Author Archives: Evan Eschliman

Mental Health in the “Happiest Place on Earth”

Bhutan calls itself the “Happiest Place on Earth,” and some statistics suggest that it might indeed be close to claiming that top spot. The small Himalayan kingdom of around 750,000 was ranked as the eighth most subjectively happy country in the world in 2007. Such a high rank is impressive for such a small nation, but it is surprising that Bhutan is not ranked higher due to its longstanding prioritization of well-being. Since 1972, the nation has officially affirmed that the sole purpose of government is to ensure citizens’ happiness.

The “Last Shangri-La” had been largely isolated for many years due to its geographic location and its isolationist policies, but Bhutan ended its feudal society and formally opened itself to the Western world in 1953. In 1972, facing rapid development and modernization, Bhutan’s Fourth Dragon King Jigme Singye Wangchuck famously held fast to his predecessors’ beliefs and proclaimed that the popular development metric of Gross Domestic Product (GDP) would not guide his country’s future. Instead, he proposed a novel guiding metric—Gross National Happiness (GNH)—putting an official policy behind traditional beliefs. Bhutan’s belief in the purpose of government has not changed since then, but much about the country has: television and internet were introduced in 1999, traditional dress—once ubiquitous—is becoming increasingly uncommon, and the capital of Thimphu now has one bar for every 250 inhabitants. But there is a looming problem that hangs among the nation’s traditional lanterns and temple rooftops. Paradoxically for a country as focused on happiness as Bhutan, there are severe challenges facing the kingdom’s mental health.

GNH has many potential advantages as a development principle. Unlike GDP, it puts citizens’ perceived well-being at the forefront of development. Moreover, it encourages participation in cultural traditions, involvement in the community, and even stewardship of the environment. Even though it was originally conceived as a means to align development and modernization with traditional Bhutanese and Buddhist values, the country believes measurement of happiness is of international importance. In 2011, the UN passed Bhutan-proposed measures suggesting that all countries begin to integrate happiness and satisfaction metrics in their national surveys.

Although there is global agreement on the importance of monitoring happiness, there is international concern about the true state of happiness of the Bhutanese people. Using a standardized—although admittedly Western-designed—system, the UN ranked Bhutan eighty-fourth in its 2016 World Happiness Report, bringing the moniker of “Happiest Place on Earth” into question.

Despite the nation’s determination to ensure individual happiness, little is done for its mentally ill. This shortfall contrasts with the nation’s general attitude toward health care. Bhutan spends 10 percent of its GDP on health care, making it free for all inhabitants, and its national health care system is considered “exemplary for the region” by the World Health Organization. In contrast, only 1 percent of that health spending is allocated to mental health. Mental health legislation is lacking as well. Bhutan passed a mental health policy 1997, but currently has no legislation to implement it. The lack of a formal system means that the country has few mental health care personnel. Shockingly, Bhutan has no psychologists, social workers, or occupational therapists, and the country has exactly one practicing psychiatrist.

Critics of the country’s approach to mental health—including Dr. Chencho Dorji, Bhutan’s sole practicing psychiatrist— worry that the obsession with GNH actually only serves to worsen the nation’s mental wellness. Even though education about the importance of happiness occurs throughout Bhutan, there exists no program to increase mental health literacy. This leaves many Bhutanese unaware of how to seek modern pharmacological or therapeutic treatment (although many would be unable to access Dr. Dorji’s office in Thimphu anyway). Instead, patients who do seek treatment often turn to traditional medicine. Traditional Bhutanese medical practices are often of religious origin and frequently involve plant-based therapy. Such practices should not entirely be discounted, but they have little effect on even moderately severe conditions. Neuropsychiatric medicine and counseling is free to patients in Bhutan, but use remains low. Often, Dorji reports, patients are brought into his office in catatonic states after weeks of seeking traditional treatment, allowing the disease to progress. Additionally, he sees many patients who come with complaints of physical symptoms. Only after sensitive questioning do they reveal emotional trauma, depressive symptoms, or the like. These patients are not able to self-identify the cause of their symptoms due to a pervasive lack of mental health awareness.

This lack of mental wellness literacy has major ramifications in rates of two linked manifestations of mental illness: suicide and substance abuse. Bhutan had the twenty-second highest suicide rate in the world in 2014, and the rate is probably even higher now. The incidence of suicide, Dorji notes, is especially high in rural areas of the country. Karma Tsheetem, secretary of the GNH Commission, attributes the increasing rates to a disconnect between traditional and modern ways of life, saying suicide rates will continue to rise until there is “a better balance between the spiritual and the material.”

Along with suicide, rates of substance abuse in Bhutan are also increasing. Prior to modernization, the Bhutanese would drink alcohol almost solely as part of spiritual ceremonies. But now, since the introduction of commercial alcohol in 1972, alcoholism has become a rapidly growing problem. A lack of social stigma around consumption inhibits the implementation of laws restricting access to minors and during certain times during the day. This absence of stigma and the high prevalence of bars in Thimphu have given Bhutan the highest per-capita level of alcohol consumption in South Asia. With little government control or social pressure, Dorji sees that drinking easily leads to alcohol abuse; he believes the “alarming proportion” of substance abuse and alcohol-related problems threatens the nation’s mental health and its GNH.

Despite these challenges, progress is being made towards a more mentally healthy Bhutan. Dorji continues to strongly advocate for international attention to the issue. Universities and other organizations are beginning to invest time and resources into researching and implementing programs to better Bhutan’s mental wellness. The newly elected prime minister, Ushering Tobgay, has seemingly noticed that Bhutan’s carefully cultivated reputation for happiness is something of a facade. When he was elected in 2013, his platform included the idea that “rather than talking about happiness, [Bhutan should] want to work on reducing the obstacles to happiness.” He has since allocated significant government funds to health and mental health infrastructure.

As the WHO proclaimed in its Comprehensive Mental Health Action Plan 2013–2020, a person cannot be healthy without being mentally healthy. This can be extended to the health of a country and its governance as well. Although the necessary changes are beginning to be made, Bhutan’s situation is cautionary tale for the rest of the world. As happiness and general well-being become more and more integrated into development metrics, governments must also increase their support for mental health programs. Going forward, it is essential to remember that just as an individual’s mental health is an essential part of his overall health, the mental health of a nation is inextricably linked to its overall development.

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