. It wasn’t until a year after the “expat honeymoon” stage that the clouds began to form again. 

“You lose interest in everything. You become less active – a lack of will to do anything or accomplish your goals. Basically, you just let life go by. That’s what happened,” he said. 

The 29-year-old, who asked to use a pseudonym for this article, sought out addictive activities to “fill the gap that was left” – cigarettes, sex, online social networks and gaming. 

“I could deal with it, but I didn’t want to. I could live almost a normal life, but I was aware it wasn’t life at its full potential. And that’s what bugged me. That’s when I decided to see a therapist.” 

David is just one of many expatriates dealing with depression in the Kingdom. Listed by the World Health Organization as “the leading cause of disability worldwide” with an estimated 350 million impaired, depression is one of humanity’s most pervasive and least understood illnesses. 

Among people living abroad, it is strikingly common. According to a joint study on the prevalence of mental disorders among US expats conducted by the Truman Group and Chestnut Global Partners in 2012, those living in a foreign country were 2.5 times more likely to be suffering from a mental ailment such as depression or anxiety than their countrymen living at home. 

“Geographic moves and intense travel are linked to disruptions in social support, and problems that would be less impairing and intrusive can grow and become unmanageable when people are isolated and highly stressed,” said Sean Truman, one of the study’s authors.

“In addition, in many communities, people drink and/or use drugs more than they would in their home countries and cultures, both of which are related to problems with mood.”

Mood-altering drugs like Valium and Xanax – which actually intensify depressive symptoms – are easily available in the Kingdom, as are harder narcotics like heroin, cocaine and crystal meth.

Depression is easily diagnosed by trained physicians. Repeated bouts, known as chronic depression, can come in mild to severe episodes. Symptoms include less interest or enjoyment in activities, increased anxiety, insomnia and decreased energy. In severe cases, daily tasks like work or social interactions can become extremely difficult to perform. 

Depression is typically treated with regular counselling, the substance of which must be tailored to the individual. In some cases, anti-depressant medications may be prescribed.

“[Depression is] by far the most common reason that I see in patients here in Phnom Penh,” said Wilson Howe, 43, an American clinical psychologist at Indigo Psychological Services, one of Phnom Penh’s few mental health clinics with qualified English-speaking therapists. Howe said that out of his nearly two dozen patients, about 80 per cent suffer from clinical depression. 

“In general, loneliness is a big problem among [my patients] because relationships tend to be shorter-lived among the expat community because people come and go,” he said. 

That lack of a firm support network is one of the biggest reasons behind the higher prevalence of depression among expats, according to Truman, whose company the Truman Group offers remote psychological counseling to professionals living abroad. 

The extraordinary amount of both past and present suffering in Cambodia might also contribute to the depression figures. As one writer wrote in an online essay about dealing with depression here: “When you look for sadness in Cambodia, there is no shortage of it.” For people struggling with negative emotions, it can be exacerbating. 

“I think that comes up in any environment when you’re around a large population where people have experienced years of trauma, usually in terms of vicarious trauma or vicarious depression,” said Boyd Bergeson, 36, an American mental health counsellor at Indigo. 

“But other people might see Cambodians as some of the most resilient, positive people to be around in Southeast Asia. It depends on which way you want to spin it,” he added.

From David’s point of view, Cambodia didn’t cause his depression, but it didn’t help it either. 

“In Cambodia, I don’t see much compassion. It’s like everyone is on his own. There’s no civic sense. There are no values really in general. That’s how I feel at least. I think that helps to strengthen my nihilist view of the world,” he said. 

Bergeson said that there a distinction between depression associated with culture shock and sudden change, which is generally short-lived, and the kind of depression experienced mostly by long-term expats. 

“They are two different types of depression. New people who have moved here may feel depressed, but that usually passes once they make new friends and have established themselves. But then you get the expats who have lived here for several years, and their depression is harder to treat,” he said. 

The symptoms of depression in people living abroad, according to Truman, can be much the same as those in people suffering at home.

“It is common for [depressed] people to feel ‘flat’, and the way in which people think about the world can shift and their outlook becomes negative and pessimistic,” he said. 

“People can also become preoccupied with past mistakes and are distressed by things at a level that are out of proportion to what they are actually coping with; small tasks or responsibilities can feel overwhelming and impossible. 

“In some cases, people have thoughts of death and what it would be like to end their lives.”

Local Khmer-language news outlets often carry news items about foreigners committing suicide; however, embassies contacted by Post Weekend – including those for Australia, the UK, Japan and the US – either did not respond or said they did not keep cause-of-death statistics.

“I have more experience then I would like to in dealing with suicide working in Phnom Penh,” lamented Bergeson.

“I think that for people who do [commit] suicide here, they’ve already made that decision before getting on the airplane. 

“This is one of those places where they believe that no one will care, no one will notice and their friends and families back home might not be able to find them. They don’t want some big fancy funeral. They just want to disappear.” 

In the early 2000s, a US man reportedly ran a website promoting assisted euthanasia from Kampot.

“In Cambodia anything is possible,” his site, euthanasiaincambodia.com, read.

“For those of you who prefer to take charge of your own destiny, come to Cambodia! Live your life the way you want and end it when you are ready.”

The site’s owner, who was deported before later killing himself, told the Telegraph in 2005 that he chose Cambodia because it has no law against assisted suicide. The man was reported to be involved in at least one woman’s suicide.

Wilson Howe said that in suicidal cases, there were generally two types. 

“The first is impulsive, where a person gets really emotional or scared and just kills himself. Those are easier to stop. But someone who is really wanting to disappear, they’ll plan it long term in advance, and it’s very hard to prevent that. The closer they get to the suicide event, the calmer they get,” he said. 

One Frenchman who last December shot himself in the head in his third-storey room at a local guest house would spend days locked in his rented room, according to a receptionist there. 

“He was here almost a year. He was normal, friendly and spoke with the reception often,” he said. No one heard the gunshot and it was days before they discovered what had happened. 

For many, Cambodia is a place to nurse old wounds.

“The long-term expats that came here in the late ’90s and early 2000s probably saw it as a way to escape whatever traumas they were experiencing in their home country. And I guess they’re finding it harder and harder to be invisible. But being invisible and not being noticed is a double-edged sword,” said Bergeson. “Being a recluse here you can end up with depression, loneliness, suicidal thinking.” 

But is depression among expats really more prevalent here than elsewhere?

“I would definitely say so,” said Bergeson. “Cambodia is great for what it is. I certainly enjoy living here. But for people who need big cities and lots of professional opportunities, they usually end up moving on. 

“A lot of people see Phnom Penh as a stepping stone. The people who do stay are either happy with their careers or are kind of destitute. They’ve come here to try to be become invisible.”

But depression is not a never-ending storm. With proper counselling and treatment, it can be overcome. 

“I’m quite proud to say I’ve helped several snap out of this doom and gloom mentality that nothing’s going to change,” said Bergeson.

“It’s usually from a change in lifestyle and change in environment. You can’t force them to do it overnight. It’s a slow transition to a healthier lifestyle and hanging out with positive people.” 

For David, things are much better, but the clouds haven’t fully cleared. 

“I ask myself: How can you not be happy; how can you not feel good even though everything else is going very well? Still it’s not so easy; it’s very complicated.” 

ADDITIONAL REPORTING BY SREYNOCH VANN

If you or someone you know is suffering from depression in Cambodia, call Indigo Psychological Services at 012 208 318 to set up an appointment. Sunshine Mental Clinic, while primarily a Khmer service, also has English-speaking therapists. They can be reached at 023 955 777.